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==Overview==
Pharmacologic medical therapy is indicated in Legionnaires' disease. The preferred regimens for both mild and moderate-to-severe pneumonia include either [[azithromycin]] or a [[fluoroquinolone]].  Patients who develop legionellosis-related complications may require other or additional pharmacologic agents. Pontiac fever is self-limited and may be treated with symptomatic therapy only.


==Medical Therapy==
==Medical Therapy==
Legionnaires' disease can be very serious and can cause death in up to 5% to 30% of cases. Most cases can be treated successfully with antibiotics [drugs that kill bacteria in the body], and healthy people usually recover from infection.


Current treatments of choice are the respiratory tract [[quinolones]] ([[levofloxacin]], [[moxifloxacin]], [[gemifloxacin]]) or newer [[macrolides]] ([[azithromycin]], [[clarithromycin]], [[roxithromycin]]). The [[antibiotic]]s used most frequently have been levofloxacin and azithromycin. Macrolides are used in all age groups while tetracyclines are prescribed for children above the age of 12 and quinolones above the age of 18.<br>[[Rifampin]] can be used in combination with a quinolone or macrolide. [[Tetracyclines]] and [[erythromycin]] led to improved outcome compared to other antibiotics in the original American Legion outbreak. These antibiotics are effective because they have excellent intracellular penetration and ''Legionella'' infects cells. The mortality at the original American Legion convention in 1976 was high (34 deaths in 180 infected individuals) because the antibiotics used (including [[penicillin]]s, [[cephalosporin]]s, and [[aminoglycoside]]s) had poor intracellular penetration. Mortality has plunged to less than 5% if therapy is started quickly. Delay in giving the appropriate antibiotic leads to higher mortality.
 
Pontiac fever requires no specific antibiotic treatment.
===Antimicrobial Regimen===
==Antimicrobial therapy==
:* 1. '''Atypical pneumonia (Legionnaires' disease)'''<ref>{{cite book | last = Bennett | first = John | title = Mandell, Douglas, and Bennett's principles and practice of infectious diseases | publisher = Elsevier/Saunders | location = Philadelphia, PA | year = 2015 | isbn = 978-1455748013 }}</ref>
:* 1.'''Atypical pneumonia (Legionnaires' disease )'''<ref>{{cite book | last = Bennett | first = John | title = Mandell, Douglas, and Bennett's principles and practice of infectious diseases | publisher = Elsevier/Saunders | location = Philadelphia, PA | year = 2015 | isbn = 978-1455748013 }}</ref>
::* 1.1  '''Mild pneumonia, non-immunocompromised (inpatient or outpatient)'''
::* 1.1  '''Mild pneumonia inpatient or outpatient, non immunocompromised'''
:::* Preferred regimen (1): [[Azithromycin]] 500 mg PO qd for 3-5 days
:::* Preferred regimen (1): [[Azithromycin]] 500 mg PO qd for 3-5 days
:::* Preferred regimen (2): [[Levofloxacin]] 500 mg PO qd for 7-10 days
:::* Preferred regimen (2): [[Levofloxacin]] 500 mg PO qd for 7-10 days
Line 17: Line 18:
:::* Preferred regimen (4): [[Moxifloxacin]] 400 mg PO qd for 7-10 days
:::* Preferred regimen (4): [[Moxifloxacin]] 400 mg PO qd for 7-10 days
:::* Preferred regimen (5): [[Clarithromycin]] 500 mg PO bid for 10-14 days
:::* Preferred regimen (5): [[Clarithromycin]] 500 mg PO bid for 10-14 days
:::* Alternative regimen (1): [[Doxycycline]] 200 mg PO loading dose, then 100 mg PO bid for 10-14 days
:::* Alternative regimen (1): [[Doxycycline]] 200 mg PO loading dose {{then}} 100 mg PO bid for 10-14 days
:::* Alternative regimen (2): [[Erythromycin]] 500 mg PO qid for 10-14 days
:::* Alternative regimen (2): [[Erythromycin]] 500 mg PO qid for 10-14 days
:::* Note: Patients with mild disease may be treated entirely with oral therapy
:::* Note: Patients with mild disease may be treated entirely with oral therapy
::* 1.2 '''Moderate to severe pneumonia or immunocompromised'''
::* 1.2 '''Moderate to severe pneumonia or immunocompromised'''
:::* Preferred regimen (1): [[Azithromycin]] 500 mg PO/IV q24h for 5-7 days
:::* Preferred regimen (1): [[Azithromycin]] 500 mg PO/IV q24h for 5-7 days
:::* Preferred regimen (2): [[Levofloxacin]] 500 mg PO/IV q24h for 7-10 days {{or}} 750 mg PO/IV q24h for 5-7 days
:::* Preferred regimen (2): [[Levofloxacin]] 500 mg PO/IV q24h for 7-10 days {{or}} 750 mg PO/IV q24h for 5-7 days
:::* Alternative regimen (1): [[Ciprofloxacin]] 750 mg PO bid for 14 days  
:::* Alternative regimen (1): [[Ciprofloxacin]] 750 mg PO bid for 14 days
:::* Alternative regimen (2): [[Moxifloxacin]] 400 mg PO qd for 14 days  
:::* Alternative regimen (2): [[Moxifloxacin]] 400 mg PO qd for 14 days
:::* Alternative regimen (3): [[Erythromycin]] 750-1000 mg IV q6h for 3-7 days, then 500 mg PO qid for a total course of 21 days
:::* Alternative regimen (3): [[Erythromycin]] 750-1000 mg IV q6h for 3-7 days {{then}} 500 mg PO qid for a total course of 21 days
:::* Alternative regimen (4): [[Clarithromycin]] 500 mg IV q12h for 3-7 days, and then 500 mg PO bid for a total course of 21 days
:::* Alternative regimen (4): [[Clarithromycin]] 500 mg IV q12h for 3-7 days {{then}} 500 mg PO bid for a total course of 21 days
:::* Note: Severely ill patients parenteral therapy is advised until improvement is seen and oral absorption is sufficient.
:::* Note: Severely ill patients parenteral therapy is advised until improvement is seen and oral absorption is sufficient.
:* 2 '''Pontiac fever'''  
:* 2. '''Pontiac fever'''<ref>{{cite book | last = Bartlett | first = John | title = Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases | publisher = Jones and Bartlett Learning | location = Burlington, MA | year = 2012 | isbn = 978-1449625580 }}</ref>
::*  Pontiac fever is febrile, self-limited form of Legionella infection which requires only symptomatic therapy, such as analgesics for headache. Antibiotics are not indicated.
::*  Pontiac fever is febrile, self-limited form of Legionella infection which requires only symptomatic therapy, such as analgesics for headache. Antibiotics are not indicated.
:* 3. '''Endocarditis'''<ref>{{cite book | last = Bartlett | first = John | title = Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases | publisher = Jones and Bartlett Learning | location = Burlington, MA | year = 2012 | isbn = 978-1449625580 }}</ref>
::* Preferred regimen (1): [[Levofloxacin]] 750 mg PO/IV qd for 7-10 days {{and}} [[Rifampin]] 300 mg PO bid for 4-6 weeks
::* Preferred regimen (2): [[Moxifloxacin]] 400 mg PO/IV qd for 7-10 days {{and}} [[Rifampin]] 300 mg PO bid for 4-6 weeks


==References==
==References==
{{reflist|2}
{{reflist|2}}
 
[[Category:Infectious Disease Project]]
[[Category:Infectious Disease Project]]
[[Category:Infectious disease]]
 
[[Category:Pulmonology]]
[[Category:Pulmonology]]
[[Category:Disease]]
[[Category:Disease]]
[[Category:Bacterial diseases]]
[[Category:Bacterial diseases]]
[[Category:Medical disasters]]
[[Category:Medical disasters]]
[[Category:Needs overview]]


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Latest revision as of 18:09, 18 September 2017

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Pharmacologic medical therapy is indicated in Legionnaires' disease. The preferred regimens for both mild and moderate-to-severe pneumonia include either azithromycin or a fluoroquinolone. Patients who develop legionellosis-related complications may require other or additional pharmacologic agents. Pontiac fever is self-limited and may be treated with symptomatic therapy only.

Medical Therapy

Antimicrobial Regimen

  • 1. Atypical pneumonia (Legionnaires' disease)[1]
  • 1.1 Mild pneumonia, non-immunocompromised (inpatient or outpatient)
  • Preferred regimen (1): Azithromycin 500 mg PO qd for 3-5 days
  • Preferred regimen (2): Levofloxacin 500 mg PO qd for 7-10 days
  • Preferred regimen (3): Ciprofloxacin 500 mg PO bid for 7-10 days
  • Preferred regimen (4): Moxifloxacin 400 mg PO qd for 7-10 days
  • Preferred regimen (5): Clarithromycin 500 mg PO bid for 10-14 days
  • Alternative regimen (1): Doxycycline 200 mg PO loading dose THEN 100 mg PO bid for 10-14 days
  • Alternative regimen (2): Erythromycin 500 mg PO qid for 10-14 days
  • Note: Patients with mild disease may be treated entirely with oral therapy
  • 1.2 Moderate to severe pneumonia or immunocompromised
  • Preferred regimen (1): Azithromycin 500 mg PO/IV q24h for 5-7 days
  • Preferred regimen (2): Levofloxacin 500 mg PO/IV q24h for 7-10 days OR 750 mg PO/IV q24h for 5-7 days
  • Alternative regimen (1): Ciprofloxacin 750 mg PO bid for 14 days
  • Alternative regimen (2): Moxifloxacin 400 mg PO qd for 14 days
  • Alternative regimen (3): Erythromycin 750-1000 mg IV q6h for 3-7 days THEN 500 mg PO qid for a total course of 21 days
  • Alternative regimen (4): Clarithromycin 500 mg IV q12h for 3-7 days THEN 500 mg PO bid for a total course of 21 days
  • Note: Severely ill patients parenteral therapy is advised until improvement is seen and oral absorption is sufficient.
  • 2. Pontiac fever[2]
  • Pontiac fever is febrile, self-limited form of Legionella infection which requires only symptomatic therapy, such as analgesics for headache. Antibiotics are not indicated.
  • 3. Endocarditis[3]
  • Preferred regimen (1): Levofloxacin 750 mg PO/IV qd for 7-10 days AND Rifampin 300 mg PO bid for 4-6 weeks
  • Preferred regimen (2): Moxifloxacin 400 mg PO/IV qd for 7-10 days AND Rifampin 300 mg PO bid for 4-6 weeks

References

  1. ↑ Bennett, John (2015). Mandell, Douglas, and Bennett's principles and practice of infectious diseases. Philadelphia, PA: Elsevier/Saunders. ISBN 978-1455748013.
  2. ↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
  3. ↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.


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