Lionel A. Mandell, Richard G. Wunderink, Antonio Anzueto, John G. Bartlett, G. Douglas Campbell, Nathan C. Dean, Scott F. Dowell, Thomas M. File, Jr. Daniel M. Musher, Michael S. Niederman, Antonio Torres, and Cynthia G. Whitney McMaster University Medical School, Hamilton, Ontario, Canada; Northwestern University Feinberg School of Medicine, Chicago, Illinois; University of Texas Health Science Center and South Texas Veterans Health Care System, San Antonio, and Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, Texas; Johns Hopkins University School of Medicine, Baltimore, Maryland; Division of Pulmonary, Critical Care, and Sleep Medicine, University of Mississippi School of Medicine, Jackson; Division of Pulmonary and Critical Care Medicine, LDS Hospital, and University of Utah, Salt Lake City, Utah; Centers for Disease Control and Prevention, Atlanta, Georgia; Northeastern Ohio Universities College of Medicine, Rootstown, and Summa Health System, Akron, Ohio; State University of New York at Stony Brook, Stony Brook, and Department of Medicine, Winthrop University Hospital, Mineola, New York; and Cap de Servei de Pneumologia i Allergia Respiratoria, Institut Clinic del Torax, Hospital Clinic de Barcelona, Facultat de Medicina, Universitat de Barcelona, Institut d’Investigacions Biomediques August Pi i Sunyer, CIBER CB06/06/0028, Barcelona, Spain.

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Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management of Community-Acquired Pneumonia in Adults

The Infectious Diseases Society of America (IDSA) produced guidelines for community-acquired pneumonia (CAP) in immunocompetent adults in 1998 and again in 2000 [1, 2]. Because of evolving resistance to antimicrobials and other advances, it was felt that an update should be provided every few years so that important developments could be highlighted and pressing questions answered. We addressed those issues that the committee believed were important to the practicing physician, including suggestions for initial empiric therapy for CAP. In some cases, only a few paragraphs were needed, whereas, in others, a somewhat more in-depth discussion was provided. Because many physicians focus on the tables rather than on the text of guidelines, it was decided that all of the information dealing with the initial empiric treatment regimens should be in tabular format with footnotes (tables 1–3). The topics selected for updating have been organized according to the headings used in the August 2000 CAP guidelines pub-

Update of Practice Guidelines for the Management of Community-Acquired Pneumonia in Immunocompetent Adults

Guidelines for the management of adult lower respiratory tract infections (LRTIs) were first published by a Task Force of the European Respiratory Society (ERS) in 1998 [1]. In 2005, a completely revised version was produced, this time by a joint Task Force of the ERS and the European Society for Clinical Microbiology and Infectious Diseases (ESCMID) [2]. They used up-to-date methodology for guideline development, including a transparent and objective systematic literature search strategy, and evidence and recommendation grading [2]. Now, 6 yrs later, a joint Task Force of the two Societies, using the same methodology as in 2005, has produced a further update of these guidelines incorporating publications through to May 2010. The Task Force included an epidemiologist with expertise in guideline methodology and experts in the specialty areas relevant to LRTI management, including general practice, microbiology, infectious diseases, respiratory medicine, intensive care and public health.

A short version of the guidelines containing only the recommendations has now been published in Clinical Microbiology and Infection [3], with more detailed versions available on each Society’s website. The guidelines cover the breadth of adult community-acquired respiratory infection, including prevention (both vaccine- and nonvaccine-related), infections in the community and infections in those admitted to hospital, including pneumonia, exacerbations of chronic obstructive pulmonary disease (COPD) and exacerbations of bronchiectasis. The …

https://erj.ersjournals.com/content/erj/26/6/1138.full.pdf

Guidelines for the management of adult lower respiratory tract infections

The increased use of fluoroquinolones has led to increasing resistance to these antimicrobials, with rates of resistance that vary by both organism and geographic region. Resistance to fluoroquinolones typically arises as a result of alterations in the target enzymes (DNA gyrase and topoisomerase IV) and of changes in drug entry and efflux. Mutations are selected first in the more susceptible target: DNA gyrase, in gram-negative bacteria, or topoisomerase IV, in gram-positive bacteria. Additional mutations in the next most susceptible target, as well as in genes controlling drug accumulation, augment resistance further, so that the most-resistant isolates have mutations in several genes. Resistance to quinolones can also be mediated by plasmids that produce the Qnr protein, which protects the quinolone targets from inhibition. Qnr plasmids have been found in the United States, Europe, and East Asia. Although Qnr by itself produces only low-level resistance, its presence facilitates the selection of higher-level resistance mutations, thus contributing to the alarming increase in resistance to quinolones.

Mechanisms of resistance to quinolones

https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(09)61114-4.pdf

Pathogenesis, treatment, and prevention of pneumococcal pneumonia.

This report describes four patients with pneumococcal pneumonia in whom empirical treatment with levofloxacin failed. In these patients, the isolates of Streptococcus pneumoniae were resistant to levofloxacin, and in two of them the resistance appeared to have been acquired during the current course of treatment with fluoroquinolones.

https://www.nejm.org/doi/pdf/10.1056/NEJMoa012122

Pamela Kibsey

Papers

Resistance to Levofloxacin and Failure of Treatment of Pneumococcal Pneumonia