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Mona Bafadhel, MBChB; Christopher E. Brightling, PhD
Author and Funding Information

From the Institute for Lung Health, University of Leicester, and Department of Infection, Immunity and Inflammation, Glenfield Hospital.

Correspondence to: Christopher E. Brightling, PhD, Institute for Lung Health, University of Leicester, Department of Infection, Immunity and Inflammation, Clinical Sciences Wing, Glenfield Hospital, Groby Rd, Leicester LE3 9QP, England; e-mail: ceb17@le.ac.uk

Financial/nonfinancial disclosures: The authors have reported to CHEST the following conflicts of interest: Dr Brightling has received consultancy fees from Medimmune, AstraZeneca, GlaxoSmithKline, and Roche, and research grants from AstraZeneca, Medimmune, and GlaxoSmithKline. Dr Bafadhel has reported that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).


Financial/nonfinancial disclosures: The authors have reported to CHEST the following conflicts of interest: Dr Brightling has received consultancy fees from Medimmune, AstraZeneca, GlaxoSmithKline, and Roche, and research grants from AstraZeneca, Medimmune, and GlaxoSmithKline. Dr Bafadhel has reported that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Financial/nonfinancial disclosures: The authors have reported to CHEST the following conflicts of interest: Dr Brightling has received consultancy fees from Medimmune, AstraZeneca, GlaxoSmithKline, and Roche, and research grants from AstraZeneca, Medimmune, and GlaxoSmithKline. Dr Bafadhel has reported that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).


Chest. 2011;140(6):1668. doi:10.1378/chest.11-2492
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To the Editor:

We thank Dr Cunha for his interest in our study on the potential role of procalcitonin and C-reactive protein in the management of exacerbations of airways disease.1 We agree with Dr Cunha that biomarkers should complement rather than replace good clinical practice and that results from biomarkers should be considered in light of the pretest probability. Indeed, in the absence of good clinical judgment, biomarkers may impair rather than facilitate decision making. Biomarkers are particularly valuable in helping to stratify risk, where the management strategy is uncertain or controversial, and to direct therapy. For example, in the management of chronic heart failure, directing therapy based on peripheral blood levels of brain natriuretic hormone reduces all-cause mortality.2 Likewise in asthma, there is increasing evidence that sputum eosinophilia helps to identify patients who will respond to corticosteroids and targeted anti-IL-5 therapy.3

In our study of the patients admitted to the hospital with pneumonia or exacerbations of asthma or COPD,1 we found that in addition to those patients with pneumonia, a large proportion of patients with asthma or COPD received antibiotics. Current guidelines do not advocate antibiotics for asthma exacerbations, although there is evidence to suggest that macrolide antibiotics hasten the rate of recovery.4 Most hospitalized patients with exacerbations of COPD fulfill current clinical guidelines to receive antibiotic therapy, but the benefit is relatively small and likely to be limited to a subgroup within those with more severe exacerbations. This is demonstrated in studies that have successfully reduced antibiotic usage in an acute setting by using procalcitonin to direct clinical decision making without increased adverse events in those patients not treated with antibiotics.5 The application of biomarkers such as procalcitonin or C-reactive protein add value beyond standard clinical care, and in our study,1 the modified early warning score, which is a composite of clinical assessment, was a poor discriminator between patients with pneumonia and an exacerbation of asthma. We, therefore, wholeheartedly agree with Dr Cunha that we must not lose the “art” of medicine, but this needs to be informed by the “science” of medicine.

Bafadhel M, Clark TW, Reid C, et al. Procalcitonin and C-reactive protein in hospitalized adult patients with community-acquired pneumonia or exacerbation of asthma or COPD. Chest. 2011;1396:1410-1418 [CrossRef] [PubMed]
 
Felker GM, Hasselblad V, Hernandez AF, O’Connor CM. Biomarker-guided therapy in chronic heart failure: a meta-analysis of randomized controlled trials. Am Heart J. 2009;1583:422-430 [CrossRef] [PubMed]
 
Haldar P, Brightling CE, Hargadon B, et al. Mepolizumab and exacerbations of refractory eosinophilic asthma. N Engl J Med. 2009;36010:973-984 [CrossRef] [PubMed]
 
Johnston SL, Blasi F, Black PN, Martin RJ, Farrell DJ, Nieman RB. TELICAST Investigators The effect of telithromycin in acute exacerbations of asthma. N Engl J Med. 2006;35415:1589-1600 [CrossRef] [PubMed]
 
Schuetz P, Christ-Crain M, Thomann R, et al. ProHOSP Study Group Effect of procalcitonin-based guidelines vs standard guidelines on antibiotic use in lower respiratory tract infections: the ProHOSP randomized controlled trial. JAMA. 2009;30210:1059-1066 [CrossRef] [PubMed]
 

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References

Bafadhel M, Clark TW, Reid C, et al. Procalcitonin and C-reactive protein in hospitalized adult patients with community-acquired pneumonia or exacerbation of asthma or COPD. Chest. 2011;1396:1410-1418 [CrossRef] [PubMed]
 
Felker GM, Hasselblad V, Hernandez AF, O’Connor CM. Biomarker-guided therapy in chronic heart failure: a meta-analysis of randomized controlled trials. Am Heart J. 2009;1583:422-430 [CrossRef] [PubMed]
 
Haldar P, Brightling CE, Hargadon B, et al. Mepolizumab and exacerbations of refractory eosinophilic asthma. N Engl J Med. 2009;36010:973-984 [CrossRef] [PubMed]
 
Johnston SL, Blasi F, Black PN, Martin RJ, Farrell DJ, Nieman RB. TELICAST Investigators The effect of telithromycin in acute exacerbations of asthma. N Engl J Med. 2006;35415:1589-1600 [CrossRef] [PubMed]
 
Schuetz P, Christ-Crain M, Thomann R, et al. ProHOSP Study Group Effect of procalcitonin-based guidelines vs standard guidelines on antibiotic use in lower respiratory tract infections: the ProHOSP randomized controlled trial. JAMA. 2009;30210:1059-1066 [CrossRef] [PubMed]
 
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