Use Of Antibiotics For Exacerbations Research Articles

Acute exacerbations in chronic obstructive pulmonary disease: should we use antibiotics and if so, which ones?

Acute exacerbations are a major cause of morbidity and mortality in chronic obstructive pulmonary disease (COPD) with evidence suggesting at least 50% of exacerbations involve bacteria that benefit from antibiotic treatment. Here, we review the most relevant data regarding the use of antibiotics in exacerbations of COPD and provide insights on the selection of initial antibiotic therapy for their treatment. Identification of bacterial exacerbations still relies on clinical assessment rather than laboratory biomarkers. Several recent studies, including a meta-analysis and placebo-controlled trials, demonstrate improved outcomes with antibiotics in all but mild exacerbations of COPD, including both inpatient and outpatient. A broader antibiotic regimen should be used for patients who have risk factors for poor outcomes. A risk-stratification approach can guide antibiotic choice, although the stratification algorithm still needs to be validated in a randomized controlled trial. The use of antibiotics for the treatment of moderate-to-severe suspected bacterial exacerbations in COPD is supported by published trials and evidence-based systematic reviews. Recent trials also show differences in outcomes based on antibiotic choice. More research is necessary to evaluate risk stratification approaches when selecting initial antibiotic therapy.

Doxycycline for outpatient-treated acute exacerbations of COPD: does it offers any additional value?

Despite its accepted role, a number of controversies persist regarding the use of antibiotics for exacerbations of chronic obstructive pulmonary disease (COPD). The adequate selection of patients, the identification of biomarkers for treatment response, the adequacy to disease and exacerbation severities or the short-term impact on the exacerbation outcome in different settings remain some of the aspects under current debate (1,2). One specific topic that warrants investigation is the potential long-term impact of antibiotic prescription during exacerbations, specifically on the prevention of subsequent exacerbations. The question about whether a specific treatment during the exacerbation can have an impact on the long term preventing future acute episodes is intriguing. Beyond the potential rationale behind, the topic results to be not easy to face, since a number of factors associated with subsequent exacerbations or with re-admissions after an index event are well-known (3).

Is It Possible to Identify Exacerbations of Mild to Moderate COPD That Do Not Require Antibiotic Treatment?

Anthonisen criteria are widely used to guide the use of antibiotics in exacerbations of COPD. We evaluated the best predictors of outcomes in exacerbations of mild to moderate COPD not treated with antibiotics. We used data from 152 patients of the placebo arm of a randomized trial of amoxicillin/clavulanate for exacerbations of mild to moderate COPD. Clinical response in relation to Anthonisen criteria and point-of-care serum C-reactive protein (CRP) tests (cutoff, 40 mg/L) was assessed with multivariate logistic regression analysis. Clinical failure without antibiotics was 19.9% compared with 9.5% with amoxicillin/clavulanate (P = .022). The only factors significantly associated with an increased risk of failure without antibiotics were the increase in sputum purulence (OR, 6.1; 95% CI, 1.5-25.0; P = .005) and a CRP concentration ≥ 40 mg/L (OR, 13.4; 95% CI, 4.6-38.8; P < .001). When both factors were present, the probability of failure without antibiotics was 63.7%. The Anthonisen criteria showed an area under the curve of 0.708 (95% CI, 0.616-0.801) for predicting clinical outcome. With the addition of CRP level, the area under the curve rose significantly to 0.842 (95% CI, 0.76-0.924; P < .001). Among the Anthonisen criteria, only an increase in sputum purulence is a significant predictor of failure without antibiotics. The use of a point-of-care CRP test significantly increases the predictive accuracy of failure. Both of these easy-to-obtain factors may help clinicians to identify patients with exacerbated mild to moderate COPD who can be safely treated without antibiotics in an ambulatory setting. ClinicalTrials.gov; No.: NCT00495586; URL: www.clinicaltrials.gov.

Improving outcomes in asthma by Commissioning Quality and Innovation (CQUIN)

<h3>Background</h3> Our catchment population has had higher than national average of asthma attendances to primary care and emergency department in this area of Northwest England. CQUIN payment framework enables commissioners to reward excellence, by linking a proportion of the healthcare providers income to the achievement of local quality improvement goals. <h3>Methodology</h3> BTS annual children9s asthma audit pre and post introduction of CQUIN (Commissioning Quality and Innovation) recommendations to reduce admission rates and maintain good control of their symptoms. Clinical Setting: 4 district general hospitals attached to Pennine Acute Trust with a catchment population of nearly 1 million. <h3>Results</h3> Initial audit results in November 2009 identified suboptimal performance in asthma education, discharge planning and the early use of oral steroids. Following the CQUIN recommendations, an intervention team was formed to address the issues raised and a robust strategy was developed and the outcomes were evaluated by a repeat BTS audit in November 2010. Strategies included developing clear guidelines, seamless integrated care pathway from admission to discharge, robust education programme for all frontline medical and nursing personnel and enrolling nurses for diploma in asthma management to take on a more specialist role. The distribution of cases in relation to age, gender and severity was similar to the national cohort. These interventions resulted in good outcomes for a number of CQUIN indicators including more than 50% improvement in discharge planning, 50% reduction in CXR9s and 3 fold reduction in the use of antibiotics for exacerbations. The results for oral steroids administration within an hour of diagnosis was well above national average. <h3>Conclusions</h3> Focussed education to patients, parents and clinical personnel improves clinical outcomes. Integrated care pathway standardises care and improves patient experience. CQUIN schemes reward excellence and improve clinical outcomes.

Antibiotics in COPD exacerbations: practice and evidence

Clinical practice should be directed by scientifi c evidence in this era of evidencebased medicine. It might then appear curious that paradoxes between practice and the evidence can still occur. Take the example of the use of antibiotics in exacerbations of chronic obstructive pulmonary disease (COPD). A recent systematic review of placebo-controlled antibiotic trials in