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Antibiotics in exacerbations of COPD: lessons from the past

The controversy about the use of the adequate antibiotic therapy for exacerbations of chronic obstructive pulmonary disease (COPD) continues. The new antibiotics, particularly the fluoroquinolones, have been included in most guidelines based on their excellent in vitro activity against respiratory pathogens, optimal bronchial penetration and convenient regimens of administration. However, clinical trials have only demonstrated equivalence of fluoroquinolones to traditional antibiotics and no conclusive evidence exists of their superiority in clinical practice.

In this context, we must either accept that no differences exist between antibiotics in this indication or that the majority of studies performed so far are inadequate to demonstrate them. The authors firmly believe that the second statement is more likely to be true than the first 1. In fact, observational studies suggested that moxifloxacin produces a faster resolution of symptoms of exacerbation in COPD patients compared with amoxicillin-clavulanate, clarithromycin or cefuroxime 2. In addition, the direct costs of exacerbations treated with clarithromycin appeared to be higher than the costs associated with the use of moxifloxacin or amoxicillin-clavulanate, due to the higher rate of relapse with the macrolide 3. However, the definitive evidence of superiority derived from randomised, double-blind, clinical trials is scarce, and most guidelines recommend the new and supposedly more potent antibiotics for patients more at risk of relapse, based more on common sense rather than on scientific evidence, which is well recognised by the authors of the guidelines themselves 4.

In an attempt to demonstrate differences in outcomes between a fluoroquinolone, levofloxacin, and clarithromycin, Lode et al. 6 in this issue of the Journal present the results of a randomised, double-blind, clinical trial in patients with exacerbations of COPD. This trial presents two strengths, in comparison with most of the trials performed previously: the inclusion …