Guiding Principles for the use of Fluroquinolones in Out-patient Community Settings of India: Panel Consensus

Respiratory tract infections have been an important cause of morbidity and mortality worldwide that is looming large especially in context of antibiotic resistance that is confronted both by a pulmonologist as well as a general practitioner. A reflection to this trend has been the rising phenomenon of MICs as shown the respiratory pathogens towards conventional antibiotics including macrolides or β lactam/β lactamase inhibitor combinations. Respiratory fluoroquinolones offer broad yet potent cover of respiratory pathogens leading to their obvious choice for empirical therapy for clinical persisters or high risk cases with prior history of antibiotics not-withstanding the clinical concerns in tropical countries.

To further assess the clinical role of respiratory quinolones in outpatient settings of India especially in line with the known endemicity of chronic infections or tuberculosis.

Cross-sectional, national survey questionnaire survey to explore the clinical perceptions, attitude and insights on the clinical use of respiratory fluoroquinolones was rolled out amongst pulmonologists and consultant physicians practicing respiratory medicine in India. Descriptive statistics was utilized to describe the numerical and categorical data.

Nationwide representative sample of fourteen pulmonologists provided response and clinical insight on the current management strategies for community acquired pneumonia (CAP) with 'respiratory' fluoroquinolones. Each of the doctor in the panel agreed that the ideal antibiotic for the treatment in CAP or lower respiratory tract infection (LRTI) should be highly effective with lesser side effects and broader spectrum covering atypical bacteria. Doctors agreed that most the fixed dose combination (FDC) has gone into disrepute probably because of pharmacokinetic incompatibility that could have further fuelled the epidemic of antibiotic resistance. 9 (64%) doctors suggested that there is omnipresence if not overwhelming presence of patient poor response to beta-lactam or fluoroquinolones in clinical practice. It was agreed that fluoroquinolones would be the rightful choice for patients with prior history of antibiotic use with or without comorbidities. Amongst the newer fluoroquinolones available, Garenoxacin offers broad and potent action against resistant strains for CAP. Despite the overwhelming concern of tropical infection in Indian context, Garenoxacin could be considered for mono- or add-on therapy in moderate to severe yet stable cases of CAP. Short course therapy of 5 to 10 days should offer no complimentary masking of anti-mycobacterial activity since the relevant minimum inhibitory concentration (MIC90) are high that are beyond the comprehension of suggested therapeutic dose of 400 mg tablets.

The growing incidence of Macrolide resistance suggests the clinical role of new generation fluoroquinolones including Garenoxacin as a clinically useful therapeutic strategy for moderate to severe CAP as monotherapy or in combination.