Lower respiratory tract infection medical therapy
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
There are a number of acute and chronic infections that can affect the lower respiratory tract. Antibiotics are often thought to be the first line treatment in lower respiratory tract infections however these are not indicated in viral infections. It is important to use appropriate antibiotic selection based on the infecting organism and to ensure this therapy changes with the evolving nature of these infections and the emerging resistance to conventional therapies.
Medical Therapy
Non-Pharmacological Treatments
For many years, the main stay of non pharmacological treatment has been rest and increased fluid intake. Although it is common for doctors and other health professional to recommend extra fluid intake, a Cochrane systematic review could find no evidence for or against increased fluid intake. Although the idea of replacing fluids lost through fever and rapid breathing was sound, some observational studies reported harmful effects such as dilution of blood sodium concentration leading to headache, confusion or possibly seizures. Rest will allow the body to conserve energy to fight off the infection. Physiotherapy is indicated in some types of pneumonia and should be encouraged where appropriate.
Antibiotic Choice
With increased development of drug resistance, traditional empirical treatments are becoming less effective, hence it is important to base antibiotic choice on isolated bacteria and sensitivity tests. According to the Cochrane review of antibiotic use in CAP in adults, the current evidence from RCTs is insufficient in order to make evidenced based decisions on the antibiotic of choice. Further studies are required to make these decisions. For children they found amoxicillin or procaine penicillin to have greater effect than co-trimoxazole for the treatment of CAP. In hospital settings, penicillin and gentamycin was found to be more effective than chloramphenicol, with oral amoxicillin giving similar results to injectable penicillins. In another review of children with severe pneumonia, oral antibiotics were found to be as effective as injectable ones without the side effects of pain, risk of infection and high cost. Also in a Cochrane review, azithromycin has been shown to be no better than amoxycillin or amoxycillin with clavulanic acid in the treatment of lower respiratory infections. The AMH lists amoxycillin as the first line choice for AECB and community acquired pneumonia whereas IV azithromycin is first line choice in case there is high risk of death. In case of severe hospital acquired pneumonia, IV gentamicin and ticarcillin with clavulanic acid is recommended.
For optimal management of pneumonia, the following must be assessed:
- Pneumonia severity (including where to treat e.g. home, hospital or intensive care),
- Identification of causative organism,
- Analgesia for chest pain,
- Need for supplemental oxygen, physiotherapy, hydration and bronchodilators, and
- Possible complications of emphysema or lung abscess.
The appropriate use of fluoroquinolones is a therapeutic option in case of community acquired respiratory infections. These have been demonstrated to have targeted in vitro activity against both the typical and atypical pathogens of interest. The newer fluoroquinolones (e.g, moxifloxacin or gatifloxacin) have extended gram positive activity and are used as once daily dosing. This makes them potential first line in the treatment of lower respiratory tract infections. However it is the clinical response that is best indicator of efficacy. Moxifloxacin or gatifloxacin have been proven to be effective against community acquired respiratory tract infections clinically.
Treatment of acute bronchitis with antibiotics is common but controversial as their use has only moderate benefit weighted against potential side effects (nausea and vomiting), increased resistance, and cost of treatment in a self-limiting condition. Beta2 agonists are sometimes used to relieve the cough associated with acute bronchitis. In a recent systematic review it was found there was no evidence to support their use.
AECB are frequently due to non-infective causes along with viral ones. 50% of patients are colonized with Hemophilus influenzae, Streptococcus pneumoniae or Moraxella catarrhalis. Antibiotics have only been shown to be effective if all three of the following symptoms are present:- increased dyspnea, increased sputum volume, and purulence. In these cases, 500 mg of amoxycillin orally, 8 hourly for 5 days or or 100 mg doxycycline orally BD for 5 days should be used.