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Schoffelen T, Papan C, Carrara E, Eljaaly K, Paul M, Keuleyan E, Martin Quirós A, Peiffer-Smadja N, Palos C, May L, Pulia M, Beovic B, Batard E, Resman F, Hulscher M, Schouten J. European Society of Clinical Microbiology and Infectious Diseases (ESCMID) guidelines for Antimicrobial Stewardship in Emergency Departments (endorsed by European Association of Hospital Pharmacists). Clin Microbiol Infect 2024:S1198-743X(24)00251-9. [PMID: 39029872 DOI: 10.1016/j.cmi.2024.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 05/24/2024] [Accepted: 05/26/2024] [Indexed: 07/21/2024]
Abstract
SCOPE This ESCMID guideline provides evidence-based recommendations to support a selection of appropriate antibiotic use practices for patients seen in the emergency department (ED) and guidance for their implementation. The topics addressed in this guideline are: 1) Do biomarkers or rapid pathogen tests improve antibiotic prescribing and/or clinical outcomes? 2) Does taking blood cultures in common infectious syndromes improve antibiotic prescribing and/or clinical outcomes? 3) Does watchful waiting without antibacterial therapy or with delayed antibiotic prescribing reduce antibiotic prescribing without worsening clinical outcomes in patients with specific infectious syndromes? 4) Do structured culture follow-up programs in patients discharged from the ED with cultures pending improve antibiotic prescribing? METHODS An expert panel was convened by ESCMID and the guideline chair. The panel selected in consensus the four most relevant AMS topics according to pre-defined relevance criteria. For each main question for the four topics, a systematic review was performed, including randomized controlled trials and observational studies. Both clinical outcomes as well as stewardship process outcomes related to antibiotic use were deemed relevant. The literature searches were conducted between May 2021 and March 2022. In April 2022, the panel members were formally asked to suggest additional studies that were not identified in the initial searches. Data were summarized in a meta-analysis if possible or otherwise summarized narratively. The certainty of the evidence was classified according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria. The guideline panel reviewed the evidence per topic critically appraising the evidence and formulated recommendations through a consensus-based process. The strength of the recommendations was classified as strong or weak. To substantiate the implementation process, implementation trials or observational studies describing facilitators/barriers for implementation were identified from the same searches and were summarized narratively. RECOMMENDATIONS The recommendations on the use of biomarkers and rapid pathogen diagnostic tests focus on the initiation of antibiotics in patients admitted through the ED. Their effect on the discontinuation or de-escalation of antibiotics during hospital stay was not reported, neither was their effect on hospital infection prevention and control practices. The recommendations on watchful waiting (i.e., withholding antibiotics with some form of follow-up) focus on specific infectious syndromes for which the primary care literature was also included. The recommendations on blood cultures focus on the indication in three common infectious syndromes in the ED explicitly excluding patients with sepsis or septic shock. Most recommendations are based on very-low- and low-certainty of evidence, leading to weak recommendations or, when no evidence was available, to best practice statements. Implementation of these recommendations needs to be adapted to the specific settings and circumstances of the ED. The scarcity of high-quality studies in the area of antimicrobial stewardship in the ED highlights the need for future research in this field.
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Affiliation(s)
- Teske Schoffelen
- Radboud Center for Infectious Diseases, Radboud university medical center, Nijmegen, the Netherlands; Department of Internal Medicine, Radboud university medical center, Nijmegen, the Netherlands.
| | - Cihan Papan
- Institute for Hygiene and Public Health, University Hospital Bonn, Bonn, Germany; Centre for Infectious Diseases, Institute of Medical Microbiology and Hygiene, Saarland University, Homburg, Germany
| | - Elena Carrara
- Division of Infectious Diseases, Department of Diagnostic and Public Health, University of Verona, Verona, Italy
| | - Khalid Eljaaly
- Department of Pharmacy Practice, College of Pharmacy, King Abdulaziz University, Jeddah, Saudi Arabia; King Abdulaziz University Hospital, Jeddah, Saudi Arabia
| | - Mical Paul
- Infectious Diseases, Rambam Health Care Campus, Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| | - Emma Keuleyan
- Department of Clinical Microbiology and Virology, University Hospital Lozenetz, Sofia, Bulgaria; Ministry of Health, Sofia, Bulgaria
| | | | - Nathan Peiffer-Smadja
- Infectious Diseases Department, Bichat-Claude Bernard Hospital, Assistance-Publique Hôpitaux de Paris, Paris, France; Université Paris Cité, INSERM, IAME, F-75018 Paris, France; National Institute for Health Research, Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK
| | - Carlos Palos
- Hospital da Luz, Infection Control and Antimicrobial Resistance Committee, Lisbon, Portugal
| | - Larissa May
- University of California Davis, Department of Emergency Medicine, Sacramento, CA, USA
| | - Michael Pulia
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Bojana Beovic
- Faculty of Medicine, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Eric Batard
- Emergency Department, CHU Nantes, Nantes, France; Cibles et médicaments des infections et du cancer, IICiMed UR1155, Nantes Université, Nantes, France
| | - Fredrik Resman
- Clinical Infection Medicine, Department of Translational Medicine, Lund University, Malmö, Sweden
| | - Marlies Hulscher
- IQ Health science department, Radboud university medical center, Nijmegen, the Netherlands
| | - Jeroen Schouten
- Radboud Center for Infectious Diseases, Radboud university medical center, Nijmegen, the Netherlands; Department of Intensive Care Medicine, Radboud university medical center, Nijmegen, the Netherlands
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Suzuki Y, Sato K, Sato S, Inoue S, Shibata Y. Antibiotic treatment for patients with exacerbation of chronic obstructive pulmonary disease: A systematic review and meta-analysis. Respir Investig 2024; 62:663-668. [PMID: 38761481 DOI: 10.1016/j.resinv.2024.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 04/09/2024] [Accepted: 05/11/2024] [Indexed: 05/20/2024]
Abstract
BACKGROUND Although respiratory tract infection is a significant factor that triggers exacerbation of chronic obstructive pulmonary disease (COPD), the benefit of antibiotics for patients with COPD exacerbation remains controversial. It is necessary to evaluate the efficacy and safety of antibiotics versus placebo in such patients. METHODS We conducted a systematic review and meta-analysis of randomized controlled trials of antibiotics versus placebo for the treatment of COPD exacerbation, and compared the frequencies of treatment failure, mortality, and adverse events between patients treated with antibiotics and those treated with placebo. RESULTS A total of six studies were included in this meta-analysis. The frequency of treatment failure was significantly lower in the antibiotic-treated patients compared to the placebo-treated patients (odds ratios [OR] 0.50, 95% confidence intervals [CI] 0.35-0.71, p = 0.0001). There was no significant difference between the two groups in mortality (OR 0.44, 95% CI 0.05-3.76, p = 0.45) or frequency of adverse events (OR 1.05, 95% CI 0.75-1.48, p = 0.78). CONCLUSION In the current systematic review and meta-analysis, we found that antibiotics were superior to placebo in patients with exacerbated COPD, as shown by the lower treatment failure rate.
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Affiliation(s)
- Yasuhito Suzuki
- Department of Pulmonary Medicine, Fukushima Medical University School of Medicine, 1 Hikarigaoka, Fukushima City, Fukushima, 960-1295, Japan
| | - Kento Sato
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University Faculty of Medicine, 2-2-2 Iida-Nishi, Yamagata-City, Yamagata, 990-9585, Japan
| | - Suguru Sato
- Department of Pulmonary Medicine, Fukushima Medical University School of Medicine, 1 Hikarigaoka, Fukushima City, Fukushima, 960-1295, Japan
| | - Sumito Inoue
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University Faculty of Medicine, 2-2-2 Iida-Nishi, Yamagata-City, Yamagata, 990-9585, Japan
| | - Yoko Shibata
- Department of Pulmonary Medicine, Fukushima Medical University School of Medicine, 1 Hikarigaoka, Fukushima City, Fukushima, 960-1295, Japan.
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3
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Ruiying W, Zhaoyun, Jianying X. Clinical features and three-year prognosis of AECOPD patients with different levels of blood eosinophils. Heart Lung 2022; 56:29-39. [PMID: 35687923 DOI: 10.1016/j.hrtlng.2022.05.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 05/27/2022] [Accepted: 05/28/2022] [Indexed: 01/21/2023]
Abstract
BACKGROUND Eosinophils are thought to be associated with the frequency and severity of acute exacerbations of chronic obstructive pulmonary disease (AECOPD); however, the role of eosinophilic inflammation in AECOPD is still incompletely understood. OBJECTIVES To investigate the relationship between different levels of blood eosinophils and clinical features, including comorbidities, therapy, and prognosis, and to further explore the optimal eosinophilic cutoff. METHODS We retrospectively collected and analyzed medical data, laboratory findings, chest CT images, treatment, and three-year follow-up data from 984 AECOPD patients with different blood eosinophil (EOS) levels: EOS%<2%, ≥2%; EOS%<3%, ≥3%; eosinophil counts<100 cells/L, ≥100 cells/L. RESULTS The prevalence of eosinophilia was 36.48% of EOS≥2% (359 cases), 22.87% of EOS≥3% (225 cases), and 48.48% with eosinophil counts≥100 cells/µl (477 cases). EOS was associated with comorbidities, including pulmonary heart disease, arrhythmia (atrial fibrillation), laboratory testing and clinical treatment, including respiratory failure, airway limitation, infectious inflammation, rate of antibiotic use, systemic glucocorticoids, and three mortality rates. The ROC curve showed that the indicators of AUC≥0.5 included chest CT imaging (emphysema 1.8% or ≥100/µl, bronchitis, 1.7% or ≥100/µl), osteoporosis (2.4% or ≥140/µl), mental illness 6.1% (or ≥400/µl), dust exposure (2.2% or ≥240/µl) and ex-smoker (1.3% or ≥100/µl). CONCLUSIONS The relatively higher EOS group (≥2% or ≥100/µl) was associated with fewer complications, mild airflow limitation, a tendency of noninfectious inflammation, and lower 3-year mortality. Eosinophils can not only guide clinical treatment but also be an indicator of predicting clinical outcome and prognosis in AECOPD patients.
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Affiliation(s)
- Wang Ruiying
- Department of Pulmonary and Critical Care Medicine, Shanxi Bethune Hospital Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan 030032, China.
| | - Zhaoyun
- Department of Pulmonary and Critical Care Medicine, Shanxi Bethune Hospital Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan 030032, China
| | - Xu Jianying
- Department of Pulmonary and Critical Care Medicine, Shanxi Bethune Hospital Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan 030032, China
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van Brummelen S, Tramper-Stranders G, Jonkman K, de Boer G, in ’t Veen J, Braunstahl GJ. Antibiotic Prescriptions in Hospitalized Patients with an Exacerbation COPD and a Proven Influenza or RS Virus Infection. Int J Chron Obstruct Pulmon Dis 2022; 17:1261-1267. [PMID: 35673596 PMCID: PMC9167590 DOI: 10.2147/copd.s361841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 05/19/2022] [Indexed: 11/23/2022] Open
Abstract
Background COPD exacerbations (AE-COPD) add up to over 200,000 hospitalization days annually in the Netherlands. Viral respiratory infections play a role in about half of COPD exacerbations. Although the prevalence of bacterial superinfection is estimated 10–40% in admitted AE-COPD patients with an influenza infection, the majority is treated with antibiotics. Current national and international guidelines provide limited guidance regarding antibiotic use in hospitalized patients with an AE-COPD with proven viral respiratory pathogens. Study Goal We aimed to investigate antibiotic prescription in hospitalized patients with a COPD exacerbation and an influenza- or RS virus infection. Patients and methods We performed a retrospective cohort study in patients admitted with an AE-COPD and influenza- or RS virus infection. We compared clinical characteristics of patients with and without antibiotic treatment on admission and estimated adequacy of antibiotic prescriptions. Results We included 134 patients. Seventy-nine (59%) received antibiotics on admission. Chest X-ray infiltrates and plasma CRP level (≥50 mg/L) were correlated with the prescription of antibiotics. Outcomes, such as number of hospitalized days and mortality, were not significantly different between the groups with and without antibiotic treatment. Antibiotic treatment was considered “probably adequate” in 52/79 (65.8%) patients; “not necessary” in 12/79 patients (15.2%) and “probably not necessary” in another 15/79 patients (19.0%). Conclusion Prescription of antibiotics in hospitalized COPD patients is common practice despite a proven viral infection on admission. A significant antibiotic reduction of 34.2% in these patients seems feasible. Future guidelines should include recommendations regarding antibiotic stewardship in hospitalized patients with AE-COPD with a proven viral respiratory infection.
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Affiliation(s)
- Sigrid van Brummelen
- Department of Pulmonology, Franciscus Gasthuis and Vlietland, Rotterdam, 3045 PM, the Netherlands
- Correspondence: Sigrid van Brummelen, Department of Pulmonology, Franciscus Gasthuis and Vlietland, Kleiweg 500, Rotterdam, 3045 PM, the Netherlands, Email
| | | | - Kelly Jonkman
- Department of Pulmonology, Franciscus Gasthuis and Vlietland, Rotterdam, 3045 PM, the Netherlands
| | - Geertje de Boer
- Department of Pulmonology, Franciscus Gasthuis and Vlietland, Rotterdam, 3045 PM, the Netherlands
- Department of Pulmonology, Erasmus Medical Center, Rotterdam, 3015 GD, the Netherlands
| | - Johannes in ’t Veen
- Department of Pulmonology, Franciscus Gasthuis and Vlietland, Rotterdam, 3045 PM, the Netherlands
- Department of Pulmonology, Erasmus Medical Center, Rotterdam, 3015 GD, the Netherlands
| | - Gert-Jan Braunstahl
- Department of Pulmonology, Franciscus Gasthuis and Vlietland, Rotterdam, 3045 PM, the Netherlands
- Department of Pulmonology, Erasmus Medical Center, Rotterdam, 3015 GD, the Netherlands
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5
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Barber D, Pilsworth S, Wat D. Does availability of point of care C-reactive protein measurement affect provision of antibiotics in a community respiratory service? Br J Community Nurs 2022; 27:218-224. [PMID: 35522449 DOI: 10.12968/bjcn.2022.27.5.218] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Antibiotic resistance presents a growing threat to health systems and patients at a global scale. Point of care (POC) C-reactive protein (CRP) measurement, as an adjunct to exacerbation assessment, has been studied in primary and secondary care and may represent a useful tool for community teams. A retrospective service review was conducted to determine the effect of CRP measurement on antibiotic provision in a community respiratory setting, with chronic obstructive pulmonary disease (COPD) and bronchiectasis exacerbations. This review compared antibiotic provision for COPD and bronchiectasis patients for those where CRP was measured versus those where it was not. It was found that antibiotic provision dropped by almost 25% points for COPD exacerbations, and almost 59% in bronchiectasis, when a CRP measurement was taken as a component of a respiratory assessment. Antibiotics were also provided at a greater amount based on symptom presentation. Therefore, it is concluded that CRP measurement correlates with a reduction in antibiotic provision, highlighting its use alongside symptom assessment in future work.
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Affiliation(s)
- David Barber
- Advanced Practitioner; Knowsley Community Respiratory Service, Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool
| | - Samantha Pilsworth
- Consultant Physiotherapist; Knowsley Community Respiratory Service, Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool
| | - Dennis Wat
- Consultant Respiratory Physican, Knowsley Community Respiratory Service, Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool
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6
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Mao Y, Fu T, Wang L, Wang C. The efficacy and safety of antibiotics and glucocorticoids in the treatment of elderly patients with chronic obstructive emphysema: systematic review and meta-analysis. ANNALS OF TRANSLATIONAL MEDICINE 2022; 10:287. [PMID: 35433939 PMCID: PMC9011238 DOI: 10.21037/atm-22-239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 03/04/2022] [Indexed: 12/02/2022]
Abstract
Background To systematically evaluate the efficacy and safety of inhaled corticosteroids (ICS) combined with antibiotics in the treatment of elderly chronic obstructive pulmonary disease (COPD) patients, and to provide some reference for the optimization of clinical treatment regimen for elderly COPD patients. Methods Combination of perfect search and keywords from the Chinese and foreign language databases, and the Cochrane Collaboration Center provided Review Manger 5.2 software [Cochrane Information Management System (IMS)] for statistical analysis, and the risk ratio (RR) of dichotic variables was adopted. RR and 95% confidence interval (95% CI) were used as efficacy and side effects analysis statistics in metaanalysis. Results After independent screening by two researchers, 18 studies were included into the meta-analysis. After data analysis and statistics, the results of meta-analysis showed that the observation group (glucocorticoid combined with antibiotic treatment) and the control group (glucocorticoid therapy) first second forced expiratory volume (FEV1%) expected value (OR =1.21; 95% CI: 0.11–2.32; P=0.03), and 6-min walking distances (6-MWDs) (OR =12.92; 95% CI: 4.61–21.22; P=0.002), the COPD Assessment Test (CAT) score (OR =3.08; 95% CI: 2.58−3.57; P<0.00001) the improvement was statistically significant; incidence of adverse reactions (OR =1.24; 95% CI: 0.58–2.67; P=0.58), the incidence of acute exacerbation (OR =0.65; 95% CI: 0.39–1.08; P=0.10), FEV1 (OR =0.07; 95% CI: 0.01–0.15; P=0.09). There was no statistical difference. Discussion The combination of glucocorticoids and antibiotics in elderly patients with stable COPD can significantly improve their lung function and exercise ability with minimal adverse reactions.
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Affiliation(s)
- Yanqing Mao
- Department of General Practice, The First Affiliated Hospital of Soochow University, Suzhou, China.,Department of General Practice, Dushu Lake Hospital Affiliated to Soochow University, Suzhou, China
| | - Ting Fu
- Department of General Practice, Dushu Lake Hospital Affiliated to Soochow University, Suzhou, China
| | - Ling Wang
- Department of General Practice, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Chunjie Wang
- Department of General Practice, Dushu Lake Hospital Affiliated to Soochow University, Suzhou, China
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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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Li QY, An ZY, Pan ZH, Qi RY. Rationale and design of REGULATE: an observational study protocol for relationship between plasma metabolome and the efficacy of systemic glucocorticoid in acute exacerbation of chronic obstructive pulmonary disease. BMC Pulm Med 2021; 21:250. [PMID: 34320980 PMCID: PMC8317418 DOI: 10.1186/s12890-021-01614-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 07/21/2021] [Indexed: 12/03/2022] Open
Abstract
Background Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) significantly increases the mortality of patients with COPD. Guidelines have recommended systemic glucocorticoid as a regular treatment. Recently, evidence has shown that systemic glucocorticoid cannot be a benefit to all of the patients with AECOPD. Thus, the problem that how the clinicians can screen the patients who can benefit from systemic glucocorticoid needs to be solved urgently. This study is aimed to detect the metabolic biomarkers and metabolic pathways that are related to the efficacy of systemic glucocorticoid and contribute to the precise treatment of COPD. Methods and design In this study, we will utilize ultraperformance liquid chromatography/mass spectrometry (LC–MS) and gas chromatography/mass spectrometry (GC–MS) methods for the analysis of the metabolites in AECOPD patients and compare the metabolites profiles between patients with systemic glucocorticoid treatment success group and treatment failure group. We aim to detect the metabolic biomarkers and metabolic pathways that are related to the efficacy of systemic glucocorticoid and contribute to the precise treatment of COPD. Discussion Previous studies have found that plasma metabolome changed significantly after dexamethasone treatment in healthy participants. Furthermore, inter-person variability was high and remained uninfluenced by treatment, suggesting the potential of metabolomics for predicting the efficacy and side effects of systemic glucocorticoid. Therefore, we hypothesized that metabolome changes in patients with AECOPD may be associated with the efficacy of systemic glucocorticoid. Trial registration Clinicaltrials.gov registration number NCT04710849. Registered 15 January 2021, https://clinicaltrials.gov/ct2/show/NCT04710849.
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Affiliation(s)
- Qiu-Yu Li
- Department of Respiratory and Critical Care Medicine, Peking University Third Hospital, Beijing, 100191, People's Republic of China.
| | - Zhuo-Yu An
- Peking University Institute of Hematology, Peking University People's Hospital, Beijing, 100191, People's Republic of China
| | - Zi-Han Pan
- Department of Respiratory and Critical Care Medicine, Peking University Third Hospital, Beijing, 100191, People's Republic of China
| | - Rui-Ying Qi
- Department of Respiratory and Critical Care Medicine, Peking University Third Hospital, Beijing, 100191, People's Republic of China
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Schroeder T, Kruse JM, Marcy F, Piper SK, Storm C, Nee J. Is the routine use of antipseudomonal antibiotics in acutely exacerbated COPD patients indicated: A retrospective analysis in 437 ICU patients. J Crit Care 2021; 65:49-55. [PMID: 34082255 DOI: 10.1016/j.jcrc.2021.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 05/20/2021] [Accepted: 05/20/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE Chronic obstructive pulmonary disease (COPD) is a risk factor for acquiring multiple drug resistant bacteria. The main objective of this analysis was to question a beneficial outcome in the routine use of antipseudomonal antibiotics in the empiric treatment of severe AECOPD in Intensive Care Unit patients. MATERIAL AND METHODS We report a retrospective, observational cohort study in adult patients with severe AECOPD admitted to ICU at a tertiary care university hospital. Antibiotic treatment on admission as well as microbiology samples were analyzed. The influence of SOFA score at admission, age, sex and antibiotic choice upon survival was investigated by multivariable analysis. RESULTS 437 patients were included. Mean age was 68 years (±10), 46.5% were female. 271/437 patients (62%) were initially treated with antibiotics covering Pseudomonas aeruginosa. Overall, positive microbiology samples were found in 107 patients (24.5%). P. aeruginosa was only found in 3.7%. There was no significant difference in 30-day ICU mortality after adjusting for age, sex and severity of illness (20.4% ± 11.6 in patients with Pseudomonas inactive antibiotics versus 29.3% ± 10.8 in patients with PAA, p=0.113). CONCLUSIONS Empiric use of antipseudomonal antibiotics did not result in improved ICU survival in this retrospective analysis.
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Affiliation(s)
- Tim Schroeder
- Charité - Universitätsmedizin Berlin, Department of Nephrology and Medical Intensive Care Medicine, Berlin, Germany.
| | - Jan Matthias Kruse
- Charité - Universitätsmedizin Berlin, Department of Nephrology and Medical Intensive Care Medicine, Berlin, Germany
| | - Florian Marcy
- Charité - Universitätsmedizin Berlin, Department of Nephrology and Medical Intensive Care Medicine, Berlin, Germany
| | - Sophie K Piper
- Charité - Universitätsmedizin Berlin, Institute of Biometry and Clinical Epidemiology, Berlin, Germany; Berlin Institute of Health (BIH), Anna-Louisa-Karsch-Strasse 2, 10178 Berlin, Germany
| | - Christian Storm
- Charité - Universitätsmedizin Berlin, Department of Nephrology and Medical Intensive Care Medicine, Berlin, Germany
| | - Jens Nee
- Charité - Universitätsmedizin Berlin, Department of Nephrology and Medical Intensive Care Medicine, Berlin, Germany
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10
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Mohamed Amine M, Selma M, Adel S, Khaoula BHA, Mohamed Hassene K, Imen T, Ahmed A, Nadia BB, Yosra BD, Rabie R, Mohamed Habib G, Kaouthar B, Mehdi M, Asma B, Wahid B, Riadh B, Hamdi B, Semir N. 2-Day versus C-reactive protein guided antibiotherapy with levofloxacin in acute COPD exacerbation: A randomized controlled trial. PLoS One 2021; 16:e0251716. [PMID: 34015041 PMCID: PMC8136675 DOI: 10.1371/journal.pone.0251716] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 04/28/2021] [Indexed: 01/31/2023] Open
Abstract
INTRODUCTION Duration of antibiotic treatment in acute exacerbation of COPD (AECOPD) is most commonly based on expert opinion. Biomarker guided strategy is increasingly recommended to limit unnecessary antibiotic use. We performed a randomized controlled study to evaluate the efficacy of 2-day versus C-reactive protein (CRP)-guided treatment with levofloxacin in patients with AECOPD. METHODS Patients with AECOPD were randomized to receive oral levofloxacin daily for 7 days unless the serum CRP level decreased by at least 50% from the baseline value or levofloxacin for two days; thereafter, oral placebo tablet was prescribed according to the CRP. The primary outcome measure was cure rate, and secondary outcome included need for additional antibiotics, intensive care unit (ICU) admission, exacerbation rates and exacerbation free interval (EFI) within one-year follow-up. RESULTS In intention to treat (ITT) analysis, cure rate was 76.1% (n = 118) and 79.3% (n = 123) respectively in 2-day and CRP-guided groups. In per protocol (PP) analysis, cure rate was 73% (n = 92) and 70.4% (n = 88) respectively in 2-day and CRP-guided groups. The difference between the two groups was not significant. The need for additional antibiotics and ICU admission rates were not significantly different between the two groups. One-year exacerbation rate was 27% (n = 42) in 2-day group versus 30.3% (n = 47) in CRP-guided group (p = 0.53); the EFI was 125 days (interquartile range, 100-151) versus 100 days (interquartile range, 78-123) in 2-day and CRP-guided groups respectively (p = 0.45). No difference in adverse effects was detected. CONCLUSION Levofloxacin once daily for 2 days had similar efficacy compared to CRP-guided in AECOPD. This short course treatment decreased antibiotic consumption which would improve patient compliance and reduce adverse effects.
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Affiliation(s)
- Msolli Mohamed Amine
- Emergency Department, Fattouma Bourguiba University Hospital, Monastir, Tunisia
- Research Laboratory LR12SP18, Monastir University, Monastir, Tunisia
| | - Messous Selma
- Research Laboratory LR12SP18, Monastir University, Monastir, Tunisia
| | - Sekma Adel
- Emergency Department, Fattouma Bourguiba University Hospital, Monastir, Tunisia
- Research Laboratory LR12SP18, Monastir University, Monastir, Tunisia
| | - Bel haj ali Khaoula
- Emergency Department, Fattouma Bourguiba University Hospital, Monastir, Tunisia
- Research Laboratory LR12SP18, Monastir University, Monastir, Tunisia
| | - Khalil Mohamed Hassene
- Emergency Department, Fattouma Bourguiba University Hospital, Monastir, Tunisia
- Research Laboratory LR12SP18, Monastir University, Monastir, Tunisia
| | - Trabelsi Imen
- Research Laboratory LR12SP18, Monastir University, Monastir, Tunisia
| | - Abdelghani Ahmed
- Pneumology Department, Farhat Hached University Hospital, Sousse, Tunisia
| | - Ben Brahim Nadia
- Emergency Department, Fattouma Bourguiba University Hospital, Monastir, Tunisia
- Research Laboratory LR12SP18, Monastir University, Monastir, Tunisia
| | | | | | - Grissa Mohamed Habib
- Emergency Department, Fattouma Bourguiba University Hospital, Monastir, Tunisia
- Research Laboratory LR12SP18, Monastir University, Monastir, Tunisia
| | - Beltaief Kaouthar
- Emergency Department, Fattouma Bourguiba University Hospital, Monastir, Tunisia
- Research Laboratory LR12SP18, Monastir University, Monastir, Tunisia
| | - Methamem Mehdi
- Emergency Department, Farhat Hached University Hospital, Sousse, Tunisia
| | - Belguith Asma
- Department of Preventive Medicine, Fattouma Bourguiba University Hospital, Monastir, Tunisia
| | - Bouida Wahid
- Emergency Department, Fattouma Bourguiba University Hospital, Monastir, Tunisia
- Research Laboratory LR12SP18, Monastir University, Monastir, Tunisia
| | - Boukef Riadh
- Research Laboratory LR12SP18, Monastir University, Monastir, Tunisia
- Emergency Department, Sahloul University Hospital, Sousse, Tunisia
| | - Boubaker Hamdi
- Emergency Department, Fattouma Bourguiba University Hospital, Monastir, Tunisia
- Research Laboratory LR12SP18, Monastir University, Monastir, Tunisia
| | - Nouira Semir
- Emergency Department, Fattouma Bourguiba University Hospital, Monastir, Tunisia
- Research Laboratory LR12SP18, Monastir University, Monastir, Tunisia
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Associations with antibiotic prescribing for acute exacerbation of COPD in primary care: secondary analysis of a randomised controlled trial. Br J Gen Pract 2021; 71:e266-e272. [PMID: 33657007 DOI: 10.3399/bjgp.2020.0823] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 11/23/2020] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND C-reactive protein (CRP) point-of-care testing can reduce antibiotic use in patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) in primary care, without compromising patient care. Further safe reductions may be possible. AIM To investigate the associations between presenting features and antibiotic prescribing in patients with AECOPD in primary care. DESIGN AND SETTING Secondary analysis of a randomised controlled trial of participants presenting with AECOPD in primary care (the PACE trial). METHOD Clinicians collected participants' demographic features, comorbid illnesses, clinical signs, and symptoms. Antibiotic prescribing decisions were made after participants were randomised to receive a point-of-care CRP measurement or usual care. Multivariable regression models were fitted to explore the association between patient and clinical features and antibiotic prescribing, and extended to further explore any interactions with CRP measurement category (CRP not measured, CRP <20 mg/l, or CRP ≥20 mg/l). RESULTS A total of 649 participants from 86 general practices across England and Wales were included. Odds of antibiotic prescribing were higher in the presence of clinician-recorded crackles (adjusted odds ratio [AOR] = 5.22, 95% confidence interval [CI] = 3.24 to 8.41), wheeze (AOR = 1.64, 95% CI = 1.07 to 2.52), diminished vesicular breathing (AOR = 2.95, 95% CI = 1.70 to 5.10), or clinician-reported evidence of consolidation (AOR = 34.40, 95% CI = 2.84 to 417.27). Increased age was associated with lower odds of antibiotic prescribing (AOR per additional year increase = 0.98, 95% CI = 0.95 to 1.00), as was the presence of heart failure (AOR = 0.32, 95% CI = 0.12 to 0.85). CONCLUSION Several demographic features and clinical signs and symptoms are associated with antibiotic prescribing in AECOPD. Diagnostic and prognostic value of these features may help identify further safe reductions.
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12
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Prins HJ, Duijkers R, Daniels JMA, van der Molen T, van der Werf TS, Boersma W. COPD-Lower Respiratory Tract Infection Visual Analogue Score (c-LRTI-VAS) validation in stable and exacerbated patients with COPD. BMJ Open Respir Res 2021; 8:8/1/e000761. [PMID: 33593795 PMCID: PMC7888334 DOI: 10.1136/bmjresp-2020-000761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 11/02/2020] [Accepted: 11/04/2020] [Indexed: 12/05/2022] Open
Abstract
Background We developed the chronic obstructive pulmonary disease (COPD)-Lower Respiratory Tract Infection-Visual Analogue Score (c-LRTI-VAS) in order to easily quantify symptoms during exacerbations in patients with COPD. This study aimed to validate this score. Methods In our study, patients with stable COPD as well as those with an acute exacerbations of COPD (AECOPD) were included. The results of c-LRTI-VAS were compared with other markers of disease activity (lung function parameters, oxygen saturation and two health related quality of life questionnaires (St Georges Respiratory Questionnaire (SGRQ) and Clinical COPD Questionnaire (CCQ)) and validity, reliability and responsiveness were assessed. Results Eighty-eight patients with clinically stable COPD and 102 patients who had an AECOPD completed the c-LRTI-VAS questionnaire. When testing on two separate occasions for repeatability, no statistically significant difference between total scores was found 0.143 (SD 5.42) (p=0.826). Internal consistency was high across items (Cronbach’s apha 0.755). Correlation with SGRQ and CCQ total scores was moderate to high. After treatment for hospitalised AECOPD, the mean c-LRTI-VAS total score improved 8.14 points (SD 9.13; p≤0.001). Conclusions c-LRTI-VAS showed proper validity, responsiveness to change and moderate to high correlation with other questionnaires. It, therefore, appears a reliable tool for symptom measurement during AECOPD. Trial registration number NCT01232140.
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Affiliation(s)
- Hendrik Johannes Prins
- Department Pulmonary Diseases, Noordwest Ziekenhuisgroep, Alkmaar, Noord-Holland, The Netherlands
| | - Ruud Duijkers
- Department Pulmonary Diseases, Noordwest Ziekenhuisgroep, Alkmaar, Noord-Holland, The Netherlands
| | - Johannes M A Daniels
- Pulmonary Diseases, Vrije Universiteit Amsterdam, Amsterdam, Noord-Holland, The Netherlands
| | - Thys van der Molen
- Department of Pulmonary Diseases & Tuberculosis, University Medical Centre Groningen, Groningen, Groningen, The Netherlands
| | - Tjip S van der Werf
- Infectious diseases Service and Tuberculosis unit, University of Groningen Faculty of Medical Sciences, Groningen, Groningen, The Netherlands
| | - Wim Boersma
- pulmonary disease, Noordwest Ziekenhuisgroep, Alkmaar, Noord-Holland, The Netherlands
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13
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Varol Y, Karakurt Z, Çırak AK, Şahin HD, Kıraklı C, Kömürcüoğlu B. Inappropriate Utilization of Antibiotics in COPD Exacerbations. Turk Thorac J 2020; 21:397-403. [PMID: 33352095 DOI: 10.5152/turkthoracj.2020.19074] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 12/16/2019] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Most exacerbations are mild to moderate, and antibiotic treatment for acute exacerbations of chronic obstructive pulmonary disease (AECOPD) is recommended for patients with severe exacerbations or severe underlying chronic obstructive pulmonary disease (COPD). Therefore, we aimed to investigate the patient factors that are associated with the prescription of antibiotics for inappropriate indication in AECOPD. MATERIAL AND METHODS This study was an observational cross-sectional study conducted in an outpatient clinic. The patients diagnosed with AECOPD and prescribed an antibiotic by a pulmonary physician were enrolled in the study. These prescriptions were documented by the pharmacist who asked the patient about the three cardinal symptoms. Appropriate and inappropriate prescription groups were defined by the types of exacerbations, as defined by the Global Initiative for Chronic Obstructive Lung Disease (GOLD) COPD report. RESULTS There were 138 patients, predominantly male (83%), with a mean age of 64 (±9) years. A total of 64% of the prescriptions were appropriate; however, there were 50 (36%) patients with inappropriate antibiotic prescription according to the mentioned criteria. When we compared the patient factors between the appropriate and inappropriate antibiotic prescriptions, there was no statistically significant difference in terms of age, Forced expiratory volume in first second % (FEV1%) predicted, FEV1 ml, forced vital capacity (FVC) ml, FEV1/FVC, and amount (packs/year) of smoking (p>0.05 for all parameters). FVC% was statistically significantly lower in the appropriate antibiotic prescription group compared with that in the inappropriate antibiotic prescription group (p=0.049). CONCLUSION This study shows that most pulmonary physicians have a tendency to prescribe antibiotics for AECOPD according to the defined GOLD criteria. However, some of the physicians also prefer to prescribe antibiotics self-directedly, irrespective of the GOLD criteria. A physician-based questionnaire can be completed for future studies to define the underlying reasons for antibiotic prescription demands for cases of mild AECOPD.
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Affiliation(s)
- Yelda Varol
- Department of Pulmonology, University of Health Sciences, Dr. Suat Seren Chest Diseases and Surgery Training and Research Hospital, İzmir, Turkey
| | - Zuhal Karakurt
- Department of Pulmonology, University of Health Sciences, Süreyyapasa Chest Diseases and Surgery Training and Research Hospital, İstanbul, Turkey
| | - Ali Kadri Çırak
- Department of Pulmonology, University of Health Sciences, Dr. Suat Seren Chest Diseases and Surgery Training and Research Hospital, İzmir, Turkey
| | - Hülya Doğan Şahin
- Department of Pulmonology, University of Health Sciences, Dr. Suat Seren Chest Diseases and Surgery Training and Research Hospital, İzmir, Turkey
| | - Cenk Kıraklı
- Department of Pulmonology, University of Health Sciences, Dr. Suat Seren Chest Diseases and Surgery Training and Research Hospital, İzmir, Turkey
| | - Berna Kömürcüoğlu
- Department of Pulmonology, University of Health Sciences, Dr. Suat Seren Chest Diseases and Surgery Training and Research Hospital, İzmir, Turkey
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14
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Kunadharaju R, Sethi S. Treatment of Acute Exacerbations in Chronic Obstructive Pulmonary Disease. Clin Chest Med 2020; 41:439-451. [PMID: 32800197 DOI: 10.1016/j.ccm.2020.06.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Management of a chronic obstructive pulmonary disease (COPD) exacerbation begins with an accurate diagnosis. Although more than 80% of exacerbations are managed on an outpatient basis, hospitalization is all too common and associated with considerable health care costs and mortality. Irrespective of the site of treatment, the treatment modalities are the same. Noninvasive ventilation has greatly decreased the mortality in exacerbations that require ventilatory support. Across the range of exacerbation severity, treatment failure and relapses are frequent, and should be carefully evaluated. New therapeutic options to address infection and inflammation in COPD are needed to improve the outcome of exacerbations.
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Affiliation(s)
- Rajesh Kunadharaju
- Division of Pulmonary/Critical Care and Sleep Medicine, Department of Medicine, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, SUNY, Buffalo, NY, USA
| | - Sanjay Sethi
- Division of Pulmonary/Critical Care and Sleep Medicine, Department of Medicine, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, SUNY, Buffalo, NY, USA; Clinical and Translational Research Center, Room 6045A, 875 Ellicott Street, Buffalo, NY 14203, USA.
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15
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Association of sputum microbiome with clinical outcome of initial antibiotic treatment in hospitalized patients with acute exacerbations of COPD. Pharmacol Res 2020; 160:105095. [PMID: 32730904 DOI: 10.1016/j.phrs.2020.105095] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 07/17/2020] [Accepted: 07/19/2020] [Indexed: 12/14/2022]
Abstract
Identification of risk factors for antibiotic treatment failure is urgently needed in acute exacerbations of chronic obstructive pulmonary disease (AECOPD). Here we investigated the relationship between sputum microbiome and clinical outcome of choice of initial antibiotics during hospitalization of AECOPD patients. Sputum samples of 41 AECOPD patients and 26 healthy controls were collected from Guangzhou Medical University, China. Samples were processed for 16S rRNA gene-based microbiome profiling. Thirty patients recovered with initial antibiotic treatment (antibiotic success or AS), while 11 patients showed poor outcome (antibiotic failure or AF). Substantial differences in microbiome were observed in AF versus AS patients and healthy controls. There was significantly decreased alpha diversity and increased relative abundances of Pseudomonas, Achromobacter, Stenotrophomonas and Ralstonia in AF patients. Conversely, Prevotella, Peptostreptococcus, Leptotrichia and Selenomonas were depleted. The prevalence of Selenomonas was markedly reduced in AF versus AS patients (9.1 % versus 60.0 %, P = 0.004). The AF patients with similar microbiome profiles in general responded well to the same new antibiotics in the adjusted therapy, indicating sputum microbiome may help guide the adjustment of antibiotics. Random forest analysis identified five microbiome operational taxonomic units together with C-reactive protein, procalcitonin and blood neutrophil count showing best predictability for antibiotic treatment outcome (area under curve 0.885). Functional inference revealed an enrichment of microbial genes in xenobiotic metabolism and antimicrobial resistance in AF patients, whereas genes in DNA repair and amino acid metabolism were depleted. Sputum microbiome may determine the clinical outcome of initial antibiotic treatment and be considered in the risk management of antibiotics in AECOPD.
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16
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Acute exacerbations in chronic obstructive pulmonary disease: should we use antibiotics and if so, which ones? Curr Opin Infect Dis 2020; 32:143-151. [PMID: 30672788 DOI: 10.1097/qco.0000000000000533] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
PURPOSE OF REVIEW Acute exacerbations are a major cause of morbidity and mortality in chronic obstructive pulmonary disease (COPD) with evidence suggesting at least 50% of exacerbations involve bacteria that benefit from antibiotic treatment. Here, we review the most relevant data regarding the use of antibiotics in exacerbations of COPD and provide insights on the selection of initial antibiotic therapy for their treatment. RECENT FINDINGS Identification of bacterial exacerbations still relies on clinical assessment rather than laboratory biomarkers. Several recent studies, including a meta-analysis and placebo-controlled trials, demonstrate improved outcomes with antibiotics in all but mild exacerbations of COPD, including both inpatient and outpatient. A broader antibiotic regimen should be used for patients who have risk factors for poor outcomes. A risk-stratification approach can guide antibiotic choice, although the stratification algorithm still needs to be validated in a randomized controlled trial. SUMMARY The use of antibiotics for the treatment of moderate-to-severe suspected bacterial exacerbations in COPD is supported by published trials and evidence-based systematic reviews. Recent trials also show differences in outcomes based on antibiotic choice. More research is necessary to evaluate risk stratification approaches when selecting initial antibiotic therapy.
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Dobler CC, Morrow AS, Beuschel B, Farah MH, Majzoub AM, Wilson ME, Hasan B, Seisa MO, Daraz L, Prokop LJ, Murad MH, Wang Z. Pharmacologic Therapies in Patients With Exacerbation of Chronic Obstructive Pulmonary Disease: A Systematic Review With Meta-analysis. Ann Intern Med 2020; 172:413-422. [PMID: 32092762 DOI: 10.7326/m19-3007] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Chronic obstructive pulmonary disease (COPD) is characterized by frequent exacerbations. PURPOSE To evaluate the comparative effectiveness and adverse events (AEs) of pharmacologic interventions for adults with exacerbation of COPD. DATA SOURCES English-language searches of several bibliographic sources from database inception to 2 January 2019. STUDY SELECTION 68 randomized controlled trials that enrolled adults with exacerbation of COPD treated in out- or inpatient settings other than intensive care and compared pharmacologic therapies with placebo, "usual care," or other pharmacologic interventions. DATA EXTRACTION Two reviewers independently extracted data and rated study quality and strength of evidence (SOE). DATA SYNTHESIS Compared with placebo or management without antibiotics, antibiotics given for 3 to 14 days were associated with increased exacerbation resolution at the end of the intervention (odds ratio [OR], 2.03 [95% CI, 1.47 to 2.80]; moderate SOE) and less treatment failure at the end of the intervention (OR, 0.54 [CI, 0.34 to 0.86]; moderate SOE), independent of severity of exacerbations in out- and inpatients. Compared with placebo in out- and inpatients, systemic corticosteroids given for 9 to 56 days were associated with less treatment failure at the end of the intervention (OR, 0.01 [CI, 0.00 to 0.13]; low SOE) but also with a higher number of total and endocrine-related AEs. Compared with placebo or usual care in inpatients, other pharmacologic interventions (aminophyllines, magnesium sulfate, anti-inflammatory agents, inhaled corticosteroids, and short-acting bronchodilators) had insufficient evidence, showing either no or inconclusive effects (with the exception of the mucolytic erdosteine) or improvement only in lung function. LIMITATION Scant evidence for many interventions; several studies had unclear or high risk of bias and inadequate reporting of AEs. CONCLUSION Antibiotics and systemic corticosteroids reduce treatment failure in adults with mild to severe exacerbation of COPD. PRIMARY FUNDING SOURCE Agency for Healthcare Research and Quality. (PROSPERO: CRD42018111609).
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Affiliation(s)
- Claudia C Dobler
- Evidence-Based Practice Center, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, and Institute for Evidence-Based Healthcare, Bond University and Gold Coast University Hospital, Gold Coast, Queensland, Australia (C.C.D.)
| | - Allison S Morrow
- Evidence-Based Practice Center, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota (A.S.M., B.B., M.H.F., A.M.M., M.E.W., B.H., M.O.S., L.D., M.H.M., Z.W.)
| | - Bradley Beuschel
- Evidence-Based Practice Center, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota (A.S.M., B.B., M.H.F., A.M.M., M.E.W., B.H., M.O.S., L.D., M.H.M., Z.W.)
| | - Magdoleen H Farah
- Evidence-Based Practice Center, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota (A.S.M., B.B., M.H.F., A.M.M., M.E.W., B.H., M.O.S., L.D., M.H.M., Z.W.)
| | - Abdul M Majzoub
- Evidence-Based Practice Center, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota (A.S.M., B.B., M.H.F., A.M.M., M.E.W., B.H., M.O.S., L.D., M.H.M., Z.W.)
| | - Michael E Wilson
- Evidence-Based Practice Center, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota (A.S.M., B.B., M.H.F., A.M.M., M.E.W., B.H., M.O.S., L.D., M.H.M., Z.W.)
| | - Bashar Hasan
- Evidence-Based Practice Center, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota (A.S.M., B.B., M.H.F., A.M.M., M.E.W., B.H., M.O.S., L.D., M.H.M., Z.W.)
| | - Mohamed O Seisa
- Evidence-Based Practice Center, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota (A.S.M., B.B., M.H.F., A.M.M., M.E.W., B.H., M.O.S., L.D., M.H.M., Z.W.)
| | - Lubna Daraz
- Evidence-Based Practice Center, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota (A.S.M., B.B., M.H.F., A.M.M., M.E.W., B.H., M.O.S., L.D., M.H.M., Z.W.)
| | - Larry J Prokop
- Library Public Services, Mayo Clinic, Rochester, Minnesota (L.J.P.)
| | - M Hassan Murad
- Evidence-Based Practice Center, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota (A.S.M., B.B., M.H.F., A.M.M., M.E.W., B.H., M.O.S., L.D., M.H.M., Z.W.)
| | - Zhen Wang
- Evidence-Based Practice Center, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota (A.S.M., B.B., M.H.F., A.M.M., M.E.W., B.H., M.O.S., L.D., M.H.M., Z.W.)
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18
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Francis NA, Gillespie D, White P, Bates J, Lowe R, Sewell B, Phillips R, Stanton H, Kirby N, Wootton M, Thomas-Jones E, Hood K, Llor C, Cals J, Melbye H, Naik G, Gal M, Fitzsimmons D, Alam MF, Riga E, Cochrane A, Butler CC. C-reactive protein point-of-care testing for safely reducing antibiotics for acute exacerbations of chronic obstructive pulmonary disease: the PACE RCT. Health Technol Assess 2020; 24:1-108. [PMID: 32202490 PMCID: PMC7132534 DOI: 10.3310/hta24150] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Most patients presenting with acute exacerbations of chronic obstructive pulmonary disease (AECOPD) in primary care are prescribed antibiotics, but these may not be beneficial, and they can cause side effects and increase the risk of subsequent resistant infections. Point-of-care tests (POCTs) could safely reduce inappropriate antibiotic prescribing and antimicrobial resistance. OBJECTIVE To determine whether or not the use of a C-reactive protein (CRP) POCT to guide prescribing decisions for AECOPD reduces antibiotic consumption without having a negative impact on chronic obstructive pulmonary disease (COPD) health status and is cost-effective. DESIGN A multicentre, parallel-arm, randomised controlled open trial with an embedded process, and a health economic evaluation. SETTING General practices in Wales and England. A UK NHS perspective was used for the economic analysis. PARTICIPANTS Adults (aged ≥ 40 years) with a primary care diagnosis of COPD, presenting with an AECOPD (with at least one of increased dyspnoea, increased sputum volume and increased sputum purulence) of between 24 hours' and 21 days' duration. INTERVENTION CRP POCTs to guide antibiotic prescribing decisions for AECOPD, compared with usual care (no CRP POCT), using remote online randomisation. MAIN OUTCOME MEASURES Patient-reported antibiotic consumption for AECOPD within 4 weeks post randomisation and COPD health status as measured with the Clinical COPD Questionnaire (CCQ) at 2 weeks. For the economic evaluation, patient-reported resource use and the EuroQol-5 Dimensions were included. RESULTS In total, 653 participants were randomised from 86 general practices. Three withdrew consent and one was randomised in error, leaving 324 participants in the usual-care arm and 325 participants in the CRP POCT arm. Antibiotics were consumed for AECOPD by 212 out of 274 participants (77.4%) and 150 out of 263 participants (57.0%) in the usual-care and CRP POCT arm, respectively [adjusted odds ratio 0.31, 95% confidence interval (CI) 0.20 to 0.47]. The CCQ analysis comprised 282 and 281 participants in the usual-care and CRP POCT arms, respectively, and the adjusted mean CCQ score difference at 2 weeks was 0.19 points (two-sided 90% CI -0.33 to -0.05 points). The upper limit of the CI did not contain the prespecified non-inferiority margin of 0.3. The total cost from a NHS perspective at 4 weeks was £17.59 per patient higher in the CRP POCT arm (95% CI -£34.80 to £69.98; p = 0.408). The mean incremental cost-effectiveness ratios were £222 per 1% reduction in antibiotic consumption compared with usual care at 4 weeks and £15,251 per quality-adjusted life-year gained at 6 months with no significant changes in sensitivity analyses. Patients and clinicians were generally supportive of including CRP POCT in the assessment of AECOPD. CONCLUSIONS A CRP POCT diagnostic strategy achieved meaningful reductions in patient-reported antibiotic consumption without impairing COPD health status or increasing costs. There were no associated harms and both patients and clinicians valued the diagnostic strategy. FUTURE WORK Implementation studies that also build on our qualitative findings could help determine the effect of this intervention over the longer term. TRIAL REGISTRATION Current Controlled Trials ISRCTN24346473. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 15. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Nick A Francis
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | - David Gillespie
- South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Patrick White
- Department of Primary Care & Public Health Sciences, King's College London, London, UK
| | - Janine Bates
- South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Rachel Lowe
- South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Bernadette Sewell
- Swansea Centre for Health Economics, College of Human and Health Sciences, Swansea University, Swansea, UK
| | - Rhiannon Phillips
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | - Helen Stanton
- South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Nigel Kirby
- South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Mandy Wootton
- Specialist Antimicrobial Chemotherapy Unit, University Hospital of Wales, Cardiff, UK
| | - Emma Thomas-Jones
- South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Kerenza Hood
- South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Carl Llor
- University Institute in Primary Care Research Jordi Gol, Via Roma Health Centre, Barcelona, Spain
| | - Jochen Cals
- Department of Family Medicine, CAPHRI Care and Public Health Research Institute, Maastricht University, Maastricht, the Netherlands
| | - Hasse Melbye
- General Practice Research Unit, Department of Community Medicine, Faculty of Health Sciences, University of Tromsø - The Arctic University of Norway, Tromsø, Norway
| | - Gurudutt Naik
- Department of Wound Healing, University Hospital Wales, Cardiff, UK
| | - Micaela Gal
- Wales Primary and Emergency Care Research Centre, Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | - Deborah Fitzsimmons
- Swansea Centre for Health Economics, College of Human and Health Sciences, Swansea University, Swansea, UK
| | - Mohammed Fasihul Alam
- Department of Public Health, College of Health Sciences, Qatar University, Doha, Qatar
| | - Evgenia Riga
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Ann Cochrane
- Department of Primary Care & Public Health Sciences, King's College London, London, UK
| | - Christopher C Butler
- Primary Care and Vaccines Collaborative Clinical Trials Unit, University of Oxford, John Radcliffe Hospital, Oxford, UK
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Procalcitonin and other markers to guide antibiotic use in chronic obstructive pulmonary disease exacerbations in the era of antimicrobial resistance. Curr Opin Pulm Med 2020; 25:158-164. [PMID: 30550505 DOI: 10.1097/mcp.0000000000000555] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
PURPOSE OF REVIEW This review summarizes the latest discoveries regarding the use of clinical indicators and biomarkers to guide antibiotic use in patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD), and it analyzes the advantages and disadvantages of various indicators and markers. RECENT FINDINGS For AECOPD patients admitted to emergency departments and medical wards, procalcitonin (PCT)-guided antibiotic therapy reduced antibiotic use without adverse outcomes. In contrast, for severe AECOPD patients admitted to ICUs, PCT-guided antibiotic therapy increased the overall mortality in a 3-month follow-up period, and antibiotic use was not decreased. SUMMARY PCT is the most promising biomarker to guide antibiotic use in patients with AECOPD. However, patients with severe AECOPD admitted in ICU may not benefit from PCT-guided antibiotic therapy.
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Adepoju VA. Can we use a biomarker to guide antibiotic treatment in severe COPD exacerbations? Breathe (Sheff) 2019; 15:353-355. [PMID: 31803274 PMCID: PMC6885330 DOI: 10.1183/20734735.0257-2019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
C-reactive protein (at values ≥50 mg/L) is a useful and cheap biomarker for making antibiotic decisions in patients hospitalised for an acute exacerbation of COPD with no additional risk of adverse effect or treatment failure #AECOPD http://bit.ly/342p0Nj.
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Vermeersch K, Belmans A, Bogaerts K, Gyselinck I, Cardinaels N, Gabrovska M, Aumann J, Demedts IK, Corhay JL, Marchand E, Slabbynck H, Haenebalcke C, Vermeersch S, Verleden GM, Troosters T, Ninane V, Brusselle GG, Janssens W. Treatment failure and hospital readmissions in severe COPD exacerbations treated with azithromycin versus placebo - a post-hoc analysis of the BACE randomized controlled trial. Respir Res 2019; 20:237. [PMID: 31665017 PMCID: PMC6819655 DOI: 10.1186/s12931-019-1208-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 10/09/2019] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND In the BACE trial, a 3-month (3 m) intervention with azithromycin, initiated at the onset of an infectious COPD exacerbation requiring hospitalization, decreased the rate of a first treatment failure (TF); the composite of treatment intensification (TI), step-up in hospital care (SH) and mortality. OBJECTIVES (1) To investigate the intervention's effect on recurrent events, and (2) to identify clinical subgroups most likely to benefit, determined from the incidence rate of TF and hospital readmissions. METHODS Enrolment criteria included the diagnosis of COPD, a smoking history of ≥10 pack-years and ≥ 1 exacerbation in the previous year. Rate ratio (RR) calculations, subgroup analyses and modelling of continuous variables using splines were based on a Poisson regression model, adjusted for exposure time. RESULTS Azithromycin significantly reduced TF by 24% within 3 m (RR = 0.76, 95%CI:0.59;0.97, p = 0.031) through a 50% reduction in SH (RR = 0.50, 95%CI:0.30;0.81, p = 0.006), which comprised of a 53% reduction in hospital readmissions (RR = 0.47, 95%CI:0.27;0.80; p = 0.007). A significant interaction between the intervention, CRP and blood eosinophil count at hospital admission was found, with azithromycin significantly reducing hospital readmissions in patients with high CRP (> 50 mg/L, RR = 0.18, 95%CI:0.05;0.60, p = 0.005), or low blood eosinophil count (<300cells/μL, RR = 0.33, 95%CI:0.17;0.64, p = 0.001). No differences were observed in treatment response by age, FEV1, CRP or blood eosinophil count in continuous analyses. CONCLUSIONS This post-hoc analysis of the BACE trial shows that azithromycin initiated at the onset of an infectious COPD exacerbation requiring hospitalization reduces the incidence rate of TF within 3 m by preventing hospital readmissions. In patients with high CRP or low blood eosinophil count at admission this treatment effect was more pronounced, suggesting a potential role for these biomarkers in guiding azithromycin therapy. TRIAL REGISTRATION ClinicalTrials.gov number. NCT02135354 .
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Affiliation(s)
- Kristina Vermeersch
- Laboratory of Respiratory Diseases, Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Herestraat 49, O&NI, box 706, B-3000, Leuven, Belgium
- Department of Respiratory Diseases, University Hospitals Leuven, B-3000, Leuven, Belgium
| | - Ann Belmans
- I-BioStat, KU Leuven, B-3000, Leuven, Belgium
- Universiteit Hasselt, B-3500, Hasselt, Belgium
| | - Kris Bogaerts
- I-BioStat, KU Leuven, B-3000, Leuven, Belgium
- Universiteit Hasselt, B-3500, Hasselt, Belgium
| | - Iwein Gyselinck
- Laboratory of Respiratory Diseases, Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Herestraat 49, O&NI, box 706, B-3000, Leuven, Belgium
| | - Nina Cardinaels
- Laboratory of Respiratory Diseases, Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Herestraat 49, O&NI, box 706, B-3000, Leuven, Belgium
| | - Maria Gabrovska
- Department of Pneumology, Centre Hospitalier Universitaire Saint-Pierre, Université Libre de Bruxelles, B-1000, Brussels, Belgium
| | - Joseph Aumann
- Department of Pneumology, Jessa Ziekenhuis, B-3500, Hasselt, Belgium
| | - Ingel K Demedts
- Department of Respiratory Medicine, AZ Delta Roeselare-Menen, B-8800, Roeselare, Belgium
| | - Jean-Louis Corhay
- Department of Pneumology, Centre Hospitalier Universitaire, site Sart-Tilman, B-4000, Liège, Belgium
| | - Eric Marchand
- Department of Pneumology, CHU-UCL-Namur, site Mont-Godinne, B-5530, Yvoir, Belgium
- Faculty of Medicine, NARILIS, Laboratory of Respiratory Physiology, University of Namur, B-5000, Namur, Belgium
| | - Hans Slabbynck
- Department of Respiratory Medicine, ZNA Middelheim, B-2020, Antwerpen, Belgium
| | | | - Stefanie Vermeersch
- Department of Respiratory Medicine, Ghent University Hospital, B-9000, Ghent, Belgium
| | - Geert M Verleden
- Laboratory of Respiratory Diseases, Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Herestraat 49, O&NI, box 706, B-3000, Leuven, Belgium
- Department of Respiratory Diseases, University Hospitals Leuven, B-3000, Leuven, Belgium
| | - Thierry Troosters
- Laboratory of Respiratory Diseases, Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Herestraat 49, O&NI, box 706, B-3000, Leuven, Belgium
- Department of Rehabilitation Sciences, Faculty of Kinesiology and Rehabilitation Sciences, KU Leuven, Leuven, Belgium
| | - Vincent Ninane
- Department of Pneumology, Centre Hospitalier Universitaire Saint-Pierre, Université Libre de Bruxelles, B-1000, Brussels, Belgium
| | - Guy G Brusselle
- Department of Respiratory Medicine, Ghent University Hospital, B-9000, Ghent, Belgium
| | - Wim Janssens
- Laboratory of Respiratory Diseases, Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Herestraat 49, O&NI, box 706, B-3000, Leuven, Belgium.
- Department of Respiratory Diseases, University Hospitals Leuven, B-3000, Leuven, Belgium.
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Prins HJ, Duijkers R, van der Valk P, Schoorl M, Daniels JMA, van der Werf TS, Boersma WG. CRP-guided antibiotic treatment in acute exacerbations of COPD in hospital admissions. Eur Respir J 2019; 53:13993003.02014-2018. [PMID: 30880285 DOI: 10.1183/13993003.02014-2018] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Accepted: 03/02/2019] [Indexed: 11/05/2022]
Abstract
The role of antibiotics in acute exacerbations of chronic obstructive pulmonary disease (COPD) is controversial and a biomarker identifying patients who benefit from antibiotics is mandatory. We performed a randomised, controlled trial in patients with acute exacerbations of COPD, comparing C-reactive protein (CRP)-guided antibiotic treatment to patient reported symptoms in accordance with the Global Initiative for Chronic Obstructive Lung Disease (GOLD) strategy, in order to show a reduction in antibiotic prescription.Patients hospitalised with acute exacerbations of COPD were randomised to receive antibiotics based either on the GOLD strategy or according to the CRP strategy (CRP ≥50 mg·L-1).In total, 101 patients were randomised to the CRP group and 119 to the GOLD group. Fewer patients in the CRP group were treated with antibiotics compared to the GOLD group (31.7% versus 46.2%, p=0.028; adjusted odds ratio (OR) 0.178, 95% CI 0.077-0.411, p=0.029). The 30-day treatment failure rate was nearly equal (44.5% in the CRP group versus 45.5% in the GOLD-group, p=0.881; adjusted OR 1.146, 95% CI 0.649-1.187, p=0.630), as was the time to next exacerbation (32 days in the CRP group versus 28 days in the GOLD group, p=0.713; adjusted hazard ratio 0.878, 95% CI 0.649-1.187, p=0.398). Length of stay was similar in both groups (7 days in the CRP group versus 6 days in the GOLD group, p=0.206). On day-30, no difference in symptom score, quality of life or serious adverse events was detected.Use of CRP as a biomarker to guide antibiotic treatment in severe acute exacerbations of COPD leads to a significant reduction in antibiotic treatment. In the present study, no differences in adverse events between both groups were found. Further research is needed for the generalisability of these findings.
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Affiliation(s)
- H J Prins
- Dept Pulmonary Diseases, Northwest Hospital, Alkmaar, The Netherlands
| | - Ruud Duijkers
- Dept Pulmonary Diseases, Northwest Hospital, Alkmaar, The Netherlands
| | - Paul van der Valk
- Dept of Pulmonary Diseases, Medic Spectrum Twente, Enschede, The Netherlands
| | - Marianne Schoorl
- Dept of Clinical Chemistry, Haematology and Immunology, Northwest Hospital, Alkmaar, The Netherlands
| | - Johannes M A Daniels
- Dept of Pulmonary Diseases, VU University Medical Center Amsterdam, Amsterdam, The Netherlands
| | - Tjip S van der Werf
- University of Groningen, Dept of Pulmonary Diseases and Tuberculosis, University Medical Center, Groningen, The Netherlands
| | - Wim G Boersma
- Dept Pulmonary Diseases, Northwest Hospital, Alkmaar, The Netherlands
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Vollenweider DJ, Frei A, Steurer‐Stey CA, Garcia‐Aymerich J, Puhan MA. Antibiotics for exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2018; 10:CD010257. [PMID: 30371937 PMCID: PMC6517133 DOI: 10.1002/14651858.cd010257.pub2] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Many patients with an exacerbation of chronic obstructive pulmonary disease (COPD) are treated with antibiotics. However, the value of antibiotics remains uncertain, as systematic reviews and clinical trials have shown conflicting results. OBJECTIVES To assess effects of antibiotics on treatment failure as observed between seven days and one month after treatment initiation (primary outcome) for management of acute COPD exacerbations, as well as their effects on other patient-important outcomes (mortality, adverse events, length of hospital stay, time to next exacerbation). SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), in the Cochrane Library, MEDLINE, Embase, and other electronically available databases up to 26 September 2018. SELECTION CRITERIA We sought to find randomised controlled trials (RCTs) including people with acute COPD exacerbations comparing antibiotic therapy and placebo and providing follow-up of at least seven days. DATA COLLECTION AND ANALYSIS Two review authors independently screened references and extracted data from trial reports. We kept the three groups of outpatients, inpatients, and patients admitted to the intensive care unit (ICU) separate for benefit outcomes and mortality because we considered them to be clinically too different to be summarised as a single group. We considered outpatients to have a mild to moderate exacerbation, inpatients to have a severe exacerbation, and ICU patients to have a very severe exacerbation. When authors of primary studies did not report outcomes or study details, we contacted them to request missing data. We calculated pooled risk ratios (RRs) for treatment failure, Peto odds ratios (ORs) for rare events (mortality and adverse events), and mean differences (MDs) for continuous outcomes using random-effects models. We used GRADE to assess the quality of the evidence. The primary outcome was treatment failure as observed between seven days and one month after treatment initiation. MAIN RESULTS We included 19 trials with 2663 participants (11 with outpatients, seven with inpatients, and one with ICU patients).For outpatients (with mild to moderate exacerbations), evidence of low quality suggests that currently available antibiotics statistically significantly reduced the risk for treatment failure between seven days and one month after treatment initiation (RR 0.72, 95% confidence interval (CI) 0.56 to 0.94; I² = 31%; in absolute terms, reduction in treatment failures from 295 to 212 per 1000 treated participants, 95% CI 165 to 277). Studies providing older antibiotics not in use anymore yielded an RR of 0.69 (95% CI 0.53 to 0.90; I² = 31%). Evidence of low quality from one trial in outpatients suggested no effects of antibiotics on mortality (Peto OR 1.27, 95% CI 0.49 to 3.30). One trial reported no effects of antibiotics on re-exacerbations between two and six weeks after treatment initiation. Only one trial (N = 35) reported health-related quality of life but did not show a statistically significant difference between treatment and control groups.Evidence of moderate quality does not show that currently used antibiotics statistically significantly reduced the risk of treatment failure among inpatients with severe exacerbations (i.e. for inpatients excluding ICU patients) (RR 0.65, 95% CI 0.38 to 1.12; I² = 50%), but trial results remain uncertain. In turn, the effect was statistically significant when trials included older antibiotics no longer in clinical use (RR 0.76, 95% CI 0.58 to 1.00; I² = 39%). Evidence of moderate quality from two trials including inpatients shows no beneficial effects of antibiotics on mortality (Peto OR 2.48, 95% CI 0.94 to 6.55). Length of hospital stay (in days) was similar in antibiotic and placebo groups.The only trial with 93 patients admitted to the ICU showed a large and statistically significant effect on treatment failure (RR 0.19, 95% CI 0.08 to 0.45; moderate-quality evidence; in absolute terms, reduction in treatment failures from 565 to 107 per 1000 treated participants, 95% CI 45 to 254). Results of this trial show a statistically significant effect on mortality (Peto OR 0.21, 95% CI 0.06 to 0.72; moderate-quality evidence) and on length of hospital stay (MD -9.60 days, 95% CI -12.84 to -6.36; low-quality evidence).Evidence of moderate quality gathered from trials conducted in all settings shows no statistically significant effect on overall incidence of adverse events (Peto OR 1.20, 95% CI 0.89 to 1.63; moderate-quality evidence) nor on diarrhoea (Peto OR 1.68, 95% CI 0.92 to 3.07; moderate-quality evidence). AUTHORS' CONCLUSIONS Researchers have found that antibiotics have some effect on inpatients and outpatients, but these effects are small, and they are inconsistent for some outcomes (treatment failure) and absent for other outcomes (mortality, length of hospital stay). Analyses show a strong beneficial effect of antibiotics among ICU patients. Few data are available on the effects of antibiotics on health-related quality of life or on other patient-reported symptoms, and data show no statistically significant increase in the risk of adverse events with antibiotics compared to placebo. These inconsistent effects call for research into clinical signs and biomarkers that can help identify patients who would benefit from antibiotics, while sparing antibiotics for patients who are unlikely to experience benefit and for whom downsides of antibiotics (side effects, costs, and multi-resistance) should be avoided.
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Affiliation(s)
| | - Anja Frei
- University of ZurichEpidemiology, Biostatistics and Prevention InstituteZurichSwitzerland
| | - Claudia A Steurer‐Stey
- University of ZurichEpidemiology, Biostatistics and Prevention InstituteZurichSwitzerland
| | - Judith Garcia‐Aymerich
- ISGlobalBarcelonaSpain08003
- Universitat Pompeu Fabra (UPF)BarcelonaSpain
- CIBER Epidemiologia y Salud Publica (CIBERESP)BarcelonaSpain
| | - Milo A Puhan
- University of ZurichEpidemiology, Biostatistics and Prevention InstituteZurichSwitzerland
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Crisafulli E, Barbeta E, Ielpo A, Torres A. Management of severe acute exacerbations of COPD: an updated narrative review. Multidiscip Respir Med 2018; 13:36. [PMID: 30302247 PMCID: PMC6167788 DOI: 10.1186/s40248-018-0149-0] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 08/15/2018] [Indexed: 02/08/2023] Open
Abstract
Background Patients with chronic obstructive pulmonary disease (COPD) may experience an acute worsening of respiratory symptoms that results in additional therapy; this event is defined as a COPD exacerbation (AECOPD). Hospitalization for AECOPD is accompanied by a rapid decline in health status with a high risk of mortality or other negative outcomes such as need for endotracheal intubation or intensive care unit (ICU) admission. Treatments for AECOPD aim to minimize the negative impact of the current exacerbation and to prevent subsequent events, such as relapse or readmission to hospital. Main body In this narrative review, we update the scientific evidence about the in-hospital pharmacological and non-pharmacological treatments used in the management of a severe AECOPD. We review inhaled bronchodilators, steroids, and antibiotics for the pharmacological approach, and oxygen, high flow nasal cannulae (HFNC) oxygen therapy, non-invasive mechanical ventilation (NIMV) and pulmonary rehabilitation (PR) as non-pharmacological treatments. We also review some studies of non-conventional drugs that have been proposed for severe AECOPD. Conclusion Several treatments exist for severe AECOPD patients requiring hospitalization. Some treatments such as steroids and NIMV (in patients admitted with a hypercapnic acute respiratory failure and respiratory acidosis) are supported by strong evidence of their efficacy. HFNC oxygen therapy needs further prospective studies. Although antibiotics are preferred in ICU patients, there is a lack of evidence regarding the preferred drugs and optimal duration of treatment for non-ICU patients. Early rehabilitation, if associated with standard treatment of patients, is recommended due to its feasibility and safety. There are currently few promising new drugs or new applications of existing drugs.
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Affiliation(s)
- Ernesto Crisafulli
- 1Department of Medicine and Surgery, Respiratory Disease and Lung Function Unit, University of Parma, Parma, Italy
| | - Enric Barbeta
- 2Pneumology Department, Clinic Institute of Thorax, Hospital Clinic of Barcelona - Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Antonella Ielpo
- 1Department of Medicine and Surgery, Respiratory Disease and Lung Function Unit, University of Parma, Parma, Italy
| | - Antoni Torres
- 2Pneumology Department, Clinic Institute of Thorax, Hospital Clinic of Barcelona - Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
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Camp J, Cane JL, Bafadhel M. Shall We Focus on the Eosinophil to Guide Treatment with Systemic Corticosteroids during Acute Exacerbations of COPD?: PRO. Med Sci (Basel) 2018; 6:medsci6030074. [PMID: 30208605 PMCID: PMC6163385 DOI: 10.3390/medsci6030074] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 09/02/2018] [Accepted: 09/04/2018] [Indexed: 12/15/2022] Open
Abstract
In an era of precision medicine, it seems regressive that we do not use stratified approaches to direct treatment of oral corticosteroids during an exacerbation of chronic obstructive pulmonary disease (COPD). This is despite evidence suggesting that 40% of COPD patients have eosinophilic inflammation and this is an indicator of corticosteroid response. Treatments with oral corticosteroids are not always effective and not without harm, with significant and increased risk of hyperglycemia, sepsis, and fractures. Eosinophils are innate immune cells with an incompletely understood role in the pathology of airway disease. They are detected at increased levels in some patients and can be measured using non-invasive methods during states of exacerbation and stable periods. Despite the eosinophil having an unknown mechanism in COPD, it has been shown to be a marker of length of stay in severe hospitalized exacerbations, a predictor of risk of future exacerbation and exacerbation type. Although limited, promising data has come from one prospective clinical trial investigating the eosinophil as a biomarker to direct systemic corticosteroid treatment. This identified that there were statistically significant and clinically worsened symptoms in patients with low eosinophil levels who were prescribed prednisolone, demonstrating the potential utility of the eosinophil. In an era of precision medicine our patients' needs are best served by accurate diagnosis, correct identification of maximal treatment response and the abolition of harm. The peripheral blood eosinophil count could be used towards reaching these aims.
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Affiliation(s)
- James Camp
- Respiratory Medicine Unit, Nuffield Department of Clinical Medicine, University of Oxford, Oxford OX3 7FZ, UK.
| | - Jennifer L Cane
- Respiratory Medicine Unit, Nuffield Department of Clinical Medicine, University of Oxford, Oxford OX3 7FZ, UK.
- NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford OX3 7FZ, UK.
| | - Mona Bafadhel
- Respiratory Medicine Unit, Nuffield Department of Clinical Medicine, University of Oxford, Oxford OX3 7FZ, UK.
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El-Abdeen AZ, Shaaban LH, Farghaly S, Galal H, Mohammed EH. Outcome of short-term systemic steroid therapy in chronic obstructive pulmonary disease patients with acute exacerbation. THE EGYPTIAN JOURNAL OF BRONCHOLOGY 2018. [DOI: 10.4103/ejb.ejb_104_17] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Feldman C, Richards G. Appropriate antibiotic management of bacterial lower respiratory tract infections. F1000Res 2018; 7:F1000 Faculty Rev-1121. [PMID: 30079235 PMCID: PMC6058472 DOI: 10.12688/f1000research.14226.1] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/17/2018] [Indexed: 01/05/2023] Open
Abstract
Lower respiratory tract infections are the leading cause of infectious disease deaths worldwide and are the fifth leading cause of death overall. This is despite conditions such as pneumococcal infections and influenza being largely preventable with the use of appropriate vaccines. The mainstay of treatment for the most important bacterial lower respiratory tract infections, namely acute exacerbations of chronic obstructive pulmonary disease (AECOPD) and community-acquired pneumonia (CAP), is the use of antibiotics. Yet despite a number of recent publications, including clinical studies as well as several systematic literature reviews and meta-analyses, there is considerable ongoing controversy as to what the most appropriate antibiotics are for the empiric therapy of CAP in the different settings (outpatient, inpatient, and intensive care unit). Furthermore, in the case of AECOPD, there is a need for consideration of which of these exacerbations actually need antibiotic treatment. This article describes these issues and makes suggestions for appropriately managing these conditions, in the setting of the need for antimicrobial stewardship initiatives designed to slow current emerging rates of antibiotic resistance, while improving patient outcomes.
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Affiliation(s)
- Charles Feldman
- Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, 7 York Road, Parktown, Johannesburg, 2193, South Africa
| | - Guy Richards
- Division of Critical Care, Charlotte Maxeke Johannesburg Academic Hospital, and Faculty of Health Sciences, University of Witwatersrand, 7 York Road, Parktown, Johannesburg, 2193, South Africa
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Calverley PM, Anzueto AR, Dusser D, Mueller A, Metzdorf N, Wise RA. Treatment of exacerbations as a predictor of subsequent outcomes in patients with COPD. Int J Chron Obstruct Pulmon Dis 2018; 13:1297-1308. [PMID: 29719385 PMCID: PMC5922419 DOI: 10.2147/copd.s153631] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Rationale Exacerbations of COPD are managed differently, but whether treatment of one exacerbation predicts the likelihood of subsequent events is unknown. Objective We examined whether the treatment given for exacerbations predicted subsequent outcomes. Methods This was a post-hoc analysis of 17,135 patients with COPD from TIOtropium Safety and Performance In Respimat® (TIOSPIR®). Patients treated with tiotropium with one or more moderate to severe exacerbations on study were analyzed using descriptive statistics, logistic and Cox regression analysis, and Kaplan–Meier plots. Results Of 8,061 patients with moderate to severe exacerbation(s), demographics were similar across patients with exacerbations treated with antibiotics and/or steroids or hospitalization. Exacerbations treated with systemic corticosteroids alone or in combination with antibiotics had the highest risk of subsequent exacerbation (HR: 1.21, P=0.0004 and HR: 1.33, P<0.0001, respectively), and a greater risk of having a hospitalized (severe) exacerbation (HR: 1.59 and 1.63, P<0.0001, respectively) or death (HR: 1.50, P=0.0059 and HR: 1.47, P=0.0002, respectively) compared with exacerbations treated with antibiotics alone. Initial hospitalization led to the highest risk of subsequent hospitalization (all-cause or COPD related [severe exacerbation], HR: 3.35 and 4.31, P<0.0001, respectively) or death (all-cause or COPD related, HR: 3.53 and 5.54, P<0.0001, respectively) versus antibiotics alone. Conclusion These data indicate that the way exacerbations are treated initially is a useful guide to the patient’s subsequent clinical course. Factors that clinicians consider when making treatment choices require further clarification.
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Affiliation(s)
- Peter Ma Calverley
- Clinical Science Centre, Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, UK
| | - Antonio R Anzueto
- Pulmonary/Critical Care, University of Texas and South Texas Veterans Health Care System, San Antonio, TX, USA
| | - Daniel Dusser
- Department of Pneumology, Hôpital Cochin, AP-HP, Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Achim Mueller
- Biostatistics and Data Sciences Europe, Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach an der Riss, Germany
| | - Norbert Metzdorf
- Respiratory Medicine, Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim am Rhein, Germany
| | - Robert A Wise
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Zhang HL, Tan M, Qiu AM, Tao Z, Wang CH. Antibiotics for treatment of acute exacerbation of chronic obstructive pulmonary disease: a network meta-analysis. BMC Pulm Med 2017; 17:196. [PMID: 29233130 PMCID: PMC5727987 DOI: 10.1186/s12890-017-0541-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Accepted: 11/29/2017] [Indexed: 01/16/2023] Open
Abstract
Background Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is the most common reason for the hospitalization and death of pulmonary patients. The use of antibiotics as adjuvant therapy for AECOPD, however, is still a matter of debate. Methods In this study, we searched the PubMed, EmBase, and Cochrane databases for randomized controlled trials published until September 2016 that evaluated the use of antibiotics for AECOPD treatment. The major outcome variables were clinical cure rate and adverse effects. The microbiological response rate, relapse of exacerbation, and mortality were also analysed. A random-effect network was used to assess the effectiveness and tolerance of each antibiotic used for AECOPD treatment. Results In this meta-analysis, we included 19 articles that assessed 17 types of antibiotics used in 5906 AECOPD patients. The cluster ranking showed that dirithromycin had a high clinical cure rate with a low rate of adverse effects. Ofloxacin, ciprofloxacin, and trimethoprim-sulfamethoxazole had high clinical cure rates with median rates of adverse effects. In terms of the microbiological response rate, only doxycycline was significantly better than placebo (odds ratio (OR), 3.84; 95% confidence interval (CI), 1.96–7.54; p < 0.001). There were no other significant results with respect to the frequency of recurrence or mortality. Conclusions Our study indicated that dirithromycin is adequate for improving the clinical cure rate of patients with AECOPD with few adverse effects. Ofloxacin, ciprofloxacin, and trimethoprim-sulfamethoxazole are also recommended for disease treatment. However, caution should still be exercised when using antibiotics to treat AECOPD. Trial Registration Not applicable. Electronic supplementary material The online version of this article (doi: 10.1186/s12890-017-0541-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Hai-Lin Zhang
- Department of Respiration, Shanghai Tenth People's Hospital, Clinical Medical College, Nanjing Medical University, Extension of Middle Road 301#, Zhabei District, Shanghai, 200000, Shanghai, People's Republic of China.,Department of Respiration, The Affiliated Yancheng Hospital, School of Medicine, Southeast University, Yancheng, People's Republic of China
| | - Min Tan
- Department of Respiration, Shanghai Tenth People's Hospital, Clinical Medical College, Nanjing Medical University, Extension of Middle Road 301#, Zhabei District, Shanghai, 200000, Shanghai, People's Republic of China
| | - Ai-Min Qiu
- Department of Respiration, The Affiliated Yancheng Hospital, School of Medicine, Southeast University, Yancheng, People's Republic of China
| | - Zhang Tao
- Department of Respiration, The Affiliated Yancheng Hospital, School of Medicine, Southeast University, Yancheng, People's Republic of China
| | - Chang-Hui Wang
- Department of Respiration, Shanghai Tenth People's Hospital, Clinical Medical College, Nanjing Medical University, Extension of Middle Road 301#, Zhabei District, Shanghai, 200000, Shanghai, People's Republic of China.
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General practitioner use of a C-reactive protein point-of-care test to help target antibiotic prescribing in patients with acute exacerbations of chronic obstructive pulmonary disease (the PACE study): study protocol for a randomised controlled trial. Trials 2017; 18:442. [PMID: 28969667 PMCID: PMC5623969 DOI: 10.1186/s13063-017-2144-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 08/14/2017] [Indexed: 11/12/2022] Open
Abstract
Background Most patients presenting with acute exacerbations of chronic obstructive pulmonary disease (AECOPD) in primary care are prescribed an antibiotic, which may not always be appropriate and may cause harm. C-reactive protein (CRP) is an acute-phase biomarker that can be rapidly measured at the point of care and may predict benefit from antibiotic treatment in AECOPD. It is not clear whether the addition of a CRP point-of-care test (POCT) to clinical assessment leads to a reduction in antibiotic consumption without having a negative impact on COPD health status. Methods/design This is a multicentre, individually randomised controlled trial (RCT) aiming to include 650 participants with a diagnosis of AECOPD in primary care. Participants will be randomised to be managed according to usual care (control) or with the addition of a CRP POCT to guide antibiotic prescribing. Antibiotic consumption for AECOPD within 4 weeks post randomisation and COPD health status (total score) measured by the Clinical COPD Questionnaire (CCQ) at 2 weeks post randomisation will be co-primary outcomes. Primary analysis (by intention-to-treat) will determine differences in antibiotic consumption for superiority and COPD health status for non-inferiority. Secondary outcomes include: COPD health status, CCQ domain scores, use of other COPD treatments (weeks 1, 2 and 4), EQ-5D utility scores (weeks 1, 2 and 4 and month 6), disease-specific, health-related quality of life (HRQoL) at 6 months, all-cause antibiotic consumption (antibiotic use for any condition) during first 4 weeks post randomisation, total antibiotic consumption (number of days during first 4 weeks of antibiotic consumed for AECOPD/any reason), antibiotic prescribing at the index consultation and during following 4 weeks, adverse effects over the first 4 weeks, incidence of pneumonia (weeks 4 and 6 months), health care resource use and cost comparison over the 6 months following randomisation. Prevalence and resistance profiles of bacteria will be assessed using throat and sputum samples collected at baseline and 4-week follow-up. A health economic evaluation and qualitative process evaluation will be carried out. Discussion If shown to be effective (i.e. leads to a reduction in antibiotic use with no worse COPD health status), the use of the CRP POCT could lead to better outcomes for patients with AECOPD and help reduce selective pressures driving the development of antimicrobial resistance. PACE will be one of the first studies to evaluate the cost-effectiveness of a POCT biomarker to guide clinical decision-making in primary care on patient-reported outcomes, antibiotic prescribing and antibiotic resistance for AECOPD. Trial registration ISRCTN registry, ID: ISRCTN24346473. Registered on 20 August 2014. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-2144-8) contains supplementary material, which is available to authorized users.
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Mantero M, Rogliani P, Di Pasquale M, Polverino E, Crisafulli E, Guerrero M, Gramegna A, Cazzola M, Blasi F. Acute exacerbations of COPD: risk factors for failure and relapse. Int J Chron Obstruct Pulmon Dis 2017; 12:2687-2693. [PMID: 28932112 PMCID: PMC5598966 DOI: 10.2147/copd.s145253] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Acute exacerbations are a leading cause of worsening COPD in terms of lung function decline, quality of life, and survival. They also have a relevant economic burden on the health care system. Determining the risk factors for acute exacerbation and early relapse could be a crucial element for a better management of COPD patients. This review analyzes the current knowledge and underlines the main risk factors for recurrent acute exacerbations. Comprehensive evaluation of COPD patients during stable phase and exacerbation could contribute to prevent treatment failure and relapses.
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Affiliation(s)
- Marco Mantero
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano.,Internal Medicine Department, Respiratory Unit and Regional Adult Cystic Fibrosis Center, IRCCS Fondazione Cà Granda Ospedale Maggiore Policlinico, Milan
| | - Paola Rogliani
- Respiratory Unit, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Marta Di Pasquale
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano.,Internal Medicine Department, Respiratory Unit and Regional Adult Cystic Fibrosis Center, IRCCS Fondazione Cà Granda Ospedale Maggiore Policlinico, Milan
| | - Eva Polverino
- Respiratory Disease Department, Servei de Pneumologia, Hospital Universitari Vall d'Hebron (HUVH), Institut de Recerca Vall d'Hebron (VHIR), Barcelona, Spain
| | - Ernesto Crisafulli
- Department of Medicine and Surgery, Respiratory Disease and Lung Function Unit, University of Parma, Parma, Italy
| | - Monica Guerrero
- Hospital d'Igualada, Consorci Socisanitari de l'Anoia, Barcelona, Spain
| | - Andrea Gramegna
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano.,Internal Medicine Department, Respiratory Unit and Regional Adult Cystic Fibrosis Center, IRCCS Fondazione Cà Granda Ospedale Maggiore Policlinico, Milan
| | - Mario Cazzola
- Respiratory Unit, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Francesco Blasi
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano.,Internal Medicine Department, Respiratory Unit and Regional Adult Cystic Fibrosis Center, IRCCS Fondazione Cà Granda Ospedale Maggiore Policlinico, Milan
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Liu HM, Liu YT, Zhang J, Ma LJ. Bone marrow mesenchymal stem cells ameliorate lung injury through anti-inflammatory and antibacterial effect in COPD mice. ACTA ACUST UNITED AC 2017; 37:496-504. [PMID: 28786060 DOI: 10.1007/s11596-017-1763-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Revised: 06/01/2017] [Indexed: 01/08/2023]
Abstract
The anti-inflammatory and antibacterial mechanisms of bone marrow mesenchymal stem cells (MSCs) ameliorating lung injury in chronic obstructive pulmonary disease (COPD) mice induced by cigarette smoke and Haemophilus Parainfluenza (HPi) were studied. The experiment was divided into four groups in vivo: control group, COPD group, COPD+HPi group, and COPD+HPi+MSCs group. The indexes of emphysematous changes, inflammatory reaction and lung injury score, and antibacterial effects were evaluated in all groups. As compared with control group, emphysematous changes were significantly aggravated in COPD group, COPD+HPi group and COPD+HPi+MSCs group (P<0.01), the expression of necrosis factor-kappaB (NF-κB) signal pathway and proinflammatory cytokines in bronchoalveolar lavage fluid (BALF) were increased (P<0.01), and the phagocytic activity of alveolar macrophages was downregulated (P<0.01). As compared with COPD group, lung injury score, inflammatory cells and proinflammatory cytokines were significantly increased in the BALF of COPD+HPi group and COPD+HPi+MSCs group (P<0.01). As compared with COPD+HPi group, the expression of tumor necrosis factor-α stimulated protein/gene 6 (TSG-6) was increased, the NF-κB signal pathway was depressed, proinflammatory cytokine was significantly reduced, the anti-inflammatory cytokine IL-10 was increased, and lung injury score was significantly reduced in COPD+HPi+MSCs group. Meanwhile, the phagocytic activity of alveolar macrophages was significantly enhanced and bacterial counts in the lung were decreased. The results indicated cigarette smoke caused emphysematous changes in mice and the phagocytic activity of alveolar macrophages was decreased. The lung injury of acute exacerbation of COPD mice induced by cigarette smoke and HPi was alleviated through MSCs transplantation, which may be attributed to the fact that MSCs could promote macrophages into anti-inflammatory phenotype through secreting TSG-6, inhibit NF-кB signaling pathway, and reduce inflammatory response through reducing proinflammatory cytokines and promoting the expression of the anti-inflammatory cytokine. Simultaneously, MSCs could enhance phagocytic activity of macrophages and bacterial clearance. Meanwhile, we detected anti-inflammatory and antibacterial activity of macrophages regulated by MSCs in vitro. As compared with RAW264.7+HPi+CSE group, the expression of NF-кB p65, IL-1β, IL-6 and TNF-α was significantly reduced, and the phagocytic activity of macrophages was significantly increased in RAW264.7+HPi+CSE+MSCs group (P<0.01). The result indicated the macrophages co-cultured with MSCs may inhibit NF-кB signaling pathway and promote phagocytosis by paracrine mechanism.
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Affiliation(s)
- Hong-Mei Liu
- Department of Respiratory Medicine, Henan Provincial People's Hospital, Zhengzhou University People's Hospital, Zhengzhou, 450003, China.
| | - Yi-Tong Liu
- Department of Respiratory Medicine, Henan Provincial People's Hospital, Zhengzhou University People's Hospital, Zhengzhou, 450003, China
| | - Jing Zhang
- Department of Respiratory Medicine, Henan Provincial People's Hospital, Zhengzhou University People's Hospital, Zhengzhou, 450003, China
| | - Li-Jun Ma
- Department of Respiratory Medicine, Henan Provincial People's Hospital, Zhengzhou University People's Hospital, Zhengzhou, 450003, China
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Miravitlles M, Anzueto A. Chronic Respiratory Infection in Patients with Chronic Obstructive Pulmonary Disease: What Is the Role of Antibiotics? Int J Mol Sci 2017. [PMID: 28644389 PMCID: PMC5535837 DOI: 10.3390/ijms18071344] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Chronic infections are associated with exacerbation in patients with chronic obstructive pulmonary disease (COPD). The major objective of the management of these patients is the prevention and effective treatment of exacerbations. Patients that have increased sputum production, associated with purulence and worsening shortness of breath, are the ones that will benefit from antibiotic therapy. It is important to give the appropriate antibiotic therapy to prevent treatment failure, relapse, and the emergence of resistant pathogens. In some patients, systemic corticosteroids are also indicated to improve symptoms. In order to identify which patients are more likely to benefit from these therapies, clinical guidelines recommend stratifying patients based on their risk factor associated with poor outcome or recurrence. It has been identified that patients with more severe disease, recurrent infection and presence of purulent sputum are the ones that will be more likely to benefit from this therapy. Another approach related to disease prevention could be the use of prophylactic antibiotics during steady state condition. Some studies have evaluated the continuous or the intermittent use of antibiotics in order to prevent exacerbations. Due to increased bacterial resistance to antibiotics and the presence of side effects, several antibiotics have been developed to be nebulized for both treatment and prevention of acute exacerbations. There is a need to design long-term studies to evaluate these interventions in the natural history of the disease. The purpose of this publication is to review our understanding of the role of bacterial infection in patients with COPD exacerbation, the role of antibiotics, and future interventions.
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Affiliation(s)
- Marc Miravitlles
- Pneumology Department, Hospital Universitari Vall d'Hebron, Ciber de Enfermedades Respiratorias (CIBERES), 08035 Barcelona, Spain.
| | - Antonio Anzueto
- Department of Medicine, Division of Pulmonary Diseases/Critical Care Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA.
- Pulmonary Section, The South Texas Veterans Health Care System, Audie L. Murphy Memorial Veterans Hospital Division, Pulmonary Diseases Section (111E), 7400 Merton Minter Boulevard, San Antonio, TX 78229, USA.
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Pontier-Marchandise S. [Antibiotics for acute exacerbation in hospitalized COPD patients]. Rev Mal Respir 2017; 34:416-422. [PMID: 28502367 DOI: 10.1016/j.rmr.2017.03.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- S Pontier-Marchandise
- Service de pneumologie et USIR, hôpital Larrey, 24, chemin de Pouvourville, 31059 Toulouse, France.
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Doxycycline for outpatient-treated acute exacerbations of COPD: a randomised double-blind placebo-controlled trial. THE LANCET RESPIRATORY MEDICINE 2017; 5:492-499. [PMID: 28483402 DOI: 10.1016/s2213-2600(17)30165-0] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Revised: 03/02/2017] [Accepted: 03/03/2017] [Indexed: 02/01/2023]
Abstract
BACKGROUND Antibiotics do not reduce mortality or short-term treatment non-response in patients receiving treatment for acute exacerbations of COPD in an outpatient setting. However, the long-term effects of antibiotics are unknown. The aim of this study was to investigate if the antibiotic doxycycline added to the oral corticosteroid prednisolone prolongs time to next exacerbation in patients with COPD receiving treatment for an exacerbation in the outpatient setting. METHODS In this randomised double-blind placebo-controlled trial, we recruited a cohort of patients with COPD from outpatient clinics of nine teaching hospitals and three primary care centres in the Netherlands. Inclusion criteria were an age of at least 45 years, a smoking history of at least 10 pack-years, mild-to-severe COPD (Global Initiative of Chronic Obstructive Lung Disease [GOLD] stage 1-3), and at least one exacerbation during the past 3 years. Exclusion criteria were poor mastery of the Dutch language, poor cognitive functioning, known allergy to doxycycline, pregnancy, and a life expectancy of shorter than 1 month. If a participant had an exacerbation, we randomly assigned them (1:1; with permuted blocks of variable sizes [ranging from two to ten]; stratified by GOLD stage 1-2 vs 3) to a 7 day course of oral doxycycline 100 mg daily (200 mg on the first day) or placebo. Exclusion criteria for randomisation were fever, admission to hospital, and current use of antibiotics or use within the previous 3 weeks. Patients in both groups received a 10 day course of 30 mg oral prednisolone daily. Patients, investigators, and those assessing outcomes were masked to treatment assignment. The primary outcome was time to next exacerbation in all randomly allocated patients except for those incorrectly randomly allocated who did not meet the inclusion criteria or met the exclusion criteria. This trial is registered with the Netherlands Trial Register, number NTR2499. FINDINGS Between Dec 22, 2010, and Aug 6, 2013, we randomly allocated 305 (34%) patients from the cohort of 887 patients to doxycycline (152 [50%]) or placebo (153 [50%]), excluding four (1%) patients (two [1%] from each group) who were incorrectly randomly allocated from the analysis. 257 (85%) of 301 patients had a next exacerbation (131 [87%] of 150 in the doxycycline group vs 126 [83%] of 151 in the placebo group). Median time to next exacerbation was 148 days (95% CI 95-200) in the doxycycline group compared with 161 days (118-211) in the placebo group (hazard ratio 1·01 [95% CI 0·79-1·31]; p=0·91). We did not note any significant differences between groups in the frequency of adverse events during the first 2 weeks after randomisation (47 [31%] of 150 in the doxycycline group vs 53 [35%] of 151 in the placebo group; p=0·54) or in serious adverse events during the 2 years of follow-up (42 [28%] vs 43 [29%]; p=1). INTERPRETATION In patients with mild-to-severe COPD receiving treatment for an exacerbation in an outpatient setting, the antibiotic doxycycline added to the oral corticosteroid prednisolone did not prolong time to next exacerbation compared with prednisolone alone. These findings do not support prescription of antibiotics for COPD exacerbations in an outpatient setting. FUNDING Netherlands Organization for Health Research and Development.
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36
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Leung JM, Tiew PY, Mac Aogáin M, Budden KF, Yong VFL, Thomas SS, Pethe K, Hansbro PM, Chotirmall SH. The role of acute and chronic respiratory colonization and infections in the pathogenesis of COPD. Respirology 2017; 22:634-650. [PMID: 28342288 PMCID: PMC7169176 DOI: 10.1111/resp.13032] [Citation(s) in RCA: 130] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Revised: 02/09/2017] [Accepted: 02/09/2017] [Indexed: 12/16/2022]
Abstract
COPD is a major global concern, increasingly so in the context of ageing populations. The role of infections in disease pathogenesis and progression is known to be important, yet the mechanisms involved remain to be fully elucidated. While COPD pathogens such as Haemophilus influenzae, Moraxella catarrhalis and Streptococcus pneumoniae are strongly associated with acute exacerbations of COPD (AECOPD), the clinical relevance of these pathogens in stable COPD patients remains unclear. Immune responses in stable and colonized COPD patients are comparable to those detected in AECOPD, supporting a role for chronic colonization in COPD pathogenesis through perpetuation of deleterious immune responses. Advances in molecular diagnostics and metagenomics now allow the assessment of microbe–COPD interactions with unprecedented personalization and precision, revealing changes in microbiota associated with the COPD disease state. As microbial changes associated with AECOPD, disease severity and therapeutic intervention become apparent, a renewed focus has been placed on the microbiology of COPD and the characterization of the lung microbiome in both its acute and chronic states. Characterization of bacterial, viral and fungal microbiota as part of the lung microbiome has the potential to reveal previously unrecognized prognostic markers of COPD that predict disease outcome or infection susceptibility. Addressing such knowledge gaps will ultimately lead to a more complete understanding of the microbe–host interplay in COPD. This will permit clearer distinctions between acute and chronic infections and more granular patient stratification that will enable better management of these features and of COPD.
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Affiliation(s)
- Janice M Leung
- Centre for Heart Lung Innovation, Vancouver, British Columbia, Canada.,Division of Respiratory Medicine, St Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Pei Yee Tiew
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore
| | - Micheál Mac Aogáin
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Kurtis F Budden
- Priority Research Centre for Healthy Lungs, University of Newcastle, Newcastle, New South Wales, Australia.,Hunter Medical Research Institute, Newcastle, New South Wales, Australia
| | | | - Sangeeta S Thomas
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Kevin Pethe
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Philip M Hansbro
- Priority Research Centre for Healthy Lungs, University of Newcastle, Newcastle, New South Wales, Australia.,Hunter Medical Research Institute, Newcastle, New South Wales, Australia
| | - Sanjay H Chotirmall
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
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Bathoorn E, Groenhof F, Hendrix R, van der Molen T, Sinha B, Kerstjens HA, Friedrich AW, Kocks JW. Real-life data on antibiotic prescription and sputum culture diagnostics in acute exacerbations of COPD in primary care. Int J Chron Obstruct Pulmon Dis 2017; 12:285-290. [PMID: 28144133 PMCID: PMC5245804 DOI: 10.2147/copd.s120510] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are generally treated with optimization of bronchodilation therapy and a course of oral corticosteroids, mostly without antibiotics. The Dutch guidelines recommend prudent use of antibiotics, with amoxicillin or doxycycline as first choice. Here we evaluate adherence to these guidelines with regard to antibiotic prescription in AECOPD in primary care and the use of sputum cultures. Methods We retrospectively analyzed a longitudinal cohort of patients in three primary care practices in the north-eastern region of the Netherlands from 2009 to 2013 (n=36,172 subjects) participating in the Registration Network Groningen. Antibiotics prescribed for AECOPD −10/+28 days from the start date of corticosteroid courses were evaluated. In addition, we assessed regional data on the susceptibility of respiratory pathogens from COPD patients. Results We identified 1,297 patients with COPD. Of these, 616 experienced one or more exacerbations, resulting in a total of 1,558 exacerbations, for which 1,594 antibiotic courses were prescribed. The recommended antibiotics doxycycline and amoxicillin accounted for 56% of the prescribed antibiotics overall and for 35% in subsequent antibiotic courses. The alternative choices were not based on culture results because only in 67 AECOPD events (2.9%) sputum samples were taken. Regional data including 3,638 sputum samples showed that pathogens relevant in AECOPD were detected in 19% of cultures. Conclusion Our study shows that guidelines regarding the prescription of antibiotics are poorly followed, particularly in recurrent exacerbations. Sputum cultures were performed in a small minority of cases. Performing sputum diagnostics in patients with early treatment failure or a repeated exacerbation when antibiotic treatment is started may further rationalize antibiotic treatment.
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Affiliation(s)
- Erik Bathoorn
- Department of Medical Microbiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Feikje Groenhof
- Department of Primary Care, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Ron Hendrix
- Department of Medical Microbiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands; Department of Pulmonary Diseases and Tuberculosis, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Thys van der Molen
- Department of Primary Care, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands; Department of Medical Microbiology, Certe - Laboratory for Infectious Diseases, Groningen, the Netherlands
| | - Bhanu Sinha
- Department of Medical Microbiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Huib Am Kerstjens
- GRIAC Research Institute, Groningen, University of Groningen, University Medical Center Groningen, the Netherlands
| | - Alex W Friedrich
- Department of Medical Microbiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Janwillem Wh Kocks
- Department of Primary Care, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands; Department of Medical Microbiology, Certe - Laboratory for Infectious Diseases, Groningen, the Netherlands
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Mathioudakis AG, Chatzimavridou-Grigoriadou V, Corlateanu A, Vestbo J. Procalcitonin to guide antibiotic administration in COPD exacerbations: a meta-analysis. Eur Respir Rev 2017; 26:26/143/160073. [PMID: 28143877 PMCID: PMC9488925 DOI: 10.1183/16000617.0073-2016] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Accepted: 09/26/2016] [Indexed: 02/07/2023] Open
Abstract
Challenges in the differentiation of the aetiology of acute exacerbations of chronic obstructive pulmonary disease (AECOPD) have led to significant overuse of antibiotics. Serum procalcitonin, released in response to bacterial infections, but not viral infections, could possibly identify AECOPD requiring antibiotics. In this meta-analysis we assessed the clinical effectiveness of procalcitonin-based protocols to initiate or discontinue antibiotics in patients presenting with AECOPD.Based on a prospectively registered protocol, we reviewed the literature and selected randomised or quasi-randomised trials comparing procalcitonin-based protocols to initiate or discontinue antibiotics versus standard care in AECOPD. We followed Cochrane and GRADE (Grading of Recommendations, Assessment, Development and Evaluation) guidance to assess risk of bias, quality of evidence and to perform meta-analyses.We included eight trials evaluating 1062 patients with AECOPD. Procalcitonin-based protocols decreased antibiotic prescription (relative risk (RR) 0.56, 95% CI 0.43-0.73) and total antibiotic exposure (mean difference (MD) -3.83, 95% CI (-4.32--3.35)), without affecting clinical outcomes such as rate of treatment failure (RR 0.81, 0.62-1.06), length of hospitalisation (MD -0.76, -1.95-0.43), exacerbation recurrence rate (RR 0.96, 0.69-1.35) or mortality (RR 0.99, 0.58-1.69). However, the quality of the available evidence is low to moderate, because of methodological limitations and small overall study population.Procalcitonin-based protocols appear to be clinically effective; however, confirmatory trials with rigorous methodology are required.
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Affiliation(s)
- Alexander G Mathioudakis
- Division of Infection, Immunity and Respiratory Medicine, University Hospital of South Manchester, University of Manchester, Manchester, UK
| | | | - Alexandru Corlateanu
- Department of Respiratory Medicine, State University of Medicine and Pharmacy "Nicolae Testemitanu", Chisinau, Moldova
| | - Jørgen Vestbo
- Division of Infection, Immunity and Respiratory Medicine, University Hospital of South Manchester, University of Manchester, Manchester, UK
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Pereira JA, Mauricio AF, Marques MJ, Neto HS. Dual Therapy Deflazacort/Doxycyclyne Is Better Than Deflazacort Monotherapy to Alleviate Cardiomyopathy in Dystrophin-Deficient mdx Mice. J Cardiovasc Pharmacol Ther 2016; 22:458-466. [PMID: 28793824 DOI: 10.1177/1074248416686189] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Cardiomyopathy related to the absence of dystrophin is an important feature in Duchenne muscular dystrophy (DMD) and in the mdx mouse. Doxycycline (DOX) could be a potential therapy for mdx skeletal muscles dystrophy. We investigated whether the corticoid deflazacort (DFZ) plus DOX could improve cardiac mdx dystrophy better than DFZ alone, later (17 months) in dystrophy. Mdx mice (8 months old) received DFZ/DOX or DFZ for 9 months. The combined therapy was greater than DFZ in reducing fibrosis (60% decrease with DFZ/DOX and 40% with DFZ alone) in the right ventricle and transforming growth factor β levels (6.8 ± 3.2 in untreated mdx mice, 2.8 ± 1.4 in combined therapy, and 4.6 ± 1.7 in DFZ; P < .05). Combined therapy more effectively ameliorated cardiac dysfunction (electrocardiogram [ECG]) than DFZ. Improvements were seen in the cardiomyopathy index (0.8 ± 0.1 in combined therapy and 1.0 ± 0.2 in DFZ), heart rate (418 ± 46 bpm in combined therapy and 457 ± 29 bpm in DFZ), QRS interval (11.3 ± 2 in combined therapy and 13.6 ± 1 in DFZ), and Q wave amplitude (-40.7 ± 21 in combined therapy and -90.9 ± 36 in DFZ). Both therapies decreased markers of inflammation (tumor necrosis factor α, nuclear factor κB, and metalloproteinase 9). DFZ/DOX improved mdx cardiomyopathy at this stage of the disease, supporting further clinical investigations.
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Affiliation(s)
- Juliano Alves Pereira
- 1 Department of Structural and Functional Biology, Institute of Biology, University of Campinas (UNICAMP), Campinas, São Paulo, Brazil
| | - Adriana Fogagnolo Mauricio
- 1 Department of Structural and Functional Biology, Institute of Biology, University of Campinas (UNICAMP), Campinas, São Paulo, Brazil
| | - Maria Julia Marques
- 1 Department of Structural and Functional Biology, Institute of Biology, University of Campinas (UNICAMP), Campinas, São Paulo, Brazil
| | - Humberto Santo Neto
- 1 Department of Structural and Functional Biology, Institute of Biology, University of Campinas (UNICAMP), Campinas, São Paulo, Brazil
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Acute exacerbations of chronic obstructive pulmonary disease with low serum procalcitonin values do not benefit from antibiotic treatment: a prospective randomized controlled trial. Int J Infect Dis 2016; 48:40-5. [DOI: 10.1016/j.ijid.2016.04.024] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Revised: 04/26/2016] [Accepted: 04/28/2016] [Indexed: 02/02/2023] Open
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Pereira JA, Marques MJ, Santo Neto H. Co-administration of deflazacort and doxycycline: a potential pharmacotherapy for Duchenne muscular dystrophy. Clin Exp Pharmacol Physiol 2016; 42:788-94. [PMID: 25959722 DOI: 10.1111/1440-1681.12417] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Revised: 02/27/2015] [Accepted: 03/01/2015] [Indexed: 11/29/2022]
Abstract
The standard therapy used in the treatment of Duchenne muscle dystrophy (DMD) is corticoids, such as deflazacort and prednisone. However, they have limited therapeutic value, and their combination with drugs already in use to treat other human diseases could potentially increase corticoid outcomes in DMD. In the present study, we evaluated whether a combined therapy of the corticoid deflazacort with doxycycline could result in greater improvement in mdx dystrophy than deflazacort alone. Deflazacort alone or deflazacort/doxycycline were administered for 36 days (starting on postnatal day 0) in drinking water. Histopathological, biochemical (creatine kinase), functional (forelimb muscle grip strength and fatigue) parameters and inflammatory markers (MMP-9, TNF-α, NF-kB) were evaluated in biceps brachii and diaphragm muscles of the mdx mice. The combined therapy was superior in improving the dystrophic phenotype compared to monotherapy. The primary results were observed in attenuating muscle fatigue, decreasing muscle total calcium and inflammatory markers and increasing β-dystroglycan, a main component of the dystrophin-protein complex. Furthermore, the combined therapy was effective in preventing the loss of body mass observed with deflazacort alone at this very early stage of therapy. The present study offers preclinical data to support further studies with deflazacort/doxycycline combined therapy in DMD clinical trials.
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Affiliation(s)
- Juliano Alves Pereira
- Department of Structural and Functional Biology, Institute of Biology, State University of Campinas (Unicamp), Campinas, São Paulo, Brazil
| | - Maria Julia Marques
- Department of Structural and Functional Biology, Institute of Biology, State University of Campinas (Unicamp), Campinas, São Paulo, Brazil
| | - Humberto Santo Neto
- Department of Structural and Functional Biology, Institute of Biology, State University of Campinas (Unicamp), Campinas, São Paulo, Brazil
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Clark TW. Are C-reactive protein levels associated with bacteria in COPD exacerbations? Eur Respir J 2016; 45:1515-6. [PMID: 25931496 DOI: 10.1183/09031936.00020015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Tristan W Clark
- Dept of Clinical and Experimental Sciences and Respiratory Biomedical Research Unit, University of Southampton, Southampton, UK Dept of Infection, Immunity and Inflammation, University of Leicester, Leicester, UK
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Liapikou A, Torres A. The clinical management of lower respiratory tract infections. Expert Rev Respir Med 2016; 10:441-452. [PMID: 26894943 DOI: 10.1586/17476348.2016.1156537] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The 2010 Global Burden of Disease Study reported that lower respiratory tract infections, including pneumonia, are the fourth most common cause of death globally. The etiology of acute bronchitis and asthma exacerbations is mostly viral and the therapy is symptomatic. Management decisions in community acquired pneumonia regarding site of care, extent of assessment, and level of treatment are based primarily on disease severity (outpatient, inpatient, ICU admission). Antibiotics are the main choice of treatment for patients with pneumonia, acute exacerbations (AE) of COPD (including increased sputum purulence and worsening shortness of breath) and AE of non-CF bronchiectasis. Inhaled antibiotics may represent a more optimal approach for the treatment and prevention of AE of non-CF bronchiectasis. Approved strategies for the prevention of exacerbations include smoking cessation and rehabilitation programs, drug therapy and vaccination.
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Affiliation(s)
| | - Antoni Torres
- b Department of Pneumology, Institut Clinic del Tórax, Institut d'investigacions Biomèdiques August Pi i Sunyer - IDIBAPS , University of Barcelona - UB - Ciber de Enfermedades Respiratorias - CIBERES, Hospital Clinic , Barcelona , Spain
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Crisafulli E, Torres A, Huerta A, Guerrero M, Gabarrús A, Gimeno A, Martinez R, Soler N, Fernández L, Wedzicha JA, Menéndez R. Predicting In-Hospital Treatment Failure (≤ 7 days) in Patients with COPD Exacerbation Using Antibiotics and Systemic Steroids. COPD 2015; 13:82-92. [PMID: 26451913 DOI: 10.3109/15412555.2015.1057276] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Although pharmacological treatment of COPD exacerbation (COPDE) includes antibiotics and systemic steroids, a proportion of patients show worsening of symptoms during hospitalization that characterize treatment failure. The aim of our study was to determine in-hospital predictors of treatment failure (≤ 7 days). Prospective data on 110 hospitalized COPDE patients, all treated with antibiotics and systemic steroids, were collected; on the seventh day of hospitalization, patients were divided into treatment failure (n = 16) or success (n = 94). Measures of inflammatory serum biomarkers were recorded at admission and at day 3; data on clinical, laboratory, microbiological, and severity, as well data on mortality and readmission, were also recorded. Patients with treatment failure had a worse lung function, with higher serum levels of C-reactive protein (CRP), procalcitonin (PCT), tumour necrosis factor-alpha (TNF-α), interleukin (IL) 8, and IL-10 at admission, and CRP and IL-8 at day 3. Longer length of hospital stay and duration of antibiotic therapy, higher total doses of steroids and prevalence of deaths and readmitted were found in the treatment failure group. In the multivariate analysis, +1 mg/dL of CRP at admission (OR, 1.07; 95% CI, 1.01 to 1.13) and use of penicillins or cephalosporins (OR, 5.63; 95% CI, 1.26 to 25.07) were independent variables increasing risk of treatment failure, whereas cough at admission (OR, 0.20; 95% CI, 0.05 to 0.75) reduces risk of failure. In hospitalized COPDE patients CRP at admission and use of specific class of antibiotics predict in-hospital treatment failure, while presence of cough has a protective role.
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Affiliation(s)
- Ernesto Crisafulli
- a 1 Cardio-Thoracic Department, Pneumology and Respiratory Intensive Care Unit, "Carlo Poma" Hospital , Mantova , Italy
| | - Antoni Torres
- b 2 Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) - University of Barcelona (UB) , Barcelona , Spain
| | - Arturo Huerta
- b 2 Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) - University of Barcelona (UB) , Barcelona , Spain
| | - Mónica Guerrero
- b 2 Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) - University of Barcelona (UB) , Barcelona , Spain
| | - Albert Gabarrús
- b 2 Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) - University of Barcelona (UB) , Barcelona , Spain
| | - Alexandra Gimeno
- c 3 Pneumology Department, Hospital Universitario y politecnico La Fe, CIBERES , Valencia , Spain
| | - Raquel Martinez
- c 3 Pneumology Department, Hospital Universitario y politecnico La Fe, CIBERES , Valencia , Spain
| | - Néstor Soler
- b 2 Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) - University of Barcelona (UB) , Barcelona , Spain
| | - Laia Fernández
- b 2 Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) - University of Barcelona (UB) , Barcelona , Spain
| | - Jadwiga A Wedzicha
- d 4 Centre for Respiratory Medicine, Royal Free Campus, University College London Medical School , London , United Kingdom
| | - Rosario Menéndez
- c 3 Pneumology Department, Hospital Universitario y politecnico La Fe, CIBERES , Valencia , Spain
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Ouanes I, Ouanes-Besbes L, Ben Abdallah S, Dachraoui F, Abroug F. Trends in use and impact on outcome of empiric antibiotic therapy and non-invasive ventilation in COPD patients with acute exacerbation. Ann Intensive Care 2015; 5:30. [PMID: 26429357 PMCID: PMC4591222 DOI: 10.1186/s13613-015-0072-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2015] [Accepted: 09/22/2015] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Empiric antibiotic therapy is routinely prescribed in patients with acute COPD exacerbations (AECOPD) requiring ventilatory support on the basis of studies including patients conventionally ventilated. Whether this practice remains valid to current management with first-line non-invasive ventilation (NIV) is unclear. METHODS In a cohort of ICU patients admitted between 2000 and 2012 for AECOPD, we analyzed the trends in empiric antibiotic therapy and in primary ventilatory support strategy, and their respective impact on patients' outcome. RESULTS 440 patients admitted for 552 episodes were included; primary NIV use increased from 29 to 96.7 % (p < 0.001), whereas NIV failure rate decreased significantly (p = 0.004). In parallel, ventilator-associated pneumonia (VAP) rate, VAP density and empiric antibiotic therapy use decreased (p = 0.037, p = 0.002, and p < 0.001, respectively). These figures were associated with a trend toward lower ICU mortality rate (p = 0.058). Logistic regression showed that primary NIV use per se was protective against fatal outcome [odds ratios (OR) = 0.08, 95 %CI 0.03-0.22; p < 0.001], whereas NIV failure, VAP occurrence, and cardiovascular comorbidities were associated with increased ICU mortality [OR = 17.6 (95 %CI 5.29-58.93), 11.5 (95 %CI 5.17-25.45), and 3 (95 %CI 1.37-6.63), respectively]. Empiric antibiotic therapy was associated with decreased VAP rate (log rank; p < 0.001), but had no effect on mortality (log rank; p = 0.793). CONCLUSIONS The sustained increase in NIV use allowed a decrease in empiric antibiotic prescriptions in AECOPD requiring ventilatory support. Primary NIV use and its success, but not empiric antibiotic therapy, were associated with a favorable impact on patients' outcome.
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Affiliation(s)
- Islem Ouanes
- Intensive Care Unit, Fattouma Bourguiba University Hospital, Rue 1er juin, 5000, Monastir, Tunisia. .,Laboratoire de Recherche (LR12SP15), University of Monastir, Monastir, Tunisia.
| | - Lamia Ouanes-Besbes
- Intensive Care Unit, Fattouma Bourguiba University Hospital, Rue 1er juin, 5000, Monastir, Tunisia. .,Laboratoire de Recherche (LR12SP15), University of Monastir, Monastir, Tunisia.
| | - Saoussen Ben Abdallah
- Intensive Care Unit, Fattouma Bourguiba University Hospital, Rue 1er juin, 5000, Monastir, Tunisia. .,Laboratoire de Recherche (LR12SP15), University of Monastir, Monastir, Tunisia.
| | - Fahmi Dachraoui
- Intensive Care Unit, Fattouma Bourguiba University Hospital, Rue 1er juin, 5000, Monastir, Tunisia. .,Laboratoire de Recherche (LR12SP15), University of Monastir, Monastir, Tunisia.
| | - Fekri Abroug
- Intensive Care Unit, Fattouma Bourguiba University Hospital, Rue 1er juin, 5000, Monastir, Tunisia. .,Laboratoire de Recherche (LR12SP15), University of Monastir, Monastir, Tunisia.
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Determinants of bacteriological outcomes in exacerbations of chronic obstructive pulmonary disease. Infection 2015; 44:65-76. [PMID: 26370552 PMCID: PMC4735236 DOI: 10.1007/s15010-015-0833-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Accepted: 08/14/2015] [Indexed: 12/03/2022]
Abstract
Purpose Changes in sputum microbiology following antibiotic treatment of acute exacerbations of chronic obstructive pulmonary disease (AECOPD), including patterns of bacteriological relapse and superinfection are not well understood. Sputum microbiology at exacerbation is not routinely performed, but pathogen presence and species are determinants of outcomes. Therefore, we determined whether baseline clinical factors could predict the presence of bacterial pathogens at exacerbation. Bacterial eradication at end of treatment (EOT) is associated with clinical resolution of exacerbation. We determined the clinical, microbiological and therapeutic factors that were associated with bacteriological eradication in AECOPD at EOT and in the following 8 weeks. Methods Sputum bacteriological outcomes (i.e., eradication, persistence, superinfection, reinfection) from AECOPD patients (N = 1352) who were randomized to receive moxifloxacin or amoxicillin/clavulanate in the MAESTRAL study were compared. Independent predictors of bacterial presence in sputum at exacerbation and determinants for bacteriological eradication were analyzed by logistic regression and receiver operating characteristic (ROC) analyses. Results Significantly greater bacteriological eradication with moxifloxacin was mainly driven by superior Haemophilus influenzae eradication (P = 0.002, EOT). Baseline clinical factors were a weak predictor of the presence of pathogens in sputum (AUCROC = 0.593). On multivariate analysis, poorer bacterial eradication was associated with antibiotic resistance (P = 0.0001), systemic steroid use (P = 0.0024) and presence of P. aeruginosa (P = 0.0282). Conclusions Since clinical prediction of bacterial presence in sputum at AECOPD is poor, sputum microbiological analysis should be considered for guiding antibiotic therapy in moderate-to-severe AECOPD, particularly in those who received concomitant systemic corticosteroids or are at risk for infection with antibiotic-resistant bacteria. Electronic supplementary material The online version of this article (doi:10.1007/s15010-015-0833-3) contains supplementary material, which is available to authorized users.
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Saltürk C, Karakurt Z, Adiguzel N, Kargin F, Sari R, Celik ME, Takir HB, Tuncay E, Sogukpinar O, Ciftaslan N, Mocin O, Gungor G, Oztas S. Does eosinophilic COPD exacerbation have a better patient outcome than non-eosinophilic in the intensive care unit? Int J Chron Obstruct Pulmon Dis 2015; 10:1837-46. [PMID: 26392758 PMCID: PMC4572725 DOI: 10.2147/copd.s88058] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND COPD exacerbations requiring intensive care unit (ICU) admission have a major impact on morbidity and mortality. Only 10%-25% of COPD exacerbations are eosinophilic. AIM To assess whether eosinophilic COPD exacerbations have better outcomes than non-eosinophilic COPD exacerbations in the ICU. METHODS This retrospective observational cohort study was conducted in a thoracic, surgery-level III respiratory ICU of a tertiary teaching hospital for chest diseases from 2013 to 2014. Subjects previously diagnosed with COPD and who were admitted to the ICU with acute respiratory failure were included. Data were collected electronically from the hospital database. Subjects' characteristics, complete blood count parameters, neutrophil to lymphocyte ratio (NLR), delta NLR (admission minus discharge), C-reactive protein (CRP) on admission to and discharge from ICU, length of ICU stay, and mortality were recorded. COPD subjects were grouped according to eosinophil levels (>2% or ≤2%) (group 1, eosinophilic; group 2, non-eosinophilic). These groups were compared with the recorded data. RESULTS Over the study period, 647 eligible COPD subjects were enrolled (62 [40.3% female] in group 1 and 585 [33.5% female] in group 2). Group 2 had significantly higher C-reactive protein, neutrophils, NLR, delta NLR, and hemoglobin, but a lower lymphocyte, monocyte, and platelet count than group 1, on admission to and discharge from the ICU. Median (interquartile range) length of ICU stay and mortality in the ICU in groups 1 and 2 were 4 days (2-7 days) vs 6 days (3-9 days) (P<0.002), and 12.9% vs 24.9% (P<0.034), respectively. CONCLUSION COPD exacerbations with acute respiratory failure requiring ICU admission had a better outcome with a peripheral eosinophil level >2%. NLR and peripheral eosinophilia may be helpful indicators for steroid and antibiotic management.
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Affiliation(s)
- Cüneyt Saltürk
- Respiratory Intensive Care Unit, Sureyyapasa Chest Diseases and Thoracic. Surgery Teaching Hospital, Istanbul, Turkey
| | - Zuhal Karakurt
- Respiratory Intensive Care Unit, Sureyyapasa Chest Diseases and Thoracic. Surgery Teaching Hospital, Istanbul, Turkey
| | - Nalan Adiguzel
- Respiratory Intensive Care Unit, Sureyyapasa Chest Diseases and Thoracic. Surgery Teaching Hospital, Istanbul, Turkey
| | - Feyza Kargin
- Respiratory Intensive Care Unit, Sureyyapasa Chest Diseases and Thoracic. Surgery Teaching Hospital, Istanbul, Turkey
| | - Rabia Sari
- Respiratory Intensive Care Unit, Sureyyapasa Chest Diseases and Thoracic. Surgery Teaching Hospital, Istanbul, Turkey
| | - M Emin Celik
- Respiratory Intensive Care Unit, Sureyyapasa Chest Diseases and Thoracic. Surgery Teaching Hospital, Istanbul, Turkey
| | - Huriye Berk Takir
- Respiratory Intensive Care Unit, Sureyyapasa Chest Diseases and Thoracic. Surgery Teaching Hospital, Istanbul, Turkey
| | - Eylem Tuncay
- Respiratory Intensive Care Unit, Sureyyapasa Chest Diseases and Thoracic. Surgery Teaching Hospital, Istanbul, Turkey
| | - Ozlem Sogukpinar
- Respiratory Intensive Care Unit, Sureyyapasa Chest Diseases and Thoracic. Surgery Teaching Hospital, Istanbul, Turkey
| | - Nezihe Ciftaslan
- Respiratory Intensive Care Unit, Sureyyapasa Chest Diseases and Thoracic. Surgery Teaching Hospital, Istanbul, Turkey
| | - Ozlem Mocin
- Respiratory Intensive Care Unit, Sureyyapasa Chest Diseases and Thoracic. Surgery Teaching Hospital, Istanbul, Turkey
| | - Gokay Gungor
- Respiratory Intensive Care Unit, Sureyyapasa Chest Diseases and Thoracic. Surgery Teaching Hospital, Istanbul, Turkey
| | - Selahattin Oztas
- Respiratory Intensive Care Unit, Sureyyapasa Chest Diseases and Thoracic. Surgery Teaching Hospital, Istanbul, Turkey
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Lopez-Campos JL, Agustí A. Heterogeneity of chronic obstructive pulmonary disease exacerbations: a two-axes classification proposal. THE LANCET RESPIRATORY MEDICINE 2015; 3:729-734. [PMID: 26165134 DOI: 10.1016/s2213-2600(15)00242-8] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/07/2015] [Revised: 05/29/2015] [Accepted: 06/04/2015] [Indexed: 12/24/2022]
Abstract
Exacerbations of chronic obstructive pulmonary disease (COPD) are clinically relevant events with therapeutic and prognostic implications. Yet, they are heterogeneous and can need different therapeutic strategies. In this Viewpoint, we propose an admittedly crude approach to a COPD exacerbation classification that might eventually help to define the most appropriate pharmacological treatment and clinical treatment setting for these patients. Our suggestion is to combine a pathobiological axis (biomarkers) to guide treatment decisions (use of antibiotics, steroids, or both) with a clinical axis (severity score) to decide the organisational context in which to optimally treat the patient. Needless to say, this proposal needs to be researched and eventually validated, refined, or disproved, but we hope that this process will contribute to the improvement of personalised treatment for patients with COPD exacerbations.
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Affiliation(s)
- Jose Luis Lopez-Campos
- Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocio/Universidad de Sevilla, Seville, Spain; CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain.
| | - Alvar Agustí
- CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain; Thorax Institute, Hospital Clinic, IDIBAPS, Universitat de Barcelona, Barcelona, Spain
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Wilson R, Anzueto A, Miravitlles M, Arvis P, Haverstock D, Trajanovic M, Sethi S. Prognostic factors for clinical failure of exacerbations in elderly outpatients with moderate-to-severe COPD. Int J Chron Obstruct Pulmon Dis 2015; 10:985-93. [PMID: 26082623 PMCID: PMC4459615 DOI: 10.2147/copd.s80926] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Acute exacerbations represent a significant burden for patients with moderate-to-severe chronic obstructive pulmonary disease. Each exacerbation episode is frequently associated with a lengthy recovery and impaired quality of life. Prognostic factors for outpatients that may predict poor outcome after treatment with antibiotics recommended in the guidelines, are not fully understood. We aimed to identify pretherapy factors predictive of clinical failure in elderly (≥60 years old) outpatients with acute Anthonisen type 1 exacerbations. Trial registration NCT00656747. Methods Based on the moxifloxacin in AECOPDs (acute exacerbations of chronic obstructive pulmonary disease) trial (MAESTRAL) database, this study evaluated pretherapy demographic, clinical, sputum bacteriological factors using multivariate logistic regression analysis, with internal validation by bootstrap replicates, to investigate their possible association with clinical failure at end of therapy (EOT) and 8 weeks posttherapy. Results The analyses found that the independent factors predicting clinical failure at EOT were more frequent exacerbations, increased respiratory rate and lower body temperature at exacerbation, treatment with long-acting anticholinergic drugs, and in vitro bacterial resistance to study drug. The independent factors predicting poor outcome at 8 weeks posttherapy included wheezing at preexacerbation, mild or moderate (vs extreme) sleep disturbances, lower body temperature at exacerbation, forced expiratory volume in 1 second <30%, lower body mass index, concomitant systemic corticosteroids for the current exacerbation, maintenance long-acting β2-agonist and long-acting anticholinergic treatments, and positive sputum culture at EOT. Conclusion Several bacteriological, historical, treatment-related factors were identified as predictors of early (EOT) and later (8 weeks posttherapy) clinical failure in this older outpatient population with moderate-to-severe chronic obstructive pulmonary disease. These patients should be closely monitored and sputum cultures considered before and after treatment.
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Affiliation(s)
- Robert Wilson
- Host Defence Unit, Royal Brompton Hospital, London, UK
| | - Antonio Anzueto
- University of Texas Health Science Center, South Texas Veterans Health Care System, San Antonio, TX, USA
| | - Marc Miravitlles
- Pneumology Department, Hospital Universitari Vall d'Hebron, CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
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