The Impact of Chronic Bronchial Infection in COPD: A Proposal for Management

Abstract

Up to 50% of patients with chronic obstructive pulmonary disease (COPD) in stable state may carry potentially pathogenic microorganisms (PPMs) in their airways. The presence of PPMs has been associated with increased symptoms, increased risk and severity of exacerbations, a faster decline in lung function and impairment in quality of life. Although some clinical trials have demonstrated a reduction in exacerbations in patients chronically treated with systemic antibiotics, particularly macrolides, the selection of patients was based on the previous frequency of exacerbations and not on the presence of PPMs in their airways. Therefore, unlike in bronchiectasis, there is a lack of evidence-based recommendations for assessment and treatment of the presence of PPMs in either single or repeated isolations in COPD. In this article, we propose that chronic bronchial infection (CBI) in COPD be defined as the isolation of the same PPM in at least three sputum samples separated by more than one month; we review the impact of CBI on the natural course of COPD and suggest a course of action in patients with a single isolation of a PPM or suspected CBI. Antibiotic treatment in stable COPD should be recommended based on four main criteria: a) the presence of comorbid bronchiectasis, b) the demonstration of a single or multiple isolation of the same PPM, c) the clinical impact of CBI on the patients, and d) the type of PPM, either Pseudomonas aeruginosa or non-pseudomonal PPM. These recommendations are derived from evidence generated in patients with bronchiectasis and, until new evidence specifically obtained in COPD is available, they may help in the management of these challenging patients with COPD. Existing evidence suggests that inhaled therapy is insufficient to manage patients with moderate-to-severe COPD, frequent exacerbations, and CBI. New studies must be conducted in this particularly demanding population.

Stepwise management of COPD: What is next after bronchodilation?

“…99 The mean prevalence of bronchiectasis in patients with COPD has been reported to be 54.3% (ranging from 4% to 72% in some studies). 97,101…”

Infección bronquial crónica en EPOC estable

“…Una reciente revisión sobre el tema muestra un gráfico de colores que, más allá de la evidencia científica existente, refuerza los aspectos lógicos de un posible tratamiento de estos pacientes basado en el tipo de MPP y el impacto del mismo (sobre todo incremento en el número de agudizaciones) que provoca en el paciente ( fig. 1 ) 75 .

Figura 1 Aproximación al tratamiento de la IBC en pacientes con EPOC dependiendo del tipo de MPP y del número de agudizaciones EPOC: enfermedad pulmonar obstructiva crónica; IBC: infección bronquial crónica; MPP: microorganismos potencialmente patógenos; BGN: bacilos gran negativos; PA: Pseudomona aeruginosa .

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Inhaled Colistimethate Sodium in the Management of Patients with Bronchiectasis Infected by Pseudomonas aeruginosa: A Narrative Review of Current Evidence

“…In short, all this evidence has encouraged the more frequent inclusion of inhaled antibiotics in the therapeutic regimens of those patients with COPD and CBI, regardless of whether or not they have associated bronchiectasis. 65 , 66 …”

“…In short, all this evidence has encouraged the more frequent inclusion of inhaled antibiotics in the therapeutic regimens of those patients with COPD and CBI, regardless of whether or not they have associated bronchiectasis. 65,66 Finally, with regard to studies on new forms of administration, the retrospective multicenter study by Martínez-García et al 67 evaluating the effectiveness of dry-powder inhaled antibiotics (DPIA) is worthy of note. It included 164 patients with bronchiectasis, 86% of whom received colistin.…”