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Editor's Correspondence
July 14, 2003

Nonspecific Guidelines Lead to Inappropriate Fluoroquinolone Use

Arch Intern Med. 2003;163(13):1617-1618. doi:10.1001/archinte.163.13.1617-a

Although a small study, the article by Lautenbach et al1 underscores the alarming prevalence of inappropriate fluoroquinolone use in a sample of emergency departments. Particularly in the setting of community-acquired pneumonia (CAP), the widespread use of fluoroquinolones has led to emergence of not only resistant pneumococci, but also a host of gram-negative organisms that often have nothing to do with the cause of a patient's pneumonia.2 One of the problems of influencing practitioners treating CAP to limit the use of fluoroquinolones to those deemed appropriate for such therapy1 is the lack specific recommendations for the treatment of CAP by guidelines published by the American Thoracic Society and Infectious Diseases Society of America (IDSA). In outpatient CAP, the IDSA recommends doxycycline, a macrolide, or a fluoroquinolone in no specific order of preference.3 In stable, hospitalized patients, the American Thoracic Society recommends an intravenous β-lactam plus an intravenous or oral macrolide, or doxycycline, or an intravenous fluoroquinolone alone, as equivalent recommendations for first-line therapy.4 In this same population of patients, the IDSA recommends an extended-spectrum cephalosporin plus a macrolide, or a β-lactam/lactamase inhibitor plus a macrolide, or a fluoroquinolone alone—equally as first-line therapy. Only the Centers for Disease Control Drug Resistant Streptococcus pneumoniae Therapeutic Working Group and the Antibiotic Selection for Community Acquired Pneumonia panel consistently recognize the potential impact of widespread fluoroquinolone resistance due to its widespread use, as well as the need to reserve fluoroquinolones for selected patients with CAP, in the outpatient, inpatient, and intensive care unit settings.5,6 Nevertheless, even with well-established widely disseminated local hospital guidelines that specifically addressed the issue of appropriate fluoroquinolone use, the vast majority of fluoroquinolone use was still inappropriate.1 In view of such variance in national guidelines, as well as poor compliance with local hospital guidelines, it is not surprising that confusion over what should be considered first-line empiric therapy for CAP has led to a high level of inappropriate use of fluoroquinolones in the outpatient and inpatient settings. Any hope of limiting emergence of fluoroquinolone resistance will require major interventions in educating health care providers on the appropriate use of fluoroquinolones in our hospitals, emergency departments, and clinics, not only for CAP, but for many other infectious diseases as well.

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