title: 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.
authors.affiliation: Division of Respiratory and Critical Care Medicine, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan.
authors.forename: Gwan-Han
authors.initials: GH
authors.lastname: Shen
authors.forename: Thomas Chang-Yao
authors.initials: TC
authors.lastname: Tsao
authors.forename: Shang-Jyh
authors.initials: SJ
authors.lastname: Kao
authors.forename: Jen-Jyh
authors.initials: JJ
authors.lastname: Lee
authors.forename: Yen-Hsu
authors.initials: YH
authors.lastname: Chen
authors.forename: Wei-Chung
authors.initials: WC
authors.lastname: Hsieh
authors.forename: Gwo-Jong
authors.initials: GJ
authors.lastname: Hsu
authors.forename: Yen-Tao
authors.initials: YT
authors.lastname: Hsu
authors.forename: Ching-Tai
authors.initials: CT
authors.lastname: Huang
authors.forename: Yeu-Jun
authors.initials: YJ
authors.lastname: Lau
authors.forename: Shih-Ming
authors.initials: SM
authors.lastname: Tsao
authors.forename: Po-Ren
authors.initials: PR
authors.lastname: Hsueh
mesh_terms: D000900:Anti-Bacterial Agents / Q000009:adverse effects / Q000627:therapeutic use; D017714:Community-Acquired Infections / Q000188:drug therapy* / Q000453:epidemiology / Q000382:microbiology; D057210:Delayed Diagnosis; D024901:Drug Resistance, Multiple, Bacterial; D019353:Endemic Diseases / Q000517:prevention & control; D024841:Fluoroquinolones / Q000009:adverse effects / Q000627:therapeutic use*; D006801:Humans; D008168:Lung / Q000187:drug effects / Q000382:microbiology / Q000473:pathology; D009169:Mycobacterium tuberculosis / Q000187:drug effects / Q000472:pathogenicity*; D013624:Taiwan / Q000453:epidemiology; D013997:Time Factors; D014397:Tuberculosis, Pulmonary / Q000188:drug therapy* / Q000453:epidemiology / Q000473:pathology
chemical_list: D000900:Anti-Bacterial Agents; D024841:Fluoroquinolones