From the Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research.
CORRESPONDENCE TO: Inderpaul Singh Sehgal, MD, DM, Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Sector-12, Chandigarh-160012, India; e-mail: firstname.lastname@example.org
FINANCIAL/NONFINANCIAL DISCLOSURES: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.
Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.
We read with interest the point/counterpoint editorials in a recent issue of CHEST (January 2015)1,2 debating whether American College of Chest Physicians (CHEST) guidelines are global in coverage. Although we agree that evidence-based guidelines formulated by leading international societies cover a vast array of respiratory disorders and are drafted after a thorough review of literature, they may not be applicable and practical at all centers, especially resource-limited settings. For example, the international evidence-based Infectious Diseases Society of America/American Thoracic Society guidelines for the management of community-acquired pneumonia (CAP)3 endorse the use of respiratory fluoroquinolones for management of CAP in patients with comorbidities and those who have received antibiotics within 3 months. However, this cannot be extrapolated to the Indian population where TB is endemic and continues to be an important health issue.
Respiratory fluoroquinolones are an integral component for the treatment of drug-resistant TB. Such a recommendation is likely to cause indiscriminative use of quinolones for treatment of community-acquired respiratory tract infections.4 The prior use of quinolones can lead to an increased risk of acquiring infection with drug-resistant Mycobacterium tuberculosis, thus adding to the burden of drug-resistant TB.5 In recent pneumonia guidelines, we have discouraged the indiscriminate use of quinolones in routine management of CAP, reserving its use for treatment of drug-resistant TB.6 In similar fashion, we have also recommended against the use of linezolid for nosocomial pneumonia, reserving its use for drug-resistant TB.6,7 The international guidelines also recommend the use of investigations like measurement of urinary antigen for diagnosis of Streptococcus pneumoniae and Legionella pneumonia. This is not practical for developing countries like India, as these investigations are either not freely available or are too expensive to be used routinely.
Hence, we feel that although the international guidelines including CHEST guidelines are evidence-based and robust, they need to be modified by national chest societies to better suit their population.
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