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LONG TERM MACROLIDES IN CF
There has been increasing interest in the anti-inflammatory effects of macrolide antibiotics and they have now been studied in a number of conditions. A large trial of the macrolide azithromycin taken over 6 months showed benefit in adult patients with cystic fibrosis (CF) colonised with Pseudomonas aeruginosa, but it is not clear if macrolides are beneficial in younger CF patients. In this issue of Thorax, Clement and colleagues describe a randomised controlled trial of azithromycin given for 3 days per week to CF patients (age 6–21 years) and followed for 12 months. The authors report that azithromycin reduced the number of exacerbations, the time to the first exacerbation, and the number of additional courses of antibiotics, regardless of whether or not they were infected with P aeruginosa. This trial shows that the beneficial effect of azithromycin can be observed at an earlier stage of lung disease and is safe. The next question to be addressed in larger longer term trials is whether treatment with azithromycin can reduce pulmonary disease progression in CF.
See page 895
FLUOROQUINOLONES IN TB
Fluorquinolones (FQs) have very good activity in vitro and in vivo against Mycobacterium tuberculosis. However, it has been suggested that using FQs empirically in sputum negative patients may be associated with a delay in starting appropriate treatment and thus affect survival. In this month’s Thorax, Wang and colleagues report on the empirical treatment of TB in northern Taiwan, which is an endemic area. The results showed that 14.4% of TB patients received an FQ antibiotic, and these patients had longer delays before starting antituberculous therapy and worse outcomes. The authors also found that, with empirical use of FQs for 1–3 weeks, 11.1% of M tuberculosis isolates became resistant to ofloxacin. This suggests that diagnostic tests for TB should be performed as soon as possible and that care needs to be taken with the use of empirical FQs.
See page 903
FOCUS ON COPD HOSPITAL ADMISSIONS
As Calverley points out in his editorial to two papers published this month in Thorax on the recent UK national COPD audit, the number of COPD patients presenting for hospital admission, particularly those over the age of 80, will remain a major healthcare problem with the continuing rise in the burden of COPD. COPD exacerbations are one of the most common reasons for hospital admissions, and these admissions are associated with appreciable mortality and healthcare cost. Another problem is the rate of hospital readmission, and the paper by Price and colleagues confirms the high readmission rates previously reported. They also show that respiratory units with more resources and better organised care have lower mortality and improved outcomes. The second paper, by Connolly and colleagues, shows how mortality associated with COPD exacerbations is influenced by age, with very elderly patients (>85 years) having approximately three times higher inpatient and 90 day mortality. The authors conclude that care needs to be improved, especially for the elderly, but how to reduce hospital admissions in COPD is a complex issue which will need targeted novel approaches. However, the best news of the summer in the UK was the announcement by the Department of Health of a National Service Framework (NSF) for COPD to improve the standard of care and reduce inequalities in its management. The External Reference Group (ERG) for this NSF will be chaired by Professor Sue Hill (Chief Scientific Officer at the Department of Health) and Professor Peter Calverley (President of the British Thoracic Society).
See pages 831, 837 and 843
WHO QUITS SMOKING?
Smoking cessation is one of the few interventions that can reduce disease progression in COPD. However, smoking cessation programmes have often proved to be a challenge and success rates are still relatively low. In this month’s Thorax, Bednarek and colleagues show in an observational study that spirometric testing combined with feedback to patients showing their lung function decline curve resulted in good smoking cessation rates of 16.3% overall in patients with airway obstruction, compared with 12% in patients with normal spirometric results. The quit rates related to the severity of airway obstruction and are shown in the table below. In his accompanying editorial, Mannino points out that these excellent results from a Polish population should be used as a model to test whether this simple intervention will improve cessation rates in other populations.
See pages 834 and 869