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The course of chronic obstructive pulmonary disease (COPD) is affected by the presence of exacerbations that are episodes of worsening of respiratory symptoms commonly triggered by airway infections, including respiratory viruses and airway bacteria.1 COPD exacerbations have important adverse effects on health status2 and mortality3 and affect the course of the disease.4 Thus there is considerable interest in the effectiveness of interventions used both to treat exacerbations and prevent further events.
Exacerbations are usually treated with oral corticosteroids and/or antibiotics depending on exacerbation severity and the nature of the symptoms. There is now considerable evidence for benefit of a course of oral corticosteroids at exacerbation5 6 and also for antibiotics when two of the three symptoms of increased dyspnoea, sputum volume and purulence are present.7 However, there is still some controversy concerning the role of antibiotics at COPD exacerbation, especially in studies performed in primary care8 where generally patients with milder disease have been recruited. There is now clear documentation of the involvement of bacteria at exacerbations with increased bacterial detection and load,9 while bacterial strain changes have also been associated with development of exacerbations.10 Eradication of bacteria in the airways with antibiotics prescribed at exacerbation has been linked to exacerbation recovery and reduction in airway inflammatory markers.11 Some of the controversy regarding antibiotics relates to the fact that patients with COPD show lower airway bacterial colonisation (LABC) in the stable state, and increased LABC is associated with greater airway inflammation12 and exacerbation frequency.13
There are a number of reasons for the observed …