Obstructive, occupational and environmental diseases: Edited by Basil Varkey
This issue of Current Opinion in Pulmonary Medicine contains a mixture of articles that the readers would find informative and thought provoking. In the lead article, the topic of prophylactic vaccinations in chronic obstructive pulmonary disease (COPD) is thoroughly reviewed; even in the United States, with its high healthcare expenditure, there still is a gap between where we are in vaccination rates and where we should be. Articles on racial and sex differences in COPD and indoor air pollution update and expand on a theme that was introduced 5 years ago in this journal . Other articles in this issue cover smoking cessation, adult tracheomalacia, role of rehabilitation in reducing anxiety, outdoor air pollution and berylliosis.
A cluster of articles, interwoven on the theme of acute exacerbations of COPD, provide timely and substantive information on utility of biomarkers, inhaled corticosteroids, Pseudomonas infections and colonization and discriminate use of antibiotics.
The issue of appropriate use of antibiotic(s) in COPD is subject to swings in opinion. The prevalent pattern of early and liberal use of antibiotics in exacerbations of COPD is largely the result of conventional clinical teaching based on observations that patients with acute exacerbations with purulent sputum seemed to improve faster with antibiotic and later supported by studies by Anthonisen et al. . This approach has come under scrutiny because of the recognition of viral etiology in most exacerbations of COPD and concern over the emergence of antibiotic-resistant bacteria . This underscored the need for discriminate use of antibiotics. The apparent solution is to find clinical and laboratory measures that reliably discriminate a bacterial infection from a viral infection (see article by Stolz and Tamm, in this issue). Would such measures lead to a valid and noncontroversial recommendation on the use of antibiotics in COPD exacerbations and bring the pendulum of opinion swings to rest?
The tools that discriminate bacterial and viral infections are not perfect. In addition, in a recent study, long-term macrolide therapy was associated with decreased COPD exacerbations , thus providing a rationale to use a macrolide for its immune-modulating effect, even when the nature of infection is unclear. The pendulum has not come to rest.
1 Varkey AB. Chronic obstructive pulmonary disease in women: exploring gender differences. Curr Opin Pulm Med 2004; 10:98–103.
2 Anthonisen NR, Manfreda J, Warren CP, et al
. Antibiotic therapy in exacerbations of chronic obstructive pulmonary disease. Ann Intern Med 1987; 106:196–204.
3 Varkey JB, Varkey B. Viral infections in patients with chronic obstructive pulmonary disease. Curr Opin Pulm Med 2008; 14:89–94.
4 Seemungal TA, Wilkinson TM, Hurst JR, et al
. Long-term erythromycin therapy is associated with decreased chronic obstructive pulmonary disease exacerbations. Am J Respir Crit Care Med 2008; 178:1139–1147.