Legionella Infection Treatment & Management

April 14, 2013 robot Uncategorized

For Legionnaires disease (LD), a high level of feeling and prompt initiation of sufficient antimicrobial therapy are crucial to boost clinical outcomes.[27] In comparison, for Pontiac fever, treatment is symptomatic, and no antimicrobial therapy is preferred.

Treatment successful in patients with legionellosis should be considered for initial empirical therapy for serious community-acquired pneumonia (CAP) and for specific patients with nosocomial pneumonia. Support therapy in patients with shock and respiratory failure is given as needed.

Circumstances indicating Legionella disease:

– Gram stains of respiratory products revealing many polymorphonuclear leukocytes with few or no organisms

Hyponatremia

– Pneumonia with outstanding extrapulmonary manifestations (eg, diarrhoea, distress, other neurologic signs)

– Failure to answer administration of beta-lactams, aminoglycoside antibiotics, or both

– Antimicrobial therapy for Legionella condition

Specific therapy includes antibiotics with the capacity of reaching high intracellular concentrations (eg, macrolides, quinolones, ketolides, tetracyclines, rifampin). The reported rank order of in vitro and intracellular activity against L pneumophila is quinolones, then ketolides, and then macrolides[28]. Beta-lactams and aminoglycosides have activity against Legionella species in vitro but are not clinically effective.

No prospective randomized studies have already been conducted regarding antibiotic effectiveness in patients with Legionella illness. Guidelines are derived from retrospective evaluations and experimental (laboratory and animal) studies.

Azithromycin is the drug of choice for children with suspected or confirmed Legionella disease.[1] With rare exceptions, the first course should be intravenously administered. After a good clinical response is seen, it could be moved to the oral route. In patients with severe disease or who appear to be unresponsive to monotherapy, the addition of rifampin is advised.

Certain fluoroquinolones (eg, levofloxacin, moxifloxacin) are powerful and are recommended for people with severe disease.[29] Because macrolides might interfere with drugs metabolized by cytochrome P450 (CYP) 3A4 isoenzyme (eg, cyclosporine), the quinolones mentioned previously are appropriate alternatives to treat Legionnaires infection in patients taking cyclosporine or other CYP3A4 substrates. An older fluoroquinolone, ciprofloxacin, does inhibit CYP3A4. Even though the US Food and Drug Administration (FDA) has not approved fluoroquinolones for individuals younger than 18 years (as a result of issues about arthropathy in studies of juvenile animals), they’ve been successfully used to treat children with Legionnaires disease[2, 30, 12] and may be used in children in special circumstances.

Other options incorporate doxycycline or trimethoprim (TMP) and sulfamethoxazole (SMZ).

The recommended duration of therapy is 5-10 days if azithromycin is used. If other drugs are used, the length should be 2-3 days. For patients with severe disease or immunocompromise, extended courses may be needed.

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