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Individualized Approach Urged in Treating Bronchitis and Pneumonia: Presented at ACP-ASIM

By Bonnie Darves

NEW ORLEANS, LA -- April 26, 2004 -- In light of the growing evidence on effective strategies in antibiotic use, physicians should tailor therapies to individual patients based on their laboratory test results, said Merle Sande, MD, professor of medicine, University of Utah School of Medicine, Salt Lake City, Utah, during his lecture here at the American College of Physicians - American Society of Internal Medicine Annual Session.

Despite the massive education campaign targeting inappropriate use of antibiotics, some internists continue to prescribe antibiotics for such conditions as acute bronchitis, or prescribe antibiotics later than they should when treating community-acquired pneumonia (CAP).

"Acute bronchitis is not an antibiotic-deficient state, and it almost never requires treatment, yet more than 50% of Americans continue to receive antibiotics when they present with upper respiratory infection (URI) and cough," Dr. Sande said. Such therapy may only be indicated in very severe cases "where the data points slightly toward using antibiotics."

He noted that when the winter Olympics were being held in Utah in 2002, the physician-education campaign that preceded the arrival of the athletes resulted in inappropriate use of antibiotics in 4% of URI cases -- without resulting in worse outcomes for patients -- proving that "education works if you really focus on it."

The prospective study to which Dr. Sande referred took place at the Olympic Village. Researchers collected clinical and epidemiological data on all patients who presented [to medical staff there] with URI, and found that of the 8% of patients who received antibiotics, half were positive for Group B Streptococcus.

For mild or moderate acute exacerbation of chronic bronchitis in patients who smoke and have chronic obstructive pulmonary disease, antimicrobial treatment is not required, Dr. Sande said, but should be used when disease is severe. When influenza is suspected or confirmed, Dr. Sande recommended starting oseltamivir (Temiflu) or zanamivir within 12 hours of fever onset. "The point is that we have treatment for influenza now, so it should be used" to not only shorten the course of the illness but also to help prevent its spread, he said. Studies have shown that the therapy can reduce total illness duration by 74 hours.

In discussing new approaches to the treatment of CAP, Dr. Sande said that a growing number of studies are pointing to the benefit of starting antibiotics -- a macrolide plus a betalactam or quinolone -- sooner in the course of the illness. "Starting antibiotics within 4 hours of when a patient reaches the emergency room seems to be important and to provide the best result," he said.

For patients with hospital-acquired pneumonia, a short course of therapy (5 days vs the traditional 14 days) "appears to be as good as a long course, and is associated with fewer complications and superinfections," Dr. Sande said.

"What we're learning about this hodgepodge of diseases is that when therapy appears to be indicated, start it quick -- but don't let it go too long, particularly if you have a positive blood culture or other evidence confirming bacterial infection," Dr. Sande concluded.


[Presentation Title: Bronchitis and Pneumonia: Tailoring Therapy to Individual Patient.]

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