Antibiotic Treatment in Elderly Patients with AECB
Elderly patients have alterations in pharmacokinetics and pharmacodynamics as a result of drug interactions, and decreases in renal and metabolic clearances of drugs are seen with many drugs used in CB. Specific attention to potential drug–drug interactions is required by prescribers to avoid adverse reactions. Owing to the potential complexity in elderly patients, it is important to carefully evaluate drug selection, monitoring and dosing. Empirical antibiotic treatment is almost always required, as the pathologic organisms are not rapidly and reliably identified in routine clinical practice. When antibiotics are started before hospitalization, significant decreases in the short-term mortality in the elderly patients with AECB have been reported. Antibiotics appear to be effective in treating AECB in elderly patients when they are selected based on a risk-stratification approach that involves comorbidity evaluation, including recent exposure to antibiotics.
The general approach of most risk-stratification-based guidelines for the treatment of AECB is to treat lower-risk patients with an antibiotic that has a more limited spectrum of antibacterial coverage. Several useful, but not prospectively validated, guidelines have been published for the treatment of AECB. Table 1 outlines the risk-stratification system and Table 2 summarizes the antibiotic recommendations of the Canadian guidelines for treating AECB. A recent meta-analysis of 21 double-blind randomized, controlled studies demonstrated that antibiotic treatment lasting 5 days or less was as effective as longer duration therapy in patients with AECB associated with COPD. Excellent response rates to even 3-day courses of azithromycin compared with amoxicillin and amoxicillin/clavulanate in the treatment of AECB have been reported. A recent meta-analysis of seven, randomized controlled trials meeting strict criteria compared short- (5 days) versus long-duration (7 or 10 days) antibiotic therapy in AECB. Short-duration antibiotic therapy was as effective and had fewer adverse events (relative risk: 0.84; 95% CI: 0.72–0.97).
Antibiotic treatment for elderly patients with bronchiectasis closely follows the suppurative CB guidelines. The selection of oral or parental antibiotics is often based on previous or current sputum culture results. Frequent P. aeruginosa infections can result in the common use of ciprofloxacin (orally or intravenously) together with other anti-pseudomonal agents. Although not approved by the US FDA, inhaled tobramycin has been used in these patients, with limited proven efficacy. Non-TB mycobacteria are frequently isolated in these patients and may require treatment by a specialist.
Macrolide antibiotics have been used in cystic fibrosis for their anti-inflammatory characteristics. A recent randomized, controlled trial of long-term erythromycin use demonstrated a reduction in frequency and duration of exacerbations of CB and COPD. Despite significant data on treating cystic fibrosis with azithromycin, data on AECB are limited, with one study showing benefit to using three doses of azithromycin every 3 weeks in COPD patients.
In addition to antimicrobial therapy, anti-inflammatory therapy (inhaled corticosteroids and chronic oral macrolides) should be considered in patients with bronchiectasis. Replacement therapy (e.g., IgG or α1-antitrypsin infusion) is used in the appropriately deficient patients. Mechanical and pharmacologic techniques for the mobilization of secretions are often important adjunctive treatments in these patients.
This article was originally written by, Timothy E Albertson; Andrew L Chan
Article Source: http://www.medscape.com/viewarticle/710939_8