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Correspondence |

Antibiotic Use in Acute Exacerbations of Chronic BronchitisResponseLetters Re Dr. Friedrich Wegener FREE TO VIEW

Petey Laohaburanakit, MD, FCCP
Author and Funding Information

Affiliations: Pulmonary Consultants and Sleep Specialists, Medford, OR,  Intensive Care Unit, “Attikon” University Hospital, Athens, Greece,  Alfa Institute of Biomedical Sciences, Athens, Greece,  Department of Medicine, Tufts University School of Medicine, Boston, MA,  Editor in Chief, CHEST

Correspondence to: Petey Laohaburanakit, MD, FCCP, Pulmonary Consultants and Sleep Specialists, 555 Black Oak Dr, Suite 300, Medford, OR 97504; e-mail: peteyl@mind.net



Chest. 2007;132(6):2063-2064. doi:10.1378/chest.07-2131
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Published online

In a recent issue of CHEST (August 2007),1 I read the article by Dimopoulos et al with great interest. In their metaanalysis, the authors found that second-line antibiotics were more effective than first-line antibiotics in the treatment of COPD exacerbations. They mentioned several limitations of their work but omitted one important variable that could potentially influence their primary finding.

The use of corticosteroids during acute exacerbations of COPD has been the standard of practice for quite some time.2The Montelukast Study of Asthma in Children study group3identified the use of systemic corticosteroids during acute exacerbations of COPD as one of the factors influencing short-term and long-term outcomes. In the landmark study by Anthonisen et al,4 patients with acute exacerbations of chronic bronchitis who received corticosteroids had no statistically significant improvement in treatment success rate whether they had received antibiotic therapy or not. One might speculate that first-line and second-line antibiotics would fare comparably in the face of concomitant corticosteroid treatment. It would be curious to see whether the report by Dimopoulos et al1 would have had a different conclusion had a subgroup analysis been performed among the patients receiving concomitant systemic corticosteroid therapy during their exacerbations.

The author has reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

The authors have no conflicts of interest to disclose.

Dimopoulos, G, Siempos, II, Korbila, IP, et al (2007) Comparison of first-line with second-line antibiotics for acute exacerbations of chronic bronchitis.Chest132,447-455. [PubMed] [CrossRef]
 
Stoller, JK Acute exacerbations of COPD.N Engl J Med2002;341,988-994
 
Wilson, R, Jones, P, Schaberg, T, et al Antibiotic treatment and factors influencing short and long term outcomes of acute exacerbations of chronic bronchitis.Thorax2006;61,337-342. [PubMed]
 
Anthonisen, NR, Manfreda, J, Warren, CPW, et al Antibiotic therapy in exacerbations of COPD.Ann Intern Med1987;106,196-204. [PubMed]
 
To the Editor:

We thank Dr. Laohaburanakit for his comment on the potential impact of concomitant use of systemic corticosteroids during acute exacerbations of chronic bronchitis (AECB) on the main findings of our metaanalysis1that compared second-line to first-line antimicrobials for the treatment of patients with AECB. We agree with our colleague that use of corticosteroids should be standardized because they modulate local and systemic inflammatory response and, thereby, may act as a potential confounding factor. Indeed, a Cochrane review2revealed that treatment with corticosteroids, compared to placebo, was associated with fewer treatment failures in patients with AECB (odds ratio, 0.48; 95% confidence interval, 0.34 to 0.68). Acknowledging this evidence in another metaanalysis,3 we commented on the potential confounding role of the administration of corticosteroids when evaluating the comparative effectiveness of several second-line antimicrobials for the treatment of AECB.

Unfortunately, 8 of the 12 randomized controlled trials (RCTs) included in the present metaanalysis1 did not provide data on the concurrent administration of systemic corticosteroids for the management of AECB. As concerns the remaining four RCTs, in the trial by De Vlieger et al,4“concomitant methylprednisolone consumption of > 8 mg was an exclusion criterion,” while in the three remaining RCTs the compared groups of patients were similar regarding use of systemic corticosteroids during AECB (44% vs 39%, 100% vs 80%, and 19% vs 19%, in the RCTs by Ulmer et al,5Mertens et al,6and Bachand et al,7 respectively). Specific information on the treatment success of corticosteroid recipients was not given.

We performed a subgroup analysis by including only the three latter RCTs that mentioned concomitant use of corticosteroids. Our main finding was the same, namely that first-line antibiotics were associated with lower treatment success compared to second-line antibiotics (odds ratio, 0.42; 95% confidence interval, 0.22 to 0.79), a result that should be in the context of several other factors that influence clinical decision making and that are discussed in our article.1

References
Dimopoulos, G, Siempos, II, Korbila, IP, et al Comparison of first-line with second-line antibiotics for acute exacerbations of chronic bronchitis: a meta-analysis of randomized controlled trials.Chest2007;132,447-455. [PubMed] [CrossRef]
 
Wood-Baker, RR, Gibson, PG, Hannay, M, et al Systemic corticosteroids for acute exacerbations of chronic obstructive pulmonary disease.Cochrane Database Syst Rev2005;1,CD001288. [PubMed]
 
Siempos, II, Dimopoulos, G, Korbila, IP, et al Macrolides, quinolones and amoxicillin/clavulanate for chronic bronchitis: a meta-analysis.Eur Respir J2007;29,1127-1137. [PubMed]
 
De Vlieger, A, Druart, M, Puttemans, M Roxithromycin versus doxycycline in the treatment of acute exacerbations of chronic bronchitis.Diagn Microbiol Infect Dis1992;15,123S-127S. [PubMed]
 
Ulmer, W Fleroxacin versus amoxicillin in the treatment of acute exacerbation of chronic bronchitis.Am J Med1993;94,136S-141S. [PubMed]
 
Mertens, JC, van Barneveld, PW, Asin, HR, et al Double-blind randomised study comparing the efficacies and safeties of a short (3-day) course of azithromycin and a 5-day course of amoxicillin in patients with acute exacerbations of chronic bronchitis.Antimicrob Agents Chemother1992;36,1456-1459. [PubMed]
 
Bachand, RT, Jr Comparative study of clarithromycin and ampicillin in the treatment of patients with acute bacterial exacerbations of chronic bronchitis.J Antimicrob Chemother1991;27(suppl A),91-100. [PubMed]
 
Editor’s Note:

Because of space constraints, we are publishing four of the letters received. They contain interesting comments and reflect divergent points of view.


Figures

Tables

References

Dimopoulos, G, Siempos, II, Korbila, IP, et al (2007) Comparison of first-line with second-line antibiotics for acute exacerbations of chronic bronchitis.Chest132,447-455. [PubMed] [CrossRef]
 
Stoller, JK Acute exacerbations of COPD.N Engl J Med2002;341,988-994
 
Wilson, R, Jones, P, Schaberg, T, et al Antibiotic treatment and factors influencing short and long term outcomes of acute exacerbations of chronic bronchitis.Thorax2006;61,337-342. [PubMed]
 
Anthonisen, NR, Manfreda, J, Warren, CPW, et al Antibiotic therapy in exacerbations of COPD.Ann Intern Med1987;106,196-204. [PubMed]
 
Dimopoulos, G, Siempos, II, Korbila, IP, et al Comparison of first-line with second-line antibiotics for acute exacerbations of chronic bronchitis: a meta-analysis of randomized controlled trials.Chest2007;132,447-455. [PubMed] [CrossRef]
 
Wood-Baker, RR, Gibson, PG, Hannay, M, et al Systemic corticosteroids for acute exacerbations of chronic obstructive pulmonary disease.Cochrane Database Syst Rev2005;1,CD001288. [PubMed]
 
Siempos, II, Dimopoulos, G, Korbila, IP, et al Macrolides, quinolones and amoxicillin/clavulanate for chronic bronchitis: a meta-analysis.Eur Respir J2007;29,1127-1137. [PubMed]
 
De Vlieger, A, Druart, M, Puttemans, M Roxithromycin versus doxycycline in the treatment of acute exacerbations of chronic bronchitis.Diagn Microbiol Infect Dis1992;15,123S-127S. [PubMed]
 
Ulmer, W Fleroxacin versus amoxicillin in the treatment of acute exacerbation of chronic bronchitis.Am J Med1993;94,136S-141S. [PubMed]
 
Mertens, JC, van Barneveld, PW, Asin, HR, et al Double-blind randomised study comparing the efficacies and safeties of a short (3-day) course of azithromycin and a 5-day course of amoxicillin in patients with acute exacerbations of chronic bronchitis.Antimicrob Agents Chemother1992;36,1456-1459. [PubMed]
 
Bachand, RT, Jr Comparative study of clarithromycin and ampicillin in the treatment of patients with acute bacterial exacerbations of chronic bronchitis.J Antimicrob Chemother1991;27(suppl A),91-100. [PubMed]
 
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