Does empirical treatment of community-acquired pneumonia with fluoroquinolones delay tuberculosis treatment and result in fluoroquinolone resistance in Mycobacterium tuberculosis? Controversies and solutions

Abstract

The role of fluoroquinolones (FQs) as empirical therapy for community-acquired pneumonia (CAP) remains controversial in countries with high tuberculosis (TB) endemicity owing to the possibility of delayed TB diagnosis and treatment and the emergence of FQ resistance in Mycobacterium tuberculosis. Although the rates of macrolide-resistant Streptococcus pneumoniae and amoxicillin/clavulanic acid-resistant Haemophilus influenzae have risen to alarming levels, the rates of respiratory FQ (RFQ) resistance amongst these isolates remain relatively low. It is reported that ca. 1-7% of CAP cases are re-diagnosed as pulmonary TB in Asian countries. A longer duration (≥ 7 days) of symptoms, a history of night sweats, lack of fever (> 38 °C), infection involving the upper lobe, presence of cavitary infiltrates, opacity in the lower lung without the presence of air, low total white blood cell count and the presence of lymphopenia are predictive of pulmonary TB. Amongst patients with CAP who reside in TB-endemic countries who are suspected of having TB, imaging studies as well as aggressive microbiological investigations need to be performed early on. Previous exposure to a FQ for >10 days in patients with TB is associated with the emergence of FQ-resistant M. tuberculosis isolates. However, rates of M. tuberculosis isolates with FQ resistance are significantly higher amongst multidrug-resistant M. tuberculosis isolates than amongst susceptible isolates. Consequently, in Taiwan and also in other countries with TB endemicity, a short-course (5-day) regimen of a RFQ is still recommended for empirical therapy for CAP patients if the patient is at low risk for TB.

Counterinsurgency Doctrine Applied to Infectious Disease

“…Inappropriate antibiotic selection is already a recognized outcome from hasty action (Schweizer et al 2010, Shen et al 2012, Moehring et al 2013. Clinical management of dismounted complex blast injury (DCBI) has changed over the past several years.…”

Fluoroquinolone-resistant tuberculosis: implications in settings with weak healthcare systems

“…18 The impact of FQ on the development of resistance in MTB has mostly been discussed in the context of CAP. [45][46][47][48] A recent meta-analysis evaluating the association of prior FQ usage and the development of resistance in MTB reports a three-fold higher risk of FQ-resistant MTB in patients prescribed FQ before TB diagnosis. 40 Prolonged FQ exposure (defined as more than 10 days of treatment), or multiple FQ prescriptions have been highlighted as significant risk factors for the development of FQ resistance in MTB.…”

Commentary on: Does empirical treatment of community-acquired pneumonia with fluoroquinolones delay tuberculosis treatment and result in fluoroquinolone resistance in Mycobacterium tuberculosis? Controversies and solutions

“…The review in this journal by Shen et al [7] addresses one of the current controversies regarding antimicrobial therapy: which drug should be selected for the initial treatment of community-acquired pneumonia (CAP), both in ambulatory and hospital settings?…”

“…However, the guidelines recommend treating 'previously healthy patients with no recent history (up to 90 days) of antibiotic consumption' with a macrolide or doxycycline. As Shen et al [7] mention in their review, E-mail address: glevyhara@fibertel.com.ar the IDSA/ATS guidelines recommend a fluoroquinolone (FQ) or a ␤-lactam agent plus a macrolide for patients 'with co-morbid conditions, with recent consumption of antibiotics, or if "high-level" pneumococcal resistance is a concern in the region or country. '…”

“…Regarding the important issue of using FQs in countries where tuberculosis (TB) is an endemic problem, Shen et al [7] note that various studies have shown that the delay in initiation of anti-TB medication was longer in patients who had previously received a FQ than amongst patients who had not received FQ-based treatments. They also showed that Mycobacterium tuberculosis resistance to FQs is related to their previous use, as demonstrated in a recent metaanalysis by Chen et al [6].…”