Therapeutic solutions Therapeutic solutions for patients with for patients with community-acquired community-acquired pneumonia in Bulgariapneumonia in BulgariaYavor Ivanov, Pavlina Nikolova,Yavor Ivanov, Pavlina Nikolova,Tsanya Popova, Plamen PavlovTsanya Popova, Plamen PavlovUniversity Pulmonary ClinicUniversity Pulmonary ClinicPleven, BulgariaPleven, Bulgaria

  Incidence of CAP in Incidence of CAP in BulgariaBulgaria

yearyear numbernumber perper 100 000 100 000 populationpopulation

19951995 31 08031 080 450.3450.3

19961996 32 85432 854 500.3500.3

19971997 23 94623 946 365.3365.3

19981998 24 64524 645 376.1376.1

19991999 22 84322 843 348.5348.5

20002000 24 37524 375 371.8371.8

20012001 21 86521 865 342.1342.1

20022002 35 71535 715 550.0550.0

20032003 40 54240 542 635.0635.0

20042004 38 27038 270 599.8599.8

0

100

200

300

400

500

600

700

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

Incidence of CAP in Bulgaria 1995-2004 (provided by NCHI)per 100 000

population

years

  Mortality from CAP Mortality from CAP in Bulgariain Bulgaria

yearyear numbernumber perper 100 000 100 000 populationpopulation

19951995 26682668 38.638.6

19961996 28312831 41.041.0

19971997 27062706 39.239.2

19981998 22032203 32.032.0

19991999 19281928 28.028.0

20002000 19721972 28.728.7

20012001 14611461 21.821.8

20022002 13801380 20.620.6

20032003 14051405 21.021.0

20042004 12721272 19.019.0

0

5

10

15

20

25

30

35

40

45

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

Mortality from CAP in Bulgaria 1995-2004 (provided by NCHI)

years

per 100 000 population

40.1

16.915.7

14.5

10.5 2.3S. pneumoniae

H. influenzae

K. pneumoniae

M. catarrhalis

P. aeruginosa

Other

EtiologyEtiology

•4669 patients hospitalized for CAP4669 patients hospitalized for CAP•21,5% had positive sputum result21,5% had positive sputum result

24.7

16.4

6

9.6

19.4

8.5

6.3

Penicillin

Erytromycin

Azithromycin

Clindamycin

Doxycycline

Ceftriaxone

Rifampin

S. pneumoniae resistanceS. pneumoniae resistance

Clinical considerationsClinical considerations

Assess the patientAssess the patient– Clinical condition – CRB 65Clinical condition – CRB 65– As a host of a probable agentAs a host of a probable agent– As a social beingAs a social being

The key advice for the The key advice for the prescribing doctorprescribing doctor

MIC Concentration at the site of infection Power

Number of antibiotics Number of antibiotics till clinical curetill clinical cure

59,3%49,3%

31,3%37,3%

8,6%12,6%

0,6%

1AB 2 AB 3 AB 4 AB

Number of antibiotics

Outpatients

Hospitalised

Setting Severity Recommended Alternative

Out-patient All

beta-lactam and/or macrolide

levofloxacinmoxifloxacin

Hospital

mild/moderate penicillin ± macrolide levofloxacin, moxifloxacin

    beta-lactam ± macrolide  

    co-amoxiclav ± macrolide  

    cephalosporin II-III ± macrolide  

Hospital Severe cephalosporin II-III ± macrolide

cephalosporin II-III ± levofloxacin, moxifloxacin

Hospital

Severe and risk

Antipseudomonas cephalosporin +

acilureidopenicillin/beta-lactamase inhibitor +

 

for Ps.aeruginosa ciprofloxacin ciprofloxacin

      or carbapenem + ciprofloxacin

Bulgarian CAP guidelinesBulgarian CAP guidelines

Setting Severity Recommended Alternative

Out-patient All beta-lactam and/or macrolide

levofloxacin, moxifloxacin

hospital mild/moderate penicillin ± macrolide levofloxacin,

    beta-lactam ± macrolide  

    co-amoxiclav ± macrolide moxifloxacin

    cephalosporin II-III ± macrolide  

Hospital Severe cephalosporin II-III ± macrolide

cephalosporin II-III ± levofloxacin, moxifloxacin

Hospital Severe and risk Antipseudomonas cephalosporin +

acilureidopenicillin/beta-lactamase inhibitor +

  for Ps.aeruginosa ciprofloxacin ciprofloxacin

     or carbapenem + ciprofloxacin

Bulgarian CAP guidelinesBulgarian CAP guidelines

Setting Severity Recommended Alternative

Out-patient All beta-lactam and/or macrolide

levofloxacin, moxifloxacin

Hospitalmild/moderate penicillin ± macrolide

levofloxacin, moxifloxacin

    beta-lactam ± macrolide  

    co-amoxiclav ± macrolide  

    cephalosporin II-III ± macrolide  

hospital severe cephalosporin II-III ± macrolide

cephalosporin II-III ± levofloxacin or moxifloxacin

HospitalSevere and risk Antipseudomonas cephalosporin +

acilureidopenicillin/beta-lactamase inhibitor +

 

for Ps.aeruginosa ciprofloxacin ciprofloxacin

     or carbapenem + ciprofloxacin

Bulgarian CAP guidelinesBulgarian CAP guidelines

Setting Severity Recommended Alternative

Out-patient All

beta-lactam and/or macrolide levofloxacin, moxifloxacin

Hospital mild/moderatepenicillin ± macrolide levofloxacin, moxifloxacin

   beta-lactam ± macrolide  

   co-amoxiclav ± macrolide  

   cephalosporin II-III ± macrolide  

Hospital Severecephalosporin II-III ± macrolide

cephalosporin II-III ± levofloxacin, moxifloxacin

Hospital Severe and risk

Antipseudomonal cephalosporin +

antipseudomonal beta-lactam/ beta-lactamase inhibitor + ciprofloxacin

  for Ps.aeruginosa ciprofloxacin

or carbapenem + ciprofloxacin

     

Bulgarian CAP guidelinesBulgarian CAP guidelines

150 outpatients vs 150 hospitalized patients150 outpatients vs 150 hospitalized patients

0

10

20

30

40

50

60

70

Outpatients Hospitalised

Macrolides

Quinolones

Amoxicillin/clavulanate

Ceftriaxone

Doctors’ solutionsDoctors’ solutions

11,47days

10,17days

Outpatients Hospitalized

Duration of treatment

21,1 €

72,06 €

Outpatients Hospitalized

Average cost of antibiotic treatment per patient

Summary – practical Summary – practical solutionssolutions Simple and clear guidelinesSimple and clear guidelines Teach the doctorsTeach the doctors Inform the regulatorsInform the regulators Follow the tendenciesFollow the tendencies

– Health outcomesHealth outcomes– Drug prescriptionsDrug prescriptions– Microbiological dataMicrobiological data– ExpensesExpenses