BMJ 1994;308:1437 (28 May)

Letters

Ciprofloxacin in general practice

EDITOR, - The Lesson of the week by Roland J Korner and colleagues highlighted the dangers of fluoroquinolones.1 We have also noted that patients with chest infections have been treated with ciprofloxacin in general practice; the slower resolution of their Streptococcus pneumoniae infection required a change of antimicrobial agent, and one patient died.

We understand, however, that ciprofloxacin is not promoted as first line treatment in general practice for community acquired chest infections, but some general practitioners in our area have provided promotional material that does. This material contains data showing that 14.4% of bacterial pathogens in acute exacerbations of chronic bronchitis are S pneumoniae.

Bantz and colleagues (some of whom worked for Bayer) are cited in Bayer's promotional leaflet for Ciproxin; they mentioned a >95% resolution rate but compared only doxycycline with ciprofloxacin and made no reference to bacterial pathogens. In the same supplement to the American Journal of Medicine, however, other papers gave less favourable views-for example, "the activity of ciprofloxacin against Streptococci and Enterococci is marginal, at best."3

The only other reference concerning efficacy that is cited in Bayer's promotional leaflet is a study of just 34 patients.4 Those with Haemophilus influenzae rapidly recovered, and these organisms were not culturable beyond three days. Of those with S pneumoniae infection, five still had positive results after three days, five after 11 days, and one after 25 days. Five patients had a relapse and were then treated with either amoxycillin or cotrimoxazole and clinically recovered. Six patients acquired S pneumoniae infection during or after treatment, and three required treatment. Two patients had rising minimum inhibitory concentrations to ciprofloxacin in S pneumoniae, with organisms being isolated further into ciprofloxacin treatment.

In the same issue of the Journal of Antimicrobial Chemotherapy a leading article on quinolones in chest infections, concludes that there is little reason for optimism about the role of quinolones in chest infections mainly because of problems with resistance, recurrence, and reinfection with Pseudomonas aeruginosa and S pneumoniae.5

Clearly, ciprofloxacin is not a suitable agent for use in general practice for the blind initial treatment of chest infections and should not be so promoted.

We believe that there are major discrepancies between the promoted image and the clinically interpreted usefulness of ciprofloxacin. We hope that this sort of problem is not widespread in the pharmaceutical industry but wonder how extensive it is considering the gamut of drugs being actively promoted, often to those without the time or resources to easily and critically interpret the data presented to them.

P M W Donaldson, A P Palleti, M P Carroll

Southampton University Hospitals Trust, Southampton SO9 4XY.

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References and Citations:

Korner RJ, Reeves DS, MacGowan AP. Dangers of oral fluoroquinolone treatment in community acquired upper respiratory tract infections. BMJ 1994;308:191-2. (15 January.) [Free Full Text]

Bantz PM, Grote J, Peters-Haertel W, Stahmann J, Timm J, Kasten R, et al. Low-dose ciprofloxacin in respiratory tract infections. Am J Med 1987;82 (suppl 4A):208-10.

Barry AL, Jones RN. In vitro activity of ciprofloxacin against Gram positive cocci. Am J Med 1987;82 (suppl 4A):27-32.

Hoogkamp-Korstanje JAA, Klien SJ. Ciprofloxacin in acute exacerbations of chronic bronchitis. J Antimicrob Chemother 1986;18:407-13. [Abstract]

Davies BI, Maesen FPV. Quinolones in chest infections. J Antimicrob Chemother 1986;18:296-99. [Medline]