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Mathioudakis AG, Ananth S, Bradbury T, Csoma B, Sivapalan P, Stovold E, Fernandez-Romero G, Lazar Z, Criner GJ, Jenkins C, Papi A, Jensen JU, Vestbo J. Assessing Treatment Success or Failure as an Outcome in Randomised Clinical Trials of COPD Exacerbations. A Meta-Epidemiological Study. Biomedicines 2021; 9:biomedicines9121837. [PMID: 34944653 PMCID: PMC8698292 DOI: 10.3390/biomedicines9121837] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 12/02/2021] [Accepted: 12/03/2021] [Indexed: 11/16/2022] Open
Abstract
A recently published ERS core outcome set recommends that all trials of COPD exacerbation management should assess the treatment success (or “cure” of the exacerbation), defined as a dichotomous measure of the overall outcome of an exacerbation. This methodological systematic review describes and compares the instruments that were used to assess treatment success or failure in 54 such RCTs, published between 2006–2020. Twenty-three RCTs used composite measures consisting of several undesirable outcomes of an exacerbation, together defining an overall unfavourable outcome, to define treatment failure. Thirty-four RCTs used descriptive instruments that used qualitative or semi-quantitative descriptions to define cure, marked improvement, improvement of the exacerbation, or treatment failure. Treatment success and failure rates among patients receiving guidelines-directed treatments at different settings and timepoints are described and could be used to inform power calculations in future trials. Descriptive instruments appeared more sensitive to treatment effects compared to composite instruments. Further methodological studies are needed to optimise the evaluation of treatment success/failure. In the meantime, based on the findings of this systematic review, the ERS core outcome set recommends that cure should be defined as sufficient improvement of the signs and symptoms of the exacerbation such that no additional systemic treatments are required.
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Affiliation(s)
- Alexander G. Mathioudakis
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, The University of Manchester, Manchester M23 9LT, UK;
- North West Lung Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester M23 9LT, UK
- Correspondence:
| | - Sachin Ananth
- West Hertfordshire Hospital NHS Trust, Watford WD18 0HB, UK;
| | - Thomas Bradbury
- The George Institute for Global Health, University of New South Wales, Sydney 1466, Australia; (T.B.); (C.J.)
| | - Balazs Csoma
- Department of Pulmonology, Faculty of Medicine, Semmelweis University, 1085 Budapest, Hungary; (B.C.); (Z.L.)
| | - Pradeesh Sivapalan
- Section of Respiratory Medicine, Department of Internal Medicine, Herlev-Gentofte Hospital, 2900 Hellerup, Denmark; (P.S.); (J.-U.J.)
- Department of Internal Medicine, Zealand University Hospital, 4000 Roskilde, Denmark
| | - Elizabeth Stovold
- Cochrane Airways Group, Population Health Research Institute, St George’s University of London, London SW17 0RE, UK;
| | - Gustavo Fernandez-Romero
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA 19140, USA; (G.F.-R.); (G.J.C.)
| | - Zsofia Lazar
- Department of Pulmonology, Faculty of Medicine, Semmelweis University, 1085 Budapest, Hungary; (B.C.); (Z.L.)
| | - Gerard J. Criner
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA 19140, USA; (G.F.-R.); (G.J.C.)
| | - Christine Jenkins
- The George Institute for Global Health, University of New South Wales, Sydney 1466, Australia; (T.B.); (C.J.)
| | - Alberto Papi
- Research Center on Asthma and COPD, Faculty of Medical Sciences, University of Ferrara, 44121 Ferrara, Italy;
| | - Jens-Ulrik Jensen
- Section of Respiratory Medicine, Department of Internal Medicine, Herlev-Gentofte Hospital, 2900 Hellerup, Denmark; (P.S.); (J.-U.J.)
- Institute of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, 1165 Copenhagen, Denmark
| | - Jørgen Vestbo
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, The University of Manchester, Manchester M23 9LT, UK;
- North West Lung Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester M23 9LT, UK
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Cornejo OM, Nava JL. Mineralization of the antibiotic levofloxacin by the electro-peroxone process using a filter-press flow cell with a 3D air-diffusion electrode. Sep Purif Technol 2021. [DOI: 10.1016/j.seppur.2020.117661] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Rhee CK, Chang JH, Choi EG, Kim HK, Kwon YS, Kyung SY, Lee JH, Park MJ, Yoo KH, Oh YM. Zabofloxacin versus moxifloxacin in patients with COPD exacerbation: a multicenter, double-blind, double-dummy, randomized, controlled, Phase III, non-inferiority trial. Int J Chron Obstruct Pulmon Dis 2015; 10:2265-75. [PMID: 26543359 PMCID: PMC4622522 DOI: 10.2147/copd.s90948] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
A new quinolone, zabofloxacin, has now been developed; hence, a non-inferiority trial is needed to compare this new compound with another widely used quinolone to examine its efficacy and safety for the treatment of chronic obstructive pulmonary disease (COPD) exacerbations. This was a prospective, multicenter, double-blind, double-dummy, randomized, controlled, parallel-group, Phase III, non-inferiority clinical trial designed to compare oral zabofloxacin (367 mg once daily for 5 days) with moxifloxacin (400 mg once daily for 7 days) for the treatment of patients with COPD exacerbation. In all, 345 COPD patients with a moderate COPD exacerbation were enrolled in the study via the outpatient clinics at 31 university hospitals. Clinical per protocol analysis revealed that the clinical cure rate for zabofloxacin was 86.7% and that for moxifloxacin was 86.3% (the rate difference, 0.4%; 95% confidence interval, −7.7%–8.6%). Intention-to-treat analysis revealed clinical cure rates of 77.1% and 77.3% (difference, −0.2%; 95% confidence interval, −9.0%–8.8%), respectively. These results confirm that zabofloxacin is not inferior to moxifloxacin. The favorable microbiological response rate for zabofloxacin was 67.4% and that for moxifloxacin was 79.5% (P=0.22). Patients in the zabofloxacin group showed better patient-oriented outcomes, as measured by EXAcerbations of Chronic Pulmonary Disease Tool-Patient-Reported Outcome and the COPD assessment test scores, than patients in the moxifloxacin group. Adverse drug reactions related to zabofloxacin occurred in 9.7% of cases and those related to moxifloxacin occurred in 9.6% of cases (P=0.97). The dropout rate due to adverse events was 0% (0/175) in the zabofloxacin group and 1.8% (3/167) in the moxifloxacin group (P=0.12). Oral zabofloxacin (367 mg once daily for 5 days) was not inferior to oral moxifloxacin (400 mg once daily for 7 days) for the treatment of patients with COPD exacerbation.
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Affiliation(s)
- Chin Kook Rhee
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Korea
| | - Jung Hyun Chang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, School of Medicine, Ewha Womans University Medical Center, Seoul, Korea
| | - Eu Gene Choi
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Daejeon Hankook Hospital, Daejeon, Korea
| | - Hyun Kuk Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Yong-Soo Kwon
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Sun Young Kyung
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Ji-Hyun Lee
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, CHA Bundang Medical Center of CHA University, Seongnam, Korea
| | - Myung Jae Park
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, KyungHee University Hospital, Seoul, Korea
| | - Kwang Ha Yoo
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea
| | - Yeon Mok Oh
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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He L, Zhou C, Zhao S, Weng H, Yang G. Once-daily, oral levofloxacin monotherapy for low-risk neutropenic fever in cancer patients: a pilot study in China. Anticancer Drugs 2015; 26:359-62. [PMID: 25486597 PMCID: PMC4314102 DOI: 10.1097/cad.0000000000000187] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2014] [Accepted: 11/01/2014] [Indexed: 01/13/2023]
Abstract
This pilot study assesses the safety and efficacy of once-daily, oral levofloxacin monotherapy in Chinese patients with low-risk febrile neutropenia. In this prospective, single-arm, open-label, multicenter clinical trial, 46 adult Chinese patients with solid tumors and low-risk febrile neutropenia were included. Patients received oral levofloxacin monotherapy (500 mg orally/day) until day 12, followed by 7 days of follow-up (day 19). Body temperature was measured three times per day. On days 2, 3, 5-7, 9, 12, and 19, disease symptoms and vital signs were recorded, adverse drug reactions were assessed, and blood samples were collected to determine the whole-blood cell count and the absolute neutrophil count. Blood cultures and chest radiographs were performed simultaneously until negative results were found. Oral levofloxacin was effective and well tolerated in 97.6% of patients irrespective of the cancer type and cause of fever. Body temperature began to decline in 24.4, 68.3, and 90.2% of patients, respectively, at 12, 24, and 48 h after initiating levofloxacin therapy. On days 5 and 7, 95.1 and 97.6% of the patients had complete defervescence, respectively. The median time for absolute neutrophil count recovery to at least 1500/mm after initiation of treatment was 3 days. Only one patient reported mild diarrhea. This pilot study showed that oral levofloxacin quickly and effectively reduced fever, initiated neutrophil recovery, and was well tolerated in Chinese low-risk febrile neutropenic patients with solid tumors. Further study is needed to compare patient data of levofloxacin with the standard amoxicillin/ciprofloxacin protocol in this population for both safety and efficacy.
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Affiliation(s)
- Lixian He
- Zhongshan Hospital, Fudan University
| | - Caicun Zhou
- Shanghai Pulmonary Hospital, Tongji University, Shanghai
| | - Su Zhao
- Tongji Medical College Huazhong University of Science & Technology, The Central Hospital of Wuhan, Wuhan
| | - Heng Weng
- Fuzhou Pulmonary Hospital of Fujian, Fuzhou
| | - Guowang Yang
- Beijing Hospital of T.C.M Affiliated to Capital University of Medicine Sciences, Beijing, China
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Lode HM. Preserving the efficacy of front-line fluoroquinolones through selective use to optimise clinical outcomes. Int J Antimicrob Agents 2014; 43:497-507. [DOI: 10.1016/j.ijantimicag.2014.02.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2014] [Revised: 02/18/2014] [Accepted: 02/20/2014] [Indexed: 01/06/2023]
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Chilet-Rosell E, Ruiz-Cantero MT, Pardo MA. Gender analysis of moxifloxacin clinical trials. J Womens Health (Larchmt) 2013; 23:77-104. [PMID: 24180298 DOI: 10.1089/jwh.2012.4171] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
PURPOSE To determine the inclusion of women and the sex-stratification of results in moxifloxacin Clinical Trials (CTs), and to establish whether these CTs considered issues that specifically affect women, such as pregnancy and use of hormonal therapies. Previous publications about women's inclusion in CTs have not specifically studied therapeutic drugs. Although this type of drug is taken by men and women at a similar rate, adverse effects occur more frequently in the latter. METHODS We reviewed 158 published moxifloxacin trials on humans, retrieved from MedLine and the Cochrane Library (1998-2010), to determine whether they complied with the gender recommendations published by U.S. Food and Drug Administration Guideline. RESULTS Of a total of 80,417 subjects included in the moxifloxacin CTs, only 33.7% were women in phase I, in contrast to phase II, where women accounted for 45%, phase III, where they represented 38.3% and phase IV, where 51.3% were women. About 40.9% (n=52) of trials were stratified by sex and 15.3% (n=13) and 9% (n=7) provided data by sex on efficacy and adverse effects, respectively. We found little information about the influence of issues that specifically affect women. Only 3 of the 59 journals that published the moxifloxacin CTs stated that authors should stratify their results by sex. CONCLUSIONS Women are under-represented in the published moxifloxacin trials, and this trend is more marked in phase I, as they comprise a higher proportion in the other phases. Data by sex on efficacy and adverse effects are scarce in moxifloxacin trials. These facts, together with the lack of data on women-specific issues, suggest that the therapeutic drug moxifloxacin is only a partially evidence-based medicine.
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Wilson R, Sethi S, Anzueto A, Miravitlles M. Antibiotics for treatment and prevention of exacerbations of chronic obstructive pulmonary disease. J Infect 2013; 67:497-515. [PMID: 23973659 DOI: 10.1016/j.jinf.2013.08.010] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2013] [Revised: 08/14/2013] [Accepted: 08/16/2013] [Indexed: 11/18/2022]
Abstract
Acute exacerbations (AE) can be recurrent problems for patients with moderate-to-severe chronic obstructive pulmonary disease (COPD) increasing morbidity and mortality. Evidence suggests that ≥50% of acute exacerbations involve bacteria requiring treatment with an antibiotic which should have high activity against the causative pathogens. However, sputum analysis is not a pre-requisite for antibiotic prescription in outpatients as results are delayed and patients are likely to be colonised with bacteria in the stable state. Clinicians rely on the clinical symptoms, sputum appearance and the patient's medical history to decide if an AE-COPD should be treated with antibiotics. This article reviews the available data of antibiotic trials in AE-COPD. Management of frequent exacerbators is particularly challenging for physicians. This may include antibiotic prophylaxis, especially macrolides because of anti-inflammatory properties; though successful in reducing exacerbations, concerns about resistance development remain. Inhalation of antibiotics achieves high local concentrations and minimal systemic exposure; therefore, it may represent an attractive alternative for antibiotic prophylaxis in certain COPD patients. Inhaled antibiotic prophylaxis has been successfully used in other respiratory conditions such as non-cystic fibrosis bronchiectasis which itself might be present in COPD patients who have chronic bacterial infection, particularly with Pseudomonas aeruginosa.
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Affiliation(s)
- Robert Wilson
- Host Defence Unit, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK.
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Albertson TE, Chan AL. Antibiotic therapy in elderly patients with acute exacerbation of chronic bronchitis. Expert Rev Respir Med 2012; 3:539-48. [PMID: 20477342 DOI: 10.1586/ers.09.37] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Chronic bronchitis (CB) is a critical component of chronic obstructive pulmonary disease (COPD). Emphysema, reversible airway disease and bronchiectasis also contribute to COPD. Elderly patients are at increased risk for COPD and its components - emphysema, CB and bronchiectasis. In addition, older patients are at increased risk for resistant organisms during episodes of acute exacerbation of CB (AECB). These organisms include the more common bacteria implicated in AECB, such as Haemophilus influenzae, Moraxella catarrhalis and Streptococcus pneumoniae, and less common nonenteric, Gram-negative organisms such as Pseudomonas aeruginosa. Risk-stratified antibiotic treatment guidelines for AECB appear to be useful, although they have not been prospectively validated for the general CB population, and especially not in the elderly CB population. Many of the AECB treatment guidelines that are stratified based on risk factors have recommended that the oral respiratory fluoroquinolone antibiotics (gemifloxacin, levofloxacin and moxifloxacin) play a second-line but pivotal role, particularly in patients who have failed initial antibiotic treatment for simple CB or as initial treatment for complicated CB.
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Affiliation(s)
- Timothy E Albertson
- Professor and Chief, Division of Pulmonary and Critical Care Medicine, UCDHS and VA Northern California Health Care System, 4150 V Street, Suite 3400, Sacramento, CA 95817, USA.
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Torres A, Liapikou A. Levofloxacin for the treatment of respiratory tract infections. Expert Opin Pharmacother 2012; 13:1203-12. [PMID: 22594848 DOI: 10.1517/14656566.2012.688952] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Fluoroquinolone use has dramatically increased since the introduction of the first respiratory fluoroquinolone in the late 1990s. Levofloxacin , like other fluoquinolones, is a potent antibiotic, due to high levels of susceptibility among Gram-negative, Gram-positive (including penicillin-resistant strains of Streptococcus pneumonia) and atypical pathogens. Levofloxacin is recommended for the treatment of community-acquired pneumonia (CAP), hospital-acquired pneumonia (HAP) and in the management of acute exacerbations of chronic bronchitis (AECB). Levofloxacin demonstrates good safety, bioavailability and tissue penetration, thus maintaining adequate concentrations at the site of infection. High-dose (750 mg), short-course (5 days) therapy regimens may offer improved treatment, especially in HAP, due to higher drug concentrations, increased adherence and the potential to reduce the development of resistance. AREAS COVERED This article covers medical literature published in any language since 1990 until November 2011, on 'levofloxacin', identified using PubMed and MEDLINE. The search terms used were 'levofloxacin' and 'community acquired pneumonia', 'hospital pneumonia' or 'AECB'. EXPERT OPINION Levofloxacin is a valuable antimicrobial agent and an optimal treatment option for AECB, CAP (as a monotherapy) and HAP (as combination therapy at a high-dose regimen). Its improved bioavailability and safety profile makes the possibility of shorter hospital stays a reality.
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Affiliation(s)
- Antoni Torres
- University of Barcelona, Respiratory Department, Villarroel 170 Barcelona 08036, Spain.
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Gotfried MH, Grossman RF. Short-course fluoroquinolones in acute exacerbations of chronic bronchitis. Expert Rev Respir Med 2010; 4:661-72. [PMID: 20923343 DOI: 10.1586/ers.10.52] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
It is estimated that 50-70% of acute exacerbations of chronic bronchitis (AECB) are caused by bacterial infections. Appropriate selection of antimicrobials may lead to better outcomes and reduced healthcare costs. Respiratory fluoroquinolones (moxifloxacin, levofloxacin and gemifloxacin) have a broad spectrum of activity against most AECB-causing pathogens and are used as first-line treatment in patients with comorbidity, severe airway obstruction or recurrent exacerbations. We review studies, identified through a MEDLINE search, that compared clinical efficacy and speed of recovery for short-course (≤ 5 days) fluoroquinolone therapy with commonly prescribed standard therapy (≥ 7 days). Among 177 studies reporting the use of fluoroquinolones for AECB treatment, 23 used a short-course regimen, shown to be at least as effective as standard therapy of 7 or more days duration. Furthermore, evidence suggests that short-course therapy offers faster resolution of symptoms, faster rate of recovery, fewer relapses, fewer and shorter hospitalizations, and longer time between recurrences.
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Affiliation(s)
- Mark H Gotfried
- College of Medicine, University of Arizona, 1112 East McDowell Road, Phoenix, AZ 85006, USA.
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Anzueto A, Miravitlles M. Short-course fluoroquinolone therapy in exacerbations of chronic bronchitis and COPD. Respir Med 2010; 104:1396-403. [DOI: 10.1016/j.rmed.2010.05.018] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2009] [Revised: 05/25/2010] [Accepted: 05/26/2010] [Indexed: 10/19/2022]
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Sethi S. Antibiotics in acute exacerbations of chronic bronchitis. Expert Rev Anti Infect Ther 2010; 8:405-17. [PMID: 20377336 DOI: 10.1586/eri.09.133] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Acute exacerbations of chronic bronchitis (AECB) are a major contributor to morbidity and mortality in patients with chronic obstructive pulmonary disease, accounting for more than 16 million physician office visits and over 500,000 hospitalizations in the USA each year. Antimicrobials have been recognized by clinical guidelines as an important component in the management of AECB with a bacterial etiology. The challenge of identifying patients most likely to benefit from antimicrobial therapy is difficult in the clinical setting. However, appropriate risk stratification of patients, and the use of antimicrobials within the correct spectrum and for a suitable duration, can improve clinical outcomes while minimizing induction of antimicrobial resistance. With an improved design in pharmacologic and clinical studies, differences can be appreciated among the various antimicrobial agents available to treat AECB. Factors to be considered in antimicrobial agent selection include local tissue penetration, effects on bacteriological eradication, duration of therapy, speed of resolution and prevention or delay of recurrences.
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Affiliation(s)
- Sanjay Sethi
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University at Buffalo SUNY Buffalo, NY, USA.
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Albertson TE, Louie S, Chan AL. The diagnosis and treatment of elderly patients with acute exacerbation of chronic obstructive pulmonary disease and chronic bronchitis. J Am Geriatr Soc 2010; 58:570-9. [PMID: 20398122 PMCID: PMC7166863 DOI: 10.1111/j.1532-5415.2010.02741.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The syndrome of chronic obstructive pulmonary disease (COPD) consists of chronic bronchitis (CB), bronchiectasis, emphysema, and reversible airway disease that combine uniquely in an individual patient. Older patients are at risk for COPD and its components—emphysema, CB, and bronchiectasis. Bacterial and viral infections play a role in acute exacerbations of COPD (AECOPD) and in acute exacerbations of CB (AECB) without features of COPD. Older patients are at risk for resistant bacterial organisms during their episodes of AECOPD and AECB. Organisms include the more‐common bacteria implicated in AECOPD/AECB such as Haemophilus influenzae, Moraxella catarrhalis, and Streptococcus pneumoniae. Less‐common nonenteric, gram‐negative organisms including Pseudomonas aeruginosa, gram‐positive organisms including Staphylococcus aureus, and strains of nontuberculosis Mycobacteria are more often seen in AECOPD/AECB episodes involving elderly patients with frequent episodes of CB or those with bronchiectasis. Risk‐stratified antibiotic treatment guidelines appear useful for purulent episodes of AECOPD and episodes of AECB. These guidelines have not been prospectively validated for the general population and especially not for the elderly population. Using a risk‐stratification approach for elderly patients, first‐line antibiotics (e.g., amoxicillin, ampicillin, pivampicillin, trimethoprim/sulfamethoxazole, and doxycycline), with a more‐limited spectrum of antibacterial coverage, are used in patients who are likely to have a low probability of resistant organisms during AECOPD/AECB. Second‐line antibiotics (e.g., amoxicillin/clavulanic acid, second‐ or third‐generation cephalosporins, and respiratory fluoroquinolones) with a broader spectrum of coverage are reserved for patients with significant risk factors for resistant organisms and those who have failed initial antibiotic treatment.
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Affiliation(s)
- Timothy E Albertson
- Division of Pulmonary, Critical Care and Sleep Medicine, School of Medicine University of California at Davis, Sacramento, California, USA.
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Abstract
Completing its initial phases of drug development in the mid 1990s as the one of the first fluoroquinolones that could be used with confidence to treat respiratory tract infections, levofloxacin went on to become one of the most widely prescribed antibiotics in the world. Available in both oral (po) and intravenous (IV) formulations and with characteristics of over 90% bioavailability, distribution into both extracellular and intracellular pulmonary compartments, highly predictable pharmacokinetics with over 90% of the drug being excreted unchanged in urine, and reliable activity against a broad spectrum of clinically important pathogens, levofloxacin has been used successfully to treat patients with a variety of serious infectious diseases as well as common infections most often treated outside of the hospital setting. Results of clinical trials involving patients with respiratory tract, urinary tract, and skin infections have consistently shown rates of clinical success and bacteriological eradication that were comparable to other widely used broad-spectrum agents. Regimens of levofloxacin, initially involving total daily doses of 250 mg to 500 mg, but more recently regimens involving 750 mg doses, have been shown to be safe and effective. Nearly a decade and a half of clinical experience has defined a safety and tolerability profile that permits data-driven assessment of the risks and benefits of using levofloxacin. As resistance to currently available fluoroquinolones has emerged, the clinical value of levofloxacin deserves continued evaluation. However, consistently high rates of susceptibility of clinically important bacteria, especially among those bacteria that commonly cause respiratory tract infections, such as Streptococcus pneumoniae and Haemophilus influenzae, suggest that this agent will continue to be a widely used well past the 20-year anniversary of its introduction into the antibacterial armamentarium.
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Affiliation(s)
- Gary J. Noel
- Johnson & Johnson Pharmaceutical Research and Development, LLC, Raritan, NJ, USA
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One hundred years of respiratory medicine chronic obstructive pulmonary disease (COPD)—Republished article. ACTA ACUST UNITED AC 2008. [DOI: 10.1016/j.rmedu.2007.11.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Abstract
Chronic obstructive pulmonary disease (COPD) is an increasing health problem and one of the leading causes of morbidity and mortality worldwide, but knowledge about its pathogenesis has increased substantially in recent years. The disease results from interaction between individual risk factors (like enzymatic deficiencies) and environmental exposures to noxious agents, like cigarette smoking, occupational dusts, air pollution and infections in childhood. The main mechanisms that may contribute to airflow limitation in COPD are fixed narrowing of small airways, emphysema and luminal obstruction with mucus secretions. COPD is characterised by a chronic inflammatory process in the pulmonary tissue, with a pattern different from bronchial asthma, associated with extrapulmonary effects and is considered now a complex, systemic disease. Optimal therapeutic targeting of COPD depends on a clear understanding of the precise mechanisms of these complex processes and on early and correct evaluation of disease severity. A combination of pharmacological and non-pharmacological approaches is used to treat COPD. Bronchodilators are the mainstay of COPD treatment and can be combined with inhaled corticosteroids for greater efficacy and fewer side effects. The use of LTOT for hypoxemic patients has resulted in increased survival, and expanded drug therapy options have effectively improved dyspnoea and quality of life. Recent studies have documented the benefits of pulmonary rehabilitation. In addition, non-invasive mechanical ventilation offers new alternatives for patients with acute or chronic failure.
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Affiliation(s)
- Mario Cazzola
- Department of Internal Medicine, Unit of Respiratory Diseases, University of Rome Tor Vergata, Rome, Italy.
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