Community-acquired pneumonia and its management - The role of levofloxacin

Community-acquired pneumonia (CAP) is a common cause of morbidity and morta lity worldwide and places a large burden on medical and economic resources, particularly if hospitalization is required. Indeed, it has been estimated that annual costs of inpatient treatment of patients with CAP currently ex ceed $US6 billion in the US; a large proportion of this cost is directly re lated to the duration of hospital stay. Initial antibacterial therapy for C AP is usually empirical, as culture and antibacterial sensitivity test resu lts are rarely available at initial diagnosis. Importantly, treatment must be initiated promptly to achieve the best patient outcome thereby potential ly reducing healthcare costs, largely as a result of a decrease in hospital isation. Any agent selected for empirical therapy should have good activity against pathogens associated with CAP, a favorable tolerability profile an d be administered in a simple dosage regimen for good compliance. Streptococcus pneumoniae remains the most common causative pathogen in nons evere and severe CAP, although the incidence of this organism varies widely . S. pneumoniae strains with decreased susceptibility to penicillin have be come increasingly prevalent over the past 30 years and are now a serious pr oblem worldwide. In addition, an increase in the prevalence of pneumococci resistant to macrolides has been observed in Europe over recent years. Myco plasma pneumoniae and Chlamydia pneumoniae are among the most common atypic al pathogens isolated from patients with CAP. Haemophilus influenzae, Staph ylococcus aureus and Moraxella catarrhalis are less commonly identified as causative organisms. Because the spectrum of antibacterial activity of levofloxacin includes the pathogens associated with CAP, including penicillin-resistant S. pneumonia e, it is included in US guidelines as an option for the empirical therapy o f patients with mild or more severe disease. Levofloxacin is recommended fo r the initial treatment of outpatients and inpatients with suspected penici llin-resistant S. pneumoniae infection and is particularly useful in geogra phical areas where there is a high incidence of drug-resistant pneumococci. Nevertheless, beta -lactam antibacterial agents, in particular penicillin, remain agents of first choice for the treatment of CAP (caused by penicill in-susceptible pathogens) in many European countries. Levofloxacin monotherapy shows good efficacy in the treatment of patients w ith CAP and is generally well tolerated. Phototoxicity has been infrequentl y reported with levofloxacin (incidence 0.03% in 1 study) and occurs less c ommonly than with sparfloxacin (reported incidence 8%). In addition, the dr ug has a pharmacokinetic profile that allows a simple administration schedu le and offers the potential for intravenous to oral sequential therapy. In randomized comparative trials, intravenous or oral levofloxacin was more ef fective than intravenous ceftriaxone and/or oral cefuroxime axetil, at leas t as effective as azithromycin plus ceftriaxone and similar in efficacy to both amoxicillin/clavulanic acid and gatifloxacin. Data comparing the effic acy of levofloxacin with other newer fluoroquinolones, such as moxifloxacin , are as yet unavailable. Levofloxacin was also a beneficial treatment for CAP from a pharmacoeconomi c perspective. A critical pathway that used levofloxacin for the treatment of patients with CAP led to a decrease in healthcare resource costs compare d with conventional management in a randomized controlled trial conducted i n Canada. As a treatment for CAP, levofloxacin was less costly than intrave nous ceftriaxone and was more cost effective than cefuroxime plus erythromy cin, or ceftriaxone or ciprofloxacin. Conclusions: Levofloxacin monotherapy is efficacious and shows pharmacoecon omic benefits when used as empirical treatment for adult patients with CAP. The drug has a broad spectrum of antibacterial activity, is administered i n a simple dosage regimen and offers the potential for intravenous to oral sequential therapy; it is also well tolerated and is an option for patients allergic to penicillin or macrolides. Levofloxacin has a particularly usef ul role in the empirical treatment of patients with infections caused by S. pneumoniae in geographical areas where penicillin-resistant strains of pne umococci are prevalent.