ISSN:0277-0008    

DOI:10.1002/j.1875-9114.1993.tb02709.x

出版商:Blackwell Publishing Ltd    

年代:1993

数据来源: WILEY

摘要:

The fluoroquinolones represent an important advance in antimicrobial therapy. Commercially available products in the United States now include norfloxacin, ciprofloxacin, ofloxacin, enoxacin, and lomefloxacin. Although they share a common mechanism of action, they differ significantly in their antimicrobial spectrum of activity, their pharmacokinetic characteristics, and, to a lesser degree, their safety profiles. These compounds are generally highly effective against aerobic gram‐negative and many gram‐positive isolates; their activity is more limited against anaerobic bacteria. Quinolone‐resistant bacteria have been isolated, but most do not appear to pose a clinically significant problem at this time. The agents are effective in the treatment of a wide range of infections. Although some, such as ciprofloxacin and enoxacin, have been associated with clinically significant interactions with theophylline derivatives, others such as ofloxacin and lomefloxacin appear to have a limited propensity for such interac

ISSN:0277-0008    

DOI:10.1002/j.1875-9114.1993.tb02710.x

出版商:Blackwell Publishing Ltd    

年代:1993

数据来源: WILEY

摘要:

Quality health care has been defined as the maximization of desired outcomes while minimizing undesirable consequences. Therefore, the optimal antimicrobial agent for a given clinical condition will be one that is the most rapidly effective, produces the least patient discomfort, results in minimal disruption of the patient's or hospital flora, and causes minimal dissatisfaction with the treatment program and its attendant costs. The clinical utility of antimicrobials is generally judged on the basis of in vitro activity, kinetic disposition, resistance trends, safety, and cost. Fluoroquinolones possess characteristics in each of these areas; for example, broad, potent gram‐negative spectrum coupled with excellent oral absorption and tissue penetration, and relative safety and reduced cost compared with parenteral therapy. Drawbacks include the emergence of resistance among certain bacteria, particularly staphylococci andPseudomonas aeruginosa, drug interactions that may compromise efficacy, and greater cost than other potentially useful oral antimicrobial agents. Indications for the agents' use can be categorized as appropriate (gram‐negative osteomyelitis, complicated urinary tract infection, prostatitis, certain sexually transmitted diseases, bacterial gastroenteritis), potential (gastrointestinal tract decontamination in granulocytopenic patients, exacerbations of chronic obstructive pulmonary disease, nosocomial pneumonia and bacteremia, eradication of certain bacterial carrier states), or inappropriate (community‐acquired pulmonary infections, especially aspiration pneumonitis, serious gram‐positive infections, uncomplicated urinary tract infection, surgical prophylaxis except prostatic surgery). Gram‐negative osteomyelitis serves as a model to demonstrate the fluoroquinolones as agents for quality health care. Current and future investigations should focus on the cost effectiveness and cost utility of t

ISSN:0277-0008    

DOI:10.1002/j.1875-9114.1993.tb02711.x

出版商:Blackwell Publishing Ltd    

年代:1993

数据来源: WILEY

摘要:

Antimicrobials of the fluoroquinolone class are involved in a number of clinically important drug‐drug interactions. Many of these interactions occur with all the available agents and exhibit little interpatient variability. In contrast, others occur only with specific fluoroquinolones and their extent varies markedly among subjects. The oral absorption of all fluoroquinolones is significantly impaired when coadministered with aluminum‐ and magnesium‐containing antacids and sucralfate, as well as with other metal cations such as calcium and iron. Concomitant use of these agents, even when dosed several hours apart, should be avoided. Enoxacin and ciprofloxacin impair the hepatic metabolism of theophylline and caffeine, leading to significantly increased serum concentrations. Ofloxacin and lomefloxacin have only minimal effects on xanthine metabolism. Case reports suggest that concomitant administration of several fluoroquinolones and warfarin, a drug that is also highly metabolized by the liver, leads to increased hypoprothrombinemic effects; prospective studies, however, failed to confirm this interaction. Clinicians must be aware of these and other potential drug‐drug interactions with fluoroquinolones for optimal use of the

ISSN:0277-0008    

DOI:10.1002/j.1875-9114.1993.tb02712.x

出版商:Blackwell Publishing Ltd    

年代:1993

数据来源: WILEY

摘要:

Drug treatment of infectious disease requires consideration of both short‐ and long‐term therapy. Although in most settings patients receive antimicrobials for acute events, long‐term management of certain infections with drugs that delay progression of the disease adds a new facet to pharmacotherapy. In the past, broad questions regarding efficacy were posed: a drug was evaluated as either effective or not effective for a particular disorder. The actual question is, in whom is a given drug at a given dosage effective? Antibiotic control, restriction, and pharmacokinetic dosing programs have been useful, but they are reactive as opposed to proactive. The expensive products of biotechnology and the availability of oral drugs with activity exceeding that of parenteral antimicrobials require a more expanded scope of clinical pharmacy practice where patients are identified for these therapies prospectively using statistical models based on disease and other readily identified factors. Predictor variables for patient outcomes such as retreatment with other antibiotics, rehospitalization, toxicity, and mortality following the use of new drugs should be identified. Maximizing these outcome measurements will involve strategies that integrate epidemiology and statistical modeling techniques with principles of pharmaceutical

ISSN:0277-0008    

DOI:10.1002/j.1875-9114.1993.tb02713.x

出版商:Blackwell Publishing Ltd    

年代:1993

数据来源: WILEY

摘要:

It is advisable to switch patients from parenteral to oral therapy as soon as practical. High volumes of distribution, coupled with relatively low protein binding, indicate that the quinolones are widely distributed outside extracellular fluid. Interactions with aluminum‐ or magnesium‐containing antacids may be avoided by administering the antacids at least 2 hours after quinolone dosing. Some quinolones with high bioavailability (e.g., ofloxacin) are absorbed as reliably and completely after oral administration as when given parenterally, and dosage adjustments for these agents are unnecessary after sequential therapy. Treatment strategies may differ according to the route of drug elimination, and dosage adjustments are required in patients with renal failure who receive quinolones excreted primarily by the kidneys. Theophylline interactions may be more problematic in patients given quinolones that are primarily metabolized by the liver. Quinolones, which have concentration‐dependent killing and a long postantibiotic effect, should be administered in the highest tolerated dosage. A method to assess the relative antibacterial efficacy of the quinolones uses the ratio of the Cmax:MIC90of the organism, compared with a ratio derived from the NCCLS breakpoints for susceptib

ISSN:0277-0008    

DOI:10.1002/j.1875-9114.1993.tb02714.x

出版商:Blackwell Publishing Ltd    

年代:1993

数据来源: WILEY

摘要:

Comparative trials have shown that the new oral fluoroquinolones are as effective as parenteral cephalosporins and other broad‐spectrum agents in treating infections of the urinary tract, lower respiratory tract, and skin and skin structure caused by most gram‐negative and selected gram‐positive pathogens. The agents are also effective in the treatment of prostatitis and osteomyelitis. Sequential parenteral to oral therapy has also proved useful, even in patients who are severely ill and are in intensive care units. This allows patients to be transferred out of intensive care earlier, reduces hospital stay and pharmacy costs, and improves quality of life. Because of the high bioavailability (>95%) of ofloxacin, oral and parenteral doses are iden

ISSN:0277-0008    

DOI:10.1002/j.1875-9114.1993.tb02715.x

出版商:Blackwell Publishing Ltd    

年代:1993

数据来源: WILEY

摘要:

The older drugs used to treat pneumonia may still be useful in self‐limiting infections. Newer antibiotics—augmented penicillins, trimethoprim‐sulfamethoxazole, third‐generation cephalosporins, and others—are quite effective, but resistance can be a problem, and some patients cannot tolerate the adverse events associated with these agents. The fluoroquinolones are effective in treating pneumonia because of their broad spectra of activity against gram‐negative and gram‐positive organisms, includingStreptococcus pneumoniaeandHaemophilus influenzae.They are rapidly and nearly completely absorbed after oral administration; bioavailability ranges up to 100% for ofloxacin and lomefloxacin. Concentrations attained in lung tissues and sputum generally exceed the minimum inhibitory concentrations for the most common respiratory tract pathogens. The quinolones are also well tolerated; most adverse events are mild and do not lead to discontinuation of therapy. Ciprofloxacin and ofloxacin are available in parenteral as well as oral formulations. The high bioavailability of oral ofloxacin (>95%) allows a patient to be started on the parenteral form in the hospital and continued taking the oral form at home with no loss of efficacy, but with reduced costs and improved qu

ISSN:0277-0008    

DOI:10.1002/j.1875-9114.1993.tb02716.x

出版商:Blackwell Publishing Ltd    

年代:1993

数据来源: WILEY

摘要:

Urinary tract infection (UTI) is the most common infectious disease of the elderly and is especially prevalent in debilitated, institutionalized older individuals. Unlike UTI in younger women, which tends to be related to frequency of sexual intercourse and is uncomplicated, in the elderly it is more difficult to treat and its pathogenesis is related to abnormal bladder function, bladder outlet obstruction, vaginal and urethral atrophy, use of long‐term indwelling catheters, and puddling related to bed rest. The spectrum of organisms causing infection relates to the ecology of the patients' environments; those residing in nursing homes and especially with permanent indwelling catheters tend to have a greater variety of pathogenic organisms, many of which may be relatively antibiotic resistant. Short‐course antibiotic therapy is less effective in older patients, and relapse or recurrence is more common regardless of the duration of treatment. Asymptomatic bacteriuria is common in older patients with abnormal bladder function. The clinical significance of asymptomatic bacteriuria generally is minor, and treatment is not benefic

ISSN:0277-0008    

DOI:10.1002/j.1875-9114.1993.tb02717.x

出版商:Blackwell Publishing Ltd    

年代:1993

数据来源: WILEY

摘要:

The basic tenet of pharmaceutical care asserts that the delivery of optimal, cost‐effective pharmacotherapy can be best achieved by identifying, resolving, and preventing drug‐related problems. Drug use evaluation (DUE) is one of the primary tools used to achieve these ends. Fluoroquinolone antimicrobials meet Joint Commission criteria for targeting for DUE: the drugs are used in populations at high risk for adverse drug reactions, quality assurance or infection control committees target them for DUE, the drugs are costly, they may be suspected or known to be used inappropriately, and they are prescribed frequently. Outside this supplement, no published DUE criteria for parenteral fluoroquinolones currently exist. Suggested criteria include use in patients who would otherwise be candidates for oral fluoroquinolone therapy (for which published criteria exist) but who cannot use the oral route of administration due to gastrointestinal conditions predisposing to malabsorption or unavailability of the oral route; for severe infections due to gram‐negative pathogens; as a replacement for aminoglycosides when ototoxicity or nephrotoxicity is a substantial risk; targeting to resistant pathogens (i.e., not as empiric therapy); and targeting to therapeutic use only (not for prophylaxis). The DUE process is crucial for ensuring safe, effective, appropriate, and economical drug therapy. It is an effective mechanism for evaluating the use of new agents and as an educational tool for clinicians in the postmarketing p

ISSN:0277-0008    

DOI:10.1002/j.1875-9114.1993.tb02718.x

出版商:Blackwell Publishing Ltd    

年代:1993

数据来源: WILEY