Prevalence, Pattern, Risks Factors and Consequences of Antibiotic Resistance in COPD: A Systematic Review

Point-of-care testing reduces antibiotic prescribing in acute exacerbations of chronic obstructive pulmonary disease: A systematic review and meta-analysis

BACKGROUND

Challenges in identifying the causes of acute exacerbations of chronic obstructive pulmonary disease (AECOPD) have led to overuse of antibiotics. The advantages of point-of-care testing (POCT) may help to identify pathogens and use antibiotics more appropriately.

METHODS

We conducted a systematic review to evaluate the effect of POCT to guide antibiotic prescriptions for AECOPD. Adhering to a protocol (CRD42024555847), we searched eligible studies. The outcomes included antibiotic-related and clinical outcomes. We evaluated the risk of bias and performed meta-analyses with subgroup based on the type and testing timing of POCT.

RESULTS

A total of 18 studies evaluating 4346 AECOPD patients were included. Overall, POCT significantly reduced the number of AECOPD patients given antibiotic prescriptions by 16% (P < 0.001). Additionally, antibiotic treatment was reduced by 1.19 days (P = 0.04). There was no detrimental impact on clinical outcomes, such as the length of hospital stay (P = 0.19). Our results proved robust to sensitivity analyses.

CONCLUSION

We offered reasonable evidence for using POCT to reduce antibiotic exposure for AECOPD without adversely affecting clinical outcomes. As diagnostic techniques become increasingly important in combating antimicrobial resistance, the use of POCT should be encouraged.

Update of guidelines for management of Community Acquired pneumonia in adults by the French Infectious Disease Society (SPILF) and the French-Speaking Society of Respiratory Diseases (SPLF): Endorsed by the French intensive care society (SRLF), the French microbiology society (SFM), the French radiology society (SFR) and the French emergency society (SFMU)

Community-Acquired Pneumonia (CAP) of Presumed Bacterial Origin: Updated Management Guidelines Community-acquired pneumonia (CAP) of presumed bacterial origin is a common condition with varying severity, requiring either outpatient, hospital, or even critical care management. The French Infectious Diseases Society (SPILF) and the French Language Pulmonology Society (SPLF), in collaboration with the French Societies of Microbiology (SFM), Emergency Medicine (SFMU), Radiology (SFR), and Intensive Care Medicine (SRLF), along with representatives of general practice, have coordinated an update of the previous management guidelines, which dated back to 2010. From a therapeutic perspective, the updated recommendations define the choice of initial empiric antibiotic therapy, indications for combination therapy, the use of anti-Pseudomonas beta-lactams, antibiotic treatment duration, and the indications and modalities for prescribing systemic corticosteroids. On a biological level, indications for biomarkers and microbiological investigations have been refined. Regarding imaging, the role of different modalities in the diagnosis and follow-up of CAP has been reassessed, including chest X-ray, pleuropulmonary ultrasound, and thoracic CT scan.

Management of severe exacerbations of COPD by French intensivists and adherence to guidelines

BACKGROUND

Severe exacerbations of chronic obstructive pulmonary disease (ECOPD) require hospitalization in intensive care unit (ICU) in 10 % of cases. This study aims to describe current practices for the management of severe ECOPD in the ICU and to evaluate adherence to the 2017 French guidelines.

METHODS

From March to May 2019, we conducted a cross-sectional multicenter survey across 80 ICUs in France. A 9-item questionnaire exploring physicians practices in terms of diagnostic workup and management of severe ECOPD was sent to participating centers.

RESULTS

Four hundred and thirty-eight physicians responded to the survey, 75 % were senior physicians, 39 % were certified medical intensivists and 67 % worked in a medical or respiratory ICU. Nebulized short-acting beta agonists prescription was mostly driven by the presence of wheezing, silent chest or respiratory failure, even though guidelines recommend them systematically for ECOPD (moderate adhesion to guidelines). Antibiotic prescription was mostly driven by increased sputum purulence and volume, fever, signs of respiratory distress or the severity of the underlying COPD, but was not deemed systematic in case of severity signs (poor adhesion to guidelines). Regarding the use of biomarkers for antibiotics prescription, adhesion to guidelines was moderate. The prescription of systemic corticosteroids was not deemed systematic but was rather considered if no improvement was observed 72 h after admission (good adhesion to guidelines).

CONCLUSION

Reported management of severe ECOPD does not follow all guidelines. Future works should focus on understanding barriers to clinical practice guidelines implementation.

Clinical Significance of Various Pathogens Identified in Patients Experiencing Acute Exacerbations of COPD: A Multi-center Study in South Korea

BACKGROUND

Respiratory infections play a major role in acute exacerbation of chronic obstructive pulmonary disease (AECOPD). This study assessed the prevalence of bacterial and viral pathogens and their clinical impact on patients with AECOPD.

METHODS

This retrospective study included 1,186 patients diagnosed with AECOPD at 28 hospitals in South Korea between 2015 and 2018. We evaluated the identification rates of pathogens, basic patient characteristics, clinical features, and the factors associated with infections by potentially drug-resistant (PDR) pathogens using various microbiological tests.

RESULTS

Bacteria, viruses, and both were detected in 262 (22.1%), 265 (22.5%), and 129 (10.9%) of patients, respectively. The most common pathogens included Pseudomonas aeruginosa (17.8%), Mycoplasma pneumoniae (11.2%), Streptococcus pneumoniae (9.0%), influenza A virus (19.0%), rhinovirus (15.8%), and respiratory syncytial virus (6.4%). Notably, a history of pulmonary tuberculosis (odds ratio [OR], 1.66; p=0.046), bronchiectasis (OR, 1.99; p=0.032), and the use of a triple inhaler regimen within the past 6 months (OR, 2.04; p=0.005) were identified as significant factors associated with infection by PDR pathogens. Moreover, patients infected with PDR pathogens exhibited extended hospital stays (15.9 days vs. 12.4 days, p=0.018) and higher intensive care unit admission rates (15.9% vs. 9.5%, p=0.030).

CONCLUSION

This study demonstrates that a variety of pathogens are involved in episodes of AECOPD. Nevertheless, additional research is required to confirm their role in the onset and progression of AECOPD.

Molecular screening and dynamics simulation reveal potential phytocompounds in Swertia chirayita targeting the UspA1 protein of Moraxella catarrhalis for COPD therapy

Chronic obstructive pulmonary disease (COPD) is a global health burden, with Moraxella catarrhalis significantly contributing to acute exacerbations and increased healthcare challenges. This study aimed to identify potential drug candidates in Swertia chirayita, a traditional Himalayan medicinal plant, demonstrating efficacy against the ubiquitous surface protein A1 (UspA1) of M. catarrhalis through an in-silico computational approach. The three-dimensional structures of 46 phytocompounds of S. chirayita were retrieved from the IMPPAT 2.0 database. The structures underwent thorough analysis and screening, emphasizing key factors such as binding energy, molecular docking performance, drug-likeness, and toxicity prediction to assess their therapeutic potential. Considering the spectrometry, pharmacokinetic properties, docking results, drug likeliness, and toxicological effects, five phytocompounds such as beta-amyrin, calendol, episwertenol, kairatenol and swertanone were identified as the inhibitors of the UspA1 in M. catarrhalis. UspA1 demonstrated binding affinities of -9.1 kcal/mol for beta-amyrin, -8.9 kcal/mol for calendol, -9.4 kcal/mol for episwertenol, -9.6 kcal/mol for kairatenol, and -9.0 kcal/mol for swertanone. All of these affinities were stronger than that of the control drug ceftobiprole, which had a binding score of -6.6 kcal/mol. The toxicity analysis confirmed that all five compounds are safe potential therapeutic options, showing no toxicity or carcinogenicity. We also performed a 100 ns molecular dynamics simulation of the phytocompounds to analyze their stability and interactions as protein-ligand complexes. Among the five screened phytocompounds, beta-amyrin and episwertenol exhibited favorable characteristics, including stable root mean square deviation values, minimal root mean square fluctuations, and consistent radius of gyration values. Throughout the simulations, intermolecular interactions such as hydrogen bonds and hydrophobic contacts were maintained. Additionally, the compounds demonstrated strong affinity, as indicated by negative binding free energy values. Taken together, findings of this study strongly suggest that beta-amyrin and episwertenol have the potential to act as inhibitors against the UspA1 protein of M. catarrhalis, offering promising prospects for the treatment and management of COPD.

Healthcare worker views on antimicrobial resistance in chronic respiratory disease

BACKGROUND AND OBJECTIVE

Antimicrobial resistance (AMR) is a global crisis, however, relatively little is known regarding its impact in chronic respiratory disease and the specific challenges faced by healthcare workers across the world in this field. We aimed to assess global healthcare worker views on the challenges they face regarding AMR in chronic respiratory disease.

METHODS

An online survey was sent to healthcare workers globally working in chronic respiratory disease through a European Respiratory Society clinical research collaboration (AMR-Lung) focussed on AMR in chronic lung disease. Responses from different geographic regions were analysed.

RESULTS

279 responses were received across 60 countries. 54.5% of respondents encountered AMR in chronic respiratory disease weekly. There were differences in perceived high-priority diseases and species with AMR burden between Europe, Asia and Africa. 76.4% of respondents thought that inappropriate antimicrobial prescribing in chronic respiratory disease was common. However, only 43.4% of respondents thought that there were adequate antimicrobial stewardship programmes in their area for chronic respiratory disease, with limited availability in outpatient (29.0%) and ambulatory settings (24.7%). Developing rapid diagnostics for antimicrobial susceptibility (59.5%) was perceived to be the most common challenge in implementing antimicrobial stewardship, with an improved understanding of regional epidemiology of AMR strains the most important factor to improve outcome (55.2%).

CONCLUSIONS

AMR has significant perceived burden in chronic respiratory disease by healthcare professionals globally. However, current implementation of antimicrobial stewardship is limited, with significant challenges related to the availability of rapid diagnostics and understanding of regional epidemiology of AMR strains.

Triple inhaled therapy of formoterol/glycopyrrolate/budesonide reduces the use of oral corticosteroids and antibiotics during COPD exacerbations in real-world conditions

INTRODUCTION

Triple inhaled therapy (TT) in one device has been shown in clinical trials to reduce exacerbations and in some cases mortality compared to dual inhaled therapy (DT) in one device in the population of moderate to very severe COPD patients and previous exacerbations. This evidence must be contrasted in real-world conditions.

PATIENTS AND METHODS

Non-intervention retrospective cohort study comparing the incidence of moderate and severe exacerbations in COPD patients treated with TT (formoterol, glycopyrrolate and budesonide, 5mcg/72mcg/320mcg, n=112) and DT (LAMA/LABA/ or LABA/inhaled glucocorticoid, n=107) for 26 weeks under clinical practice conditions. Moderate exacerbations were evaluated by the use of oral corticosteroids and/or courses of oral antibiotics and/or attendance at the emergency room (<24h) without hospitalization. Severe exacerbations were analyzed for hospitalizations for all causes, respiratory causes, cardiovascular causes, and pneumonia. Descriptive statistics for qualitative and quantitative variables, Chi square, Student's t-test and multivariate analysis were performed.

RESULTS

Both cohorts were homogeneous except for age (71.46 vs 66.65 TT vs DT, p<0.01). TT reduced the use of oral corticosteroids by 42% (HR 0.58; 95%CI 0.41-0.82, p<0.01) and the use of antibiotics by 25% (HR 0.75; 95%CI 0.60-0.94, p<0.01). Hospitalizations due to respiratory causes were 11% lower in the TT cohort (HR 0.89; 95%CI 0.79-0.99, p=0.044) with no difference in the incidence of pneumonia.

CONCLUSIONS

Triple inhaled therapy in one device reduces the use of oral corticosteroids and antibiotics during COPD period of exacerbations and reduces respiratory hospitalizations without increasing the incidence of pneumonia in comparision with dual inhaled therapy.

Development and validation of a nomogram for predicting bacterial infections in patients with acute exacerbation of chronic obstructive pulmonary disease

Bacterial infection is a significant contributory factor in the pathogenesis of acute exacerbations of chronic obstructive pulmonary disease (AECOPD) and it has a pivotal role in exacerbating symptoms and precipitating mortality among patients with chronic obstructive pulmonary disease (COPD). The early identification of bacterial infection in individuals with COPD remains a challenge. Therefore, the present study aimed to create and validate a risk assessment tool using easily accessible serum biomarkers to predict bacterial infection in individuals with AECOPD. A retrospective cohort study was carried out at Pingxiang People's Hospital (Pingxiang, China) from January 2023 to December 2023, involving individuals diagnosed with AECOPD. A total of 544 patients with AECOPD were randomly allocated to the two following groups: The training set, which included 70% (n=384) of the patients, and the validation set, which included 30% (n=160) of the patients. Subsequently, a nomogram model was constructed using multivariate logistic regression analysis in the training set. Its discriminatory ability and calibration were internally validated, while decision curve analyses were employed to assess the clinical utility of the nomogram. The incidence of bacterial infection in hospitalized patients with AECOPD was 50% in the training set and 48.1% in the validation set. The nomogram model incorporated independent factors associated with bacterial infection, including C-reactive protein, neutrophil elastase, procalcitonin and eosinophils, identified by univariate and multivariate logistic regression analyses. The area under the curve of the nomogram model was 0.835 [95% confidence interval (CI): 0.795-0.875] in the training set and 0.785 (95% CI: 0.715-0.856) in the validation set. The model demonstrated excellent discrimination and calibration in the validation set [c-statistic: 0.79 (95% CI: 0.68-0.90)]. Furthermore, the discrimination and overfitting bias of the model were assessed through internal validation, revealing a C-index of 0.836 for the initial group and 0.788 for the subsequent validation set. The straightforward risk prediction model for early identification of bacterial infections is valuable for hospitalized patients with AECOPD.

Efficacy of Prophylactic Antibiotics in COPD: A Systematic Review

Background/Objectives: Chronic obstructive pulmonary disease (COPD) is a global health problem and the third leading contributor to mortality worldwide. This systematic review aims to summarize the results of previous studies tackling the question of the efficacy of long-term prophylaxis of antibiotics in COPD patients, with particular regard to exacerbation rate, time to first exacerbation, health status, airway bacterial load, inflammatory markers, cell counts in sputum samples, and potential adverse events. Results: Four studies found significant improvement in the exacerbation rate in patients receiving antibiotic intervention. One study found doxycycline to have negative effects on patients' exacerbation outcomes. Two studies recorded a reduction in total airway bacterial load using quantitative culture of sputum samples, but the prevalence of antibiotic-resistant bacteria increased in all studies that measured it. No change in inflammatory markers was observed; however, there was a decline in neutrophil cell counts and, subsequently, reductions in neutrophil elastase concentrations. Methods: PubMed and Web of Science databases were searched for English-language studies presenting data on the prophylactic use of antibiotics in COPD management. All included studies are randomized controlled trials (RCTs) and meet the inclusion criteria. Conclusions: Based on current evidence from RCTs, the prophylactic antibiotic approach utilizing macrolides is the most effective in reducing the incidence of COPD exacerbation. However, the emergence of antibiotic-resistant pathogens is notable. Whether the beneficial effects of macrolides on exacerbation are due to their antibacterial or immunomodulant properties is still inconclusive. Future studies are needed to better understand the interactions between antibiotics and the airway microbiome during COPD exacerbation.

Accelerated Lung Function Decline and Mucus-Microbe Evolution in Chronic Obstructive Pulmonary Disease

Rationale: Progressive lung function loss is recognized in chronic obstructive pulmonary disease (COPD); however, no study concurrently evaluates how accelerated lung function decline relates to mucus properties and the microbiome in COPD. Objectives: Longitudinal assessment of mucus and microbiome changes accompanying accelerated lung function decline in patients COPD. Methods: This was a prospective, longitudinal assessment of the London COPD cohort exhibiting the greatest FEV1 decline (n = 30; accelerated decline; 156 ml/yr FEV1 loss) and with no FEV1 decline (n = 28; nondecline; 49 ml/yr FEV1 gain) over time. Lung microbiomes from paired sputum (total 116 specimens) were assessed by shotgun metagenomics and corresponding mucus profiles evaluated for biochemical and biophysical properties. Measurements and Main Results: Biochemical and biophysical mucus properties are significantly altered in the accelerated decline group. Unsupervised principal component analysis showed clear separation, with mucus biochemistry associated with accelerated decline, whereas biophysical mucus characteristics contributed to interindividual variability. When mucus and microbes are considered together, an accelerated decline mucus-microbiome association emerges, characterized by increased mucin (MUC5AC [mucin 5AC] and MUC5B [mucin 5B]) concentration and the presence of Achromobacter and Klebsiella. As COPD progresses, mucus-microbiome shifts occur, initially characterized by low mucin concentration and transition from viscous to elastic dominance accompanied by the commensals Veillonella, Gemella, Rothia, and Prevotella (Global Initiative for Chronic Obstructive Lung Disease [GOLD] A and B) before transition to increased mucus viscosity, mucins, and DNA concentration together with the emergence of pathogenic microorganisms including Haemophilus, Moraxella, and Pseudomonas (GOLD E). Conclusions: Mucus-microbiome associations evolve over time with accelerated lung function decline, symptom progression, and exacerbations affording fresh therapeutic opportunities for early intervention.

Spectrum and antimicrobial resistance in acute exacerbation of chronic obstructive pulmonary disease with pneumonia: a cross-sectional prospective study from Vietnam

BACKGROUND

Respiratory infections have long been recognized as a primary cause of acute exacerbation of chronic obstructive pulmonary disease (AE-COPD). Additionally, the emergence of antimicrobial resistance has led to an urgent and critical situation in developing countries, including Vietnam. This study aimed to investigate the distribution and antimicrobial resistance of bacteria in patients with AE-COPD using both conventional culture and multiplex real-time PCR. Additionally, associations between clinical characteristics and indicators of pneumonia in these patients were examined.

METHODS

This cross-sectional prospective study included 92 AE-COPD patients with pneumonia and 46 without pneumonia. Sputum specimens were cultured and examined for bacterial identification, and antimicrobial susceptibility was determined for each isolate. Multiplex real-time PCR was also performed to detect ten bacteria and seven viruses.

RESULTS

The detection rates of pathogens in AE-COPD patients with pneumonia were 92.39%, compared to 86.96% in those without pneumonia. A total of 26 pathogenic species were identified, showing no significant difference in distribution between the two groups. The predominant bacteria included Klebsiella pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, and Streptococcus pneumoniae, followed by Acinetobacter baumannii and Streptococcus mitis. There was a slight difference in antibiotic resistance between bacteria isolated from two groups. The frequency of H. influenzae was notably greater in AE-COPD patients who experienced respiratory failure (21.92%) than in those who did not (9.23%). S. pneumoniae was more common in patients with stage I (44.44%) or IV (36.36%) COPD than in patients with stage II (17.39%) or III (9.72%) disease. ROC curve analysis revealed that C-reactive protein (CRP) levels could distinguish patients with AE-COPD with and without pneumonia (AUC = 0.78).

CONCLUSION

Gram-negative bacteria still play a key role in the etiology of AE-COPD patients, regardless of the presence of pneumonia. This study provides updated evidence for the epidemiology of AE-COPD pathogens and the appropriate selection of antimicrobial agents in Vietnam.

Phage Therapy for Respiratory Infections: Opportunities and Challenges

We are entering the post-antibiotic era. Antimicrobial resistance (AMR) is a critical problem in chronic lung infections resulting in progressive respiratory failure and increased mortality. In the absence of emerging novel antibiotics to counter AMR infections, bacteriophages (phages), viruses that infect bacteria, have become a promising option for chronic respiratory infections. However, while personalized phage therapy is associated with improved outcomes in individual cases, clinical trials demonstrating treatment efficacy are lacking, limiting the therapeutic potential of this approach for respiratory infections. In this review, we address the current state of phage therapy for managing chronic respiratory diseases. We then discuss how phage therapy may address major microbiologic obstacles which hinder disease resolution of chronic lung infections with current antibiotic-based treatment practices. Finally, we highlight the challenges that must be addressed for successful phage therapy clinical trials. Through this discussion, we hope to expand on the potential of phages as an adjuvant therapy in chronic lung infections, as well as the microbiologic challenges that need to be addressed for phage therapy to expand beyond personalized salvage therapy.

Sputum culture and antibiotic resistance in elderly inpatients with exacerbation of chronic obstructive pulmonary disease at a tertiary geriatric hospital in southern Vietnam

OBJECTIVE

To determine the rate of positive culture sputum and related factors as well as the microorganism features and antibiotic susceptibility of pathogens in elderly inpatients with exacerbation of chronic obstructive pulmonary disease (COPD) in Thong Nhat Hospital, Vietnam.

METHODS

This cross-sectional study included elderly patients admitted to the hospital because of exacerbation of COPD. Data of their medical history, symptoms and signs were collected, and the patients were instructed to collect sputum sample. A positive culture was identified with the growth of ≥ 10⁵ colony-forming units per milliliter. Antibiotic susceptibility testing was performed according to the European Committee on Antimicrobial Susceptibility Testing.

RESULTS

There were 167 participants (mean age: 77.5 ± 8.8 years, 87.4% male). The culture-positive rate was 25.1%. A higher proportion of positive culture was among participants with purulent sputum (p = 0.029) and with severe and very severe airflow obstruction (p = 0.005). Three most common agents were Acinetobacter baumannii (24.4%), Klebsiella pneumoniae (22.2%), and Pseudomonas aeruginosa (15.6%). Despite high resistance to almost other antibiotics (> 50% resistance), Acinetobacter baumannii and Pseudomonas aeruginosa were sensitive to colistin, tobramycin, and gentamicin (> 80% susceptibility). Klebsiella pneumoniae was highly sensitive to almost common antibiotics (> 80% susceptibility). Among Gram-positive pathogens, methicillin-resistant Staphylococcus aureus (MRSA) was completely sensitive to vancomycin, teicoplanin, and linezolid.

CONCLUSION

The sputum culture-positive rate in this study was not high. Most prevalent isolated pathogens were Acinetobacter baumannii, Klebsiella pneumoniae, and Pseudomonas aeruginosa. Acinetobacter baumannii and Pseudomonas aeruginosa were sensitive to tobramycin, gentamicin, and colistin. Commonly used antibiotics remained effective against Klebsiella pneumoniae. MRSA was sensitive to vancomycin, teicoplanin, and linezolid.

Treating Acute EXacerbations of COPD with Chinese HerbAL MedIcine to aid AntiBiotic Use Reduction (EXCALIBUR): study protocol of a randomised double-blind, placebo-controlled feasibility trial

BACKGROUND

Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are a major reason for consultations in primary care, hospital admissions, deterioration in function, and mortality. Despite the majority of exacerbations not being caused by bacteria, as many as 70% of patients who present in UK primary care with AECOPD are prescribed antibiotics as part of standard care. However, finding effective non-antibiotic treatments for COPD exacerbations is a priority to reduce antibiotic use. The Chinese herbal medicine Shufeng Jiedu® (SFJD) has the potential to reduce treatment failure and duration of hospital stay. This study aims to determine the feasibility of conducting a fully powered randomised, double blind, placebo-controlled clinical trial on SFJD for AECOPD in UK primary care.

METHODS

This study is a phase III, two-arm individually double blind, randomised, placebo-controlled feasibility trial with nested qualitative study, coordinated by the Southampton Clinical Trial Unit (SCTU). Patients aged ≥ 40 years, with a current AECOPD, presenting with increased sputum purulence/volume, or breathlessness, and for whom the GP is considering use of antibiotics, will be eligible to participate. We aim to recruit seven eligible participants per month and randomise them to receive either the patent Chinese herbal medicine SFJD capsules or placebo for 14 consecutive days and to follow-up for 12 weeks. The primary outcomes include the feasibility of recruitment, study retention, and the percentage of diary completion.

DISCUSSION

If this trial demonstrates the feasibility of recruitment, delivery, and follow-up, we will seek funding for a fully powered placebo-controlled trial of SFJD for the treatment of AECOPD in primary care.

TRIAL REGISTRATION

This trial is registered via ISRCTN on 1 July 2021, identifier: ISRCTN26614726.