Skip to main content

Main menu

  • Home
  • Current issue
  • ERJ Early View
  • Past issues
  • ERS Guidelines
  • Authors/reviewers
    • Instructions for authors
    • Submit a manuscript
    • Open access
    • Peer reviewer login
    • WoS Reviewer Recognition Service
  • Alerts
  • Subscriptions
  • ERS Publications
    • European Respiratory Journal
    • ERJ Open Research
    • European Respiratory Review
    • Breathe
    • ERS Books
    • ERS publications home

User menu

  • Log in
  • Subscribe
  • Contact Us
  • My Cart

Search

  • Advanced search
  • ERS Publications
    • European Respiratory Journal
    • ERJ Open Research
    • European Respiratory Review
    • Breathe
    • ERS Books
    • ERS publications home

Login

European Respiratory Society

Advanced Search

  • Home
  • Current issue
  • ERJ Early View
  • Past issues
  • ERS Guidelines
  • Authors/reviewers
    • Instructions for authors
    • Submit a manuscript
    • Open access
    • Peer reviewer login
    • WoS Reviewer Recognition Service
  • Alerts
  • Subscriptions

Guiding antibiotic treatment with inflammatory biomarkers in COPD? Another brick in the wall

Philipp Schuetz, Daiana Stolz
European Respiratory Journal 2019 53: 1900562; DOI: 10.1183/13993003.00562-2019
Philipp Schuetz
1Dept of Internal Medicine, Kantonsspital Aarau, Aarau, Switzerland
2University Basel, Basel, Switzerland
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • For correspondence: schuetzph@gmail.com
Daiana Stolz
3Clinic of Respiratory Medicine and Pulmonary Cell Research, University Hospital of Basel, Basel, Switzerland
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • Article
  • Info & Metrics
  • PDF
Loading

Abstract

More studies are needed to guide antibiotic treatment with inflammatory biomarkers in COPD http://ow.ly/bJcJ30oklR2

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%) [3]. 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 [4]. 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 [7]. Still, randomised trials looking at the effect of CRP for guiding antibiotic decisions in patients with acute COPD exacerbation have been largely missing.

In this issue of the European Respiratory Journal, Prins et al. [8] report the result of a trial in 220 patients with acute exacerbation of COPD, comparing antibiotic usage according to a CRP-based strategy with a strategy based on Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines. Subjects assigned to the CRP group were treated with antibiotic for 7 days if CRP on admission or after 24 h was ≥50 mg·L−1. Subjects in the GOLD group were also treated with the same antibiotic regimen if they reported increased sputum purulence in combination with increased dyspnoea and/or increased sputum volume, as propagated by the GOLD guidelines. The results showed a significant reduction in antibiotic initiation of more than 30% (from 46.2% to 31.7%) associated with the CRP algorithm. There was no difference in clinical outcomes in the short term and after 1-year of follow up, yet the study did not have the statistical power to assess safety of this approach and type II error is possible. Also of note, in 40 patients who were not treated initially, antibiotics were prescribed due to treatment failure. This deviation from the protocol, however, was well-balanced between groups.

Decisions regarding antibiotic use in an individual patient with acute exacerbation of COPD is complex and should be based on several considerations including the pretest probability for bacterial infection, which is based on clinical examination, severity of the disease and results from microbiological tests, the severity of acute episode and results of host response markers [9]. In the context of a low risk situation and a low pretest probability for bacterial infections, a low level of host response markers aids in ruling out bacterial infection and empirical antibiotic therapy can be avoided. In some patients, this strategy may not play out and clinical assessment and retesting is mandatory. While there was data on the use of PCT to direct antibiotic decisions from several trials, Prins et al. [8] have now provided important study results implying that CRP may also be helpful to direct treatment. While results are most convincing regarding the lowering of antibiotic exposure, proof of safety using CRP is still pending. Ultimately, a head to head trial will be needed to compare a CRP versus a PCT strategy taking into account effects on antibiotic treatment, patient outcomes and costs [6].

There is a strong interest in the medical community in reducing unnecessary antibiotic exposure. The urgency in rationalising and individualising antibiotic decisions is particularly meaningful in a situation in which antibiotics can be withheld in the vast majority of the cases, such as for exacerbations of COPD [10]. Integration of host response markers into treatment decision, now also including CRP, has shown promising results. These markers, however, should not be used as a substitute for good clinical practice, but rather be part of the overall assessment of a patient. Decisions pertaining to the initiation and cessation of antibiotic treatment remains strongly dependent on an assessment of all available clinical and diagnostic parameters, including a thorough patient assessment and the severity of the illness. Still, host response markers remain the best line of defence against diagnostic uncertainty and antibiotic overuse. Further research is needed to compare markers head to head, and to explore their optimal combination with pathogen-directed tests.

Footnotes

  • Conflict of interest: P. Schuetz reports grants (paid to institution) from bioMerieux, Thermofisher and Roche Diagnostics, outside the submitted work.

  • Conflict of interest: D. Stolz has received research grants from the Swiss National Foundation, AstraZeneca AG, Pan Gas AG, Weinmann AG, Curetis AG, Boston Scientific AG, Circassia Pharmaceuticals and Lungenliga Switzerland; received payment for lectures, advisory panels or sponsorship to attend scientific meetings from Novartis AG, AstraZeneca AG, GSK AG, Roche AG, Zambon, Pfizer and Schwabe Pharma AG; is the current education council chair of the European Respiratory Society and immediate past president of the European Board of Accreditation in Pneumology, and is the current GOLD representative for Switzerland.

  • Received March 20, 2019.
  • Accepted March 21, 2019.
  • Copyright ©ERS 2019
https://www.ersjournals.com/user-licence

References

  1. ↵
    1. Stolz D,
    2. Christ-Crain M,
    3. Bingisser R, et al.
    Antibiotic treatment of exacerbations of COPD: a randomized, controlled trial comparing procalcitonin-guidance with standard therapy. Chest 2007; 131: 9–19.
    OpenUrlCrossRefPubMedWeb of Science
  2. ↵
    1. Wirz Y,
    2. Meier MA,
    3. Bouadma L, et al.
    Effect of procalcitonin-guided antibiotic treatment on clinical outcomes in intensive care unit patients with infection and sepsis patients: a patient-level meta-analysis of randomized trials. Crit Care 2018; 22: 191.
    OpenUrl
  3. ↵
    1. Schuetz P,
    2. Wirz Y,
    3. Sager R, et al.
    Effect of procalcitonin-guided antibiotic treatment on mortality in acute respiratory infections: a patient level meta-analysis. Lancet Infect Dis 2018; 18: 95–107.
    OpenUrl
  4. ↵
    1. Daubin C,
    2. Valette X,
    3. Thiolliere F, et al.
    Procalcitonin algorithm to guide initial antibiotic therapy in acute exacerbations of COPD admitted to the ICU: a randomized multicenter study. Intensive Care Med 2018; 44: 428–437.
    OpenUrl
  5. ↵
    1. Cals JW,
    2. Butler CC,
    3. Hopstaken RM, et al.
    Effect of point of care testing for C reactive protein and training in communication skills on antibiotic use in lower respiratory tract infections: cluster randomised trial. BMJ 2009; 338: b1374.
    OpenUrlAbstract/FREE Full Text
  6. ↵
    1. Meili M,
    2. Muller B,
    3. Kulkarni P, et al.
    Management of patients with respiratory infections in primary care: procalcitonin, C-reactive protein or both? Expert Rev Respir Med 2015; 9: 587–601.
    OpenUrlCrossRef
  7. ↵
    1. Daniels JM,
    2. Schoorl M,
    3. Snijders D, et al.
    Procalcitonin vs C-reactive protein as predictive markers of response to antibiotic therapy in acute exacerbations of COPD. Chest 2010; 138: 1108–1115.
    OpenUrlCrossRefPubMedWeb of Science
  8. ↵
    1. Prins HJ,
    2. Duijkers R,
    3. van der Valk P, et al.
    CRP-guided antibiotic treatment in acute exacerbations of COPD in hospital admissions. Eur Respir J 2019; 53: 1802014.
    OpenUrlAbstract/FREE Full Text
  9. ↵
    1. Neeser O,
    2. Branche A,
    3. Mueller B, et al.
    How to: implement procalcitonin testing in my practice. Clin Microbiol Infect 2019; in press [https://doi.org/10.1016/j.cmi.2018.12.028].
  10. ↵
    1. Van Velzen P,
    2. Ter Riet G,
    3. Bresser P, et al.
    Doxycycline for outpatient-treated acute exacerbations of COPD: a randomised double-blind placebo-controlled trial. Lancet Respir Med 2017; 5: 492–499.
    OpenUrl
PreviousNext
Back to top
View this article with LENS
Vol 53 Issue 5 Table of Contents
European Respiratory Journal: 53 (5)
  • Table of Contents
  • Index by author
Email

Thank you for your interest in spreading the word on European Respiratory Society .

NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
Guiding antibiotic treatment with inflammatory biomarkers in COPD? Another brick in the wall
(Your Name) has sent you a message from European Respiratory Society
(Your Name) thought you would like to see the European Respiratory Society web site.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Print
Citation Tools
Guiding antibiotic treatment with inflammatory biomarkers in COPD? Another brick in the wall
Philipp Schuetz, Daiana Stolz
European Respiratory Journal May 2019, 53 (5) 1900562; DOI: 10.1183/13993003.00562-2019

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero

Share
Guiding antibiotic treatment with inflammatory biomarkers in COPD? Another brick in the wall
Philipp Schuetz, Daiana Stolz
European Respiratory Journal May 2019, 53 (5) 1900562; DOI: 10.1183/13993003.00562-2019
del.icio.us logo Digg logo Reddit logo Technorati logo Twitter logo CiteULike logo Connotea logo Facebook logo Google logo Mendeley logo
Full Text (PDF)

Jump To

  • Article
    • Abstract
    • Footnotes
    • References
  • Info & Metrics
  • PDF
  • Tweet Widget
  • Facebook Like
  • Google Plus One

More in this TOC Section

  • Long-term outcome of co-infection of COVID-19 and TB
  • Leukocyte telomere length: personalised medicine for fibrotic ILD?
  • An attack of asthma is not an attack of the heart
Show more Editorials

Related Articles

Navigate

  • Home
  • Current issue
  • Archive

About the ERJ

  • Journal information
  • Editorial board
  • Press
  • Permissions and reprints
  • Advertising

The European Respiratory Society

  • Society home
  • myERS
  • Privacy policy
  • Accessibility

ERS publications

  • European Respiratory Journal
  • ERJ Open Research
  • European Respiratory Review
  • Breathe
  • ERS books online
  • ERS Bookshop

Help

  • Feedback

For authors

  • Instructions for authors
  • Publication ethics and malpractice
  • Submit a manuscript

For readers

  • Alerts
  • Subjects
  • Podcasts
  • RSS

Subscriptions

  • Accessing the ERS publications

Contact us

European Respiratory Society
442 Glossop Road
Sheffield S10 2PX
United Kingdom
Tel: +44 114 2672860
Email: journals@ersnet.org

ISSN

Print ISSN:  0903-1936
Online ISSN: 1399-3003

Copyright © 2023 by the European Respiratory Society