Speed of recovery from acute exacerbations of chronic obstructive pulmonary disease after treatment with antimicrobials : results of a two-year study

Terms and Definitions Used to Describe Recurrence, Treatment Failure and Recovery of Acute Exacerbations of COPD: A Systematic Review of Observational Studies

Introduction

Acute exacerbations of chronic obstructive pulmonary disease (AECOPDs) are important clinical events, with many patients experiencing multiple AECOPDs annually. The terms used in the literature to define recurring AECOPD events are inconsistent and may impact the ability to describe the true burden of these events. We undertook a systematic review to identify and summarize terms and definitions used in observational studies to describe AECOPD-related events occurring after an initial AECOPD (hereafter “subsequent AECOPD”).

Methods

PubMed was searched (2000–2019) for observational studies on subsequent AECOPD events using broad search strings for “COPD”, “exacerbation”, and “subsequent exacerbation events”. Only English-language studies were included. Small studies (n<50) and studies focusing on hospital re-admission only were excluded. Extracted data were analyzed descriptively to generate a narrative summary, using a thematic approach to group studies utilizing similar terms for subsequent AECOPD.

Results

Forty-seven studies were included. No single, distinct terms or definitions were used to define and identify multiple occurrences of AECOPDs, though most (46) studies used one or more of four clustered terms and definitions: reapse (n = 13), recurrence/re-exacerbation (n = 11), treatment failure (n = 12) and non-recovery/time to recovery (n = 16). Heterogeneity was observed within and between the four clusters with respect to study setting, starting point for observing subsequent AECOPDs, time frame to identify a subsequent AECOPD (except for studies using “time to recovery”), and basis for identifying a subsequent exacerbation.

Conclusion

Our review demonstrates that subsequent AECOPDs (including events such as relapse, recurrence/re-exacerbation, treatment failure, non-recovery/time to recovery) are ill-defined in the observational study literature, emphasizing the need to reach consensus on precise and objective definitions (for example, when one AECOPD ends and another begins). Use of standardized terminology and definitions may aid comparability between, and synthesis of, studies, thus improving the understanding of the natural history and burden of exacerbations in COPD patients.

Moxifloxacin in Chronic Obstructive Pulmonary Disease: Pharmacokinetics and Penetration into Bronchial Secretions in Ward and Intensive Care Unit Patients

This study aimed to evaluate the pharmacokinetic profile of moxifloxacin (MXF) in serum and sputum/bronchial secretions of 22 patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) hospitalized in the ward and intensive care unit (ICU). The data showed that ICU patients had lower concentrations in secretions (P = 0.01). However, no other statistically significant differences were observed in pharmacokinetic parameters and penetration in secretions between ward and ICU patients. MXF showed a favorable pharmacokinetic profile, and the pharmacodynamic targets for common pathogens for AECOPD were achieved.

Pulmonary rehabilitation in patients with an acute exacerbation of chronic obstructive pulmonary disease

Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are one of the most common causes of emergency hospital admission and place great burden upon healthcare systems. Furthermore, AECOPD represent an important life event for patients, and are associated with significant reductions in physical activity, skeletal muscle function, exercise tolerance and health-related quality of life. Pulmonary rehabilitation, an intervention comprising supervised exercise-training and education, may counteract these negative consequences and target modifiable risk factors for hospital readmission. A recent Cochrane systematic review included 20 randomized controlled trials comparing pulmonary rehabilitation after exacerbation of COPD versus conventional care. Overall, the evidence supports moderate to large effects on health-related quality of life and exercise capacity. However, there is substantial heterogeneity across studies, and more recent studies have been more equivocal, including around hospital readmissions, particularly when rehabilitation is started in the inpatient setting. In this narrative review, we examine the rationale for pulmonary rehabilitation following AECOPD with a particular focus on skeletal muscle function, review the current evidence for pulmonary rehabilitation in the AECOPD setting, and identify areas that require future research, including the structure and nature of the intervention, improving uptake and adherence, and the role of alternative rehabilitation strategies for patients with AECOPD.

Efficacy and Tolerability of Eight Antimicrobial Regimens in the Outpatient Treatment of Exacerbations of Chronic Obstructive Pulmonary Disease

BACKGROUND: Bacterial infections are considered as the most important cause of exacerbations in patients with chronic obstructive pulmonary disease.AIM: To compare the efficacy and tolerability of eight antibiotics empirically administered for outpatient treatment of exacerbations of COPD.METHODS: We performed an observational study including 343 COPD patients with probable bacterial exacerbation (Group A and Group B COPD patients) managed in an outpatient setting. Eight antibiotic regimens each used 10 days were evaluated: amoxicillin/clavulonic acid, doxycycline, cefuroxime, cefixime, clarithromycin, roxithromycin, ciprofloxacin, and moxifloxacin. All patients were followed up for 30 days, with an intermediate visits at 5, 7 and 10 days at which the duration of symptoms and the side-effects of the drug were evaluated.RESULTS: The clinical success rate varied from 69.8% with doxycycline to 80.9% with moxifloxacin. The mean time to relief of symptoms varied from 5.6 days with moxifloxacin to 6.3 days with amoxicillin/clavulonic acid. Significant increase of the post-treatment FEV1value was registered in all treatment groups. Relapse within the first 20 days was registered in the group receiving doxycycline, clarithromycin, and ciprofloxacin. The prevalence of the adverse events was low varying from 6.7% with cefuroxime to 11.3% with ciprofloxacin.CONCLUSION: Our findings suggest high clinical success rate and high safety of all studied regimens.

Efficacy and safety of moxifloxacin in acute exacerbations of chronic bronchitis: a prospective, multicenter, observational study (AVANTI)

Background

Acute exacerbations of chronic bronchitis (AECB), including chronic obstructive pulmonary disease (AECOPD), represent a substantial patient burden. Few data exist on outpatient antibiotic management for AECB/AECOPD in Eastern/South Eastern Europe, in particular on the use of moxifloxacin (Avelox®), although moxifloxacin is widely approved in this region based on evidence from international clinical studies.

Methods

AVANTI (AVelox® in Acute Exacerbations of chroNic bronchiTIs) was a prospective, observational study conducted in eight Eastern European countries in patients > 35 years with AECB/AECOPD to whom moxifloxacin was prescribed. In addition to safety and efficacy outcomes, data on risk factors and the impact of exacerbation on daily life were collected.

Results

In the efficacy population (N = 2536), chronic bronchitis had been prevalent for > 10 years in 31.4% of patients and 66.0% of patients had concomitant COPD. Almost half the patients had never smoked, in contrast to data from Western Europe and the USA, where only one-quarter of COPD patients are non-smokers. The mean number of exacerbations in the last 12 months was 2.7 and 26.3% of patients had been hospitalized at least once for exacerbation. Physician compliance with the recommended moxifloxacin dose (400 mg once daily) was 99.6%. The mean duration of moxifloxacin therapy for the current exacerbation (Anthonisen type I or II in 83.1%; predominantly type I) was 6.4 ± 1.9 days. Symptom improvement was reported after a mean of 3.4 ± 1.4 days. After 5 days, 93.2% of patients reported improvement and, in total, 93.5% of patients were symptom-free after 10 days. In the safety population (N = 2672), 57 (2.3%) patients had treatment-emergent adverse events (TEAEs) and 4 (0.15%) had serious TEAEs; no deaths occurred. These results are in line with the known safety profile of moxifloxacin.

Conclusions

A significant number of patients in this observational study had risk factors for poor outcome, justifying use of moxifloxacin. The safety profile of moxifloxacin and its value as an antibiotic treatment were confirmed. Physicians complied with the recommended 400 mg once-daily dose in a large proportion of patients, confirming the advantages of this simple dosing regimen.

Trial registration

ClinicalTrials.gov identifier: NCT00846911

Daily-practice treatment of acute exacerbations of chronic bronchitis with moxifloxacin in a large cohort in Germany

OBJECTIVE

To monitor the efficacy and safety of moxifloxacin in respiratory tract infections (RTIs) focussing on acute exacerbations of chronic bronchitis (AECB).

METHODS

Patients with RTIs could be enrolled in this open-label, prospective, non-controlled post-marketing surveillance study from October 2001 until June 2002 unless moxifloxacin was contraindicated. At the initial visit, data were recorded on patient demographics, diagnosis and clinical symptoms. Two follow-up examinations could be performed to determine cure or improvement based on clinical symptoms, and to record adverse events. Clinical symptoms including fever, cough and purulent sputum were assessed individually. Efficacy, tolerability and patient acceptance were assessed globally at the final visit.

RESULTS

Of 9036 enrolled patients, 4328 had AECB, most of whom were treated with moxifloxacin at a daily dose of 400mg. Mean +/- SD time to clinical improvement was 3.4 +/- 1.5 days, and mean +/- SD time to clinical cure was 6.6 +/- 2.4 days. Cure rates were 39.4% at day 5 and 94.3% at day 10. By day 6, the proportion of patients with severe cough decreased from 85.4% at the initial visit to 6.9%, and those with severe dyspnoea from 22.5% to 1.2%. Purulent sputum was absent within 4 days in the majority of cases. Physicians rated efficacy, tolerability and patient acceptance as 'very good' or 'good' in approximately 95% of patients. There were 59 adverse events in 44 (1.0%) patients, most frequently gastrointestinal and nervous system disorders.

CONCLUSIONS

This study further confirms that AECB patients treated with moxifloxacin benefit from more rapid symptom relief and that this therapy option is well accepted in general practice.

Usefulness of a patient symptom diary card in the monitoring of exacerbations of chronic bronchitis and chronic obstructive pulmonary disease

OBJECTIVE

To assess the usefulness of a patient diary card of symptoms for monitoring the evolution of an exacerbation of chronic bronchitis (CB) and chronic obstructive pulmonary disease (COPD) in primary care.

METHOD

Multicentre, observational study. Patients with an exacerbation filled out a diary every day before bedtime during 10 days. The diary score ranged from 0 (best) to 28 (worst). A visit was performed at day 15 to collect the patient diaries.

RESULTS

Of the 1101 patients studied 921 returned the diaries (83.7%). Clinical failure was found in 236 patients (25.6%). The mean global score on day 1 was 21.5 ± 3.8. Patients considered as cured at day 10 presented a lower score at day 1 (21.1 ± 3.9) vs. those who failed (22.6 ± 4.2; p < 0.001). When no reduction was observed in the score from days 1 to 3, the percentage of failures was 36.1%, being only 11.6% with a reduction of 5 points or more (p < 0.001). The strongest correlation with failure was observed with general status, breathing, symptom scale and the need for extra inhaler doses.

CONCLUSION

A symptom diary card seems to be a valuable tool to monitor the evolution of an acute exacerbation of CB/COPD in primary care.

Identifying patients at risk of late recovery (≥ 8 days) from acute exacerbation of chronic bronchitis and COPD

OBJECTIVES

To identify factors associated with late recovery (≥ 8 days from exacerbation start) in patients with acute exacerbations of chronic bronchitis/COPD (AECB/AECOPD).

METHODS

An international, observational, non-interventional study in outpatients with AECB/AECOPD who received treatment for their exacerbation with the antibiotic moxifloxacin. Factors analyzed for late recovery included patient demographic characteristics, geographic region and disease severity. Additionally, logistic regression analysis was undertaken to identify factors associated with late recovery.

RESULTS

The analysis population was 40,435 patients aged ≥ 35 years, from Asia-Pacific, Europe, the Americas and Middle East/Africa. Most were male (63.1%), mean age 60.4 years and current or ex-smokers (60.6%) with history of ≥ 2 exacerbations in the previous year. Patients who underwent spirometry (n = 6408, 19.7%) had moderate airflow obstruction (mean FEV(1) 1.7 L). Both clinicians and patients reported that moxifloxacin provided clinical improvement in a mean of 3 days and recovery in 6 days. Clinical factors significantly associated with late recovery were: age ≥ 65 years, duration of chronic bronchitis >10 years, cardiac comorbidity, >3 exacerbations in the previous 12 months, current exacerbation type (Anthonisen I/II) and hospitalization in the last 12 months.

CONCLUSIONS

In a large cohort of patients, all treated with the same antibiotic for an exacerbation of chronic bronchitis or COPD, the main factors associated with late recovery (≥ 8 days) were: older age, history of frequent exacerbations, current exacerbation type of Anthonisen I/II, history of prior hospitalizations and cardiac comorbid conditions.

Factors affecting the cost effectiveness of antibiotics

In an era of spiraling health care costs and limited resources, policy makers and health care payers are concerned about the cost effectiveness of antibiotics. The aim of this study is to draw on published economic evaluations with a view to identify and illustrate the factors affecting the cost effectiveness of antibiotic treatment of bacterial infections. The findings indicate that the cost effectiveness of antibiotics is influenced by factors relating to the characteristics and the use of antibiotics (i.e., diagnosis, comparative costs and comparative effectiveness, resistance, patient compliance with treatment, and treatment failure) and by external factors (i.e., funding source, clinical pharmacy interventions, and guideline implementation interventions). Physicians need to take into account these factors when prescribing an antibiotic and assess whether a specific antibiotic treatment adds sufficient value to justify its costs.

Factors affecting the cost effectiveness of antibiotics

In an era of spiraling health care costs and limited resources, policy makers and health care payers are concerned about the cost effectiveness of antibiotics. The aim of this study is to draw on published economic evaluations with a view to identify and illustrate the factors affecting the cost effectiveness of antibiotic treatment of bacterial infections. The findings indicate that the cost effectiveness of antibiotics is influenced by factors relating to the characteristics and the use of antibiotics (i.e., diagnosis, comparative costs and comparative effectiveness, resistance, patient compliance with treatment, and treatment failure) and by external factors (i.e., funding source, clinical pharmacy interventions, and guideline implementation interventions). Physicians need to take into account these factors when prescribing an antibiotic and assess whether a specific antibiotic treatment adds sufficient value to justify its costs.

Short-course fluoroquinolones in acute exacerbations of chronic bronchitis

It is estimated that 50-70% of acute exacerbations of chronic bronchitis (AECB) are caused by bacterial infections. Appropriate selection of antimicrobials may lead to better outcomes and reduced healthcare costs. Respiratory fluoroquinolones (moxifloxacin, levofloxacin and gemifloxacin) have a broad spectrum of activity against most AECB-causing pathogens and are used as first-line treatment in patients with comorbidity, severe airway obstruction or recurrent exacerbations. We review studies, identified through a MEDLINE search, that compared clinical efficacy and speed of recovery for short-course (≤ 5 days) fluoroquinolone therapy with commonly prescribed standard therapy (≥ 7 days). Among 177 studies reporting the use of fluoroquinolones for AECB treatment, 23 used a short-course regimen, shown to be at least as effective as standard therapy of 7 or more days duration. Furthermore, evidence suggests that short-course therapy offers faster resolution of symptoms, faster rate of recovery, fewer relapses, fewer and shorter hospitalizations, and longer time between recurrences.

Characterisation of exacerbations of chronic bronchitis and COPD in Europe: the GIANT study

Objective: The GIANT study collected information on patients with acute exacerbations of chronic bronchitis (AECB) and chronic obstructive pulmonary disease (COPD) and the effect of treatment with moxifloxacin.

Methods: AECB history, concomitant diseases, moxifloxacin treatment, concomitant medication, clinical symptoms and adverse events were recorded. A questionnaire at the end of treatment recorded the impact on patients’ daily lives.

Results: Among 9225 patients from eight European countries, marked variation was seen in characteristics including age, smoking history and type of exacerbation. Spirometry use was more common among chest physicians (66.7%) than GPs (15.5%). Patients with Anthonisen type 1 and 2 exacerbations had more frequent exacerbations and these patients experienced a greater impact on daily activities compared with patients with type 3 episodes. Patient symptoms improved with moxifloxacin treatment after a mean (SD) of 3.4 (1.8) days, allowing return to normal daily activities after 5.4 (4.4) days and with full recovery taking 6.5 (3.1) days.

Conclusions: Characteristics of patients with AECB and acute exacerbations of COPD differ among European countries. Spirometry is under-used, particularly in primary care and antibiotic treatment does not always follow current guidelines. Results confirm the efficacy of moxifloxacin in the treatment of AECB in real-life conditions.

Moxifloxacin: a respiratory fluoroquinolone

BACKGROUND

Respiratory quinolones are a class of antimicrobials with a high activity against most respiratory pathogens. Moxifloxacin is a fourth-generation fluoroquinolone that has been shown to be effective against Gram-positive, Gram-negative, and atypical strains, as well as multi-drug resistant Streptococcus pneumoniae.

OBJECTIVE

To review and update the clinical efficacy of moxifloxacin in the treatment of respiratory infections.

METHOD

To perform a systematic review of publications on the clinical efficacy of moxifloxacin in respiratory infections.

RESULTS

The clinical efficacy of moxifloxacin has been shown in controlled studies of community-acquired pneumonia, exacerbations of chronic bronchitis and acute bacterial rhinosinusitis. Moxifloxacin has demonstrated a faster resolution of symptoms in community-acquired pneumonia and exacerbations of chronic bronchitis patients compared with first-line therapy together with excellent eradication rates.

CONCLUSIONS

The use of moxifloxacin as first-line therapy for moderate to severe respiratory infections in the community and the hospital has been recognized in international guidelines.

Pharmacoeconomics of the management of acute exacerbations of chronic obstructive pulmonary disease

Acute exacerbations of chronic obstructive pulmonary disease (COPD) impose a significant burden on society in terms of morbidity, mortality, reduced quality of life and healthcare expenditure. New generations of antibiotics are used to treat exacerbations, and other modes of delivery involving home support are being implemented. The optimal strategy to manage exacerbations on pharmacoeconomic grounds depends on issues such as diagnosis of an exacerbation and safety, effectiveness and costs of available alternatives. This review outlines the state of the art of pharmacoeconomic knowledge of the management of acute COPD exacerbations. It presents estimates of the level and distribution of costs associated with exacerbations and reports on the cost-effectiveness or cost-utility of antimicrobial therapy and other approaches to the management of exacerbations.

Real-life treatment of acute exacerbations of chronic bronchitis with moxifloxacin or macrolides: a comparative post-marketing surveillance study in general practice

OBJECTIVE

To compare the real-life treatment of acute exacerbations of chronic bronchitis (AECBs) using moxifloxacin tablets or one of the oral macrolides azithromycin, clarithromycin or roxithromycin in terms of symptom relief, time until improvement and cure, overall efficacy and tolerability.

METHODS

This prospective, non-interventional, multicentre study included out-patients with AECB whose last exacerbation was treated with a macrolide. The current AECB was treated either with moxifloxacin or with one of the macrolides azithromycin, clarithromycin or roxithromycin. Data were obtained on the patient's characteristics, disease and treatment history, the course of the current AECB including time to improvement and cure, and the final assessments of efficacy and tolerability. All adverse events were recorded in patients treated with moxifloxacin; for patients receiving macrolides, only drug-related adverse events were reported.

RESULTS

464 physicians treated 904 patients with moxifloxacin and 846 patients with one of the macrolides. Age, sex and body mass index were well matched between the two treatment groups. However, more moxifloxacin than macrolide patients presented with a generally bad condition (62.8% vs 48.6%). About 42% of patients in both groups had had chronic bronchitis for 1-5 years, and about 27% for 5-10 years. The mean number of AECBs in the previous 12 months was 2.7 and 2.6, respectively. Moxifloxacin was administered to most patients for 5 (43.8%) or 7 days (42.4%). Patients in the macrolide group were treated in most cases with clarithromycin 500 mg for 4-7 days, roxithromycin 300 mg for 6-7 days or azithromycin 500 mg for 3 days. Physicians assessed overall efficacy and tolerability as 'very good' or 'good' in 96.1% and 98.1%, respectively, of moxifloxacin-treated patients and in 67.5% and 91.7%, respectively, of macrolide-treated patients. The mean duration until improvement and cure of AECB was 3.2 days (+/- SD 1.5) and 6.2 days (+/- 2.6) in moxifloxacin-treated patients compared with 4.5 days (+/- 1.8) and 7.5 days (+/- 3.0) in macrolide-treated patients (p < 0.0001).

CONCLUSION

The results of this study conducted under real-life treatment conditions in patients with AECBs who were previously treated with a macrolide showed faster symptom relief and higher recovery rates with moxifloxacin compared with macrolides. The two treatment groups had comparably good safety and tolerability profiles.

Tratamiento farmacológico de las agudizaciones infecciosas de la EPOC

Las agudizaciones de la enfermedad pulmonar obstructiva crónica (EPOC) son episodios frecuentes y potencialmente graves, que dejan un impacto permanente en la calidad de vida y en la función pulmonar de los pacientes. Hasta un 75% de las agudizaciones tiene una etiología bacteriana, en ocasiones asociada a infección vírica. La tasa de fracaso del tratamiento ambulatorio de las agudizaciones alcanza el 20-25% y la gravedad de la enfermedad de base es el principal factor de riesgo de fracaso. La colonización bacteriana persistente es un factor de riesgo de agudizaciones frecuentes y graves, y de más rápida progresión de la EPOC. Por este motivo el tratamiento antibiótico de las agudizaciones debe perseguir no sólo la curación clínica, sino también la mejor erradicación posible para acelerar la recuperación y prevenir las recaídas. Nuevos ensayos clínicos han demostrado que el antibiótico que consigue una mejor erradicación puede prolongar el tiempo sin síntomas de agudización.

Clinical Efficacy of Moxifloxacin in the Treatment of Exacerbations of Chronic Bronchitis: A Systematic Review and Meta-Analysis

OBJECTIVE

As the research undertaken to date on the efficacy of the new antibiotics in the treatment of exacerbations of chronic bronchitis has taken the form of trials designed to demonstrate equivalence, we have no data on the advantages associated with the use of these new drugs with greater bactericidal activity. Our objective was to compare the clinical efficacy of moxifloxacin to that of the antibiotic regimens routinely used to treat such exacerbations by a systematic review of the literature and a meta-analysis.

METHODS

A manual and electronic search was performed to identify all clinical trials carried out between January 1997 and July 2005 to compare moxifloxacin and the antibiotics that are currently the first line treatment for exacerbations of chronic bronchitis. Once it had been established that the designs of the trials included were acceptable, a meta-analysis of clinical outcomes was performed.

RESULTS

Of the 45 studies identified, 9 met the inclusion criteria. Of these, 5 were double-blind randomized trials and 4 were randomized open trials. The 9 trials comprised a total of 3905 patients. The aggregate standardized mean difference in clinical success rate was 1.5% (95% confidence interval, -0.4 to 3.4%). Bacterial eradication rates ranged from 68.4% to 96% for the standard regimens, and from 87.7% to 96% for moxifloxacin. No intergroup differences in the percentages of patients lost to follow-up were observed in any of the studies.

CONCLUSIONS

Although the trials reviewed were designed to demonstrate equivalence, meta-analysis revealed that the clinical success rate achieved with moxifloxacin tended to be higher than that obtained in the groups that received standard antibiotic treatment.

Patient's perception of exacerbations of COPD--the PERCEIVE study

The evaluation of therapies requires the development of patient-reported outcomes (PROs) that help clinicians to understanding the symptoms, perceptions and feelings of patients with exacerbations of chronic obstructive pulmonary disease (COPD). With the aim of obtaining information on the perceptions of patients with COPD, their exacerbations and expectations of treatment, a random telephone contact survey in six countries was performed. From 83,592 households screened, 1100 subjects with symptoms compatible with COPD were identified. The most frequent symptom was shortness of breath (78%). The most frequent complaint was that due to their COPD: "they could not complete the activities they like to do" (54%); 17% (187) of individuals were afraid that their COPD would cripple, or eventually kill them. Exacerbations generated a mean of 5.1 medical visits/year (SD=4.6) with the mean duration of exacerbation symptoms being 10.5 days. Increased coughing was the exacerbation symptom having the strongest impact on well-being (42%). Fifty-five percent of patients declared that quicker symptom relief was the most desired requirement for treatment. New data are provided on the impact of COPD and its exacerbations on the daily life of patients. These data will help to develop PROs designed to evaluate the effectiveness of different therapies for exacerbated COPD.

[Risk factors for increased cost of exacerbations of chronic bronchitis and chronic obstructive pulmonary disease]

OBJECTIVE

To identify what variables characterizing the patients, exacerbations, and treatment of chronic bronchitis and chronic obstructive pulmonary disease (COPD) are associated with a higher direct health cost.

METHOD

Observational pharmacoeconomic study of exacerbations of chronic bronchitis and COPD (of probable bacterial etiology, defined as Anthonisen types I or II). Direct health costs were assessed during 30 days of follow-up. Logistic regression was employed for statistical analysis, with calculation of the adjusted odds ratios (OR). An exacerbation cost greater than 150 euros was defined as the dependent variable.

RESULTS

Data on 1164 patients were collected by 252 physicians. Pharmacoeconomic data were complete in 947 patients (82.6%). In the first 30 days, 206 sought medical attention because of unsatisfactory response to treatment (21.8%), 69 (7.3%) attended the emergency room, and 22 (2.3%) were admitted to hospital. Overall, 101 exacerbations (10.7%) were classified as high cost (> 150 euros). Continuous oxygen therapy (OR = 7.58) and previous hospitalization (OR = 2.6) were associated with high-cost exacerbations, whereas diagnosis of chronic bronchitis (OR = 0.41) and treatment of the exacerbation with moxifloxacin or amoxicillin-clavulanic acid as opposed to clarithromycin (OR = 0.38) were associated with low-cost exacerbations.

CONCLUSION

Treatment failure was reported for 21.8% of the patients with exacerbations of chronic bronchitis and COPD. Repeated medical visits and requests for complementary tests were the main factors responsible for increased cost. Variables associated with high-cost exacerbations were continuous oxygen therapy, previous hospitalization, and treatment with clarithromycin as opposed to moxifloxacin or amoxicillin-clavulanic acid.

Moxifloxacin in respiratory tract infections

Moxifloxacin is a fourth-generation fluoroquinolone that has been shown to be effective against respiratory pathogens, including Gram-positive (Streptococcus pneumoniae), Gram-negative (Haemophilus influenzae, Moraxella catarrhalis), and atypical strains (Chlamydia pneumoniae, Mycoplasma pneumoniae), as well as multi-drug resistant S. pneumoniae, including strains resistant to penicillin, macrolides, tetracyclines, trimethoprim/sulfamethoxazole and some fluoroquinolones. Moxifloxacin is highly concentrated in lung tissue, and has demonstrated rapid eradication rates. The bioavailability and half-life of moxifloxacin provides potent bactericidal effects at a dose of 400mg/day. The ratio of the area under the concentration-time curve to MIC of moxifloxacin is the highest among the fluoroquinolones against S. pneumoniae. The clinical efficacy of moxifloxacin has been shown in controlled studies of community-acquired pneumonia (CAP), exacerbations of chronic bronchitis (CB) and acute bacterial rhinosinusitis. Moxifloxacin has demonstrated a faster resolution of symptoms in CAP and exacerbations of CB patients compared with first-line therapy. It has also demonstrated better eradication in exacerbations of CB compared with standard therapy, in particular the macrolides. Treatment guidelines should take into account the results of clinical trials with moxifloxacin in order to establish the role of this antimicrobial in the therapeutic arsenal against respiratory tract infections.

Avaliação econômica da doença pulmonar obstrutiva crônica e de suas agudizações: aplicação na América Latina

A doença pulmonar obstrutiva crônica tem elevada prevalência em todo o mundo. Estima-se que entre 7% e 10% da população adulta seja afetada. No Brasil, a bronquite crônica tem uma prevalência de 12,7% na população de mais de 40 anos. Os estudos econômicos têm grande relevância em doenças de alta prevalência. A maioria dos estudos relacionados aos custos da doença pulmonar obstrutiva crônica provém de bases de dados nacionais de saúde. Poucos estudos avaliaram os custos sanitários diretos da doença. A partir destes, conclui-se que um paciente portador de doença pulmonar obstrutiva crônica gera um custo direto anual de 1.200 a 1.800 dólares. O custo correlaciona-se com a gravidade da doença: os pacientes graves geram um custo duas vezes maior que os menos graves, e por isso é vital o diagnóstico precoce. A estratégia mais custo-efetiva é a detecção precoce da doença, associada a campanhas contra o tabagismo. Em estágios avançados da doença, a hospitalização é responsável pelos custos mais elevados. Neste caso, o tratamento correto das agudizações é crucial como estratégia custo-efetiva. O custo médio de uma internação no Brasil é de 2.761 reais, o que representa quase o valor do tratamento ambulatorial por um ano. A antibioticoterapia é responsável por pequena parte do custo total da agudização. O uso de antibióticos mais eficazes pode ser uma estratégia custo-efetiva por reduzir a taxa de fracasso de tratamento. A análise econômica deve permitir a identificação e aplicação de estratégias custo-efetivas para o tratamento da doença.

Effect of exacerbations on quality of life in patients with chronic obstructive pulmonary disease: a 2 year follow up study

BACKGROUND

A study was undertaken to evaluate exacerbations and their impact on the health related quality of life (HRQL) of patients with chronic obstructive pulmonary disease (COPD).

METHODS

A 2 year follow up study was performed in 336 patients with COPD of mean (SD) age 66 (8.2) years and mean (SD) forced expiratory volume in 1 second (FEV(1)) 33 (8)% predicted. Spirometric tests, questions regarding exacerbations of COPD, and HRQL measurements (St George's Respiratory Questionnaire (SGRQ) and SF-12 Health Survey) were conducted at 6 month intervals.

RESULTS

A total of 1015 exacerbations were recorded, and 103 (30.7%) patients required at least one hospital admission during the study. After adjustment for baseline characteristics and season of assessment, frequent exacerbations had a negative effect on HRQL in patients with moderate COPD (FEV(1) 35-50% predicted); the change in SGRQ total score of moderate patients with > or =3 exacerbations was almost two points per year greater (worse) than those with <3 exacerbations during the follow up (p = 0.042). For patients with severe COPD (FEV(1) <35% predicted) exacerbations had no effect on HRQL. The change in SGRQ total score of patients admitted to hospital was almost 2 points per year greater (worse) than patients not admitted, but this effect failed to show statistical significance in any severity group. There was a significant and independent seasonal effect on HRQL since SGRQ total scores were, on average, 3 points better in measurements performed in spring/summer than in those measured in the winter (p<0.001).

CONCLUSIONS

Frequent exacerbations significantly impair HRQL of patients with moderate COPD. A significant and independent effect of seasonality was also observed.

[Pharmacoeconomic study of antibiotic therapy for exacerbations of chronic bronchitis and chronic obstructive pulmonary disease in Latin America]

Chronic obstructive pulmonary disease (COPD) and chronic bronchitis are highly prevalent diseases. Studies designed to analyze the economic impact of these diseases in Latin American countries have not previously been published. In the present study we analyzed the direct health care costs of treating patients with exacerbations of chronic bronchitis and COPD in Argentina, Brazil, Colombia, Ecuador, Mexico, Peru, and Venezuela, applying the real cost of drugs and medical acts in those 7 countries to the pattern of treatment and outcomes obtained from a study carried out in primary care settings in Spain. The mean direct health care cost ranged from US $98 in Colombia to $329 in Argentina. Most of the cost was related to failure of therapy, which accounted for 52% of the total cost of exacerbation, with the lowest rate in Colombia at 28.6% and the highest in Ecuador at 59.3% The cost of antibiotic therapy represented 19% of the total cost; the rest was owing to other drugs or medical visits. Exacerbations generate significant costs for health care systems. There are considerable variations related mainly to differences between systems. Antibiotic therapy represents a small part of the overall cost. The use of more effective antibiotics, if they can reduce failure rates, may be a cost-effective strategy.