Determining Factors in the Prescription of Moxifloxacin in Exacerbations of Chronic Bronchitis in??the Primary-Care Setting

Antibiotics for treatment and prevention of exacerbations of chronic obstructive pulmonary disease

Acute exacerbations (AE) can be recurrent problems for patients with moderate-to-severe chronic obstructive pulmonary disease (COPD) increasing morbidity and mortality. Evidence suggests that ≥50% of acute exacerbations involve bacteria requiring treatment with an antibiotic which should have high activity against the causative pathogens. However, sputum analysis is not a pre-requisite for antibiotic prescription in outpatients as results are delayed and patients are likely to be colonised with bacteria in the stable state. Clinicians rely on the clinical symptoms, sputum appearance and the patient's medical history to decide if an AE-COPD should be treated with antibiotics. This article reviews the available data of antibiotic trials in AE-COPD. Management of frequent exacerbators is particularly challenging for physicians. This may include antibiotic prophylaxis, especially macrolides because of anti-inflammatory properties; though successful in reducing exacerbations, concerns about resistance development remain. Inhalation of antibiotics achieves high local concentrations and minimal systemic exposure; therefore, it may represent an attractive alternative for antibiotic prophylaxis in certain COPD patients. Inhaled antibiotic prophylaxis has been successfully used in other respiratory conditions such as non-cystic fibrosis bronchiectasis which itself might be present in COPD patients who have chronic bacterial infection, particularly with Pseudomonas aeruginosa.

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.

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.