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MACROLIDES in LOWER RESPIRATORY TRACT INFECTIONS

MACROLIDES in LOWER RESPIRATORY TRACT INFECTIONS. Dr. Alpay AZAP Ankara University Medical School Infectious Diseases and Clin Micr Dept. Transparency decleration : I have no conflicts of interest. MACROLIDES. Erythromycin Roxythromycin C larithromycin Azithromycin Dyrithromycin

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MACROLIDES in LOWER RESPIRATORY TRACT INFECTIONS

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  1. MACROLIDES in LOWER RESPIRATORY TRACT INFECTIONS Dr. Alpay AZAP Ankara UniversityMedicalSchool InfectiousDiseasesandClinMicrDept

  2. Transparencydecleration: I havenoconflicts of interest

  3. MACROLIDES Erythromycin Roxythromycin Clarithromycin Azithromycin Dyrithromycin Telithromycin* Gram pozitivebacteria Gram negativebacteria Atypicalagents Mycobacteriumspp. Borreliaburgdorferi Babesiamicroti RespiratoryPathogens: Streptococcuspneumoniae Haemophilusinfluenzae Moraxellacatarrhalis Legionellaspp. Mycoplasmapneumoniae Chlamydiapneumophila

  4. TurkishThoracicSociety: Group IA: Amoxicillinor MACROLIDE Group IB: “2nd/3rd gen SF or AMC” ± MACROLIDE or Doxycycline Group II: “3rd gen SF or BLBLI + MACROLIDE” or “Fluoroquinolonealone” Grup IIIA: “3rd gen SF or BLBLI” + “MACROLIDE orquinolone” Grup IIIB: Anti-pseudomonal BL + ciprofloxacin/AGA + MACROLIDE MACROLİDES: ErythromycinAzithromycin ClarithromycinRoxythromycin Dyrithromycin J TurkishThoracicSociety 2009;10(s9):3-16

  5. EuropeanRespiratorySociety: Outpatient: Amoxicillinortetracyclineor MACROLIDE Inpatient: “Aminopenicillin ± MACROLIDE” or “BLI-aminopenicillin ± MACROLIDE” or “Penicillin G ± MACROLIDE” or “CTX/CRO ± MACROLIDE” or levofloxacin/moxifloxacin ICU Patient: 3rd gen SF + MACROLIDE OR levofloxacin/moxifloxacin ± 3rd gen SF Anti-pseudomonal BL + “Ciprofloxacinor AGA + MACROLIDE” ClinMicrobiol Infect 2011; 17 (Suppl. 6): 1–24

  6. IDSA/ATS Guideline: Outpatient: Healthywith no risk for PRSP : MACROLIDEσorDoxycycline* Underlyingdis, previousABx: Fluoroquinoloneor Beta-lactam + “MACROLIDEσorDoxycycline” σ : If PRSP incidencelowerthan %25! Inpatient: Fluoroquinoloneor Beta-lactam + “MACROLIDE orDoxycycline” Clinical Infectious Diseases 2007; 44:S27–72

  7. IDSA/ATS Guideline: ICU Patient: CRO/CTX/BLBLI + “Azithromycin * orFluoroquinolone ” ICU Patient (Pseudomonas): Anti-pseudomonal BL + “ciprofloxacinorlevofloxacin” Anti-pseudomonal BL + AGA + Azithromycin Anti-pseudomonal BL + AGA + respiratoryquinolone Clinical Infectious Diseases 2007; 44:S27–72

  8. Macrolideresistance in S. pneumoniae : 4-70% “Prospective ResistantOrganism Tracking and Epidemiology for the KetolideTelithromycin” (PROTEKT)Study: 25 country 69 centers 3362 S. pneumoniaeisolates Macrolideresistance: France: %57.6 Italy: %42.9 Türkiye: %15.6 Sweden: %4.7 J AntimicrobChemoth 2002; 50 (Suppl S1): 25-37.

  9. Türkiye • Fourprovinces, 5 centers • 1995-2000 • 283 pneumococcusisolates • Macrolideresistance: 2.3% • Int J Antimicrob Ag 2002; 19: 207-11

  10. 1999-2005 300 S. pneumoniaeisolatesnvasiveinfections Anti-microbialsensitivitytestingby E-test mef(A) anderm(B) genotypeswereidentifiedby PCR

  11. erm(B) genotype: 58,8% mef(A) genotype: 38,2% erm(B) + mef(A): 3% Turk J Med Sci2012; 42 (1): 137-144

  12. e-BASKETT-II Study: 2002-2003 18 center 260 respiratoryisolates Macrolideresistance: 17.3% Tetracyclineresistance: 21.5% erm(B) genotype: 77,8% mef(A) genotype: 17,8 % erm(B) + mef(A):2,2 % Mikrobiyol Bul. 2007 Jan;41(1):1-9.

  13. Seven centersfrom 5 provinces 301 isolatesfromcommunityacquiredinfections Childandadultpatients Journal of Antimicrobial Chemotherapy (2007) 60, 587–593

  14. Seven centersfrom 5 provinces 380 isolatesfromcommunityacquiredinfections Childandadultpatients Journal of Antimicrobial Chemotherapy (2007) 60, 587–593

  15. Do weneedmacrolides in combination? Clinical Infectious Diseases 2008; 47:S232–6

  16. BMJ 2005; 330:456–60.

  17. Beta-lactam + Macrolidecombination is not synergistic Antagonismwasobserved in animalstudies Selectionbias: Atypicalpneumoniae has a mildcourseandseen in youngerpts Patientswhorequire ICU alsoreceivemacrolides (legionella ?) Theincidence of atypicalagentsshowsvariation. Trialscomparingquinoloneswithmacrolidesdon’tinclude severe pts Journal of Antimicrobial Chemotherapy (2003) 52, 555–563

  18. BL + Macrolide vs Fluoroquinolone: PSI V pts 14 daymortality; 8.2% vs 26.8% (p=0.02) 30 daymortality: 18.4% vs 36.6% (p=0.05) PSI II-IV pts 14 day, 30 daymortalityand LOS were not different Length of stay in allpts 6 days vs 5 days (p=0.01) ANTIMICROBIAL AGENTS AND CHEMOTHERAPY, Nov. 2007, p. 3977–3982

  19. 9 countiresfromEuropa 27 ICUs, 218 entubated severe CAP pts 43 (19.7%) ptsmonotherapy 175 (80.3%) ptsdualtherapy BL + Macrolide vs BL + Quinolone: severe CAP pts: HR: 0.48 (p=0.04) severe sepsis/septicshock: HR: 0.44 (p=0.03) Intensive Care Med (2010) 36:612–620

  20. Intensive Care Med (2010) 36:612–620

  21. Intensive Care Med (2010) 36:612–620

  22. Macrolide!WhichOne ? TurkishThoracicSociety: Macrolides: Erythromycin Roxythromycin Clarithromycin Azithromycin Dyrithromycin Türk Toraks Dergisi 2009;10(s9):3-16 • IDSA/ATS : • Azithromycinfor ICU pts • Clinical Infectious Diseases 2007; 44:S27–72

  23. toconclude… Macrolides can be used as monotherapyagentfor CAP in Türkiye Macrolidesmay be superiorthanquinoloneswhenused in combinationwith BL agents Thedecision of whichmacrolideshould be useddepends on patientsclincalsituation.

  24. Thankyou….

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