Chest
Volume 132, Issue 2, August 2007, Pages 447-455
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Original Research
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Comparison of First-Line With Second-Line Antibiotics for Acute Exacerbations of Chronic Bronchitis: A Metaanalysis of Randomized Controlled Trials

https://doi.org/10.1378/chest.07-0149Get rights and content

Background

Although acute exacerbations of chronic bronchitis (AECBs) are common, there has been no metaanalysis that focused on the optimum regimen.

Methods

To evaluate the comparative effectiveness and safety of first-line antimicrobial agents (ie, amoxicillin, ampicillin, pivampicillin, trimethoprim/sulfamethoxazole, and doxycycline) and second-line antimicrobial agents (ie, amoxicillin/clavulanic acid, macrolides, second-generation or third-generation cephalosporins, and quinolones) for the treatment of patients with AECB, in an era of increasing antimicrobial resistance among the microbes responsible for AECB, we performed a metaanalysis of randomized controlled trials (RCTs) retrieved through searches of the PubMed and the Cochrane databases.

Results

Twelve RCTs were included in the metaanalysis. First-line antibiotics were associated with lower treatment success compared to second-line antibiotics in the clinically evaluable patients (odds ratio [OR], 0.51; 95% confidence interval [CI], 0.34 to 0.75). There were no differences among the compared regimens regarding mortality (OR, 0.64; 95% CI, 0.25 to 1.66) or treatment success (OR, 0.56; 95% CI, 0.22 to 1.43) in microbiologically evaluable patients, or adverse effects in general (OR, 0.75; 95% CI, 0.39 to 1.45) or diarrhea in particular (OR, 1.58; 95% CI, 0.74 to 3.35).

Conclusions

Compared to first-line antibiotics, second-line antibiotics are more effective, but not less safe, when administered to patients with AECB. The available data did not allow for stratified analyses according to the presence of risk factors for poor outcome, such as increased age, impaired lung function, airway obstruction, and frequency of exacerbations; this fact should be taken into consideration when interpreting the findings of this metaanalysis.

Section snippets

Literature Search

To identify the randomized controlled trials (RCTs) that were appropriate for inclusion in the metaanalysis, we conducted a systematic search of the PubMed and the Cochrane Central Register of Controlled Trials. We used the following search terms: “acute exacerbations”; “COPD”; and “chronic bronchitis” combined with “amoxicillin,” “clavulanic acid,” “ampicillin,” “sulfamethoxazole,” “trimethoprim”, “doxycycline,” “quinolones,” “macrolides,” “Haemophilus influenzae,” “Moraxella catarrhalis,” and

Selected Studies

This metaanalysis was performed in accordance with the QUOROM statement.18Figure 1 displays the process of identifying the relevant articles. Of the 177 articles that were initially retrieved, 80 were excluded due to reasons presented in Figure 1. In addition, 35 RCTs were omitted because they regarded the comparison of antibiotics that are not commonly used today or were withdrawn from the market for the treatment of AECBs. Also, 25 RCTs were excluded because they compared first-line

Discussion

The results of this metaanalysis suggest that the administration of first-line antimicrobial agents to CE patients with AECBs was associated with lower treatment success compared to the administration of second-line agents. However, no differences were found among the compared regimens with regard to mortality, microbiological outcomes (ie, treatment success in ME patients and pathogen eradication of most common pathogens in patients with AECBs), and safety (ie, drug-related adverse effects in

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    The authors have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

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