The Impact of Chronic Bronchial Infection in COPD: A Proposal for Management

Abstract

Up to 50% of patients with chronic obstructive pulmonary disease (COPD) in stable state may carry potentially pathogenic microorganisms (PPMs) in their airways. The presence of PPMs has been associated with increased symptoms, increased risk and severity of exacerbations, a faster decline in lung function and impairment in quality of life. Although some clinical trials have demonstrated a reduction in exacerbations in patients chronically treated with systemic antibiotics, particularly macrolides, the selection of patients was based on the previous frequency of exacerbations and not on the presence of PPMs in their airways. Therefore, unlike in bronchiectasis, there is a lack of evidence-based recommendations for assessment and treatment of the presence of PPMs in either single or repeated isolations in COPD. In this article, we propose that chronic bronchial infection (CBI) in COPD be defined as the isolation of the same PPM in at least three sputum samples separated by more than one month; we review the impact of CBI on the natural course of COPD and suggest a course of action in patients with a single isolation of a PPM or suspected CBI. Antibiotic treatment in stable COPD should be recommended based on four main criteria: a) the presence of comorbid bronchiectasis, b) the demonstration of a single or multiple isolation of the same PPM, c) the clinical impact of CBI on the patients, and d) the type of PPM, either Pseudomonas aeruginosa or non-pseudomonal PPM. These recommendations are derived from evidence generated in patients with bronchiectasis and, until new evidence specifically obtained in COPD is available, they may help in the management of these challenging patients with COPD. Existing evidence suggests that inhaled therapy is insufficient to manage patients with moderate-to-severe COPD, frequent exacerbations, and CBI. New studies must be conducted in this particularly demanding population.

Keywords:

• exacerbation
• colonization
• bronchial infection
• Pseudomonas aeruginosa
• bronchiectasis
• pathogenic microorganisms

Abbreviations

CBI, Chronic bronchial infection; COPD, Chronic obstructive pulmonary disease; CT, Computed tomography; ICS, Inhaled corticosteroid; Ig, Immunoglobulin; IgA, Immunoglobulin A; PA, Pseudomonas aeruginosa; PPM, Potentially pathogenic microorganism.

Disclosure

Miguel Angel Martinez-Garcia has received fees from Chiesi, GlaxoSmithKline, Menarini, Rovi, Bial, Zambon, Vitalaire, TEVA, Grifols and Novartis, consulting fees from Grifols, Zambon and TEVA, and research grants from TEVA, Zambon and Vitalaire. Marc Miravitlles has received speaker fees from AstraZeneca, Atrina Therapeutics, Boehringer Ingelheim, Chiesi, Cipla, GlaxoSmithKline, Menarini, Rovi, Bial, Sandoz, Zambon, CSL Behring, Grifols and Novartis, consulting fees from AstraZeneca, Boehringer Ingelheim, Chiesi, GlaxoSmithKline, Bial, Gebro Pharma, Kamada, CSL Behring, Laboratorios Esteve, Ferrer, Johnson & Johnson, Mereo Biopharma, Palobiofarma SL, Verona Pharma, TEVA, Spin Therapeutics, pH Pharma, Novartis, Sanofi, ONO Pharma, Takeda, and Grifols and research grants from Grifols. The authors report no other conflicts of interest in this work.

Additional information

Funding

No external support was received for this paper.