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

Incidence of CAP in Bulgaria Incidence of CAP in Bulgaria yearnumber per population Incidence of CAP in Bulgaria (provided by NCHI) per population years

Mortality from CAP in Bulgaria Mortality from CAP in Bulgaria yearnumber per population Mortality from CAP in Bulgaria (provided by NCHI) years per population

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

S. pneumoniae resistance

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

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

Number of antibiotics till clinical cure

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

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

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

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

150 outpatients vs 150 hospitalized patients Doctors’ solutions

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