Vancomycin-resistant Enterococcus faecalis in Serbia

criteria, and exclusion criteria available from the author). The quality of these studies is quite variable, and quality is certainly more important than quantity. Most trials of the newer agents were designed and funded by industry. In general, ciprofloxacin and levofloxacin have been studied in patient populations with more severe illnesses, including nosocomial infections, than the newer quinolones. With the exception of a single moxifloxacin trial (8), the trials of the newer quinolones have enrolled patients with predominantly mild or moderate community-acquired infections and low overall mortality rates. Scheld provides a table that lists case reports of clinical failures of levofloxacin for the treatment of pneumococcal infections. Some cases were associated with primary or secondary levofloxacin resistance. These case reports should not be surprising, since CAP trials regularly identify clinical failures regardless of the therapy chosen. The rate of clinical failure is best determined by data from prospective trials rather than case reports. Both levofloxacin and moxifloxacin have performed well in patients with severe pneumococcal infections, on the basis of the rates of therapeutic success and death (8–10). Scheld’s choice of ciprofloxacin as a component of combination therapy for suspected P. aeruginosa infections can be affirmed. Ciprofloxacin has pharmacodynamic potency against P. aeruginosa, a track record of safety in large populations, and a large published literature. Ciprofloxacin has demonstrated efficacy in patient populations with severe illnesses, including nosocomial infections. Antimicrobial drug therapy decision-making for patients with CAP and other respiratory tract infections is much more complex. Individual patient factors should be considered, including the severity of illness, coexisting illnesses, risk factors for drug-resistant S. pneumoniae, and risk factors for specific adverse effects. A respiratory quinolone will be an appropriate choice for some patients with CAP. Among the respiratory quinolones, a wholesale switch from levofloxacin to moxifloxacin, on the basis of pneumococcal potency alone, would be premature. Clinicians should use newer quinolones cautiously until their safety has been established in large patient populations.