Lieberman David, Lieberman Devora
Pulmonary Unit, The Soroka University Medical Center, Beer-Sheva, Israel.
Am J Respir Med. 2003;2(6):459-68. doi: 10.1007/BF03256673.
COPD is a common disease with increasing prevalence. The chronic course of the disease is characterized by acute exacerbations that cause significant worsening of symptoms. Bacterial infections play a dominant role in approximately half of the episodes of acute exacerbations of COPD. The importance of pseudomonal infection in patients with acute exacerbations of COPD stems from its relatively high prevalence in specific subgroups of these patients, and particularly its unique therapeutic ramifications. The colonization rate of Pseudomonas aeruginosa in patients with COPD in a stable condition is low.A review of a large number of clinical series of unselected outpatients with acute exacerbations of COPD revealed that P. aeruginosa was isolated from the patients' sputum at an average rate of 4%. This rate increased significantly in COPD patients with advanced airflow obstruction, in whom the rate of sputum isolates of P. aeruginosa reached 8-13% of all episodes of acute exacerbations of COPD. However, the great majority of bacteria isolated in these patients were not P. aeruginosa, but the three classic bacteria Streptococcus pneumoniae, Hemophilus influenzae, and Moraxella catarrhalis. The subgroup of patients, with acute exacerbations of COPD, with the highest rate of P. aeruginosa infection, which approaches 18% of the episodes, is mechanically ventilated patients. However, even in this subgroup the great majority of bacteria isolated are the above-mentioned three classic pathogens. In light of these epidemiologic data and other important considerations, and in order to achieve optimal antibacterial coverage for the common infectious etiologies, empiric antibacterial therapy should be instituted as follows. Patients with acute exacerbations of COPD with advanced airflow obstruction (FEV(1) <50% of predicted under stable conditions) should receive once daily oral therapy with one of the newer fluoroquinolones, i.e. levofloxacin, moxifloxacin, gatifloxacin, or gemifloxacin for 5-10 days. Patients with severe acute exacerbations of COPD who are receiving mechanical ventilation should receive amikacin in addition to one of the intravenous preparations of the newer fluoroquinolones or monotherapy with cefepime, a carbapenem or piperacillin/tazobactam. In both subgroups it is recommended that sputum cultures be performed before initiation of therapy so that the results can guide further therapy.
慢性阻塞性肺疾病（COPD）是一种患病率不断上升的常见疾病。该疾病的慢性病程以急性加重为特征，急性加重会导致症状显著恶化。细菌感染在约一半的COPD急性加重发作中起主要作用。铜绿假单胞菌感染在COPD急性加重患者中的重要性源于其在这些患者特定亚组中的相对高患病率，尤其是其独特的治疗影响。处于稳定状态的COPD患者中铜绿假单胞菌的定植率较低。对大量未选择的COPD急性加重门诊患者的临床系列研究回顾显示，铜绿假单胞菌从患者痰液中分离出的平均比率为4%。在气流阻塞严重的COPD患者中，这一比率显著增加，其中铜绿假单胞菌痰液分离率在所有COPD急性加重发作中达到8% - 13%。然而，这些患者中分离出的绝大多数细菌不是铜绿假单胞菌，而是三种典型细菌，即肺炎链球菌、流感嗜血杆菌和卡他莫拉菌。COPD急性加重患者中铜绿假单胞菌感染率最高的亚组是机械通气患者，其感染率接近发作次数的18%。然而，即使在这个亚组中，分离出的绝大多数细菌也是上述三种典型病原体。鉴于这些流行病学数据和其他重要因素，为了实现对常见感染病因的最佳抗菌覆盖，经验性抗菌治疗应如下进行。气流阻塞严重的COPD急性加重患者（稳定状态下FEV(1) <预测值的50%）应接受一种新型氟喹诺酮类药物（即左氧氟沙星、莫西沙星、加替沙星或吉米沙星）每日一次的口服治疗，疗程为5 - 10天。接受机械通气的COPD严重急性加重患者除了接受一种新型氟喹诺酮类药物的静脉制剂或单用头孢吡肟、碳青霉烯类或哌拉西林/他唑巴坦外，还应接受阿米卡星治疗。在这两个亚组中，建议在开始治疗前进行痰液培养，以便结果能指导进一步治疗。
