1 Treatment and Diagnosis of Community-acquired Pneumonia (CAP) in Children 兒童社區感染肺炎的診斷和治療 吳秉昇醫師 台北慈濟醫院小兒科 1 1

2 Leading Cause of Death in Children < 5 Years OldPneumonia Mortality: A Global Burden Leading Cause of Death in Children < 5 Years Old Black: p1973A Pneumonia } 4% 14% Preterm birth complications 12% Other non-communicable diseases 4% Neonatal deaths 41% Birth asphyxia 9% Other infections 9% Meningitis 2% Sepsis 6% Black: p1973A–C Worldwide, 1.3 million children under 5 years old die each year from diarrhoeal disease.1 Diarrhoeal disease ranks as the second leading cause of death in children younger than 5, accounting for 15% of all deaths.1 Pertussis 2% AIDS 2% Other 5% Malaria 8% Congenital abnormalities 3% Injury 3% Diarrhoea 14% Tetanus 1% Measles 1% Diarrhoea 1% Black RE et al. Lancet. 2010;375(9730):1969–1987. Note: Causes that led to less than 1% of deaths were not presented 2 1. Black RE et al. Lancet. 2010;375(9730):1969–1987. 2

3 How to Diagnose Pneumonia - SymptomsFever Cough Purulent sputum Pleuritic chest pain Shortness of breath Loss of appetite, fatigue, muscle aches Combination of clinical features in a decision tree might improve diagnostic performance. Since the late 1980s, pneumonia diagnosis in developing countries has relied on the presence of cough, fast breathing, and chest indrawing, as recom mended by WHO Meta-analysis of clinical predictors of pneumonia in children: Not one clinical feature was sufficient to diagnose pneumonia definitively Features with the highest pooled positive likelihood ratios: respiratory rate higher than 50 breaths per min, grunting, chest indrawing, and nasal flaring Lancet Infect Dis 2015; 15: 3

4 Etiology of Community-Acquired Pneumonia in Hospitalized ChildrenPediatrics 2004;113:701–707 4 4

5 Common bacterial and viral etiologies of CAP in childrenVirus Respiratory syncytial virus Influenza A and B Adenovirus Parainfluenza viruses 1, 2, 3 Human Metapneumovirus (2001) Bacteria S. pneumoniae H. Influenzae type b Nontypeable H. Influenzae S. aureus M. catarrhalis M. tuberculosis Bacteria (atypical) M. pneumoniae C. pneumoniae C. trachomatis Absence of a polysaccharide capsule contributes to the susceptibility of NTHi to complement-mediated bacteriolysis and phagocytosis and, thus, invasive infections with NTHi are much less common than with type b strains among otherwise healthy, unimmunized children. Many features of NTHi, such as adhesins, lipo-oligosaccharides, and nutritional requirements, have been proposed as virulence factors. With the advent of type b vaccines and increasing survival of individuals with medical co-morbidities, invasive infections with NTHi are now more common among all age groups than those caused by encapsulated strains. While localized respiratory infections with encapsulated strains are relatively rare, NTHi is a common cause of bronchitis in patients with damaged airways (such as those with chronic obstructive pulmonary disease or cystic fibrosis), of acute otitis media (particularly since the introduction of conjugated Streptococcus pneumoniae vaccines) and of sinusitis. Worldwide, hMPV infections account for at least 5 to 7% of the RTI in hospitalized children, but immunocompromised and elderly individuals are also at risk. The seasonality of hMPV infections resembles that for respiratory syncytial virus and influenza virus infections, with recurrent epidemics during the winter months. Clinical symptoms and laboratory findings associated with hMPV infection exhibit a spectrum virtually indistinguishable from those associated with respiratory syncytial virus disease. N Engl J Med, Vol. 346, No. 6, February 7, 2002 5

6 Etiology of Community-acquired Pneumonia in Hospitalized Children in Northern TaiwanMethods: From August 2001 to July 2002, children admitted with radiologically confirmed CAP Results: A total of 209 children, ages ranged from 7 months to 16 years At least 1 etiologic agent in 85.6% of all cases Typical bacterial pathogens in 88 cases (42.1%); 86 S. pneumoniae (41.1%), Mycoplasma pneumoniae in 77 cases (36.8%), Chlamydia species in 24 cases (11.5%), viral etiology in 86 cases (41.1%) and mixed viral–bacterial infections in 69 cases (33%) Conclusion: S. pneumoniae, Mycoplasma pneumoniae and viruses were equally common etiologic agents of childhood CAP in Taiwan. Frequent coinfection increased the difficulty of both predicting the responsible organisms and choosing empiric antibiotics. The following were considered indicative of infection when positive: blood or pleural effusion bacterial culture or urinary Streptococcus pneumoniae antigen test (Binax NOW), direct immunofluorescent antigen test for Chlamydia species and viruses, virus isolation and identification and viral, mycoplasmal or chlamydial serologic tests. Children with S. pneumoniae infection were significantly younger than those with Mycoplasma pneumoniae infection (P = ) or unknown etiology (P = ). The Pediatric Infectious Disease Journal • Volume 31, Number 11, November 2012

7 Etiology of CAP is age-dependentPediatrics 2004;113:701–707 7

8 Mycoplasma pneumoniae Chlamydia pneumoniaeBirth 3 m 1 year 5 years 18 years GBS E. coli S. pneumoniae H. influenzae Mycoplasma pneumoniae Chlamydia pneumoniae 8

9 化膿性細菌性肺炎的特徵 一開始病情輕微的呼吸道感染，突然出現呼吸狀況 急遽惡化 體溫正常時精神活力極差 化膿性細菌性肺炎的特徵 一開始病情輕微的呼吸道感染，突然出現呼吸狀況 急遽惡化 體溫正常時精神活力極差 呼吸急促 (呼吸速率11月以下嬰兒 > 60/min，1-4 歲 > 40/min，5歲以上 > 30/min) 血氧飽和度≤ 92%、發紺 敗血症徵候，例如意識障礙、出血傾向、低血壓 呼吸窘迫徵候，包括鼻翼搧動(nasal flaring)、呼嚕 聲(grunting)、胸壁凹陷 (chest wall retraction)等 肺部實質化 (consolidation)、空洞形成 (cavity formation) Lancet Infectious Disease 2015; 15:439-50 Findings We included 18 articles in our analysis. WHO-approved signs age-related fast breathing (six studies; pooled sensitivity 0·62, 95% CI 0·26–0·89; specifi city 0·59, 0·29–0·84) and lower chest wall indrawing (four studies; 0·48, 0·16–0·82; 0·72, 0·47–0·89) showed poor diagnostic performance in the meta-analysis. Features with the highest pooled positive likelihood ratios were respiratory rate higher than 50 breaths per min (1·90, 1·45–2·48), grunting (1·78, 1·10–2·88), chest indrawing (1·76, 0·86–3·58), and nasal fl aring (1·75, 1·20–2·56). Features with the lowest pooled negative likelihood ratio were cough (0·30, 0·09–0·96), history of fever (0·53, 0·41–0·69), and respiratory rate higher than 40 breaths per min (0·43, 0·23–0·83). Interpretation Not one clinical feature was suffi cient to diagnose pneumonia defi nitively. Combination of clinical features in a decision tree might improve diagnostic performance, but the addition of new point-of-care tests for diagnosis of bacterial pneumonia would help to attain an acceptable level of accuracy. 兒童社區肺炎處置建議 / 台灣兒科醫學會 Acta Paediatr Taiwan Jul-Aug;48(4): Review. 9

10 非典型肺炎的特徵 活力正常且無化膿性細菌性肺炎的特徵 結膜炎、中耳炎、皮疹與哮鳴聲 (wheezing) 較常見 非典型肺炎的特徵 活力正常且無化膿性細菌性肺炎的特徵 結膜炎、中耳炎、皮疹與哮鳴聲 (wheezing) 較常見 Lancet Infectious Disease 2015; 15:439-50 Findings We included 18 articles in our analysis. WHO-approved signs age-related fast breathing (six studies; pooled sensitivity 0·62, 95% CI 0·26–0·89; specifi city 0·59, 0·29–0·84) and lower chest wall indrawing (four studies; 0·48, 0·16–0·82; 0·72, 0·47–0·89) showed poor diagnostic performance in the meta-analysis. Features with the highest pooled positive likelihood ratios were respiratory rate higher than 50 breaths per min (1·90, 1·45–2·48), grunting (1·78, 1·10–2·88), chest indrawing (1·76, 0·86–3·58), and nasal fl aring (1·75, 1·20–2·56). Features with the lowest pooled negative likelihood ratio were cough (0·30, 0·09–0·96), history of fever (0·53, 0·41–0·69), and respiratory rate higher than 40 breaths per min (0·43, 0·23–0·83). Interpretation Not one clinical feature was suffi cient to diagnose pneumonia defi nitively. Combination of clinical features in a decision tree might improve diagnostic performance, but the addition of new point-of-care tests for diagnosis of bacterial pneumonia would help to attain an acceptable level of accuracy. 兒童社區肺炎處置建議 / 台灣兒科醫學會 Acta Paediatr Taiwan Jul-Aug;48(4): Review. 10

11 When Does a Child or Infant With CAP Require Hospitalization?Moderate to severe CAP Infants less than 3–6 months of age with suspected bacterial CAP Caused by a pathogen with increased virulence, such as CA- MRSA Concern about careful observation at home or who are unable to comply with therapy or unable to be followed up Clin Infect Dis Oct;53(7): 11

12 Pediatrics 2004;113:701–707 12 12 OBJECTIVES:The precise epidemiology of childhood pneumonia remains poorly defined. Accurate and prompt etiologic diagnosis is limited by inadequate clinical, radiologic, and laboratory diagnostic methods. The objective of this study was to determine as precisely as possible the epidemiology and morbidity of community-acquired pneumonia in hospitalized children. METHODS: Consecutive immunocompetent children hospitalized with radiographically confirmed lower respiratory infections (LRIs) were evaluated prospectively from January 1999 through March Positive blood or pleural fluid cultures or pneumolysin-based polymerase chain reaction assays, viral direct fluorescent antibody tests, or viral, mycoplasmal, or chlamydial serologic tests were considered indicative of infection by those organisms. Methods for diagnosis of pneumococcal pneumonia among study subjects were published by us previously. Selected clinical characteristics, indices of inflammation (white blood cell and differential counts and procalcitonin values), and clinical outcome measures (time to defervescence and duration of oxygen supplementation and hospitalization) were compared among groups of children. RESULTS: One hundred fifty-four hospitalized children with LRIs were enrolled. Median age was 33 months (range: 2 months to 17 years). A pathogen was identified in 79% of children. Typical respiratory bacteria were identified in 60% (of which 73% were Streptococcus pneumoniae), viruses in 45%, Mycoplasma pneumoniae in 14%, Chlamydia pneumoniae in 9%, and mixed bacterial/viral infections in 23%. Preschool-aged children had as many episodes of atypical bacterial LRIs as older children. Children with typical bacterial or mixed bacterial/viral infections had the greatest inflammation and disease severity. Multivariate logistic-regression analyses revealed that high temperature (> or = 38.4 degrees C) within 72 hours after admission (odds ratio: 2.2; 95% confidence interval: ) and the presence of pleural effusion (odds ratio: 6.6; 95% confidence interval: ) were significantly associated with bacterial pneumonia. CONCLUSIONS: This study used an expanded diagnostic armamentarium to define the broad spectrum of pathogens that cause pneumonia in hospitalized children. The data confirm the importance of S pneumoniae and the frequent occurrence of bacterial and viral coinfections in children with pneumonia. These findings will facilitate age-appropriate antibiotic selection and future evaluation of the clinical effectiveness of the pneumococcal conjugate vaccine as well as other candidate vaccines. Pediatrics 2004;113:701–707 12 12

13 *p<0.05, **p<0.01 and ***p<0.001.Methods A case–control study was conducted during 3 years in Stockholm, Sweden. Cases were children aged ≤5 years with radiological CAP. Healthy controls were consecutively enrolled at child health units during routine visits and matched to cases on age and calendar time. Nasopharyngeal aspirates were obtained and analysed by real-time PCR for 15 viruses. Multivariate conditional logistic regression was used to account for coinfections with other viruses and baseline characteristics. Results A total of 121 cases, of which 93 cases met the WHO criteria for radiological pneumonia, and 240 controls were included in the study. Viruses were detected in 81% of the cases (n=98) and 56% of the controls (n=134). Influenza virus, metapneumovirus and respiratory syncytial virus were detected in 60% of cases and were significantly associated with CAP with ORs >10. There was no association with parainfluenza virus, human enterovirus or rhinovirus and coronavirus and bocavirus were negatively associated with CAP. Conclusions Our study indicates viral CAP is an underestimated disease and points out hMPV as a new important target for the prevention of childhood CAP. *p<0.05, **p<0.01 and ***p<0.001. A total of 121 cases, of which 93 cases met the WHO criteria for radiological pneumonia, and 240 controls were included in the study. Viruses were detected in 81% of the cases (n=98) and 56% of the controls (n=134). Rhedin S, et al. Thorax 2015;70:847–853. 13

14 台灣抗藥性肺炎鏈球菌比率逐年上升 Hseuh PR. Clin Microbiol Infect 2005;11:925美國CLSI 在2008 年修改penicillin、cefepime 及cefotaxime 的最低抑菌濃度的判 讀標準[12]，將感染症區分為腦膜炎及非腦膜炎，非腦膜炎感染症的新標準：對 penicillin 具感受性、中度抗藥性及高度抗藥性的最低抑菌濃度分別為≦2、4 及≧ 8μg/mL，對cefepime 及cefotaxime 分別為≦1、2、≧4μg/mL，因此2008 年以前及以 後所發表的學術論文對抗藥性菌株的比例會有所差別[13]。2006 年，我們發表關於 國內 年的侵襲性肺炎鏈球菌的監測報告[14]，其中肺炎鏈球菌對penicillin 具有感受性的比例為32.2%，比本研究之55.0%為低，主要便歸因於判讀標準的修 改。 Hseuh PR. Clin Microbiol Infect 2005;11:925 14

15 分離自各年齡層的侵襲性肺炎鏈球菌對各類抗生素具有感受性比例 (2008-2012)Levofloxacin 94.7% Vancomycin 100% Amoxicillin 79.9% Cefotaxime 69% Penicillin 55% 來自年齡14 歲以下族群的菌株對amoxicillin、cefepime、cefotaxime、 clindamycin、erythromycin、meropenem、penicillin 及trimethoprim-sulfamethoxazole 具有感受性的比例，較14 歲以上族群的菌株的比例為低，其中又以3~4 歲幼 童比例最低，在統計上均有顯著差異存在（P-values < 0.01）。 血清型19A 菌株，在2008 到2012 年分別佔 當年度所有菌株的5.5%、6.4%、15.7%、21.0%及25.5%，而且在5 歲以下幼童就佔 了60.5%，因此影響到抗藥性增加的趨勢，以及幼童較嚴重的抗藥性問題。 疫情報導第29 卷 第19 期 p

16 )Invasive pneumococcal Disease2007 年10月 IPD 第四類法定傳染病 2009 年7 月: 陸續提供部分嬰幼兒族群公費接種PCV7 或 PCV10 2011 年10 月: 開始全面改採PCV13 做為公費疫苗 2013 年3 月: 將公費接種對象範圍擴大至2-5 歲幼兒 2014 年: PCV13 公費施打範圍已向下延伸至滿1 歲之幼兒 2015 年1 月: PCV13全面接種 隨著公費接種PCV 的對象範圍擴大，2013 年時2-4 歲幼兒的IPD 個案發 生率的確明顯下降 IPD 菌株血清型別在未滿5 歲者以19A 為首（佔比為39.5％)，65 歲以上 則以14、 23F 及3 為主（三者總佔比為48.8％)，值得注意的是 年間血清 型15（不包 含15B)檢出率增加，此型別不涵括在目前已上市的任何肺炎鏈球菌疫苗 裡 以2013 年為例，未滿5 歲個案之菌株血清型別在7 價結合型肺炎鏈球菌疫 苗（PCV7) 與13 價結合型肺炎鏈球菌疫苗（PCV13)涵蓋率分別為21.4％ 與79.5％ 2015年全年齡發生率為每10萬人口2.23人，主要集中在未滿5歲的嬰幼兒 及65歲以上的老年人，累積發生率以75歲以上老人最高（每10萬人口9.81 人），其次為2~4歲幼兒（每10萬人口8.8人）。全年皆有病例，但發病高 峰為冬季與春季 2017年5歲以下幼兒IPD發生率與2015年同期相較，從每十萬人1.65降到 0.94，65歲以上長者則從2.04降到1.38，2017年截至2月底，國內侵襲性肺 炎鏈球菌感染症（IPD）個案數較前去年同期下降近3成，整體疫情也是 近3年同期最低，顯示我國近年積極推動的肺炎鏈球菌疫苗接種政策已有 顯著效益 2015年全年齡發生率為每10萬人口2.23人，主要集中在未滿5歲的嬰幼兒及65歲以上的老年人，累積發生率以75歲以上老人最高（每10萬人口9.81人），其次為2~4歲幼兒（每10萬人口8.8人）。全年皆有病例，但發病高峰為冬季與春季 侵襲性肺炎鏈球菌感染症疫情週報 2016 年第 41 週（2016/10/09－2016/10/15）

17 國內常見肺炎鏈球菌血清型別及佔檢出菌株數百分比年間血清型15（不包含15B) 檢出率增加 疫情報導第30 卷 第22 期 p

18 Epidemiology of CAP in children- Atypical BacteriaIncreasing in importance 20-30% of all pneumonias are atypical pathogens! Mycoplasma pneumoniae Chlamydia pneumoniae 18

19 Chlamydia pneumoniae The prevalence of Chlamydia-associated acute respiratory infections : <1.5% Like CAP caused by Mycoplasma pneumoniae typically affects young adults Chlamydia pneumoniae has been recently identified as an agent of asthma exacerbation and has been associated with its severity Clin Infect Dis Apr;58: Clin Infect Dis 2007;44: 19 19

20 Mycoplasma pneumoniaeSmallest self-replicating organism, capable of cell-free existence Spidle-shaped cells (1-2 μ m), cell volume < 5% of typical bacillus No ability to synthesize peptidoglycan cell walls (pleomorphism) P1 adhesin: responsible for interaction with host cells

21 Epidemiology Causing 10-30 % community-acquired pneumonia in childrenTransmission: by aerosols (close personal contact), spread gradually among family members within a household Incubation period: 1-3 weeks Greatest proportion in the summer in temperate climates Cyclic epidemics every 3-5 years Reinfection: two P1 adhesin subtypes / incomplete immunity 21

22 Clinical manifestationMay manifest in upper and lower respiratory tract *Children ages less than 5 years: Wheezing and coryza *School-aged children 5-15 years of age: Bronchopneumonia Clinical presentation is often similar to C. pneumoniae and respiratory viruses May be present in the respiratory tract concomitantly with other pathogens, somehow intensify subsequent infections

23 Mycoplasma pneumoniae: Incidence by ageRate/1000/yr Age Foy et al. Am J Epidemiol 1973;97;93-102 23

24 Mycoplasma pneumoniae pneumoniaFocal reticulonodular opacification (perihilar and peripheral) Focal reticulonodular opacification (perihilar)

25 Mycoplasma pneumoniae pneumoniaGroundglass consolidation (Pseudoconsolidation) Atelectasis

26 Mycoplasma pneumoniae pneumoniaDense homogeneous consolidation and pleural effusion

27 M. pneumoniae and adenovirus co-infection100/5/30 100/5/28 100/6/1

28 Extra-pulmonary symptoms of Mycoplasma pneumoniaeSkin – Rash Joint – pains (arthralgia) or inflammation (arthritis) Blood – hemolytic anemia Heart – inflammation of heart muscle (carditis) Kidney – inflammation of kidney tissue (nephritis) Nerves – spinal cord demyelination Direct type inflammatory cytokines locally induced by lipoproteins contained in the bacterial cell membrane (ex. Pericarditis, Steven-Johnson syndrome, arthritis, early onset encephalitis) Indirect type immune modulation such as autoimmunity, allergy or immune complexes through cross-reaction between the bacterial cell components and human cells (ex. Myocarditis, erythema multiforme, urticaria, autoimmune hemolytic anemia, late onset encephalitis) Vascular occlusion type vasculitis and/or thrombosis with or without systemic hypercoagulable state induced by the bacterium (ex. DIC, stroke) 28

30 Taiwan Guideline of pneumonia Management 台灣肺炎診治指引Known Typical Pathogens First line Second line Streptococcus pneumoniae Penicillin, amoxicillin 30 or 40 cephalosporin, vancomycin + Rifampicin, (Fluoroquinolones) vancomycin, 30 or 40 cephalosporin Haemophilus influenzae Ampicillin or amoxicillin, New macrolides, 30 cephalosporin, (Fluoroquinolones) Ampicillin / sulbactam, Amoxicillin / clavulanate 20 cephalosporin Moraxella catarrhalis 20 cephalosporin, Erythromycin or Ampicillin / clavulanate= Augmentin ampicillin / sulbactam=Unasyn 兒童社區肺炎處置建議 / 台灣兒科醫學會 Acta Paediatr Taiwan Jul-Aug;48(4): Review. 30 30 30

31 Taiwan Guideline of pneumonia Management 台灣肺炎診治指引Known Atypical Pathogens First line Second line Legionella species Erythromycin or new macrolides Erythro or new macrolides + Rifampicin, Tetracycline, (Fluoroquinolones) Mycoplasma pneumoniae Chlamydia pneumoniae Tetracycline, (Fluoroquinolones) 兒童社區肺炎處置建議 / 台灣兒科醫學會 Acta Paediatr Taiwan Jul-Aug;48(4): Review. 31 31

32 Antibiotics for Atypical PathogensErythromycin Tetracycline Adverse reactions: Teeth & bone: not recommended for children up to 8 yr GI irritation, fatty liver etc. New macrolides: Less GI side effect, less drug interaction, longer half-life Clarithromycin (Klaricid®): bid, 7-10 days Azithromycin (Zithromax®): qd, 3-5 days 非典型細菌感染抗生素的選擇：  四環素 ： - 副作用：牙齒及骨組織：不建議 6-8歲以下 之兒童 - 腸胃道刺激， 脂肪肝, etc.  紅黴素 New Macrolide ：Rulid ，Klaricid ， Zithromax 32 32

34 Macrolides Inhibit Protein Synthesis (50S Robosomal Subunit)It binds reversibly to 50S ribosomal subunits of sensitive microorganism, interferes with transpeptidation and translocation thus there is inhibition of protein synthesis and hence inhibition of cell growth. Macrolides block growth of nascent peptide chain by stimulating dissociation of the peptidyl-tRNA from the ribosome 34

35 Kill curve analysis alone showed trovafloxacin to be more bactericidal than levofloxacin, grepafloxacin and moxifloxacin against four isolates of Streptococcus pneumoniae. However, using the bactericidal index (BI) method, levofloxacin was the most bactericidal fluoroquinolone using serum or lung biopsy concentration levels against the ofloxacin-susceptible strains and trovafloxacin was the most bactericidal against the ofloxacin-intermediate strain. None of the fluoroquinolones was bactericidal against the ofloxacin- resistant strain. With BIs using epithelial lining fluid or alveolar macrophage concentration levels, trovafloxacin or grepafloxacin was most bactericidal, respectively. These data illustrate that simple analysis of traditional kill curves may not be adequate in the evaluation of fluoroquinolone bactericidal activity. The results of this study suggest a need for further investigation to assess the role of tissue concentration and bactericidal activity in antimicrobial efficacy.

36 Clarithromycin可穿過血管肺泡屏障 在 ELF 濃度比 Azithromycin 高 40 倍肺泡巨噬細胞 濃度越高代表 治療效率越好 FIG. 1.Schematic diagram of the blood-alveolar antibiotic barrier (adapted from reference38 with the permission of the publisher). The blood-alveolar barrier is composed of two membranes, the capillary wall and alveolar wall, which are separated by a fluid-filled interstitial space. Antibiotics need to diffuse across the alveolar capillary wall, the interstitial fluid, and the alveolar epithelial cells to reach ELF. Cells can carry antibiotics to the ELF also. For pulmonary infections, concentrations of antibiotics in epithelial lining fluid (ELF) for extracellular pathogens and in alveolar macrophage (AM) cells for intracellular pathogens are thought to reflect antibiotic activity in pneumonia. Antibiotics whose concentrations are high at these extravascular sites, such as macrolides and fluoroquinolones, tend to be promoted for treatment of pulmonary infection over antibiotics like beta-lactams and aminoglycosides, even though clinical trials do not show differences in clinical outcome or even bacteriological response. 間隙 肺泡上皮細胞表面液體 (ELF) 微血管壁 肺泡上皮細胞 Antimicrob Agents Chemother. 2008;52(1):24-36. 36 36

37 比較Clarithromycin, Azithromycin, Ciprofloxacin和Cefuroxime(Single-dose Study) Abstract The intrapulmonary pharmacokinetics of azithromycin, clarithromycin, ciprofloxacin, and cefuroxime were studied in 68 volunteers who received single, oral doses of azithromycin (0.5 g), clarithormycin (0.5 g), ciprofloxacin (0.5 g), or cefuroxime (0.5 g). In subgroups of four subjects each, the subjects underwent bronchoscopy and bronchoalveolar lavage at timed intervals following drug administration. Drug concentrations, including those of 14- hydroxyclarithromycin (14H), were determined in serum, bronchoalveolar lavage fluid, and alveolar cells (ACs) by high-pressure liquid chromatography. Concentrations in epithelial lining fluid (ELF) were calculated by the urea diffusion method. The maximum observed concentrations (mean +/- standard deviation) of azithromycin, clarithromycin, 14H, ciprofloxacin, and cefuroxime in serum were /- 0.07, 1.0 +/- 0.6, /- 0.41, / , and 1.1 +/- 0.3 microgram/ml, respectively (all at 6 h). None of the antibiotics except clarithromycin (39.6 +/ micrograms/ml) was detectable in ELF at the 6-h bronchoscopy. The movement into and persistence in cells was different for azithromycin and clarithromycin. In ACs azithromycin was not detectable at 6 h, reached its highest concentration at 120 h, and exhibited the greatest area under the curve (7,403 micrograms.hr ml-1). The peak concentration of clarithromycin (181 +/ micrograms/ml) was greater and occurred earlier (6 h), but the area under the curve (2,006 micrograms.hr ml-1) was less than that observed for azithromycin. 14H was detectable in ACs at 6 h ( /- 5.2 micrograms/ml) and 12 h (32.8 +/ micrograms/ml). The peak concentration of ciprofloxacin occurred at 6 h (4.3 +/- 5.2 micrograms/ml), and the area under the curve was micrograms.hr ml-1. The data indicate that after the administration of a single dose, azithromycin, clarithromycin, and ciprofloxacin penetrated into ACs in therapeutic concentrations and that only clarithromycin was present in ELF. The correlation of these kinetic observations with clinical efficacy or toxicity was not investigated and is unclear, but the data provide a basis for further kinetic and clinical studies. Clarithromycin組織濃度高，抑菌效果好 Alveolar cell (AC) 肺泡細胞 Ciprofloxacin: quinolone antibiotics抑制DNA合成 Cefuroxime: cephalosporin antibiotic抑制細胞壁合成 Antimicrob Agents Chemother Jul;40(7): 37 37

38 The ONLY Macrolide with an ACTIVE metabolite14-OH Clarithromycin = an active metabolite Routine susceptibility testing underestimates Clari activity. It does not account for in vivo synergy with its metabolite,14-OH clarithromycin, as evidenced by the following MIC90.5,6 Against H. influenzae, 14-OH clarithromycin is twice as active as the parent compound in vitro:514-OH metabolite provides in vitro activity (92%)/synergistic activity (8%) against H influenzae.7 The in vitro activity of clarithromycin alone and in combination with its primary human metabolite, 14-hydroxy-clarithromycin, was determined against 203 strains of Haemophilus influenzae. Microdilution broth MICs and MBCs of both clarithromycin and 14-hydroxy-clarithromycin were determined. The clarithromycin MIC50 was 4 mg/l and the MIC90 was 8 mg/l. The hydroxy metabolite was 2-4-fold more active with an MIC50 and MIC90 of 2 mg/l. The MBCs were equal to the MICs. The microbicidal effect of combinations of clarithromycin and 14-hydroxy-clarithromycin was tested using a microdilution checkerboard technique and the fractional inhibitory index was calculated. The combination was additive in 92% and synergistic in 8% of all strains of H. influenzae tested; no antagonism was found. The results were independent of the site of isolation of the strain or presence of beta-lactamase. These findings suggest the potential clinical utility of clarithromycin for the treatment of H. influenzae infections. Infection 1992 May-Jun;20(3):164-7. 38

39 Patel KB, et al. ICMAS No. 407. Lisbon. 1996.Multiple Dose Plasma Concentrations of Clarithromycin and Azithromycin Compared to Pathogens Half life (hrs) Clarithromycin 6 Azithromycin 68 The minimum inhibitory concentration (MIC) is the lowest concentration of a chemical that prevents visible growth of a bacterium (in other words, at which it has bacteriostatic activity), whereas the minimum bactericidal concentration (MBC) is the concentration that results in microbial death (In other words, the concentration at which it is bactericidal).[1] MIC90是指可以抑制百分之九十測試菌之最低抗生素濃度 Patel KB, et al. ICMAS No Lisbon 39

40 Potential of Various Macrolide Antibiotics to Induce ResistantMutant Selection Window Hypothesis  MIC: Minimal inhibitory concentration MPC: Mutant prevention concentration 10.00 1.00 0.1 0.01 0.001 Clarithromycin Azithromycin Days Mutant Selection Window MPC MIC g/ mL  For many antibiotics, high concentrations block the growth of all single-step mutants. Above such a concentration, which is called the mutant prevention concentration (MPC), a second resistance mutation must also be present for growth to occur. Consequently, fully susceptible (wild-type) cells must acquire two resistance mutations concurrently for growth above the MPC. That is expected to occur only rarely. For example, if two resistance mutations arise independently, each at a frequency of one in a million (10-6), the probability that two will arise concurrently is 10-6 x 10-6 = 10-12, one in a trillion. Keeping drug concentrations above MPC does not prevent the occurrence of mutations (changes in DNA nucleotide sequence), but it does block growth of cells after they become mutant. With respect to the hill climbing idea, keeping antibiotic concentrations above MPC forces the pathogens to jump up a steep cliff. Mutant selection window. The mutant selection window, the concentration range between MIC and MPC, is shown for three hypothetical treatments that produce three hypothetical pharmacokinetic curves. Curve a is above the window for much of the treatment time and is expected to restrict the amplification of resistant microbial subpopulations. Curve b falls inside the window for much of the dosing period and is expected to enable mutant amplification. Curve c is below the window and exerts little selective pressure. MIC and MPC are determined from agar-plate colony-growth studies; pharmacokinetics are measured with animals or patients. Clin Infect DIs Mar 1;44(5):681-8.  40

41 Macrolide resistance (%) Azithromycin use (% of macrolides)Azithromycin Use versus Macrolide Resistance (S. pneumoniae) 25 Strong correlation between azithromycin use and macrolide resistance NS 20 NB QUE 15 R=0.9659 p<0.0001 ON AB Macrolide resistance (%) 10 SK MB BC Previous work showed a higher prevalence of macrolide/azalide resistance in provinces of Canada where azithromycin was the major treatment for Streptococcus pneumoniae as compared with regions where clarithromycin was the dominant treatment.  5 NFLD 10 20 30 40 50 60 Azithromycin use (% of macrolides) Davidson RJ, Chan CCK, Doern G, Zhanel GG. Presented at 13th ECCMID Clin Microbiol Infect. 2003;9:240–1 41 41

42 Mechanism of MLr strainMacrolide – binding to domain V of 23S rRNA at positions and 2064 Mutation at A2063 or A2064 – highest resistance Lower level of antibiotic resistance – A2067 and C2617 J Infect Chemother (2010) 16:78-86

43 Worldwide macrolide-resistant M. pneumoniae (MRMP) ratesTaiwan MRMP incidence (2011) 12.3% CGMH ( ) 23% NTUH Macrolide-resistant (MLr) strain in children since 2000 ; first isolated in adult since 2007, both in Japan Taiwan MRMP incidence (2011) 12.3% CGMH (9/73) Longer hospital stay was observed in the MR patients than MS patients [median, 7 days vs. 5 days (P = 0.019)] ( ) 23% NTUH (14/60) The ML(r) group had longer mean duration of fever after azithromycin treatment (3.2 days vs. 1.6 days, P = 0.02) and significantly higher percentage of changing antibiotics for suspected ML(r) strain (42% vs. 13%, P = 0.04). Although 58% of children in the ML(r) group did not receive effective antibiotics, all children were discharged without sequelae. Macrolide – binding to domain V of 23S rRNA at positions 2063 and 2064 Mutation at A2063 or A2064 – highest resistance Lower level of antibiotic resistance –A2067 and C2617 Pediatr Pulmonol. 2013;48(9): J Infect Chemother 2013;19(4):782-6 Front Microbiol 2016; 7:329

44 Summary Community-acquired pneumonia 仍是兒童常見且重要的疾病Severity & Age Incidence of invasive pneumococcal disease: decreased Atypical pathogens cause as much as 20-30% of all CAP Co-infection was usual Atypical pneumonia is under-tested, under-diagnosed and under- treated Macrolide resistant Mycoplasma pneumoniae emergence New macrolide is indicated as first-line drug for atypical pathogens Clarithromycin & Azithromycin High tissue concentration Less resistance-inducing Active metabolites 44

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