Abstract
Chronic obstructive pulmonary disease (COPD) remains a major cause of morbidity and mortality worldwide. COPD is especially prevalent in the elderly, affecting 25% of those aged ≥75 years. The course of the disease in the elderly is often complicated by co-morbid conditions, and its management is complicated by drug-drug interactions. Exacerbations of COPD increase rates of hospitalization and mortality and decrease quality of life. Exacerbations are marked by an increase from baseline in dyspnoea, sputum volume and sputum purulence. Approximately 50% of acute exacerbations of symptoms in COPD are caused by non-typeable Haemophilus influenzae, Moraxella catarrhalis, Streptococcus pneumoniae and Pseudomonas aeruginosa.
Stratification of exacerbations based on severity of symptoms and signs, and severity of underlying COPD, is useful in selecting patients likely to benefit from antibacterial therapy. Patients who are hospitalized with exacerbations, those who have all three symptoms (increased dyspnoea, sputum volume and sputum purulence), and those with severe underlying COPD and exacerbations benefit most from antibacterials. Antibacterial susceptibility patterns among the bacterial pathogens are evolving, and knowledge of local susceptibility patterns is useful in antibacterial selection. Penicillin, amoxicillin, cotrimoxazole (trimethoprim/sulfamethoxazole) and doxycycline should not be used as an initial antibacterial because of resistance patterns. We recommend second-/third-generation cephalosporins, amoxicillin/clavulanic acid, azithromycin and respiratory fluoroquinolones as initial choices. In patients at risk of colonization by, and infection as a result of, P. aeruginosa, ciprofloxacin, levofloxacin or an advanced penicillin/penicillinase combination effective against this species should be used. Drug-drug interactions should be considered in antibacterial choice. The goals of antibacterial therapy for exacerbations of COPD are the prevention of complications such as respiratory failure and death, and the reduction of treatment failures.
The role of pathogenic bacteria in progression of stable COPD and the use of prophylactic antibacterials in stable COPD are under investigation. Currently available evidence does not support routine clinical use of prophylactic antibacterials in stable COPD.
In conclusion, pathogenic bacteria cause a significant proportion of acute exacerbations of COPD. Use of antibacterials, based on current susceptibility patterns, is beneficial in patients with severe COPD experiencing exacerbations and in patients with severe exacerbations.
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References
Celli BR, MacNee W. Standards for the diagnosis and treatment of patients with COPD: a summary of the ATS/ERS position paper. Eur Respir J 2004 Jun; 23(6): 932–46
Brown DW, Croft JB, Greenlund KJ, et al. Deaths from chronic obstructive pulmonary disease: United States, 2000–2005. MMWR Morb Mortal Wkly Rep 2008 Nov 14; 57(45): 1229–32
Liu S, Zhou Y, Wang X, et al. Biomass fuels are the probable risk factor for chronic obstructive pulmonary disease in rural South China. Thorax 2007 Oct; 62(10): 889–97
Sullivan SD, Ramsey SD, Lee TA. The economic burden of COPD. Chest 2000 Feb; 117(2 Suppl.): 5S–9S
Sethi S, Murphy TF. Infection in the pathogenesis and course of chronic obstructive pulmonary disease. N Engl J Med 2008 Nov 27; 359(22): 2355–65
Mannino DM, Homa DM, Akinbami LJ, et al. Chronic obstructive pulmonary disease surveillance: United States, 1971–2000. MMWR Surveill Summ 2002 Aug 2; 51(6): 1–16
Isoaho R, Puolijoki H, Huhti E, et al. Prevalence of chronic obstructive pulmonary disease in elderly Finns. Respir Med 1994 Sep; 88(8): 571–80
Yohannes AM, Roomi J, Waters K, et al. Quality of life in elderly patients with COPD: measurement and predictive factors. Respir Med 1998 Oct; 92(10): 1231–6
Peruzza S, Sergi G, Vianello A, et al. Chronic obstructive pulmonary disease (COPD) in elderly subjects: impact on functional status and quality of life. Respir Med 2003 Jun; 97(6): 612–7
Cydulka RK, McFadden Jr ER, Emerman CL, et al. Patterns of hospitalization in elderly patients with asthma and chronic obstructive pulmonary disease. Am J Respir Crit Care Med 1997 Dec; 156(6): 1807–12
Seneff MG, Wagner DP, Wagner RP, et al. Hospital and 1-year survival of patients admitted to intensive care units with acute exacerbation of chronic obstructive pulmonary disease. JAMA 1995 Dec 20; 274(23): 1852–7
Ranieri P, Bianchetti A, Margiotta A, et al. Predictors of 6-month mortality in elderly patients with mild chronic obstructive pulmonary disease discharged from a medical ward after acute nonacidotic exacerbation. J Am Geriatr Soc 2008 May; 56(5): 909–13
Almagro P, Calbo E, Ochoa de Echaguen A, et al. Mortality after hospitalization for COPD. Chest 2002 May 2002; 121(5): 1441–8
Bonomo RA. Multiple antibiotic-resistant bacteria in long-term care facilities: an emerging problem in the practice of infectious diseases. Clin Infect Dis 2000; 31(6): 1414–22
Muder RR, Brennen C, Drenning SD, et al. Multiply antibiotic-resistant Gram-negative bacilli in a long-term-care facility: a case-control study of patient risk factors and prior antibiotic use. Infect Control Hosp Epidemiol 1997 Dec; 18(12): 809–13
Papi A, Bellettato CM, Braccioni F, et al. Infections and airway inflammation in chronic obstructive pulmonary disease severe exacerbations. Am J Respir Crit Care Med 2006 May 15; 173(10): 1114–21
Greenberg SB, Allen M, Wilson J, et al. Respiratory viral infections in adults with and without chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2000 Jul; 162(1): 167–73
Seemungal TA, Wedzicha JA. Viral infections in obstructive airway diseases. Curr Opin Pulm Med 2003 Mar; 9(2): 111–6
Fagon JY, Chastre J, Trouillet JL, et al. Characterization of distal bronchial microflora during acute exacerbation of chronic bronchitis: use of the protected specimen brush technique in 54 mechanically ventilated patients. Am Rev Respir Dis 1990 Nov; 142(5): 1004–8
Monso E, Ruiz J, Rosell A, et al. Bacterial infection in chronic obstructive pulmonary disease: a study of stable and exacerbated outpatients using the protected specimen brush. Am J Respir Crit Care Med 1995 Oct; 152 (4 Pt 1): 1316–20
Soler N, Torres A, Ewig S, et al. Bronchial microbial patterns in severe exacerbations of chronic obstructive pulmonary disease (COPD) requiring mechanical ventilation. Am J Respir Crit Care Med 1998 May; 157 (5 Pt 1): 1498–505
Rosell A, Monso E, Soler N, et al. Microbiologic determinants of exacerbation in chronic obstructive pulmonary disease. Arch Intern Med 2005 Apr 25; 165(8): 891–7
Sethi S, Evans N, Grant BJ, et al. New strains of bacteria and exacerbations of chronic obstructive pulmonary disease. N Engl J Med 2002 Aug 15; 347(7): 465–71
Hill AT, Campbell EJ, Hill SL, et al. Association between airway bacterial load and markers of airway inflammation in patients with stable chronic bronchitis. Am J Med 2000 Sep; 109(4): 288–95
Stockley RA, O’Brien C, Pye A, et al. Relationship of sputum color to nature and outpatient management of acute exacerbations of COPD. Chest 2000 Jun; 117(6): 1638–45
White AJ, Gompertz S, Bayley DL, et al. Resolution of bronchial inflammation is related to bacterial eradication following treatment of exacerbations of chronic bronchitis. Thorax 2003 Aug; 58(8): 680–5
Yi K, Sethi S, Murphy TF. Human immune response to nontypeable Haemophilus influenzae in chronic bronchitis. J Infect Dis 1997 Nov; 176(5): 1247–52
Bakri F, Brauer AL, Sethi S, et al. Systemic and mucosal antibody response to Moraxella catarrhalis after exacerbations of chronic obstructive pulmonary disease. J Infect Dis 2002 Mar 1; 185(5): 632–40
Sethi S, Wrona C, Eschberger K, et al. Inflammatory profile of new bacterial strain exacerbations of chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2008 Mar 1; 177(5): 491–7
Anthonisen NR, Manfreda J, Warren CP, et al. Antibiotic therapy in exacerbations of chronic obstructive pulmonary disease. Ann Intern Med 1987 Feb; 106(2): 196–204
Sachs AP, Koeter GH, Groenier KH, et al. Changes in symptoms, peak expiratory flow, and sputum flora during treatment with antibiotics of exacerbations in patients with chronic obstructive pulmonary disease in general practice. Thorax 1995 Jul 1; 50(7): 758–63
Ram FS, Rodriguez-Roisin R, Granados-Navarrete A, et al. Antibiotics for exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2006; (2): CD004403
Quon BS, Gan WQ, Sin DD. Contemporary management of acute exacerbations of COPD: a systematic review and metaanalysis. Chest 2008 Mar; 133(3): 756–66
Roede BM, Bresser P, Prins JM, et al. Reduced risk of next exacerbation and mortality associated with antibiotic use in COPD. Eur Respir J 2009 Feb; 33(2): 282–8
Dimopoulos G, Siempos II, Korbila IP, et al. Comparison of first-line with second-line antibiotics for acute exacerbations of chronic bronchitis: a metaanalysis of randomized controlled trials. Chest 2007 Aug; 132(2): 447–55
Soler N, Agusti C, Angrill J, et al. Bronchoscopic validation of the significance of sputum purulence in severe exacerbations of chronic obstructive pulmonary disease. Thorax 2007 Jan; 62(1): 29–35
Johnson DM, Sader HS, Fritsche TR, et al. Susceptibility trends of Haemophilus influenzae and Moraxella catarrhalis against orally administered antimicrobial agents: five-year report from the SENTRY Antimicrobial Surveillance Program. Diagn Microbiol Infect Dis 2003 Sep; 47(1): 373–6
Sahm DF, Brown NP, Thornsberry C, et al. Antimicrobial susceptibility profiles among common respiratory tract pathogens: a GLOBAL perspective. Postgrad Med 2008 Sep; 120 (3 Suppl. 1): 16–24
Deshpande LM, Sader HS, Fritsche TR, et al. Contemporary prevalence of BRO β-lactamases in Moraxella catarrhalis: report from the SENTRY Antimicrobial Surveillance Program (North America, 1997 to 2004). J Clin Microbiol 2006 Oct 1; 44(10): 3775–7
Musher DM. Streptococcus pneumoniae. In: Mandell GL, Douglas RG, Bennett JE, et al., editors. Mandell, Douglas, and Bennett’s principles and practice of infectious diseases. 6th ed. Philadelphia (PA): Elsevier Churchill Livingstone, 2005: 2392–411
Stolz D, Christ-Crain M, Bingisser R, et al. Antibiotic treatment of exacerbations of COPD: a randomized, controlled trial comparing procalcitonin-guidance with standard therapy. Chest 2007 Jan; 131(1): 9–19
Woodhead M, Blasi F, Ewig S, et al. Guidelines for the management of adult lower respiratory tract infections. Eur Respir J 2005 Dec 1; 26(6): 1138–80
Eller J, Ede A, Schaberg T, et al. Infective exacerbations of chronic bronchitis. Chest 1998 June 1998; 113(6): 1542–8
Blasi F, Tarsia P, Pappalettera M, et al. Antibiotic therapy and prophylaxis in COPD. Respir Med COPD Update 2007; 2(4): 124–32
Falagas ME, Avgeri SG, Matthaiou DK, et al. Short- versus long-duration antimicrobial treatment for exacerbations of chronic bronchitis: a meta-analysis. J Antimicrob Chemother 2008 Sep; 62(3): 442–50
Fletcher CM. Chronic bronchitis: its prevalence, nature, and pathogenesis. Am Rev Respir Dis 1959 Oct; 80: 483–94
Banerjee D, Khair OA, Honeybourne D. Impact of sputum bacteria on airway inflammation and health status in clinical stable COPD. Eur Respir J 2004 May; 23(5): 685–91
Black P, Staykova T, Chacko E, et al. Prophylactic antibiotic therapy for chronic bronchitis. Cochrane Database Syst Rev 2003; (1): CD004105
Seemungal TAR, Wilkinson TMA, Hurst JR, et al. Long-term erythromycin therapy is associated with decreased chronic obstructive pulmonary disease exacerbations. Am J Respir Crit Care Med 2008 Dec 1; 178(11): 1139–47
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No sources of funding were used to assist in the preparation of this article. Timothy Murphy has acted as a consultant to GlaxoSmithKline, Merck and Mpex Pharmaceuticals. Iyer Parameswaran has no conflicts of interest that are directly relevant to the content of this article.
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Parameswaran, G.I., Murphy, T.F. Chronic Obstructive Pulmonary Disease. Drugs Aging 26, 985–995 (2009). https://doi.org/10.2165/11315700-000000000-00000
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DOI: https://doi.org/10.2165/11315700-000000000-00000