Antibiotic Prescription for COPD Exacerbations Admitted to Hospital: European COPD Audit

Males are at Higher Risk for Colonizations and Infections with Multidrug Resistant Organisms than Females

BACKGROUND

Global rise of multidrug-resistant organisms (MDRO) is alarming and antimicrobial resistance (AMR) poses a significant public health threat globally. Although certain risk factors are known including recent antimicrobial therapy, inappropriate use and hospitalization, the focus on gender-specific aspects in MDRO is scarce. Our aim was to show gender-specific differences in colonization and infections of multiple MDRO and their detection sites.

METHODS

For this multicentre, retrospective cohort study surveillance data between 2015 and 2020 was collected in 86 hospitals of the Helios group, Germany. The following multidrug-resistant bacteria were analysed according to sample site: MRSA, Enterococcus spp., Escherichia coli, Klebsiella pneumonia, Pseudomonas aeruginosa and Acinetobacter baumannii.

RESULTS

Out of the 7,081,708 cases in the database, 187,656 patients were found to be colonized with MDRO (2.65%). A documented infection with MDRO was identified in 33,023 patients (0.466%), with the origin of infection known in 24,231 cases. Male gender was a risk factor for both infection and colonization of any MDRO (p< .001). Males exhibited a higher likelihood of MDRO detection in superficial skin/soft tissue, blood cultures (p < .001), and respiratory samples (p = .002). Additionally, gender-specific differences in MDRO detection site and pathogens were found with slightly higher proportion of MRSA infection in deep skin/soft tissue and respiratory samples for females.

CONCLUSIONS

Our study reinforces the existing hypothesis that male gender is a risk factor for MDRO, supported by our large dataset. It highlights the need to acknowledge gender-specific MDRO susceptibility in clinical practice.

The use of antibiotics in the early stage of acute exacerbation of chronic obstructive pulmonary disease in patients without obvious signs of infection: a multicenter, randomized, parallel-controlled study

Introduction

Chronic obstructive pulmonary disease (COPD) is a chronic respiratory disease with high prevalence and mortality. In some acute exacerbations of COPD (AECOPD) in patients with no obvious signs of infection, early antibiotic treatment seems to clinically improve the disease, but more studies are needed to determine the prognostic impact of antibiotic treatment in AECOPD patients with no obvious signs of infection.

Purpose

To clarify the impact of antibiotic treatment on the short-term and long-term prognoses of AECOPD patients without obvious signs of infection.

Methods

The impact of the two treatment methods on the prognosis of patients was compared at 30, 90, 180, and 360 days after discharge. A multicenter, randomized, parallel-controlled clinical trial was conducted in a department of respiratory and critical care medicine in Central China. All patients met the inclusion criteria for AECOPD, and the patients were randomly assigned to the antibiotic group or the nonantibiotic group at a 1:1 ratio. Patients in the antibiotic group were given moxifloxacin 400 mg/day intravenously for 7 days. Patients in the nonantibiotic group were intravenously injected with the same amount of normal saline as the amount of moxifloxacin given to those in the antibiotic group for 7 days.

Results

There were 406 patients in the antibiotic group and 410 patients in the nonantibiotic group. During the short-term and long-term follow-ups, the acute exacerbation frequency, intensive care unit (ICU) treatment rate, mortality, and mMRC and CAT scores were not significantly different between the two groups (p > 0.05). At the 180- and 360-day follow-ups, the forced expiratory volume in 1 s (FEV1%) and peak expiratory flow (PEF) were not significantly different between the two groups (p > 0.05). The 30-day readmission rate was significantly lower in the antibiotic group than in the nonantibiotic group (p < 0.05). The time from discharge to the first acute exacerbation was not significantly different between the two groups (p > 0.05). The length of the first hospital stay after discharge was significantly lower in the antibiotic group (5.84 days) than in the nonantibiotic group (6.75 days) (p < 0.05). At the 30-day follow-up, the acute exacerbation frequency, age, C-reactive protein (CRP) level, and sputum viscosity were significantly greater in the nonantibiotic group than in the antibiotic group (p < 0.05). In addition, according to the receiver operating characteristic (ROC) analysis, the frequency of acute exacerbations at the 30-day follow-up was significantly greater in COPD patients aged >62.5 years, with a CRP level >12.56 mg/L or with a sputum viscosity >III, in the nonantibiotic group than in those in the antibiotic group, suggesting that the short-term prognosis was poor.

Conclusion

Patients who are >62.5 years of age, have a CRP concentration >12.56 mg/L, or have a sputum viscosity >III without obvious signs of infection should be treated with antibiotics to improve their short-term prognosis.

Clinical Trial Registration

(https://www.chictr.org.cn), (ChiCTR1800018921).

Antimicrobial stewardship in primary health care programs in humanitarian settings: the time to act is now

Fragile and conflict-affected settings bear a disproportionate burden of antimicrobial resistance, due to the compounding effects of weak health policies, disrupted medical supply chains, and lack of knowledge and awareness about antibiotic stewardship both among health care providers and health service users. Until now, humanitarian organizations intervening in these contexts have confronted the threat of complex multidrug resistant infections mainly in their surgical projects at the secondary and tertiary levels of care, but there has been limited focus on ensuring the implementation of adequate antimicrobial stewardship in primary health care, which is known to be setting where the highest proportion of antibiotics are prescribed. In this paper, we present the experience of two humanitarian organizations, Médecins sans Frontières and the International Committee of the Red Cross, in responding to antimicrobial resistance in their medical interventions, and we draw from their experience to formulate practical recommendations to include antimicrobial stewardship among the standards of primary health care service delivery in conflict settings. We believe that expanding the focus of humanitarian interventions in unstable and fragile contexts to include antimicrobial stewardship in primary care will strengthen the global response to antimicrobial resistance and will decrease its burden where it is posing the highest toll in terms of mortality.

Clinical Management of COPD in the Real World: Can Studies Reveal Errors in Management and Pathways to Improve Patient Care?

Real world data comprise information on health care that is derived from multiple sources outside typical clinical research settings. This review focuses on what real world evidence tells us about problems with the diagnosis of chronic obstructive pulmonary disease (COPD), problems with the initial and follow-up pharmacological and non-pharmacological management, problems with the management of exacerbations and problems with palliative care. Data from real world studies show errors in the management of COPD with delays to diagnosis, lack of confirmation of the diagnosis with spirometry, lack of holistic assessment, lack of attention to smoking cessation, variable adherence to management guidelines, delayed implementation of appropriate interventions, under-recognition of patients at higher risk of adverse outcomes, high hospitalisation rates for exacerbations and poor implementation of palliative care. Understanding that these problems exist and considering how and why they occur is fundamental to developing solutions to improve the diagnosis and management of patients with COPD.

Time-Updated Phenotypic Guidance of Corticosteroids and Antibiotics in COPD: Rationale, Perspective and a Proposed Method

Chronic obstructive pulmonary disease (COPD) is a heterogeneous disease with distinct phenotypes, each having distinct treatment needs. Eosinophilic airway inflammation is present in a subset of COPD patients in whom it can act as a driver of exacerbations. Blood eosinophil counts are a reliable way to identify patients with an eosinophilic phenotype, and these measurements have proven to be successful in guiding the use of corticosteroids in moderate and severe COPD exacerbations. Antibiotic use in COPD patients induces a risk of Clostridium difficile infection, diarrhea, and antibiotic resistance. Procalcitonin could possibly guide antibiotic treatment in patients admitted with AECOPD. Current studies in COPD patients were successful in reducing exposure to antibiotics with no changes in mortality or length of stay. Daily monitoring of blood eosinophils is a safe and effective way to reduce oral corticosteroid exposure and side effects for acute exacerbations. No evidence on time-updated treatment guidance for stable COPD exists yet, but a current trial is testing an eosinophil-guided approach on inhaled corticosteroid use. Procalcitonin-guided antibiotic treatment in AECOPD shows promising results in safely and substantially reducing antibiotic exposure both in time-independent and time-updated algorithms.

In-hospital antibiotic use for severe chronic obstructive pulmonary disease exacerbations: a retrospective observational study

BACKGROUND

The use of antibiotics in mild to severe acute exacerbations of chronic obstructive pulmonary disease (COPD) remains controversial.

AIM

To explore in-hospital antibiotic use in severe acute exacerbations of COPD (AECOPD), to analyze determinants of in-hospital antibiotic use, and to investigate its association with hospital length of stay (LOS) and in-hospital mortality.

METHODS

A retrospective, observational study was conducted in Ghent University Hospital. Severe AECOPD were defined as hospitalizations for AECOPD (ICD-10 J44.0 and J44.1) discharged between 2016 and 2021. Patients with a concomitant diagnosis of pneumonia or 'pure' asthma were excluded. An alluvial plot was used to describe antibiotic treatment patterns. Logistic regression analyses identified determinants of in-hospital antibiotic use. Cox proportional hazards regression analyses were used to compare time to discharge alive and time to in-hospital death between antibiotic-treated and non-antibiotic-treated AECOPD patients.

RESULTS

In total, 431 AECOPD patients (mean age 70 years, 63% males) were included. More than two-thirds (68%) of patients were treated with antibiotics, mainly amoxicillin-clavulanic acid. In multivariable analysis, several patient-related variables (age, body mass index (BMI), cancer), treatment-related variables (maintenance azithromycin, theophylline), clinical variables (sputum volume and body temperature) and laboratory results (C-reactive protein (CRP) levels) were associated with in-hospital antibiotic use independent of sputum purulence, neutrophil counts, inhaled corticosteroids and intensive care unit of which CRP level was the strongest determinant. The median hospital LOS was significantly longer in antibiotic-treated patients (6 days [4-10]) compared to non-antibiotic-treated patients (4 days [2-7]) (p < 0.001, Log rank test). This was indicated by a reduced probability of hospital discharge even after adjustment for age, sputum purulence, BMI, in-hospital systemic corticosteroid use and forced expiratory volume in one second (FEV₁) (adjusted hazard ratio 0.60; 95% CI 0.43; 0.84). In-hospital antibiotic use was not significantly associated with in-hospital mortality.

CONCLUSIONS

In this observational study in a Belgian tertiary hospital, in-hospital antibiotic use among patients with severe AECOPD was determined by the symptom severity of the exacerbation and the underlying COPD severity as recommended by the guidelines, but also by patient-related variables. Moreover, in-hospital antibiotic use was associated with a longer hospital stay, which may be linked to their disease severity, slower response to treatment or 'harm' due to antibiotics.

TRIAL REGISTRATION

Number: B670201939030; date of registration: March 5, 2019.

A systematic review and Bayesian meta-analysis of the antibiotic treatment courses in AECOPD

Background: No consensus exists on the antibiotic treatment course for patients with acute exacerbations of chronic obstructive pulmonary disease (AECOPD). Former studies indicate that shorter courses might have the same efficacy with fewer adverse events, which is inconsistent with guidelines and general practice. Existing evidence allows us to conduct a systematic review and Bayesian analysis on this topic. Methods: Four databases were searched from their inception to January 5, 2023. All statistical estimations were performed using R. "Gemtc" was the core package of analysis. CINeMA was used to assess the grade of confidence of the results. Results: Fourteen studies were included in the Bayesian meta-analysis. No difference in the clinical success rate of antibiotic treatment was observed from a super short course (1-3 days) to a long course (≥10 days). Considering the adverse events, the short course (4-6 days) might be the safest. The majority of results were of high or moderate confidence grade. Conclusion: Short course might cause the fewest adverse events. The clinical efficacy of antibiotics might not depend on the course length. Undeniably, more systematic explorations are warranted to investigate the clinical application of a shorter course of antibiotic treatment.

Antibiotics Use among Patients with Acute Exacerbation of Chronic Obstructive Pulmonary Disease in the Department of Internal Medicine of a Tertiary Care Centre: A Descriptive Cross-sectional Study

Introduction

Acute exacerbation of chronic obstructive pulmonary disease is a life-threatening condition triggered by infections or non-infectious agents. Antibiotics use in such cases prevents severe deterioration and treatment failure. Past studies have shown inappropriate use of antibiotics in different health care settings. The objective of this study was to find out the prevalence of antibiotics use in patients with acute exacerbation of chronic obstructive pulmonary disease in the Department of Internal Medicine of a tertiary care centre.

Methods

A descriptive cross-sectional study was conducted among patients with acute exacerbation of Chronic Obstructive Pulmonary Disease admitted to Department of Internal Medicine of a tertiary care centre from 12th February, 2022 to 15th April, 2022 after taking ethical clearance from Institutional Review Committee (Reference number: 417). Convenience sampling was done. Data analysis was done using the Statistical Package for the Social Sciences version 23.0. Point estimate at 95% Confidence Interval was calculated along with frequency and percentage for binary data along with median and interquartile range for continuous data.

Results

The prevalence of antibiotics use among study participants was 106 (98.15%) (95.61-100 at a 95% Confidence Interval). Penicillin 82 (75.93%) was the most commonly used antibiotics group.

Conclusions

The use of antibiotics in acute exacerbation of chronic obstructive pulmonary disease was higher as compared to other similar studies.

Keywords

anti-bacterial agents; chronic obstructive pulmonary disease; guideline adherence.

Eosinopenia as a biomarker for antibiotic use in COPD exacerbations: protocol for a retrospective hospital-based cohort study

INTRODUCTION

The acute exacerbation of chronic obstructive pulmonary disease (AECOPD) has a seriously negative impact on patients' healths condition and disease progression. Bacterial infection is closely related to AECOPD, and antibiotics are frequently used in clinical practice. The lack of specific biomarkers for rational antibiotics use always leads to antibiotics abuse in chronic obstructive pulmonary disease (COPD) flare-ups. Eosinopenia has been considered to be related to increased bacterial load of potentially pathogenic organisms at the onset of COPD exacerbations. Therefore, this study aims to investigate whether eosinopenia could be used as a reference for the use of antibiotics in AECOPD.

METHODS AND ANALYSIS

In this study, a hospital-based retrospective cohort design will be adopted to analyse the clinical data of inpatients who are primarily diagnosed with AECOPD in West China Hospital of Sichuan University from 1 January 2010 to 31 December 2020. Relevant data will be extracted from the Clinical Big Data Platform for Scientific Research in West China Hospital, including demographic characteristics, blood eosinophil count, procalcitonin, C reactive protein, microbial cultivation, antibiotics use, length of hospital stay, non-invasive ventilation use, intensive care unit transfer and mortality, etc. The collected data will be described and inferred by corresponding statistical methods according to the data type and their distributions. Multiple binary logistic regression models will be used to analyse the relationship between blood eosinophil count and bacterial infection. The antibiotics use, and patient morbidity and mortality will be compared between patients with or without eosinopenia.

ETHICS AND DISSEMINATION

This study has been approved by the Biomedical Ethics Review Board of West China Hospital of Sichuan University (Approval No. 2020-1056). And the research results will be published in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

ChiCTR2000039379.

Optimal cut-off value of serum procalcitonin in predicting bacterial infection induced acute exacerbation in chronic obstructive pulmonary disease: A prospective observational study

Objective

To explore the optimal cut-off value of serum procalcitonin (PCT) level in predicting bacterial infection in hospitalized patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD).

Methods

204 hospitalized patients with AECOPD were enrolled in this study. Their diagnoses and treatments followed routine protocols in Fu-Xing Hospital affiliated to Capital Medical University, Beijing, China. Extra blood samples were taken for serum PCT level testing and the results were blinded to the treating physicians. On discharge, clinical data were collected and the treating physicians made comprehensive analyses to determine whether the AECOPD were triggered by respiratory tract bacterial infection or non-bacterial causes according to the “new diagnostic criteria” defined in this study. In the AECOPD patients with bacterial infection, treating physicians decided whether they had bacterial pneumonia based on imaging studies. Receiver operating characteristic curve (ROC) was used to analyze the accuracy of serum PCT level in predicting bacterial infection.

Results

In the 173 AECOPD patients who did not have pneumonia, 115 had evidences of bacterial infection while 58 did not. The median PCT levels were 0.1(0.08, 0.18) ng/ml and 0.07 (0.05, 0.08) ng/ml for each group, which were statistically different. The proposed optimal cut-off value of serum PCT level in predicting bacterial infection was 0.08 ng/mL according to this study, with a sensitivity of 81%, specificity of 67% and area under the ROC curve (AUC) of 0.794. There were 31 AECOPD patients diagnosed with pneumonia, their median PCT level was 0.23 ng/mL.

Conclusions

The serum PCT levels slightly increased in the majority of hospitalized patients with AECOPD compared with reference range. When PCT level was ≥0.08 ng/mL, AECOPD was more likely to be caused by bacterial infection. A significantly elevated PCT levels may indicate combination of AECOPD and bacterial pneumonia.

Effectiveness of Nationwide COPD Pay-for-Performance Program on COPD Exacerbations in Taiwan

Background

Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality worldwide. It has also imposed a substantial economic and social burden on the health care system. In Taiwan, a nationwide COPD pay-for-performance (P4P) program was designed to improve the quality of COPD-related care by introducing financial incentives for health care providers and employing a multidisciplinary team to deliver guideline-based, integrated care for patients with COPD, reducing adverse outcomes, especially COPD exacerbation. However, the results of a survey of the effectiveness of the pay-for-performance program in COPD management were inconclusive. To address this knowledge gap, this study evaluated the effectiveness of the COPD P4P program in Taiwan.

Methods

This retrospective cohort study used data from Taiwan’s National Health Insurance claims database and nationwide COPD P4P enrollment program records from June 2016 to December 2018. Patients with COPD were classified into P4P and non-P4P groups. Patients in the P4P group were matched at a ratio of 1:1 based on age, gender, region, accreditation level, Charlson Comorbidity Index (CCI), and inhaled medication prescription type to create the non-P4P group. A difference-in-difference analysis was used to evaluate the influence of the P4P program on the likelihood of COPD exacerbation, namely COPD-related emergency department (ED) visit, intensive care unit (ICU) admission, or hospitalization.

Results

The final sample of 14,288 patients comprised 7144 in each of the P4P and non-P4P groups. The prevalence of COPD-related ED visits, ICU admissions, and hospitalizations was higher in the P4P group than in the non-P4P group 1 year before enrollment. After enrollment, the P4P group exhibited a greater decrease in the prevalence of COPD-related ED visits and hospitalizations than the non-P4P group (ED visit: −2.98%, p<0.05, 95% confidence interval [CI]: −0.277 to −0.086; hospitalization: −1.62%, p<0.05, 95% CI: −0.232 to −0.020), whereas no significant difference was observed between the groups in terms of the changes in the prevalence of COPD-related ICU admissions.

Conclusion

The COPD P4P program exerted a positive net effect on reducing the likelihood of COPD exacerbation, namely COPD-related ED visits and hospitalizations. Future studies should examine the long-term cost-effectiveness of the COPD P4P program.

Procalcitonin-guided initiation of antibiotics in AECOPD inpatients: study protocol for a multicenter randomised controlled trial

INTRODUCTION

Current antibiotic prescription for acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is generally based on the Anthonisen criteria in The Global Initiative for Chronic Obstructive Pulmonary Disease (GOLD) guideline that have a potential risk of antibiotics overuse. The dilemma is to identify patients who are most likely to benefit from antibiotics while avoiding unnecessary antibiotic use. Procalcitonin (PCT), a more sensitive and specific biomarker of bacterial infection than other conventional laboratory tests, has the potential to determine those patients in whom antibiotics would be beneficial. It is unclear whether PCT-guided antibiotic therapy is safe and effective for patients hospitalised with AECOPD. The study hypothesis is that PCT-guided antibiotic therapy could reduce the antibiotic prescription rate for AECOPD, compared with the GOLD guideline recommendations, without negatively impacting the treatment success rate.

METHODS AND ANALYSIS

In this multicenter, open-label, randomised controlled trial, we aim to enrol 500 hospitalised patients with AECOPD that will be randomly assigned to either a PCT-guided group or a GOLD guideline-guided group. The coprimary endpoints are antibiotic prescription rate for AECOPD within 30 days post randomisation and treatment success rate at day 30 post randomisation. The secondary outcomes include: antibiotic prescription rate at day 1 post randomisation; hospital antibiotic exposure; length of hospital stay; rate of subsequent exacerbation and hospital readmission; overall mortality within 30 days post randomisation; changes in lung function and the score of COPD assessment test and modified Medical Research Council; and rate of intensive care unit admission.

ETHICS AND DISSEMINATION

This trial has been approved by the ethic committee of China-Japan Friendship Hospital. The findings of the study will be disseminated in peer-reviewed journals. If the results of the study are positive, PCT-guided antibiotic therapy is likely to change the guidelines for antibiotic recommendations for patients with AECOPD.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov: NCT04682899.

2-Day versus C-reactive protein guided antibiotherapy with levofloxacin in acute COPD exacerbation: A randomized controlled trial

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.

Chronic obstructive pulmonary disease exacerbation fundamentals: Diagnosis, treatment, prevention and disease impact

In chronic obstructive pulmonary disease (COPD), exacerbations (ECOPD), characterized by an acute deterioration in respiratory symptoms, are fundamental events impacting negatively upon disease progression, comorbidities, wellbeing and mortality. ECOPD also represent the largest component of the socioeconomic burden of COPD. ECOPDs are currently defined as acute worsening of respiratory symptoms that require additional therapy. Definitions that require worsening of dyspnoea and sputum volume/purulence assume that acute infections, especially respiratory viral infections, and/or exposure to pollutants are the main cause of ECOPD. But other factors may contribute to ECOPD, such as the exacerbation of other respiratory diseases and non-respiratory diseases (e.g., heart failure, thromboembolism). The complexity of worsening dyspnoea has suggested a need to improve the definition of ECOPD using objective measurements such as blood counts and C-reactive protein to improve accuracy of diagnosis and a personalized approach to management. There are three time points when we can intervene to improve outcomes: acutely, to attenuate the length and severity of an established exacerbation; in the aftermath, to prevent early recurrence and readmission, which are common, and in the long-term, establishing preventative measures that reduce the risk of future events. Acute management includes interventions such as corticosteroids or antibiotics and measures to support the respiratory system, including non-invasive ventilation (NIV). Current therapies are broad and better understanding of clinical phenotypes and biomarkers may help to establish a more tailored approach, for example in relation to antibiotic prescription. Other unmet needs include effective treatment for viruses, which commonly cause exacerbations. Preventing early recurrence and readmission to hospital is important and the benefits of interventions such as antibiotics or anti-inflammatories in this period are not established. Domiciliary NIV in those patients who are persistently hypercapnic following discharge and pulmonary rehabilitation can have a positive impact. For long-term prevention, inhaled therapy is key. Dual bronchodilators reduce exacerbation frequency but in patients with continuing exacerbations, triple therapy should be considered, especially if blood eosinophils are elevated. Other options include phosphodiesterase inhibitors and macrolide antibiotics. ECOPD are a key component of the assessment of COPD severity and future outcomes (quality of life, hospitalisations, health care resource utilization, mortality) and are a central component in pharmacological management decisions. Targeted therapies directed towards specific pathways of inflammation are being explored in exacerbation prevention, and this is a promising avenue for future research.

Patient's treatment burden related to care coordination in the field of respiratory diseases

The management of respiratory diseases requires various levels of care: multidisciplinary teams, educational and behavioural interventions, self-management and home-based technical support are vital to ensure adequate care management. However, it is often difficult to access these networks due to fragmentation of patient care and treatment burden. Care coordination aims to ensure patients have a central role and that there is continuity of care among various levels and professionals involved. Moreover, the coronavirus disease pandemic has caused strain on the global healthcare system, with care coordination becoming increasingly important in increasing the resilience of health systems, supporting healthcare professionals and ensuring the right treatment and adequate level of care for these patients.

Development and Relevance of Hypercapnia in COPD

Background

Identification of patients who may become hypercapnic, or develop acidotic hypercapnic respiratory failure (AHRF), is important in chronic obstructive pulmonary disease (COPD) to avoid hospital admission and select patients for use of home NIV. This study aimed to identify factors associated with presence and development of hypercapnia.

Methods

1224 patients, 637 with COPD and 587 with alpha 1 antitrypsin deficiency (AATD), from 4 previously established patient cohorts, were included in cross-sectional analyses of hypercapnia (PaCO₂ ≥ 6.5 kPa or 48.8 mmHg), focusing on phenotypic features of COPD and mortality. Longitudinal associations of rising PaCO₂ were also assessed. A second cohort of 160 COPD patients underwent sleep studies and 1-year follow-up, analysing in a similar way, incorporating additional information from their sleep studies if appropriate.

Results

Hypercapnia was 15 times more common in usual COPD than AATD (p < 0.01) after adjustment for baseline differences by regression. Independent predictors of hypercapnia in COPD included FEV₁ and current use of oxygen; these variables, together with lack of emphysema, explained 11% of variance in CO₂. Increasing PaCO₂ also associated with higher risk of death (p=0.03). 44/160 patients exhibited sleep disordered breathing. The sleep study cohort also showed an association of low FEV₁ with hypercapnia. Prior hospital admission for AHRF was also clinically significant, being a feature of almost double the number of hypercapnic patients in both test and sleep study COPD cohorts.

Conclusion

Lower FEV₁ and prior AHRF are the main associations of hypercapnia in COPD, which carries a poor prognosis, particularly worsening over time.

Impact of the implementation of a pharmacist-driven chronic obstructive pulmonary disease exacerbation orderset in an inpatient setting

PURPOSE

The Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines provide recommendations for the management of chronic obstructive pulmonary disease (COPD) exacerbation. Studies have demonstrated shortened hospital length of stay (LOS) with use of guideline-adherent systemic corticosteroid therapy. There are no published studies evaluating the impact of an inpatient orderset on patient-oriented outcomes.

METHODS

This institutional review board-approved, retrospective, quasi-experimental, single-center cohort study included adult patients admitted to an internal medicine service for a documented COPD exacerbation from January 2014 through December 2015 (the pre-orderset group) or January 2017 through December 2018 (the post-orderset group). A pharmacy and therapeutics committee-approved orderset recommending guideline-adherent treatment with systemic corticosteroids, scheduled short-acting bronchodilators, and antibiotics was used in the post-orderset group. The primary outcome was hospital LOS. Secondary outcomes included 30-day all-cause and COPD-related readmission rates, systemic corticosteroid-related adverse events, and antibiotic use.

RESULTS

A total of 358 unique patient encounters were identified for the pre-orderset group (n = 220) and post-orderset group (n = 138). The mean (SD) hospital LOS was significantly shorter in the post-orderset group (3.4 [2.4] days vs 4.3 [3.0] days; P = 0.004). There were no significant between-group differences in rates of 30-day all-cause and COPD-related readmissions. The overall rate of antibiotic use was lower in the post-orderset group vs the pre-orderset group (71% vs 90.2%; P < 0.001). The rate of occurrence of new blood glucose elevation was significantly lower in the post-orderset group (49.3% vs 79.1%; P < 0.001), with no significant between-group difference in occurrence of new blood pressure elevation.

CONCLUSION

A significant reduction in hospital LOS was found with the implementation of a pharmacist-driven COPD exacerbation orderset.

Management of acute COPD exacerbations in Australia: do we follow the guidelines?

Objective

We aimed to assess adherence to the Australian national guideline (COPD-X) against audited practice, and to document the outcomes of patients hospitalised with an acute exacerbation of chronic obstructive pulmonary disease (COPD) at discharge and 28 days after.

Methods

A prospective clinical audit of COPD hospital admission from five tertiary care hospitals in five states of Australia was conducted. Post-discharge follow-up was conducted via telephone to assess for readmission and health status.

Results

There were 207 admissions for acute exacerbation (171 patients; mean 70.2 years old; 50.3% males). Readmission rates at 28 days were 25.4%, with one (0.6%) death during admission and eight (6.1%) post-discharge within 28 days. Concordance to the COPD-X guidance was variable; 22.7% performed spirometry, 81.1% had blood gases collected when forced expiratory volume in 1 s was <1 L, 99.5% had chest radiography performed, 95.1% were prescribed systemic corticosteroids and 95% were prescribed antibiotic therapy. There were 89.1% given oxygen therapy and 92.6% when arterial oxygen tension was <80 mmHg; 65.6% were given ventilatory assistance when pH was <7.35. Only 32.4% were referred to pulmonary rehabilitation but 76.8% had general practitioner follow-up arranged.

Conclusion

When compared against clinical practice guidelines, we found important gaps in management of patients admitted with COPD throughout tertiary care centres in Australia. Strategies to improve guideline uptake are needed to optimise care.

A multisite audit of hospital admissions for patients experiencing #AECOPD in Australia highlighted important gaps in management when compared against national guidelines. Further focus on how we can improve guideline uptake by clinicians is needed.http://bit.ly/2VjGnHw

Acute Exacerbations of Chronic Obstructive Pulmonary Disease With a Low Procalcitonin Concentration: Impact of Antibiotic Therapy

BACKGROUND

Patients admitted with acute exacerbations of chronic obstructive pulmonary disease (AECOPD) often are prescribed antibiotics. Studies have shown that the use of procalcitonin (PCT) to guide the decision to initiate antibiotic therapy in AECOPD has resulted in less antibiotic use and similar outcomes compared with standard of care. We evaluated patients with AECOPD and low PCT concentrations to determine whether antibiotic therapy was associated with improved outcomes.

METHODS

We retrospectively evaluated adult patients admitted with AECOPD who had a peak PCT concentration <0.25 µg/mL. Patients were evaluated based on their antibiotic exposure: ≤24 hours vs >24 hours. We also evaluated outcomes based upon the duration of azithromycin therapy: ≤24 hours vs >24 hours. The primary outcome was all-cause 30-day readmissions. Secondary outcomes included length of stay (LOS) and COPD-related 30-day readmissions.

RESULTS

One hundred sixty-one and 195 patients received ≤24 hours vs >24 hours of antibiotic therapy, respectively. The cohort with ≤24 hours of antibiotics had a shorter LOS (2.8 vs 3.7 days; P = .01). There were no differences in all-cause 30-day readmissions (15.5% vs 17.4%; P = .63) or COPD-related 30-day readmissions (11.2% vs 12.3%; P = .74). Additionally, patients receiving ≤24 hours of azithromycin had a shorter LOS (3.0 vs 3.8 days; P = .002) and there were no differences in all-cause 30-day readmissions (16.2% vs 17.1%; P = .82) or COPD-related 30-day readmissions (11.9% vs 11.6%; P = .94).

CONCLUSIONS

For adult patients hospitalized with nonsevere AECOPD and low PCT concentrations, antibiotic therapy beyond 24 hours did not improve outcomes.

Procalcitonin and other markers to guide antibiotic use in chronic obstructive pulmonary disease exacerbations in the era of antimicrobial resistance

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.

Comparative Effectiveness Of Fluoroquinolone Antibiotic Use In Uncomplicated Acute Exacerbations Of COPD: A Multi-Cohort Study

Purpose

Fluoroquinolone antibiotics are associated with rare, but severe adverse events. They are frequently used for the treatment of acute exacerbations of COPD (AECOPD). While their effectiveness in severe exacerbations requiring hospitalisation has been well documented, the potential benefit in the ambulatory setting is less clear, especially in uncomplicated patients with COPD.

Patients and characteristics

We carried out a retrospective cohort study using health care databases from six Canadian provinces in subjects visiting their physician for uncomplicated COPD. Subjects dispensed either a quinolone or other antibiotics were compared using inverse probability of treatment weights with high dimensional propensity scores on 30-day outcomes, including repeat visits, hospitalisation for AECOPD and subsequent antibiotic prescription. Results from each province were combined by random effects meta-analysis.

Results

We identified 286,866 AECOPD events among 203,642 unique individuals. The frequency of fluoroquinolone use, mostly levofloxacin and moxifloxacin, varied by province and ranged from 8% to 32% of AECOPD antibiotic prescriptions. The risk of a repeat ambulatory care visit was increased among patients who were dispensed a fluoroquinolone compared with other antibiotics (OR 1.32, 95% CI 1.27-1.36). The risk of a hospitalisation for AECOPD was also higher with fluoroquinolones (OR 1.52, 95% CI 1.33-1.74). There was no difference in subsequent antibiotic prescriptions (OR 1.00, 95% CI 0.94-1.07).

Conclusion

There is no apparent benefit in short-term outcomes with fluoroquinolones as compared to other antibiotics for the ambulatory treatment of AECOPD in uncomplicated patients. These findings support current recommendations that fluoroquinolones be reserved for AECOPD in patients with recurrent exacerbations, significant co-morbidity or requiring hospitalisation.

Antibiotics for COPD exacerbations: does drug or duration matter? A primary care database analysis

Introduction

Antibiotics are routinely given to people with chronic obstructive pulmonary disease (COPD) presenting with lower respiratory tract infection (LRTI) symptoms in primary care. Population prescribing habits and their consequences have not been well-described.

Methods

We conducted a retrospective analysis of antibiotic prescriptions for non-pneumonic exacerbations of COPD from 2010 to 2015 using the UK primary care Optimum Patient Care Research Database. As a proxy of initial treatment failure, second antibiotic prescriptions for LRTI or all indications within 14 days were the primary and secondary outcomes, respectively. We derived a model for repeat courses using univariable and multivariable logistic regression analysis.

Results

A total of 8.4% of the 9042 incident events received further antibiotics for LRTI, 15.5% further courses for any indication. Amoxicillin and doxycycline were the most common index and second-line drugs, respectively (58.7% and 28.7%), mostly given for 7 days. Index drugs other than amoxicillin, cardiovascular disease, pneumococcal vaccination and more primary care consultations were statistically significantly associated with repeat prescriptions for LRTI (p<0.05). The ORs and 95% CIs were: OR 1.28, 95% CI 1.10 to 1.49; OR 1.37, 95% CI 1.13 to 1.66; OR 1.33, 95% CI 1.14 to 1.55 and OR 1.05, 95% CI 1.02 to 1.07, respectively. Index duration, inhaled steroid use and exacerbation frequency were not statistically significant. The derived model had an area under the curve of 0.61, 95% CI 0.59 to 0.63.

Discussion

The prescription of multiple antibiotic courses for COPD exacerbations was relatively common-one in twelve patients receiving antibiotics for LRTI had a further course within 2 weeks. The findings support the current preference for amoxicillin as index drug within the limitations of this observational study. Further clinical trials to determine best practice in this common clinical situation appear required.

Effects of air pollution on acute exacerbation of chronic obstructive pulmonary disease: a descriptive retrospective study (pol-AECOPD)

Purpose

Acute exacerbation of COPD (AECOPD) is among the most frequent causes for hospital admission, causing morbidity and mortality. Infection is the most frequent cause, and studies on pollution have shown higher hospital admission and mortality with inconsistent results. The objective was to identify if there is a change in levels of particulate matter (PM) during the days leading up to the symptom onset.

Patients and methods

A retrospective study was carried out on medical records of patients with AECOPD from a University Hospital. PM values of the consultation day, onset symptoms, and up to three previous days were recorded. Moreover, clinical presentation, laboratory findings, treatments, and hospital outcomes were recorded.

Results

A total of 250 medical records were included, mean age of 77 years, hospital stay mean of 6.7 days, 26.8% with no previous exposure was identified, coexistence with asthma was 5%, Obstructive Sleep Apnea Syndrome 15%, Pulmonary Hypertension 34%, antibiotic use 62%, ICU admission of 14% with non-invasive mechanical ventilation of 68%, and in-patient mortality of 2.4%. PM 2.5 of 48 hrs before onset symptoms median was 20.1 μg/m³ versus 15 and 16.5 for the day of symptoms and 3 days prior to onset symptoms (p<0.001). PM 10 of 46.65 μg/m³, versus 39 and 35.6, respectively (p<0.001). Expectoration OR 4.74; Purulence OR 6.58; Pleuritic pain OR 3.62; Antibiotic use OR 2.87, and corticoids use OR 2.62, all with p<0.05.

Conclusions

Patients with AECOPD have a higher median of particulate matter 48 hrs prior to symptomatic onset, as well as greater use of antibiotics and corticosteroids.

CRP-guided antibiotic treatment in acute exacerbations of COPD in hospital admissions

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.

The association between blood eosinophil percent and bacterial infection in acute exacerbation of chronic obstructive pulmonary disease

Introduction: The use of antibiotics is based on the clinician's experience and judgment, and antibiotics may often be overused in the treatment of acute exacerbations of chronic obstructive pulmonary disease (AECOPD). Eosinophils have been studied as biomarkers of bacterial infection and prognostic factors in chronic obstructive pulmonary disease and AECOPD. Thus, the purpose of this study was to determine whether eosinophils could be used to determine bacterial infection in AECOPD events. Methods: We retrospectively analyzed the medical records of patients admitted to Korea University Guro Hospital for AECOPD between January 2011 and May 2017. Data pertaining to baseline characteristics, results of previous pulmonary function tests, treatment information during the admission period, and history of pulmonary treatment were collected before admission. Results: A total of 736 AECOPD events were eligible for inclusion and were divided into two groups based on the eosinophil count: those involving eosinophil counts of less than 2% (546 events) and those involving counts of 2% or more (190 events). In univariate analysis, the only bacterial pathogen identification events and bacterial-viral pathogen co-identification events were significantly more frequent in the group with eosinophil counts of less than 2% (P=0.010 and P=0.001, respectively). In logistic regression analysis, the rates of only bacterial pathogen identification [odds ratios =1.744; 95% confidence interval, 1.107-2.749; P=0.017] and bacterial-viral pathogen co-identification [odds ratios=2.075; 95% confidence interval, 1.081-3.984; P=0.028] were higher in the group with eosinophil count less than 2%. Conclusion: In conclusion, eosinophil counts of less than 2% are potential indicators of a bacterial infection in AECOPD events. Eosinophils could thus serve as a reference for the use of antibiotics in AECOPD treatment.

Was the implementation strategy of the ProACT trial adequately proactive?

Rising antimicrobial resistance rates represent an alarming threat to public health, currently causing over 25 000 and 23 000 deaths per year in European Union and the USA, respectively [1, 2]. The significant global overuse of antibiotics amplifies the development of resistant bacterial strains [1, 2]. A recent national audit in the USA estimated that almost half of all antibiotic prescriptions were issued for respiratory tract infections (221 antibiotic prescriptions per 1000 population per year) and half of them were inappropriate [3]. Extensive campaigns have been carried out to promote antibiotic stewardship guidance in an attempt to limit the administration of unneeded antibiotics, but their impact has been modest [4, 5].

The ProACT trial does not inform the evidence base regarding safety and clinical effectiveness of procalcitonin (PCT) as a biomarker to guide antibiotic administration for LRTIs, but reveals potential challenges in the introduction of PCT in real life.http://ow.ly/Enfr30n2TK6

Antivirals for Virus Induced Exacerbations of Asthma and COPD Treatment

Viral respiratory infections in patients with asthma or chronic obstructive pulmonary disease (COPD) can cause severe exacerbations, increasing the risk of secondary bacterial infections and having a significant impact on disease-related morbidity and mortality. Several antivirals such as oseltamivir and zanamivir evaluated in influenza and other virus-induced respiratory infections are discussed in this review as a starting point of their potential use in improving the outcome of asthma and COPD exacerbations. However, the efficacy of antiviral therapy for asthma/COPD exacerbations needs a further evaluation.

[Integral approach to the acute exacerbation of chronic obstructive pulmonary disease]

Chronic obstructive pulmonary disease is a set of clinical processes that have in common a chronic and progressive obstruction to airflow, with episodes of exacerbation. These exacerbations are more frequent and severe over time, deteriorating the lung function. The main cause of exacerbations is bacterial infection. There are multiple guidelines and documents that statement the management of this pathology. However, they focus primarily on the treatment during the stable phase. This document addresses the problem of acute exacerbation due to an infection from a multidisciplinary perspective, focusing on the integral approach to the process, and including etiology, microbiological studies, resistance to antimicrobials, risk stratification and initial empirical therapeutic management (antibiotic and concomitant). In addition, it includes an approach to more complex aspects such as the management of special populations (elderly and immunosuppressed) or therapeutic failure. Finally, more controversial topics such as prophylaxis of infection or palliative treatment are specifically discussed.

Systemic Corticosteroid and Antibiotic Use in Hospitalized Patients With Chronic Obstructive Pulmonary Disease Exacerbation

BACKGROUND

Effective inpatient chronic obstructive pulmonary disease (COPD) exacerbation management is critical to appropriately manage health care resources. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines provide recommendations on appropriate systemic corticosteroid and antibiotic use, in select patients, for COPD exacerbation.

OBJECTIVE

To determine the impact of GOLD guideline-recommended systemic corticosteroid and antibiotic therapy in the hospital setting on clinical outcomes in patients with COPD exacerbation.

METHODS

This was a noninterventional, retrospective, single-center study. Adults admitted to a non-intensive care unit internal medicine service with documented COPD exacerbation were included. Two analyses were conducted evaluating systemic corticosteroid and antibiotic therapy.

RESULTS

A total of 220 patients were included in the systemic corticosteroid cohort. No difference in 30-day readmission rates was demonstrated for the standard (⩽200 mg prednisone equivalents [PEs] for exacerbation course) and high-dose groups (>200 mg PEs; 20.5% vs 13.1%, respectively; P = 0.15). Hospital length of stay (LOS) was significantly shorter for patients prescribed standard-dose therapy (3 days [2-4.5] vs 4 days [2-6]; P < 0.001). A total of 174 patients were included in the antibiotic cohort. For the appropriate and inappropriate antibiotic use groups, no significant differences were observed between 30-day readmission rates (15% vs 18.4%, respectively; P = 0.57) and hospital LOS (4 days [2-5] in both groups; P = 0.97). Conclusion and Relevance: Hospital LOS was shorter for patients prescribed standard-dose systemic corticosteroids; however, no differences in other clinical outcomes were found in either cohort. Use of guideline-recommended systemic corticosteroid and antibiotic therapy is recommended for hospitalized patients with COPD exacerbation.

Variations in practice patterns and resource utilization in patients treated for chronic obstructive pulmonary disease

RATIONALE, AIMS, AND OBJECTIVES

Several studies have looked at patient-related variables influencing hospital length of stay (LOS) in patients with acute exacerbations of chronic obstructive pulmonary disease (AECOPD). However, there has been increasing recognition that physician-related factors also play a significant role. This study aims to evaluate differences in practice patterns between teaching and nonteaching services and their effect on LOS in a large community hospital.

METHODS

A retrospective study of 354 patients admitted to Florida Hospital, Orlando, with AECOPD between January 2009 and December 2011. Patients who presented with acute respiratory failure requiring mechanical ventilation were excluded. Practice patterns of interest were use of oral versus intravenous systemic steroids, use of oral versus intravenous antibiotics, and utilization of consultations.

RESULTS

Length of stay was significantly lower in the teaching compared with the nonteaching group (2.80 vs. 5.04 days, P < .001). There was significantly greater use of oral steroids (85% vs. 8.9%, P < .001), greater use of oral antibiotics (72% vs. 33%, P < .001), and lower utilization of consults (0.3 vs. 1.4 consults per patient, P < .001) in the teaching compared with the nonteaching group. The teaching service was independently associated with decreased LOS in a multivariable regression model. However, after adjustment for the difference in practice patterns between the 2 groups, the teaching service was no longer associated with decreased LOS. Of the practice patterns, only utilization of consults was independently associated with increased LOS.

CONCLUSIONS

The teaching service had decreased LOS compared with the nonteaching service in patients hospitalized for AECOPD. The observed difference was completely explained by differences in practice patterns between the 2 groups. The study identifies an opportunity for more efficient and cost-effective care of AECOPD patients through streamlining of consultations, use of oral steroids in lieu of IV steroids, and antibiotic stewardship.

Impact of Procalcitonin Guidance on Management of Adults Hospitalized with Chronic Obstructive Pulmonary Disease Exacerbations

BACKGROUND

Antibiotics are often prescribed for hospitalized patients with chronic obstructive pulmonary disease (COPD) exacerbations. The use of procalcitonin (PCT) in the management of pneumonia has safely reduced antibiotic durations, but limited data on the impact of PCT guidance on the management of COPD exacerbations remain.

OBJECTIVE

To determine the impact of PCT guidance on antibiotic utilization for hospitalized adults with exacerbations of COPD.

DESIGN

A retrospective, pre-/post-intervention cohort study was conducted to compare the management of patients admitted with COPD exacerbations before and after implementation of PCT guidance. The pre-intervention period was March 1, 2014, through October 31, 2014, and the post-intervention period was March 1, 2015, through October 31, 2015.

PARTICIPANTS

All patients with hospital admissions during the pre- and post-intervention period with COPD exacerbations were included. Patients with concomitant pneumonia were excluded.

INTERVENTION

Availability of PCT laboratory values in tandem with a PCT guidance algorithm and education.

MAIN MEASURES

The primary outcome was duration of antibiotic therapy for COPD. Secondary objectives included duration of inpatient length of stay (LOS) and 30-day readmission rates.

KEY RESULTS

There were a total of 166 and 139 patients in the pre- and post-intervention cohorts, respectively. There were no differences in mean age (66.2 vs. 65.9; P = 0.82) or use of home oxygenation (34% vs. 39%; P = 0.42) in the pre- and post-intervention groups, respectively. PCT guidance was associated with a reduced number of antibiotic days (5.3 vs. 3.0; p = 0.01) and inpatient LOS (4.1 days vs. 2.9 days; P = 0.01). Respiratory-related 30-day readmission rates were unaffected (10.8% vs. 9.4%; P = 0.25).

CONCLUSIONS

Utilizing PCT guidance in the management of COPD exacerbations was associated with a decreased total duration of antibiotic therapy and hospital LOS without negatively impacting hospital readmissions.

Global and Multi-National Prevalence of Fungal Diseases-Estimate Precision

Fungal diseases kill more than 1.5 million and affect over a billion people. However, they are still a neglected topic by public health authorities even though most deaths from fungal diseases are avoidable. Serious fungal infections occur as a consequence of other health problems including asthma, AIDS, cancer, organ transplantation and corticosteroid therapies. Early accurate diagnosis allows prompt antifungal therapy; however this is often delayed or unavailable leading to death, serious chronic illness or blindness. Recent global estimates have found 3,000,000 cases of chronic pulmonary aspergillosis, ~223,100 cases of cryptococcal meningitis complicating HIV/AIDS, ~700,000 cases of invasive candidiasis, ~500,000 cases of Pneumocystis jirovecii pneumonia, ~250,000 cases of invasive aspergillosis, ~100,000 cases of disseminated histoplasmosis, over 10,000,000 cases of fungal asthma and ~1,000,000 cases of fungal keratitis occur annually. Since 2013, the Leading International Fungal Education (LIFE) portal has facilitated the estimation of the burden of serious fungal infections country by country for over 5.7 billion people (>80% of the world's population). These studies have shown differences in the global burden between countries, within regions of the same country and between at risk populations. Here we interrogate the accuracy of these fungal infection burden estimates in the 43 published papers within the LIFE initiative.

Impact and prevention of severe exacerbations of COPD: a review of the evidence

Severe exacerbations of COPD, ie, those leading to hospitalization, have profound clinical implications for patients and significant economic consequences for society. The prevalence and burden of severe COPD exacerbations remain high, despite recognition of the importance of exacerbation prevention and the availability of new treatment options. Severe COPD exacerbations are associated with high mortality, have negative impact on quality of life, are linked to cardiovascular complications, and are a significant burden on the health-care system. This review identified risk factors that contribute to the development of severe exacerbations, treatment options (bronchodilators, antibiotics, corticosteroids [CSs], oxygen therapy, and ventilator support) to manage severe exacerbations, and strategies to prevent readmission to hospital. Risk factors that are amenable to change have been highlighted. A number of bronchodilators have demonstrated successful reduction in risk of severe exacerbations, including long-acting muscarinic antagonist or long-acting β2-agonist mono- or combination therapies, in addition to vaccination, mucolytic and antibiotic therapy, and nonpharmacological interventions, such as pulmonary rehabilitation. Recognition of the importance of severe exacerbations is an essential step in improving outcomes for patients with COPD. Evidence-based approaches to prevent and manage severe exacerbations should be implemented as part of targeted strategies for disease management.

Clinical and social barriers to antimicrobial stewardship in pulmonary medicine: A qualitative study

BACKGROUND

The treatment of pulmonary infections is one of the largest indications for antibiotics in human health care, offering significant potential for antibiotic optimization internationally. This study explores the perspectives of pulmonary clinicians on antibiotic use in hospital pulmonary infections.

METHODS

Twenty-eight pulmonary doctors and nurses from 2 hospitals participated in semi-structured interviews focusing on their experiences of antibiotic use.

RESULTS

Barriers to antibiotic optimization in pulmonary infections were identified. Clinical barriers are as follows. The first is differentiating pneumonia vs chronic obstructive pulmonary disease: differentiating pulmonary diagnoses was reported as challenging, leading to overtreatment. The second is differentiating viral vs bacterial: diagnostic differentiation was perceived to contribute to excess antibiotic use. The third is differentiating colonization vs pathogen: the interpretation of ambiguous results was reported to lead to under- or overprescribing depending on the perspective of the treating team. Social barriers are as follows. The first is the perception of resistance: antibiotic resistance was not perceived as an immediate threat. The second is the perceived value of antibiotic clinical guidelines: there was mistrust in antibiotic guidelines. The third is hospital hierarchies: hierarchical structures had a significant influence on prescribing.

CONCLUSIONS

Substantial barriers to antibiotic optimization in pulmonary infections were identified. To facilitate change in antibiotic use there must be a systematic understanding and interventions to address specific clinical issues. In the case of pulmonary medicine, significant identified issues, such as mistrust in clinical guidelines and diagnostic challenges, need to be addressed.

Effectiveness of a simple intervention on management of acute exacerbations of chronic obstructive pulmonary disease and its cardiovascular comorbidities: COREPOC study

BACKGROUND AND OBJECTIVE

To determine the effectiveness of a simple educational intervention to improve the management of cardiovascular comorbidities in patients hospitalized with an acute exacerbation of chronic obstructive pulmonary disease (COPD).

MATERIAL AND METHODS

Multicenter study participated in by 26 hospital centers. A panel of experts elaborated a set of recommendations about diagnostic and therapeutic management of acute exacerbation of COPD and cardiovascular comorbidities (coronary artery disease, atrial fibrillation, heart failure and diabetes). The recommendations were graduated as indispensable, advisable and outstanding. Compliance with recommendations were assessed in the discharge letter for COPD patients hospitalized with acute exacerbation in Internal Medicine departments. The protocols to treat the comorbidities in COPD were explained in a clinical session. After 6 months' compliance with recommendations they were reassessed.

RESULTS

A total of 390 cases before and after the intervention were assessed. There was significant progress in 53% of cases. The improvement was greater in cases referred to general management and COPD management (66.7 and 76.9%, respectively), and lower in cases referred to ischemic heart disease (11.1%) and none in those referred to coronary artery disease. After the intervention, the adherence to overall and indispensable recommendations was higher (P=.020 and P=.017, respectively) and a trend to improve was observed in advisable (P=.058) and outstanding recommendations (P=.063).

CONCLUSIONS

A simple intervention can improve the management of lung disease in COPD patients with an acute exacerbation, but has less effect on the management of comorbidities.

Delivering on Antimicrobial Resistance Agenda Not Possible without Improving Fungal Diagnostic Capabilities

Antimicrobial resistance, a major public health concern, largely arises from excess use of antibiotic and antifungal drugs. Lack of routine diagnostic testing for fungal diseases exacerbates the problem of antimicrobial drug empiricism, both antibiotic and antifungal. In support of this contention, we cite 4 common clinical situations that illustrate this problem: 1) inaccurate diagnosis of fungal sepsis in hospitals and intensive care units, resulting in inappropriate use of broad-spectrum antibacterial drugs in patients with invasive candidiasis; 2) failure to diagnose chronic pulmonary aspergillosis in patients with smear-negative pulmonary tuberculosis; 3) misdiagnosis of fungal asthma, resulting in unnecessary treatment with antibacterial drugs instead of antifungal drugs and missed diagnoses of life-threatening invasive aspergillosis in patients with chronic obstructive pulmonary disease; and 4) overtreatment and undertreatment of Pneumocystis pneumonia in HIV-positive patients. All communities should have access to nonculture fungal diagnostics, which can substantially benefit clinical outcome, antimicrobial stewardship, and control of antimicrobial resistance.

Procalcitonin to guide antibiotic administration in COPD exacerbations: a meta-analysis

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.

Meta-analysis and systematic review of procalcitonin-guided treatment in acute exacerbation of chronic obstructive pulmonary disease

INTRODUCTION

To evaluate the method of procalcitonin (PCT)-guided treatment on antibiotics in acute exacerbation of chronic obstructive pulmonary disease (AECOPD).

METHODS

Database including PubMed, EMBASE, and the Cochrane Central Register of Controlled Trails were searched to find relevant trails. Randomized and quasi-randomized trials of PCT-guided treatment in adult patients with AECOPD were included. Effects on primary outcome (i.e., antibiotic prescriptions, mortality, and clinical success) were accessed in this meta-analysis.

RESULTS

Four trials involving 679 patients were included. PCT-guided treatment significantly reduced antibiotic use (OR 0.26, 95% CI 0.14-0.50, P < 0.0001) in comparison to standard treatment, without increasing clinical failure (OR 1.10, 95% CI 0.70-1.74, P = 0.68; I²  = 0%) and mortality (OR 0.86, 95% CI 0.44-1.68, P = 0.66). The rate of readmission and exacerbation at follow-up period was similar in both groups.

CONCLUSION

Results from this meta-analysis suggest PCT-guided treatment can safely reduce antibiotic overuse in patients with AECOPD.