An update on the pharmacotherapeutic management of lower respiratory tract infections

ABSTRACT

Introduction: Our knowledge about lower respiratory tract infections (LRTIs) has improved substantially in the last years, but the management of respiratory infections is still a challenge and we are still far from using precision medicine in their treatment.

Areas covered: The approaches developed in recent years to improve the pharmacotherapeutic management of LRTIs, such as novel diagnostic assays to facilitate medical decision-making, attempts for selecting an optimal empiric antibiotic regimen, and the role of new and possibly unproven adjunctive therapies, are described.

Expert opinion: Early and appropriate antibiotics remain the cornerstone in the treatment of LRTIs. The updated trend is to apply antimicrobial stewardship principles and initiatives to optimize both the management and the outcomes of LTRIs. Biomarkers, mainly C-reactive protein (CRP) and procalcitonin (PCT), can improve the diagnostic and prognostic assessment of LRTIs and aid to guide antibiotic therapy. The widespread use of antimicrobial agents has greatly contributed to faster development of antibiotic resistance and the emergence of opportunistic pathogens, which substitute the indigenous microbiota. However, very few new antibiotics in development to overcome existing resistance and ensure continued success in the treatment of LRTIs have been approved, likely because antibiotic stewardship programs discourage the use of new agents.

KEYWORDS:

• Adjuvant therapies
• antibiotic regimen
• biomarkers
• bronchiectasis
• community-acquired pneumonia
• COPD exacerbation
• guidelines
• hospital acquired pneumonia
• lower respiratory tract infections
• novel antibiotics

Article highlights

• Early and appropriate antibiotics remain the cornerstone in the treatment of LRTIs. Guidelines have been developed in an attempt to optimise LTRI management and, when adhered to, these have been shown to lead to better clinical outcomes and a reduced risk that patients are exposed to overuse of antimicrobials and, consequently, that the resistance of microorganisms to these agents increases. However, LRTIs are often mismanaged regarding the correct diagnosis, indication, dosage, time to first antibiotic dose and duration of antimicrobial treatment.

• When used in conjunction with an optimal clinical assessment, biomarkers can improve the diagnostic and prognostic assessment of LRTIs and provide objective data to augment clinicians’ intuition in starting, withholding, or stopping antibiotics.

• There is a huge need for the development of adjuvant therapeutic strategies in addition to antibiotics because despite appropriate antibiotic treatment, many patients suffering from LRTIs still die. Systemic corticosteroids and IVIG could be useful adjuvant therapies in addition to antibiotics mainly when treating patients with pneumonia.

• Only very few new antibiotics developed to overcome existing resistance and ensure continued success in the treatment of LRTIs have been approved, likely because antibiotic stewardship programs discourage the use of new agents. During the last few years ceftaroline, ceftobiprole, oritavancin, and telavancin have received marketing authorization for CAP.

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Declaration of interest

M Cazzola reports personal grants and fees from AstraZeneca, Boehringer Ingelheim, Novartis, and Zambon; and personal fees from Biofutura, Chiesi Lallemand, Menarini Group, Teva. P Rogliani reports personal fees from AstraZeneca, Biofutura, Boehringer Ingelheim, GlaxoSmithKline, Menarini Group, Mundipharma and Novartis; and both personal grants and fees from Boehringer Ingelheim and Chiesi. S Aliberti reports personal fees from Bayer Healthcare, Zambon, Novartis and Pfizer. F Blasi reports personal fees from AstraZeneca, Dompé and Novartis; and grants and personal fees from Bayer, Chiesi, Guidotti, Menarini Group, Pfizer, Teva and Zambon. MG Matera reports personal fees from AstraZeneca, Boehringer Ingelheim, Chiesi, GlaxoSmithKline, Novartis and Zambon. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Additional information

Funding

This paper was not funded