Antibiotics in the Treatment of Acute Exacerbation of Chronic Obstructive Pulmonary Disease
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1 Antibiotics in the Treatment of Acute Exacerbation of Chronic Obstructive Pulmonary Disease Sung Kyu Kim, M.D.Young Sam Kim, M.D. Department of Internal Medicine Yonsei University College of Medicine, Severance Hospital skkimpul@yumc.yonsei.ac.krysamkim@yumc.yonsei.ac.kr Abstract Chronic obstructive pulmonary disease (COPD) is the fourth leading cause of death in the United States, and is projected to rank fifth in 2020 as a worldwide burden of disease. It accounts for approximately 500,000 hospitalizations for exacerbations each year. According to a nationwide survey in Korea, the prevalence of COPD is 7.7%. New definitions of acute COPD exacerbation have been suggested, but the one used by Anthonisen is still widely accepted. It requires the presence of one or more of the following findings: increase in sputum purulence, increase in sputum volume, and worsening of dyspnea. The etiology of the exacerbations is mainly infectious. Patients experiencing COPD exacerbations with clinical signs of airway infection may benefit from antibiotic treatment. Antibiotic use has been shown to be beneficial, especially for patients with severe exacerbation. When initiating empirical antibiotic treatment physicians should always take account of any guidance issued by their local microbiologists. Antibiotic choices for patients with uncomplicated COPD include an advanced macrolide (azithromycin or clarithromycin), a ketolide (telithromycin), a cephalosporin (cefuroxime, cefpodoxime, or cefdinir) or doxycycline. In patients with complicated COPD, antibiotic choices include a new fluoroquinolone (moxifloxacin, gemifloxacin, gatfloxacin, or levofloxacin) or amoxicillin clavulanate. If Pseudomonas and other Enterobactereaces species are suspected, a combination therapy should be considered. When the initial empiric antimicrobial therapy fails, it would be appropriate to reevaluate the patient to confirm the diagnosis, to consider sputum studies to ascertain for resistant or difficulttotreat pathogens, and to treat with an alternative agent with a better in vitro microbiologic efficacy. Keywords : Chronic obstructive pulmonary disease; Keywords : Acute exacerbation; Antibiotics 385
2 (Tracheobronchial infection) (Air pollution) (Pneumonia) (Pulmonary embolism) (Pneumothorax) (Rib fractures/chest trauma) (Inappropriate use of sedatives) (narcotics, betablocking agents) (Right and/or left heart failure) (arrhythmias) 386
3 Bacteria Nontypeable Haemophilus influenzae Moraxella catarrhalis Streptococcus pneumoniae Pseudomonas aeruginosa Enterobacteriaceae Haemophilus parainfluenzae Virus Rhinovirus (common cold) Influenza Parainfluenza Coronavirus Adenovirus Respiratory syncytial virus Atypical bacteria Chlamydia pneumoniae Mycoplasma pneumoniae (rare) Legionella 387
4 (ATS/ERS Guideline) Level : ( )... - Amoxicillin, ampicillin - Cephalosporin(cefpodoxime, cefprozil, cefuroxime, cefdinir) - Doxycycline - Macrolides(azithromycin, clarithromycin, dirithromycin, roxithromycin). - Amoxicillin/clavulanate - Respiratory fluoroquinolones(gatifloxacin, levofloxacin and moxifloxacin) Level : ( )... - Amoxicillin/clavulanate - Respiratory fluoroquinolones(gatifloxacin, levofloxacin, moxifloxacin) Pseudomonas spp. Enterobactereaces spp.. Level :.. - Amoxicillin/clavulanate - Respiratory fluoroquinolones (gatifloxacin, levofloxacin, moxifloxacin) Pseudomonas spp. Enterobactereaces spp.. 388
5 Advanced macrolide (azithromycin, clarithromycin) Ketolide(telithromycin) Cephalosporin (cefuroxime, cefpodoxime, cefdinir) Doxycycline Fluoroquinolone (moxifloxacine, gemifloxacine, gatifloxacine, levofloxacine) Amoxiciline/clavulanate Pseudomonas ciprofloxacine 1. American Thoracic Society, European Respiratory Society. Stan- dards for the Diagnosis and Management of Patients with COPD: American Thoracic Society, European Respiratory Society, 2004: Soto FJ, Varkey B. Evidencebased approach to acute exacerbations of COPD. Curr Opin Pulm Med 2003; 9: National Heart, Lung, and Blood Institute, World Health Organi- 389
6 zation. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease Updated 2004: National Heart, Lung, and Blood Institute, World Health Organization, 2004: British thoracic society. Management of exacerbations of COPD. Thorax 2004; 59: Sethi S, Murphy TF. Acute exacerbations of chronic bronchitis: new developments concerning microbiology and pathophy siologyimpact on approaches to risk stratification and therapy. Infect Dis Clin North Am 2004; 18:
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