Antibiotics in addition to systemic corticosteroids for acute exacerbations of chronic obstructive pulmonary disease.

RATIONALE: The role of antibiotics in acute exacerbations is controversial and their efficacy when added to systemic corticosteroids is unknown. OBJECTIVES: We conducted a randomized, placebo-controlled trial to determine the effects of doxycycline in addition to corticosteroids on clinical outcome, microbiological outcome, lung function, and systemic inflammation in patients hospitalized with an acute exacerbation of chronic obstructive pulmonary disease. METHODS: Of 223 patients, we enrolled 265 exacerbations defined on the basis of increased dyspnea and increased sputum volume with or without increased sputum purulence. Patients received 200 mg of oral doxycycline or matching placebo for 7 days in addition to systemic corticosteroids. Clinical and microbiological response, time to treatment failure, lung function, symptom scores, and serum C-reactive protein were assessed. MEASUREMENTS AND MAIN RESULTS: On Day 30, clinical success was similar in intention-to-treat patients (odds ratio, 1.3; 95% confidence interval, 0.8 to 2.0) and per-protocol patients. Doxycycline showed superiority over placebo in terms of clinical success on Day 10 in intention-to-treat patients (odds ratio, 1.9; 95% confidence interval, 1.1 to 3.2), but not in per-protocol patients. Doxycycline was also superior in terms of clinical cure on Day 10, microbiological outcome, use of open label antibiotics, and symptoms. There was no interaction between the treatment effect and any of the subgroup variables (lung function, type of exacerbation, serum C-reactive protein, and bacterial presence). CONCLUSIONS: Although equivalent to placebo in terms of clinical success on Day 30, doxycycline showed superiority in terms of clinical success and clinical cure on Day 10, microbiological success, the use of open label antibiotics, and symptoms. Clinical trial registered with www.clinicaltrials.gov (NCT00170222).

Evaluation of an algorithm for switching from IV to PO therapy in clinical practice in patients with community-acquired pneumonia.

BACKGROUND: In patients with community-acquired pneumonia (CAP), switching from IV to PO antibiotics offers advantages over IV therapy alone, including improved cost-effectiveness through reductions in the length of hospital stay and treatment costs. OBJECTIVE: The aim of this study was to determine whether a method for switching therapy in clinical practice could be used in patients with CAP and whether differences were found in the duration of IV treatment and length of hospital stay between the 5 risk classes of the Pneumonia Severity Index (PSI) after the therapy switch. METHODS: This was a prospective, observational study of patients aged >/=18 years presenting with CAP at our teaching hospital between December 1998 and November 2000. Microbiological and serological tests were performed, and signs and symptoms of CAP, C-reactive protein levels, and white blood cell counts were assessed throughout treatment and at the 1-month follow-up. Patients were stratified by PSI risk class. When the patient's temperature had been normalized for 72 hours and respiratory symptoms (dyspnea, coughing, and thoracal pain) had improved, patients were switched from IV to PO therapy (same drug). RESULTS: The study included 180 patients with CAP Clinical cure was seen in 174 (97%) patients. No significant difference between the 5 risk classes was found in duration of therapy. Patients in risk class V remained hospitalized for a significantly longer period than patients in risk classes I through IV (P < 0.001). Furthermore, after patients were switched to PO antibiotics, the level of C-reactive protein decreased in patients in all risk classes and was normalized by follow-up. CONCLUSIONS: In the population studied, use of specific criteria (ie, absence of fever for 72 hours and reduction in respiratory symptoms) allowed successful switch from IV to PO antibiotic therapy for the treatment of CAP Duration of therapy was not affected by PSI risk class, but those in risk class V were hospitalized longer than other risk classes.

Detection of respiratory viruses and Legionella spp. by real-time polymerase chain reaction in patients with community acquired pneumonia.

We conducted a study on throat swabs obtained from a group of hospitalized patients with community acquired pneumonia (CAP). Throat swab specimens from 242 adults admitted to hospital with CAP were tested. In total, 1 or more aetiological agents were identified by real-time PCR in 55 (23%) patients. The most frequently detected pathogens were coronavirus (17%), parainfluenza virus (6%) and influenza virus (4%). Overall, viral pathogens were identified by conventional techniques in 7 (2%) patients, and real-time PCR in 50 (21%) patients (p<0.0001). The diagnostic yield increased from 137 cases (57% of patients using conventional microbiological assays) to 158 cases (65% of patients using real-time PCR assays and conventional microbiological assays; p=0.06). A significantly higher percentage of mortality was present in patients with a mixed bacterial and viral infection. L. pneumophila PCR was positive in only 3 out of 11 cases (27%) of Legionnaires' disease (LD). This study demonstrates that real-time PCR can increase the number of microbiological detections of respiratory pathogens, mainly as a result of detection of respiratory viruses.