Indexed on: 08 Dec '19Published on: 23 May '19Published in: European Respiratory Journal
Acute exacerbations of chronic obstructive pulmonary disease (COPD) often prompt initiation of empirical antibiotic treatment, although in many cases a bacterial pathogen cannot be detected, and viruses may indeed account for a large proportion of episodes. Indeed, data supporting the effectiveness of the broad antibiotic utilisation at exacerbation not requiring intensive care are insufficient. Herein, personalising antibiotic treatment based on a patient's individual risk for bacterial infection has great potential to improve antibiotic stewardship efforts to encourage judicious and correct usage of these agents and mitigate the emergence of multidrug-resistant pathogens, one of the most urgent threats to global health and directly linked to antibiotic overuse. Integration of host response markers, which correlate with bacterial infection, into the overall assessment and clinical care of patients with acute exacerbation of COPD has high potential to improve individual antibiotic decisions. Among such promising host response markers in acute exacerbation of COPD, procalcitonin (PCT), a marker specific to bacterial infections, and C-reactive protein (CRP), a more general inflammatory marker with high sensitivity, have generated most interest. Several randomised trials have found PCT to result in a significant reduction of antibiotic usage with a similar resolution of clinical symptoms in patients with sepsis and respiratory infections, including acute exacerbation of COPD [1, 2]. In fact, a meta-analysis based on individual data of 1252 patients with COPD exacerbation found PCT guidance to result in a significant reduction in antibiotic initiation (72% versus 43%) and antibiotic exposure (5.3 versus 3.1 days) with no difference in mortality (4% versus 3%) or risk of treatment failure (17% versus 17%) . Still, a recent trial investigating COPD patients needing intensive care treatment did not report a significant effect of PCT on antibiotic usage, and non-inferiority of PCT in regard to clinical outcomes could not be demonstrated . CRP has been used successfully to direct antibiotic treatment in primary care studies [5, 6], and observational research suggested CRP may be more suitable to direct antibiotic treatment in acute exacerbation of COPD compared to PCT . Still, randomised trials looking at the effect of CRP for guiding antibiotic decisions in patients with acute COPD exacerbation have been largely missing.