Levofloxacin for the Treatment of Acute Exacerbation of Chronic Bronchitis: Position in Recent Guidelines
Hartmut M Lode, MD, PhD, M Schmidt-Ioanas, MD, PhD
Department of Chest and Infectious Diseases, Helios Klinikum, Emil von Behring,
Academic Teaching Hospital of Charite, Berlin, Germany
While the role of antimicrobial therapy for treatment of exacerbations of chronic obstructive pulmonary disease (COPD) remains controversial, most guidelines now include fluoroquinolones. This paper presents results of randomized clinical trials comparing levofloxacin with other commonly used agents in the management of acute exacerbations of chronic bronchitis (AECB) and the current treatment guidelines available. Results confirm that levofloxacin is as effective and well tolerated as cefuroxime axetil, azithromycin, gemifloxacin, and clarithromycin. Levofloxacin can be given in shorter durations of therapy, with a 5-day course achieving equivalent clinical and bacteriological success to the usual 7-day course. A higher dose of 750 mg levofloxacin, given for 3 days, has also been assessed in the management of AECB, and compared with azithromycin once daily (o.d.) for 5 days (uncomplicated patients) or amoxicillin 875 mg/clavulanate 125 mg twice daily (b.i.d.) for 10 days (complicated patients). The clinical success rate was 93.0% and 90.1% for levofloxacin and azithromycin, respectively and 79.2% for levofloxacin and 81.7% for amoxicillin/clavulanate, respectively. For microbiologically evaluable patients, the clinical response rate for levofloxacin for 3 days was superior to azithromycin for 5 days, while the 5-day course of levofloxacin (81.4%) was similar to 10-day amoxicillin/clavulanate (80.9%).
Canadian guidelines for the management of AECB recommend fluoroquinolones including levofloxacin mostly for risk group II patients with AECB. A US consensus conference recommends the use of risk stratification, positioning the respiratory fluoroquinolones for the more severe AECB patients and for those having ≥1 risk factors. The 2004 Latin-American Thoracic Society (ALAT) recommendations on infectious exacerbations of COPD recommend respiratory fluoroquinolones for patients suffering mild COPD with risk factors, as well as in patients with moderate and severe COPD. 2005 German evidence-based guidelines for the treatment of AECB recommend fluoroquinolones for COPD patients suffering AECB with forced expiratory volume in one second (FEV1) < 50% of predicted values and no risk factors for Pseudomonas aeruginosa.