Rapid Responses to:

EDITORIALS: Marc J M Bonten and Jan M Prins Antibiotics in pandemic flu BMJ 2006; 332: 248-249 [Full text]

Rapid Responses: Submit a response to this article

Rapid Responses published:

Prognostic assessment and avoidance of fluoroquinolones will be important in a flu pandemic

Gavin D Barlow   (5 February 2006)

Pandemic Flu and risk of NSAIDs

NIGEL WARDLE   (10 February 2006)

Prognostic assessment and avoidance of fluoroquinolones will be important in a flu pandemic 5 February 2006
Gavin D Barlow, Consultant in Infectious Diseases and Medicine Department of Infection & Tropical Medicine, Hull & East Yorkshire Hospitals NHS Trust. HU16 5JQ Send response to journal: Re: Prognostic assessment and avoidance of fluoroquinolones will be important in a flu pandemic	Editor – As highlighted by Bonten and Prins, secondary pneumonia will cause considerable problems in an influenza pandemic1. Symptoms and signs, however, are known to have low predictive value in diagnosing pneumonia2. As patients with secondary pneumonia are likely to be sicker, prognostic assessment could support clinicians’ judgement. One potential predictive tool is CURB65, which has been validated in community-acquired pneumonia (CAP) and is recommended by the British Thoracic Society (BTS)2. This uses four bedside criteria (confusion, respiratory rate, blood pressure and age) and one laboratory criterion (urea) to determine a patient’s risk of death. In primary care, the urea component can be dropped with similar performance2. During a pandemic, CURB65 could be used to target interventions such as neuroaminidase inhibitors, antibiotics and hospital assessment. Its use in influenza infection warrants further investigation. The BTS recommends amoxicillin for patients with CAP at low risk of death (CURB65 = 0-1) and amoxicillin plus a macrolide in those at moderate risk (CURB65 = 2)2. Given that these cover the most likely cause of secondary infection (Streptococcus pneumoniae) and that co-infection with atypical pathogens is recognised3, their use should be retained in a pandemic. A regimen for severe pneumonia (CURB65 = 3-5) is more difficult. The BTS currently recommend intravenous (IV) co-amoxiclav or a 2nd/3rd generation cephalosporin plus a macrolide. IV levofloxacin plus benzylpenicillin is an alternative2. Some hospitals use the latter to limit Clostridium difficile associated diarrhoea. In North America, respiratory fluoroquinolones are commonly used. Whilst all have antipneumococcal activity, fluoroquinolones are not reliable in staphylococcal infections. In East Yorkshire, 30% of methicillin sensitive Staphylococcus aureus and 98% of methicillin resistant (MRSA) isolates are resistant. In areas with community-acquired MRSA, the optimal regimen is unclear. Glycopeptides poorly penetrate lung tissue4. Oxazalidinones may be more efficacious and are easier to use5. Hospital antibiotic committees will need to think carefully therefore, before making recommendations for pneumonia in an influenza pandemic. Gavin.Barlow@hey.nhs.uk 1. Bonten MJM, Prins JM. Antibiotics in pandemic flu will be essential for treating, but not preventing, bacterial pneumonia. BMJ 2006;332:248-9. 2. British Thoracic Society. BTS Guidelines for the Management of Community Acquired Pneumonia in Adults. Thorax 2001;56 Suppl 4:1-64. 3. Lim WS, Macfarlane JT, Boswell TCJ, Harrison TG, Rose D, Leinonen M, Saikku P. Study of community acquired pneumonia aetiology (SCAPA) in adults admitted to hospital: implications for management guidelines. Thorax 2001;56:296-301. 4. Cruciani M, Gatti G, Lazzarini L, Furlan G, Broccali G, Malena M, Franchini C, Concia E. Penetration of vancomycin into human lung tissue. J Antimicrob Chemother 1996;38:865-69. 5. Kollef MH, Rello J, Cammarata SK, Croos-Dabrera RV, Wunderink RG. Clinical cure and survival in Gram-positive ventilator-associated pneumonia: retrospective analysis of two double-blind studies comparing linezolid with vancomycin. Intensive Care Med 2004;30:388-94. Competing interests: None declared
Pandemic Flu and risk of NSAIDs 10 February 2006
NIGEL WARDLE, retired physician Baldock,Herts SG7 6SY Send response to journal: Re: Pandemic Flu and risk of NSAIDs	The article on Pandemic Flu (Feb4th, p248)certainly indicates that serious thought is being given to what we shall do if the H2N1 mutates such that it can invade the human respiratory tract. A significant approach is highlighted by Michelle Carey et al[1] at NIEHS who have shown in mice infected with influenza A that Cox-2 deficiency aids survival, whereas Cox-1 deficiency is detrimental! Not many patients take large doses of Cox-1 inhibitors, but some might if threatened by the flu. Therefore GPs please note the probable survival advantage of a safe Cox-2 inhibitor. 1.Carey M A,Bradbury J A,Seubert J M et al.Contrasting effects of Cox-1 and Cox-2 deficiency on the host response to Influenza A viral infection.J Immunol.2005;175:6878-84 Competing interests: None declared