Ball P, Tillotson G, Wilson R
Infectious Disease Unit, Victoria Hospital, Kirkcaldy, Fife, Scotland, UK.
Presse Med. 1995 Jan 21;24(3):189-94.
Chronic bronchitis is a common inflammatory disease of the airways characterised by cough, sputum production and associated features such as dyspnoea and respiratory obstruction. It has a poor prognosis once fully developed and imposes a heavy financial burden on affected societies. Chronic bronchitis is subject to periodic exacerbations in which the role of bacterial infection and the rightful place of antibiotic therapy is only slowly emerging, largely due to the non-homogeneity of the populations under study. Haemophilus influenzae is implicated as the pathogen in more than half of all bacterial exacerbations, Streptococcus pneumoniae and Moraxella catarrhalis accounting for a further third. Viruses and mycoplasmas are also involved. Some 18-25% of patients receiving domiciliary therapy may fail to respond to initial treatment, calling into question the efficacy of antibiotics in acute exacerbations. In part this may relate to sub-optimal respiratory pharmacokinetics as most antibiotics are quite effective against sensitive respiratory pathogens in vitro. However, bacterial resistance rates against traditional agents are rising rapidly in Europe and new agents are needed to counter this threat. Paradoxically few such agents have been shown to improve on the results of amoxycillin and other standard drugs, probably because most trials include patients with exacerbations of only mild-to-moderate severity due to sensitive pathogens. Since recent large scale studies have demonstrated the efficacy of antibiotic therapy compared with placebo in defined exacerbations, use of these definitions has allowed more realistic assessment of new agents which, in terms of improved antibacterial potency and respiratory pharmacokinetics, should offer superior efficacy. Regression analysis of a large scale general practice survey in the UK has now shown the frequency of exacerbations and the presence of co-morbid conditions to correlate significantly with a poor therapeutic outcome and thus, by implication, with severity. Future trials of antibacterial chemotherapy for acute bacterial exacerbations of chronic bronchitis should incorporate such criteria so that real differences between existing and improved compounds can be assessed.
慢性支气管炎是一种常见的气道炎症性疾病，其特征为咳嗽、咳痰以及呼吸困难和呼吸阻塞等相关症状。一旦病情完全发展，预后较差，给受影响的社会带来沉重的经济负担。慢性支气管炎会周期性加重，其中细菌感染的作用以及抗生素治疗的合理地位只是在缓慢显现，这主要是由于所研究人群的异质性。在所有细菌性加重病例中，超过一半与流感嗜血杆菌作为病原体有关，肺炎链球菌和卡他莫拉菌又占另外三分之一。病毒和支原体也有涉及。约18% - 25%接受家庭治疗的患者可能对初始治疗无反应，这让人质疑抗生素在急性加重期的疗效。部分原因可能与呼吸药代动力学欠佳有关，因为大多数抗生素在体外对敏感呼吸道病原体相当有效。然而，在欧洲，细菌对传统药物的耐药率正在迅速上升，需要新的药物来应对这一威胁。矛盾的是，很少有这类药物被证明比阿莫西林和其他标准药物效果更好，可能是因为大多数试验纳入的是因敏感病原体导致仅轻度至中度加重的患者。由于最近的大规模研究已证明在明确的加重期，抗生素治疗与安慰剂相比具有疗效，使用这些定义能够更实际地评估新药物，就提高抗菌效力和呼吸药代动力学而言，新药物应具有更好的疗效。英国一项大规模全科医疗调查的回归分析现已表明，加重期的频率和合并症的存在与治疗效果不佳显著相关，因此，这意味着与病情严重程度相关。未来针对慢性支气管炎急性细菌加重期的抗菌化疗试验应纳入此类标准，以便能够评估现有药物与改进药物之间的实际差异。
