Affiliations: Nassau County Medical Center
East Meadow, NY
State University of New York at Stony Brook
Stony Brook, NY,
Baystate Medical Center
Correspondence to: Arsad A. Karcic, MD, Department of Cardiology, Nassau County Medical Center, 2201 Hempstead Turnpike, East Meadow, NY 11554; e-mail: firstname.lastname@example.org
To the Editor:
We read with interest the recent article by Harwell and Brown
(February 2000),1 which reviewed drug resistance of
Streptococcus pneumoniae. However, little attention was
given to the efficacy of ciprofloxacin against the pneumococcus. The
indications and usage of ciprofloxacin in the treatment of lower
respiratory tract infections (LRTI) caused by streptococcal pneumonia
have remained controversial.
We reviewed 18 large clinical studies, including our
own,2–4 and we analyzed the results of ciprofloxacin in
the treatment of LRTI. From these 18 studies, we derived a total
cumulative number of streptococcal LRTI treated with ciprofloxacin,
which numbered 204 patients. Based on analysis of the results in these
documented patients,2 we conclude that >90% of the 204
patients with streptococcal pneumonia LRTI treated with ciprofloxacin
were reported cured.
There were isolated reports of treatment failures in this group,
particularly in a single study by Davies et al.5 In that
study, of the 26 patients with pneumococcal acute exacerbation of
chronic bronchitis, only 9 improved and the remaining 17 were clinical
failures. The bacterial eradication rate was only 56%. It is possible
that this study was flawed because two lots of medications were used
and there were four different treatment regimens. We agree that
ciprofloxacin and other floroquinolones are not the first choice of
treatment in patients with community-acquired LRTI who have no
comorbidities. By contrast, the practical results of worldwide
experience have demonstrated that ciprofloxacin works well and remains
one of the treatment choices for patients with LRTI and comorbidities
like diabetes, COPD, alcoholism, or nursing home-acquired LRTI, who
often have polymicrobial infections with S pneumoniae as one
of the pathogens.
Drs. Karcic and Khan correctly state that the use of
ciprofloxacin for S pneumoniae-associated lower respiratory
infections remains controversial. We think it important to
differentiate between pneumonia and acute exacerbations of chronic
bronchitis. Methods for predicting flouroquinolone outcomes have
recently been reviewed1and suggest that ciprofloxacin is
suboptimal for many pneumococcal infections. Additionally, as mentioned
by the authors of the letter, clinical failures in documented cases of
pneumococcal pneumonia have been published.2–3 This was
noted and referenced in our review. Such an observation is in keeping
with our experiences of several cases of this disease that have either
failed to respond and/or were associated with sustained bacteremia
despite use of this agent. The Infectious Disease Society, in its
guidelines for the management of community-acquired pneumonia does not
consider it comparable to newer quinolones, especially at historically
recommended doses.4 Use of ciprofloxacin for acute
exacerbation of chronic bronchitis is more difficult to judge, because
of difficulties in assessing causal pathogens, as well as a different
natural history of disease. In general, we believe that there should be
few downsides to use of newer quinolones for management of presumed
pneumococcal infections and for the documented problems with the use of
the more venerable agent.
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