Chapter 128. Pneumococcal Infections (Part 8)

Acute Sinusitis Just as the pathogenesis and microbial etiology of acute rhinosinusitis are similar to those of otitis media, so are the principles of diagnosis and treatment. The diagnosis is often empirical, and the less rigorously it is made, the more irrelevant antibiotics are likely to be. The estimated efficacy rate for amoxicillin/clavulanic acid, fluoroquinolones, and ceftriaxone (available for parenteral use only) is 90–92%, as opposed to 83–88% for amoxicillin, trimethoprim-sulfamethoxazole, and oral secondor third-generationcephalosporins and 71–81% for macrolides and doxycycline. Treatment should be given for longer periods than are recommended for otitis media (perhaps 10–14 days), but the...
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Chapter 128. Pneumococcal Infections (Part 8) Chapter 128. Pneumococcal Infections (Part 8) Acute Sinusitis Just as the pathogenesis and microbial etiology of acute rhinosinusitis aresimilar to those of otitis media, so are the principles of diagnosis and treatment.The diagnosis is often empirical, and the less rigorously it is made, the moreirrelevant antibiotics are likely to be. The estimated efficacy rate foramoxicillin/clavulanic acid, fluoroquinolones, and ceftriaxone (available forparenteral use only) is 90–92%, as opposed to 83–88% for amoxicillin,trimethoprim-sulfamethoxazole, and oral second- or third-generationcephalosporins and 71–81% for macrolides and doxycycline. Treatment should begiven for longer periods than are recommended for otitis media (perhaps 10–14days), but the optimal duration is uncertain. Pneumonia (Table 128-5) This section will deal primarily with the treatment ofpneumococcal pneumonia. The broader issue of empirical therapy for community-acquired pneumonia is covered elsewhere (Chap. 251). Unless epidemiologic,clinical, and radiologic findings strongly favor another etiology, empirical therapyfor pneumonia must include an agent that will be effective against S. pneumoniae,which remains the most likely causative agent of community-acquired pneumonia. Table 128-5 Regimens for the Treatment of Pneumococcal Pneumoniain Adultsa Route, Drug Dose, Scheduleb Oral Therapy Amoxicillin 1 g q8h Quinolone, e.g., levofloxacin 500 mg q24h Telithromycin 800 mg q24h Parenteral Therapy Penicillinc 3–4 mU q4h Ampicillin 1–2 g q6h Ceftriaxone 1 g q12–24h Cefotaxime 1–2 g q6–8h Quinolone, e.g., gatifloxacin 400 mg q24h Imipenem 500 mg q6h Vancomycind 500 mg q6h a These regimens are recommended for treatment after a presumptivediagnosis of pneumococcal pneumonia is made on the basis of examination of aGram-stained sputum sample or as a replacement for broader spectrum empiricaltherapy after a diagnosis of pneumococcal pneumonia is proven by culture. Whena valid sputum specimen cannot be obtained, concern about other likely pathogensshould prompt the selection of more all-inclusive therapeutic regimens. Readersare referred to guidelines for empirical treatment of community-acquiredpneumonia. b Therapy should continue for 5 days after defervescence, not to exceed 7–10 days total. A switch from parenteral to oral drug administration may be madeas soon as the patient can tolerate oral medications. c This regimen is listed more for historic than for practical reasons. Thespectrum is overly narrow, although perfectly acceptable if a Gram-stained sputumspecimen shows only pneumococci. However, the need for frequentadministration, mandated by the short half-life of penicillin, renders this regimenimpractical. d Not proven to be effective by the extensive clinical experience that appliesto the other regimens. Outpatient Therapy Amoxicillin (1 g three times daily) effectively treats virtually all cases ofpneumococcal pneumonia. Neither cefuroxime nor cefpodoxime offers anyadvantages over amoxicillin, and they are far more expensive. Telithromycin islikely to be equally effective. Moxifloxacin is also highly likely to be effective inthe United States except in patients who come from a closed population wherethese drugs are used widely or who have themselves been treated recently with aquinolone. Clindamycin is effective in 90% of cases and doxycycline,azithromycin, or clarithromycin in 80%. Treatment failure resulting in bacteremicdisease due to macrolide-resistant isolates has been amply documented in patientstreated empirically with azithromycin. As noted above, rates of resistance to allthese antibiotics are lower in some countries and much higher in others; high-doseamoxicillin remains the best option worldwide.