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Rapid Responses: Rapid Responses published:
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Be alert to underlying malignancy
- Iain R Crossingham, Rebecca Grue (8 May 2006)
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Empiric antibiotic prescribing for community-acquired pneumonia: macrolides or amoxicillin?
- Federico Marchetti, Irene Berti (9 May 2006)
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Are we putting the CURB score into practice?
- D Owen, Tamara Shiner, Christopher Hilton, Ramachandran Sivakumar, Richard Dent (9 May 2006)
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Treatment of MRSA in Community acquired pneumonia
- James Greig, Peter Jenks (12 May 2006)
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Appropriate use of CURB-65?
- Kirsty Challen, Darren Walter, John Bright, Andrew Bentley (12 May 2006)
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Iain R Crossingham, SpR Nottingham City Hospital, NG5 1PB, Rebecca Grue
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Editor, Hoare & Lim rightly note the importance of follow up of patients with pneumonia. They recommend repeat chest X ray at six weeks. However several studies [1,2] have demonstrated a high (5-13%) rate of underlying malignancy in heavy smokers who are over the age of 50, but do not have obvious pointers to a neoplasm. Consideration of early bronchoscopy in this group may avoid the delay in diagnosis inherent in waiting six weeks. [1] Gibson SP, Weir DC, Burge PS. A prospective audit of the value of fibre optic bronchoscopy in adults admitted with community acquired pneumonia. Respir Med. 1993 Feb;87(2):105-9. [2] Gloria C, Freitas MG. [The usefulness of bronchofibroscopy in the diagnosis of lung neoplasms in patients with protracted pneumonia] Acta Med Port. 1995 Sep;8(9):493-6. Competing interests: None declared |
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Federico Marchetti, Clinical Paediatrician Department of Paediatrics, Institute of Child Health, IRCSS Burlo Garofolo, Trieste, Italy, Irene Berti
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EDITOR- In their update for the management of community acquired pneumoniae (CAP), Hoare Z and Lim W.S (1) reported the current recommendations of the British Thoracic Society for empirical antibiotic treatment of CAP. As for adults, the recommendation for the antibiotic treatment of CAP in children, considering the national guidelines (2) or the conventional review (3) on this topic, are based on low level of evidence (4). A critical issue, involving adults as well as children older than 5 years of age, concerns the use of macrolides as first line treatment of outpatient with CAP, advice that is not based on randomised controlled trials. We disagree with this indication because S pneumoniae is not only the most common causative agent of CAP but also it is associated with more severe diseases in respect to other pathogens. The prevalence of macrolide resistance in patients with S pneumoniae infection continues to rise worldwide (4). The latest update (2001) of the Alexander Project (available at: www.Alexander-Network.com), indicated that in the United States the prevalence of pneumococcal macrolide resistance is 28.3%. These high prevalence rates were comparable to those found in Spain (26.4%) and Italy (35.9%), even if not as high as in France (56.4%). Although prevalence rates in the United Kingdom and Germany remain relatively low (11.5% and 7.5%, respectively), the trend is growing. Moreover, treatment failure in patients with pneumococcal pneumonia as a result of macrolide use in the outpatient setting appears to be increasing (4,5). In general practice the risk of lack of efficacy of macrolides in the case of pneumonia caused by S. Pneumoniae should be taken into the account. For this reason we believe that in patients with clinical signs suggestive of pneumococcal pneumonia the first line empirical antibiotic treatment should be amoxicillin. However, further randomised controlled trial are needed to compare the cost/benefits of ß-lactam agent versus macrolides, both in adults and in children with >5 years of age affected by CAP. References 1. Hoare Z and Lim W.S. Pneumonia: update on diagnosis and management. BMJ 2006;332:1077-1079 2. BTS guidelines for the management of community acquired pneumoniae in childhood. British thoracic society standards of care committee. Thorax 2002;57 (suppl. 1):i1-i24 3. McIntosh K. Community-acquired pneumoniae in children. NEJM 2002;346(6):429-37. 4. File TM Jr, Garau J, Blasi F, et al. Guidelines for empiric antimicrobial prescribing in community-acquired pneumonia. Chest. 2004;125(5):1888-901. 5. Dylewski J, Davidson R. Bacteremic pneumococcal pneumonia associated with macrolide failure. Eur J Clin Microbiol Infect Dis. 2006;25(1):39-42. Federico Marchetti, MD, Irene Berti, MD Department of Paediatrics, Institute of Child Health, IRCSS Burlo Garofolo, Trieste, Italy Via dell'Istria 65/1, 34100 Trieste, Italy Correspondence to:
Federico Marchetti
Competing interests: None declared |
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D Owen, Medical SHO Queen Elizabeth II Hospital, AL7 4HQ, Tamara Shiner, Christopher Hilton, Ramachandran Sivakumar, Richard Dent
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Hoare and Lim (1) suggest that patients with pneumonia should receive antibiotics intravenously if they have a CURB score of at least 3, or contraindications to oral therapy which may include malabsorption, impaired consciousness or risk of aspiration. They also assert that intravenous antibiotics should be changed to oral therapy as soon as possible. These two points are in accordance with current BTS guidelines and are designed to limit the prescription of intravenous antibiotics when not indicated. This is because of their undesirable effect on microbial resistance, as well as their side effect profile and greater cost. We recently audited the treatment of pneumonia in our district general hospital and found that antibiotics were prescribed intravenously to 54% of patients (28 of 52) with a CURB score of 0 or 1. These patients do not qualify for intravenous antibiotics according to current BTS guidelines. We surmise that this over prescription of intravenous antibiotics is partly because junior doctors, who are responsible for admitting such patients, are not officially taught the CURB score, which rarely features in either finals or MRCP examinations. Indeed, in only 1.6% of cases (2 of 126) was the CURB score documented on the admission clerking. Of all the well validated scoring systems used in clinical practice, the CURB score is probably the most memorable and simple to apply. Hence its inclusion in the BTS guidelines for the treatment of CAP. Despite this, it is not being put into practice. These findings illustrate the wider problem of transferring knowledge produced from academic research, to the clinical shop floor. References 1 Zara Hoare, Wei Shen Lim Pneumonia: update on diagnosis and management BMJ 2006; 332: 1077-1079 Competing interests: None declared |
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James Greig, Consultant Microbiologist Department of Microbiology, Derriford Hospital, Derriford Road, Plymouth PL6 8DH, UK, Peter Jenks
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Hoare and Lim's update on the diagnosis and management of community- acquired pneumonia fails to mention methicillin resistant Staphylococcus aureus (MRSA)[1]. This traditional hospital-acquired pathogen is becoming more common in the community as a true community-associated organism, in patients in residential care and in those discharged from hospital. Patients who have newly acquired MRSA often develop further infections unless carriage is cleared. One study showed that in the 18 months following first colonization over one quarter of individuals developed further MRSA infections many of which were pneumonias [2]. All MRSAs are resistant to penicillins and cephalosporins; over 90% of hospital- associated strains are resistant to quinolones and over 70% resistant to erythromycin and clarithromycin[3]. True community associated MRSA strains have a greater overall antibiotic susceptibility but are uncommon in the UK unlike other areas of the world. Treatment regimens as advised in the article are inappropriate where MRSA is a likely pathogen. The burden of unidentified MRSA colonization is high. At Plymouth Hospitals NHS Trust in the last year, 39% of all MRSA bacteraemias presented in the community, nearly half of all serious MRSA infections were in patients not previously known to be colonized and nearly 20% of residents of Nursing Homes admitted to the Orthopaedic service were colonized. With such high levels of unidentified carriage in the community, empirical treatment for MRSA pneumonia in many at risk groups would seem prudent. Recent UK MRSA treatment guidelines advise the use of vancomycin or linezolid for proven MRSA pneumonia[3]. Doxycyline is a well tolerated antibiotic to which over 95% of MRSA strains are sensitive as well as most of the atypical pathogens that Hoare and Lim suggest should be treated with the poorly tolerated antibiotic erythromycin or its more expensive relative clarithromycin. Although not mentioned in the British Thoracic Society guidelines, in Plymouth doxycyline is used in addition to a penicillin for treatment of atypical pathogens. This has the additional benefit of providing some activity against unidentified MRSA infections. Where conventional antibiotic treatment has failed or in those intolerant of penicillins, an oral respiratory quinolone (levofloxacin) is used. In such patients who are at increased risk of MRSA infection eg. elderly, past history of carriage etc we suggest intravenous vancomycin or linezolid be added as it should for at risk patients with severe pneumonia. Where MRSA pneumonia is subsequently confirmed conversion to a regimen as recommended in the UK guidelines would be appropriate in most patients. With rising rates of MRSA infections in the community we urge other providers to consider the use of empirical treatment with a tetracycline or vancomycin in community-acquired pneumonia in high risk patients, where MRSA cannot be ruled out. 1. Hoare Z, Lim WS. Pneumonia: update on diagnosis and management. BMJ 2006; 332: 1077-79. 2. Huang S, Platt R. Risk of methicillin resistant Staphylococcus aureus infection after previous infection or colonization. Clin Infect Dis 2003; 36: 281-85. 3. Gemmell CG et al. Guidelines for the prophylaxis and treatment of methicillin resistant Staphylococcus aureus (MRSA) infections in the UK. J Antimicrob Chemotherap 2006; 57: 589-608. Competing interests: None declared |
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Kirsty Challen, Research Fellow, Emergency Medicine South Manchester University Hospitals Trust, M23 9LT, Darren Walter, John Bright, Andrew Bentley
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We welcome the commitment shown by Owen et al to reducing inappropriate intravenous antibiotic prescribing but are concerned by some of their assumptions. Although the BTS guidelines state that patients with a CURB-65 score of 0 or 1 are likely to be suitable for home treatment, Hoare and Lim have recognised that clinical judgement is also needed(1). Similarly, recent Department of Health/Health Protection Agency guidance on the management of Panton - Valentine Leukocidin- associated staphylococcal pneumonia has stated that CURB-65 may be misleadingly low in fit young adults(2). In a study in our own institution over the last year (in preparation) 5 of 40 patients with a CURB-65 score of 1 at presentation required HDU or ITU care. We would be concerned if blind adherence to a score designed for mortality prognostication without reference to the current or deteriorating physiological state of the patient resulted in patients being managed inappropriately, and feel that if CURB-65 is used then decision-making should also allow for the inclusion of clinical judgement as suggested by Hoare and Lim. Correspondence to: Dr Challen; kirsty.challen@smtr.nhs.uk References: 1. Hoare Z, Lim WS. Pneumonia: update on diagnosis and management. BMJ 2006; 332: 1077-1079 2. McCartney C, Cookson B, et al. Interim guidance on diagnosis and management of Panton-Valentine Leukocidin-associated Staphylococcal infections in the UK. London, Department of Health, 2006. http://www.dh.gov.uk/AboutUs/MinistersAndDepartmentLeaders/ChiefMedicalOfficer/Features/FeaturesArticle/fs/en?CONTENT_ID=4133761&chk=oW8s4w Competing interests: None declared |
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