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Review
. 2022 Feb;35(1):16-29.
doi: 10.37201/req/172.2021. Epub 2022 Jan 19.

Decalogue for the selection of oral antibiotics for lower respiratory tract infections

R Cantón  1 , J Barberán, M Linares, J M Molero, J M Rodríguez-González-Moro, M Salavert, J González Del Castillo  2
Affiliations
Review

Decalogue for the selection of oral antibiotics for lower respiratory tract infections

R Cantón et al. Rev Esp Quimioter. 2022 Feb.

Abstract
in English, Spanish

Lower respiratory tract infections, including chronic obstructive pulmonary disease exacerbations (COPD-E) and community acquired pneumonia (CAP), are one of the most frequent reasons for consultation in primary care and hospital emergency departments, and are the cause of a high prescription of antimicrobial agents. The selection of the most appropriate oral antibiotic treatment is based on different aspects and includes to first consider a bacterial aetiology and not a viral infection, to know the bacterial pathogen that most frequently cause these infections and the frequency of their local antimicrobial resistance. Treatment should also be prescribed quickly and antibiotics should be selected among those with a quicker mode of action, achieving the greatest effect in the shortest time and with the fewest adverse effects (toxicity, interactions, resistance and/or ecological impact). Whenever possible, antimicrobials should be rotated and diversified and switched to the oral route as soon as possible. With these premises, the oral treatment guidelines for mild or moderate COPD-E and CAP in Spain include as first options beta-lactam antibiotics (amoxicillin and amoxicillin-clavulanate and cefditoren), in certain situations associated with a macrolide, and relegating fluoroquinolones as an alternative, except in cases where the presence of Pseudomonas aeruginosa is suspected.

Las infecciones del tracto respiratorio inferior, incluyendo las exacerbaciones de la enfermedad pulmonar obstructiva crónica (EPOC) y la neumonía adquirida en la comunidad (NAC), son uno de los motivos de consulta más frecuentes en atención primaria y los servicios de urgencias hospitalarios, y son la causa de una elevada prescripción de antimicrobianos. La selección del tratamiento oral más adecuado con antibióticos se basa en diferentes aspectos e incluye considerar en primer lugar una etiología bacteriana y no una infección vírica, conocer los patógenos bacterianos que más frecuentemente causa estas infecciones y la frecuencia local de su resistencia antimicrobiana. Además, el tratamiento debe prescribirse rápidamente y los antibióticos deben seleccionarse entre los que tienen un modo de acción más rápido, logrando el mayor efecto en el menor tiempo y con el menor número de efectos adversos (toxicidad, interacciones, resistencia y/o impacto ecológico). Siempre que sea posible, hay que rotar y diversificar los antimicrobianos y pasar a la vía oral lo antes posible. Con estas premisas, las guías de tratamiento oral de la exacerbación leve o moderada de la EPOC y NAC en España incluyen como primera opción los antibióticos betalactámicos (amoxicilina y amoxicilina-clavulánico y cefditoreno), en determinadas situaciones asociados a un macrólido, y relegando las fluoroquinolonas como alternativa, salvo en los casos en que se sospeche la presencia de Pseudomonas aeruginosa.

Keywords: antibiotic use; antimicrobial resistance; bacterial infections; oral treatment; respiratory tract infections.

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Conflict of interest statement

This manuscript has been written exclusively by the undersigned authors as part of an educational program funded by Meiji Pharma Spain, S.A. RC has participated in educational programs sponsored by Chiessi and Zambon. MS has participated in educational programs or given lectures sponsored by Angelini, Gilead, MSD and Pfizer. JGC received research grants, consultant/speaker honoraria as well as financial support for educational programs of his department from Thermofisher, Meiji, GlaxoSmithKline, Gilead, Roche, and Angelini. Other authors do not declare conflicts of interest

Figures

Figure 1
Figure 1
Suspicion of bacterial infection in COPD exacerbation and decision of antimicrobial treatment [modified from reference 9]
Figure 2
Figure 2
Antimicrobial spectrum of the main oral antibiotics in the treatment of lower respiratory tract infections [modified from reference 4].
Figure 3
Figure 3
Representation of minimal inhibitory concentration (CMI), mutant selection window and mutant prevention concentration (MPC) over a pharmacokinetic curve of an antimicrobial administered orally and different antimicrobials used in S. pneumoniae respiratory tract infections achieving different concentrations [modified from references 4 and 73]
See this image and copyright information in PMC

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