Specialists discuss scientific rationale for using more potent antibiotic first to improve clinical outcomes in lower respiratory tract infections and minimize bacterial resistance.

BARCELONA, November 24, 2005 -  A European panel of renowned experts discussed the consequences of decreasing antibiotic use and the ethics of reserving optimal antibiotic therapies when treating lower respiratory tract infections (LRTIs). Under the title "You wouldn’t eat your soup with a fork!", the theme of the meeting was to highlight the benefits of using ‘the right tool for the right job’ when treating bacterial infections. Recognizing that public actions about the overuse of antibiotics causing bacterial resistance are necessary, a case was made for using fewer antibiotics in total but when they are needed, using more potent therapies. ‘Appropriate’ use of modern antibiotics like moxifloxacin (Avelox^®) is not only better for the patient in terms of clinical outcomes but can actually help to minimize the development of bacterial resistance. The event was supported by an educational grant from Bayer HealthCare.

With the objective of reducing resistance and prolonging the useful life of antibiotics, campaigns have been introduced in many countries to reducing the total amount of antibiotics prescribed. These campaigns have included publicity aimed at educating the public about antibiotics together with incentives or penalties for prescribers themselves if they stay within or stray outside antibiotic prescribing guidance. The guidance often focuses on the use of older, cheaper and less effective generic antibiotic therapies.

Such measures have undoubtedly decreased antibiotic use but if the objective of these policies is to minimize bacterial resistance, does it work and what are the implications for the patients?

In the initial presentation, Professor David Price (UK), challenged the assumption that decreasing antibiotic use automatically reduces resistance and asked whether the implications of reducing antibiotic use were understood in terms of the impact on clinical outcome and patient mortality. Using the example of Community Acquired Pneumonia (CAP), Prof. Price summarized an analysis of antibiotic prescribing trends in the UK which showed that between 1993/4 and 1999/2000, LRTI antibiotic prescribing in the community decreased, whilst over the same period mortality from CAP increased. When adapted to take account of influenza and winter effects, the reduction in LRTI antibiotic use is related to a further rise in pneumonia death rates (p < 0.001).

Prof. Price discussed the ethics of treating individuals with suboptimal therapies and concluded, "Notwithstanding the need for being realistic about practical resource constraints, doesn’t the patient have the right to expect effective treatment and shouldn’t the doctor provide it?".

Professor Paul M. Tulkens (Belgium), explained the trends in bacterial resistance. Beta-lactam and macrolide resistance in the key respiratory pathogens is high in many countries and continuously rising. It therefore becomes more and more important to find the right rationale for antibiotic choice.

"When it comes to antibiotics" said Prof. Tulkens "the message should be ‘Less use but better prescribing’". He went on to explain an example of appropriate antibiotic prescribing. Where patients are at low risk, high-dose penicillin will normally be sufficient to treat LRTIs. However, where patients are more severely ill, elderly and likely to be suffering from underlying co-morbidity, it is appropriate to use better therapies first such as moxifloxacin. Rapid and effective killing of pathogens, ie using the best antibiotic therapies first, also means that bacteria are less likely to survive and go on to cause resistance problems in the future. The use of older and less effective therapies in these circumstances is inappropriate, "Cost is not the issue here." said Prof. Tulkens. Pharmacodynamic considerations show that fluoroquinolones have a place, but that not all are equal. For respiratory tract infections where S. penumoniae is the most common organism, moxifloxacin clearly shows an advantage over other so-called "respiratory" fluoroquinolones.

Dr. Marc Miravitlles (Spain), turned the discussion towards the patients. He gave an introduction to Chronic Obstructive Pulmonary Disease (COPD) and the impact of acute exacerbations of chronic bronchitis (AECB) on the quality of life of the sufferers and healthcare resources. Dr. Miravitlles showed some patient research which indicated that what sufferers wanted most from therapy was faster resolution of their symptoms and longer intervals between their exacerbations.

Dr. Miravitlles talked about choice of antibiotic therapy in AECB and the MOSAIC study. "In this study, treatment with moxifloxacin not only provided superior clinical cure compared with the standard therapy regimens, but it also lengthened the exacerbation free interval meaning a significant improvement for the patient’s quality of life." Dr. Miravitlles said, "The benefits of moxifloxacin seen in this study were particularly significant in the more severely ill or older patients enrolled into the study". In addition to the obvious benefit for patients, decreasing the number of exacerbations also means decreased hospital admissions and slower disease progression.

"The need for effective antibiotic treatment becomes most obvious when patients suffer from severe conditions like CAP", explained the final speaker, Dr. Javier Garau (Spain). Because most adult CAP patients are hospitalized and hospitalization forms the major proportion of costs in treating the disease, CAP is also a considerable drain on healthcare resources. "At the time patients are admitted to hospital there is usually no microbiological information to guide the prescribing physician’s choice of antibiotic." said Dr. Garau. "Early empirical intervention with an effective antibiotic is a significant factor affecting patient mortality in hospital."

Dr. Garau went on to outline two clinical studies conducted in patients with CAP. The first study, TARGET, showed the superiority of moxifloxacin monotherapy compared to standard therapy of co-amoxiclav with or without the addition of clarithromycin. Not only did moxifloxacin demonstrate clinical superiority and patients treated with it recover faster but also moxifloxacin was associated with lower costs (mainly through decreased hospitalization). Dr. Garau also presented data from the CAPRIE study which showed that moxifloxacin achieved an excellent cure rate of more than 90 percent in elderly patients suffering from CAP and in addition, significantly more patients had improved during the course of therapy compared with the comparator, levofloxacin.

The meeting concluded: Measures introduced to modify antibiotic prescribing should encourage ‘appropriate’ prescribing. Appropriate means where patients are more seriously ill, elderly or suffering from co-morbidity, use the right antibiotic first time to deliver better clinical outcomes and minimize the risk of resistance. Use the right tool for the right job: "You wouldn’t eat your soup with a fork!".

The symposium, "You wouldn’t eat your soup with a fork", was held from 1300h to 1500h on Thursday, 24 November, in Barcelona, Spain.

About Avelox
In Europe, Avelox^® IV (+ oral sequential therapy) is now approved to treat Community Acquired Pneumonia (CAP), and Complicated Skin and Skin Structure Infections (cSSSI). Avelox^® Oral is approved to treat Community Acquired Pneumonia (CAP) – except severe cases, Acute Bacterial Sinusitis (ABS) where adequately diagnosed, and Acute Exacerbations of Chronic Bronchitis (AECB). Avelox^® is also known under the brand names Avalox^®, Izilox^®, Actira^® and Avelon^® which are registered trademarks of Bayer HealthCare.

About Bayer HealthCare AG
Bayer HealthCare AG, a subsidiary of Bayer AG, is one of the world’s leading, innovative companies in the health care and medical products industry. In 2004, the Bayer HealthCare subgroup generated sales amounting to some 8.5 billion Euro.
The company combines the global activities of the divisions Animal Health, Biological Products, Consumer Care, Diabetes Care, Diagnostics and Pharmaceuticals. Bayer HealthCare employed 35,300 people worldwide in 2004.

Bayer HealthCare’s aim is to discover and manufacture innovative products that will improve human and animal health worldwide. The products enhance well-being and quality of life by diagnosing, preventing and treating disease.

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