1. Therapeutic solutions for patients with community- acquired pneumonia in Bulgaria Yavor Ivanov, Pavlina Nikolova, Tsanya Popova, Plamen Pavlov University Pulmonary Clinic Pleven, Bulgaria

3. Incidence of CAP in Bulgaria Incidence of CAP in Bulgaria yearnumber per 100 000 population 1995 31 080 450.3 1996 32 854 500.3 1997 23 946 365.3 1998 24 645 376.1 1999 22 843 348.5 2000 24 375 371.8 2001 21 865 342.1 2002 35 715 550.0 2003 40 542 635.0 2004 38 270 599.8 Incidence of CAP in Bulgaria 1995-2004 (provided by NCHI) per 100 000 population years

4. Mortality from CAP in Bulgaria Mortality from CAP in Bulgaria yearnumber per 100 000 population 1995266838.6 1996283141.0 1997270639.2 1998220332.0 1999192828.0 2000197228.7 2001146121.8 2002138020.6 2003140521.0 2004127219.0 Mortality from CAP in Bulgaria 1995-2004 (provided by NCHI) years per 100 000 population

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

6. S. pneumoniae resistance

7. Clinical considerations Assess the patient Assess the patient –Clinical condition – CRB 65 –As a host of a probable agent –As a social being

8. The key advice for the prescribing doctor MIC Concentration at the site of infection Power

9. Number of antibiotics till clinical cure

10. SettingSeverityRecommendedAlternative Out- patientAllbeta-lactam and/or macrolide levofloxacin moxifloxacin Hospitalmild/moderatepenicillin ± macrolidelevofloxacin, moxifloxacin beta-lactam ± macrolide co-amoxiclav ± macrolide cephalosporin II-III ± macrolide HospitalSeverecephalosporin II-III ± macrolide cephalosporin II-III ± levofloxacin, moxifloxacin HospitalSevere and riskAntipseudomonas cephalosporin + acilureidopenicillin/beta- lactamase inhibitor + for Ps.aeruginosaciprofloxacin or carbapenem + ciprofloxacin Bulgarian CAP guidelines

11. Setting SeverityRecommendedAlternative Out- patientAllbeta-lactam and/or macrolide levofloxacin, moxifloxacin hospitalmild/moderatepenicillin ± macrolidelevofloxacin, beta-lactam ± macrolide co-amoxiclav ± macrolide moxifloxacin cephalosporin II-III ± macrolide HospitalSeverecephalosporin II-III ± macrolide cephalosporin II-III ± levofloxacin, moxifloxacin HospitalSevere and riskAntipseudomonas cephalosporin + acilureidopenicillin/ beta-lactamase inhibitor + for Ps.aeruginosaciprofloxacin or carbapenem + ciprofloxacin Bulgarian CAP guidelines

12. Setting SeverityRecommendedAlternative Out- patientAllbeta-lactam and/or macrolidelevofloxacin, moxifloxacin Hospital mild/moderat epenicillin ± macrolidelevofloxacin, moxifloxacin beta-lactam ± macrolide co-amoxiclav ± macrolide cephalosporin II-III ± macrolide hospitalseverecephalosporin II-III ± macrolide cephalosporin II-III ± levofloxacin or moxifloxacin Hospital Severe and riskAntipseudomonas cephalosporin + acilureidopenicillin/beta- lactamase inhibitor + for Ps.aeruginosaciprofloxacin or carbapenem + ciprofloxacin Bulgarian CAP guidelines

13. Setting SeverityRecommendedAlternative Out-patientAll beta-lactam and/or macrolidelevofloxacin, moxifloxacin Hospitalmild/moderate penicillin ± macrolidelevofloxacin, moxifloxacin beta-lactam ± macrolide co-amoxiclav ± macrolide cephalosporin II-III ± macrolide HospitalSevere cephalosporin II-III ± macrolide cephalosporin II-III ± levofloxacin, moxifloxacin HospitalSevere and risk Antipseudomonal cephalosporin + antipseudomonal beta-lactam/ beta-lactamase inhibitor + ciprofloxacin for Ps.aeruginosaciprofloxacinor carbapenem + ciprofloxacin Bulgarian CAP guidelines

14. 150 outpatients vs 150 hospitalized patients Doctors’ solutions

17. Summary – practical solutions Simple and clear guidelines Simple and clear guidelines Teach the doctors Teach the doctors Inform the regulators Inform the regulators Follow the tendencies Follow the tendencies –Health outcomes –Drug prescriptions –Microbiological data –Expenses