Abstract
PurposeChanges in sputum microbiology following antibiotic treatment of acute exacerbations of chronic obstructive pulmonary disease (AECOPD), including patterns of bacteriological relapse and superinfection are not well understood. Sputum microbiology at exacerbation is not routinely performed, but pathogen presence and species are determinants of outcomes. Therefore, we determined whether baseline clinical factors could predict the presence of bacterial pathogens at exacerbation. Bacterial eradication at end of treatment (EOT) is associated with clinical resolution of exacerbation. We determined the clinical, microbiological and therapeutic factors that were associated with bacteriological eradication in AECOPD at EOT and in the following 8 weeks.MethodsSputum bacteriological outcomes (i.e., eradication, persistence, superinfection, reinfection) from AECOPD patients (N = 1352) who were randomized to receive moxifloxacin or amoxicillin/clavulanate in the MAESTRAL study were compared. Independent predictors of bacterial presence in sputum at exacerbation and determinants for bacteriological eradication were analyzed by logistic regression and receiver operating characteristic (ROC) analyses.ResultsSignificantly greater bacteriological eradication with moxifloxacin was mainly driven by superior Haemophilus influenzae eradication (P = 0.002, EOT). Baseline clinical factors were a weak predictor of the presence of pathogens in sputum (AUCROC = 0.593). On multivariate analysis, poorer bacterial eradication was associated with antibiotic resistance (P = 0.0001), systemic steroid use (P = 0.0024) and presence of P. aeruginosa (P = 0.0282).ConclusionsSince clinical prediction of bacterial presence in sputum at AECOPD is poor, sputum microbiological analysis should be considered for guiding antibiotic therapy in moderate-to-severe AECOPD, particularly in those who received concomitant systemic corticosteroids or are at risk for infection with antibiotic-resistant bacteria.Electronic supplementary materialThe online version of this article (doi:10.1007/s15010-015-0833-3) contains supplementary material, which is available to authorized users.
Highlights
Exacerbations of chronic obstructive pulmonary disease (COPD) lead to a progressive decline in lung function, with even a single episode of exacerbation having a prolonged effect on health status [1]
We aimed to identify the baseline clinical factors which could predict the presence of bacteria in sputum at exacerbation and guide antibiotic treatment choices in acute exacerbations of COPD (AECOPD)
We investigated whether there was an interaction between systemic corticosteroid use and sputum microbiology that may account for the higher clinical failure rate in corticosteroid-treated patients
Summary
Exacerbations of chronic obstructive pulmonary disease (COPD) lead to a progressive decline in lung function, with even a single episode of exacerbation having a prolonged effect on health status [1]. The controversy regarding the use of antibiotics in the treatment of acute exacerbations of COPD (AECOPD) has been largely resolved, with increasing evidence of bacterial causation and of clinical benefits with antibiotic treatment [5, 6]. Moxifloxacin (MXF) and amoxicillin/clavulanic acid (AMC) are currently recommended antibiotics for the treatment of AECOPD in patients at risk for poor outcome [5, 7, 8]. These two antibiotics demonstrated similar clinical efficacy in the recently completed MAESTRAL trial in COPD outpatients with Anthonisen type I exacerbations [9]
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