Thomas M. File, Jr, MD

20 June, 2018

Dr File began by pointing out significant changes in regard to respiratory tract infections which impact on their management. There is an increasing number of possible pathogens, and emerging resistance in standard pathogens especially S. pneumoniae.

These factors have changed the perception of how community-acquired pneumonia should be managed. The latest guidelines recommend empiric use of enhanced spectrum regimens such as levofloxacin.

Levofloxacin possesses significant advantages over older fluoroquinolones, and enhanced activity for S. pneumoniae including resistant strains. It also has greater activity against atypicals, and excellent pharmacokinetic properties allowing once-daily dosing.

Clinical trials confirm the efficacy of levofloxacin in community-acquired pneumonia. Compared to ceftriaxone or cefuroxime axetil plus or minus erythromycin, it achieved a 96% clinical response rate, compared to 90% for a comparator regimen a statistically significant benefit. A trend in reduced mortality was also noted for levofloxacin.

In terms of specific organisms, levofloxacin achieved a 100% response rate for H. influenzae and pneumococcus, compared to79% and 97%, respectively, for ceftriaxone. Almost 99% of atypical pathogens were satisfactorily treated with levofloxacin.

Levofloxacin was well tolerated in the study, with 5.8% reporting very mild drug-related ADR. 8.5% had a drug reaction in the ceftriaxone group, with nausea and vomiting seen often.

Two comparative trials assessed levofloxacin with amoxicillin clavulanic acid and with clarithromycin in the management of sinusitis. Levofloxacin was proven as effective as both agents. In another important noncomparative study including sinus aspirates taken pre- and post-treatment, levofloxacin was associated with a 100% bacteriological cure rate.

In regard to acute exacerbations of chronic bronchitis, there have been two trials comparing levofloxacin with cefuroxime axetil and cefaclor. Results confirmed the efficacy of levofloxacin, achieving bacteriological and clinical results similar to comparator agents.

Recent guidelines by the Infectious Diseases Society of America for management of community-acquired pneumonia include fluoroquinolones, specifically levofloxacin, as appropriate empiric choice to treat these important infections. For outpatients, a macrolide or antipneumococcal fluoroquinolone, or doxycycline can be used.

Two regimens are advocated for community-acquired pneumonia requiring hospitalization. Either cefotaxime or ceftriaxone, with or without a macrolide, or monotherapy with a new fluoroquinolone such as levofloxacin.

Levofloxacin is now recognized as having an important role in the management of respiratory tract infections due to its excellent clinical efficacy, safety and attractive pharmacological profile.