Respiratory Tract Infections: Focus On Efficacy And Safety Of Current Treatment Options
Glen E. Farr, PharmD,* and David P. Nicolau, PharmD, FCCP
Given that community-acquired respiratory tract infections (RTIs) are the most common reason for physician office visits, accounting for approximately 112 million office visits per year, pharmacists who provide treatment for patients with RTIs need to have a good understanding of the efficacy and safety factors associated with such treatment. Although common, appropriate treatment of these infections can be a challenging job. Initial antimicrobial therapy for RTIs is generally empiric and therefore differs from the typical pharmaceutical management of other disease states. Inappropriate use of antimicrobials for RTIs is abundant as most of these infections are viral in nature. Educational efforts directed towards patients and parents of patients that stress the importance of appropriate antibiotic use have become more prevalent over the past decade. Unfortunately, resistance to current treatment options is growing and may have community-wide implications.
Pharmacists may be able to assist in efforts designed to minimize the development of resistant organisms by promoting antibacterial stewardship. Such efforts include educating patients that most RTIs are viral in nature and are self-limited thereby avoiding the unnecessary use of antibiotics. Some pharmacies have prepared "cough and cold kits" with nonprescription medications that avoid unnecessary use of antibiotics but give the patient something for his/her symptoms. When antimicrobials are indicated, pharmacists should encourage adherence to therapy and educate patients about the dangers of sharing their antibiotics. Because appropriate management of RTIs is significant for the patient being treated and for the community as a whole, this issue of Advanced Studies in Pharmacy (ASiP) is focused on efficacy and safety characteristics of antimicrobials used to treat RTIs.
Charles W. Stratton, MD, a leading infectious diseases expert and researcher on pathogenesis of Chlamydia pneumoniae, provides an overview of community-acquired RTIs. This review of the epidemiology and pathogenesis of community-acquired RTIs sets the groundwork for a good understanding of those common infections, including acute exacerbations of bronchitis, community-acquired pneumonia, and acute bacterial sinusitis. Due to the importance of influenza as a major cause of community-acquired RTIs and even death in the United States, Dr Stratton briefly discusses RTIs resulting from Haemophilus influenzae infection. In addition, an insightful summary is given on C pneumoniae's role in causing RTIs. Important factors to be considered in the pharmaceutical management of community-acquired RTIs are reviewed, including a listing of characteristics for the ideal antibiotic for the treatment of RTIs.
Michael B. Kays, PharmD, BCPS, FCCP, has furnished an examination of the pharmaceutical management of RTIs. Classes of antibiotics used to treat RTIs (beta-lactams, macrolides, fluoroquinolones, and ketolides) are reviewed for their resistance mechanisms, efficacy, and safety. Dr Kays also details antimicrobial-resistance trends in the United States. Clinically relevant drug-drug interactions and side effects commonly encountered with antibiotics used to treat RTIs are emphasized. He also provides guidance for practicing pharmacists in assuring that the optimum drug, duration, and dose are used in the treatment of RTIs. Strategies to slow down the process of antimicrobial resistance conclude his article.
The third article is an interview with a clinical pharmacist and educator on the pharmaceutical treatment of infectious disease, Richard H. Drew, PharmD, MS, BCPS. Dr Drew provides practical information for pharmacists treating patients with RTIs. He answers questions regarding his impression of the impact of resistance in RTIs as well as treatment strategies aimed towards slowing down resistance. Patient- and pathogen-specific factors important in the selection of antimicrobial therapy are mentioned. This interview also includes tips for pharmacists to implement in their own practice that may assist in the promotion of appropriate and safe antibiotic use and education of patients about RTIs.
Two case studies conclude this edition of ASiP. Glen E. Farr, PharmD, presents a case involving drug interactions with a relatively new antibiotic for the treatment of RTIs, telithromycin. Rationale for the most common drug interactions with this ketolide antibiotic is provided. In addition, he discusses a clinically significant pharmacokinetic drug interaction between lipophilic statins and telithromycin. Dr Farr concludes with general tips for pharmacists to consider when evaluating the potential for a serious drug interaction when filling a prescription for RTI therapy.
A second case study is provided by David P. Nicolau, PharmD, FCCP. Dr Nicolau's case involves safety of antimicrobial use for an RTI. His case does not deal with the typical adverse events associated with antibiotic therapy, such as gastrointestinal events, allergic reactions, or cardiovascular events. Rather, he focuses on a relatively new concept of clinical importance, "collateral damage." Overuse of very broad-spectrum antibiotics to treat infections in a particular part of the body, such as the respiratory tract, has the potential to cause resistance in normal flora microorganisms that occur in other parts of the body, such as the urinary tract. This development of resistance among organisms that were never intended to be treated is termed collateral damage. Such resistance may result in a secondary infection or superinfection in the same patient that can not only be difficult to treat, but may also contribute to the overall increase in antimicrobial resistance.
These articles provide specific information to pharmacists who treat patients with RTIs that can be used in their individual practice setting. Pharmacists should be encouraged to promote the judicious use of antimicrobial therapy for RTIs. Not only are pharmacists in a prime position to interact with prescribers regarding the most appropriate use of antibiotics for RTIs, they are also important educators of patients about the consequences of adhering to treatment regimens and potential side effects or drug interactions of antimicrobial therapy.
*Professor of Pharmacy and Associate Dean for Continuing Education, University of Tennessee College of Pharmacy, Knoxville, Tennessee.
Director, Center for Anti-Infective Research & Development, Hartford Hospital, Hartford, Connecticut.
Address correspondence to: David P. Nicolau, PharmD, FCCP, Hartford Hospital, 80 Seymour St, PO Box 5037, Hartford, CT 06102-5037. E-mail: email@example.com.