RESUMEN

Dentro de la historia natural de la EPOC es esperado que los pacientes tengan “agudizaciones” o “exacerbaciones” de la enfermedad. Los procesos infecciosos bacterianos o virales son la causa más frecuente de este fenómeno, aunque no la única. Está demostrado que las exacerbaciones bacterianas se acompañan de mayor inflamación local y sistémica en contraste con las exacerbaciones no bacterianas produciendo un mayor deterioro de la capacidad funcional del paciente durante y después del evento, y poniendo en riesgo la vida. Aunque no es posible predecir de manera exacta cuáles pacientes son más propensos a tener exacerbaciones, se han identificado como factores de riesgo la presencia de síntomas cotidianos como tos y expectoración, el tabaquismo activo, el pobre apego al tratamiento y el antecedente de exacerbaciones previas. Estos factores son encontrados con mayor frecuencia en aquellos pacientes con más tiempo de padecer la EPOC y en aquellos con mayor severidad de la misma. Debido a que cada nuevo episodio de exacerbación acelera la progresión de la EPOC es muy importante el tratamiento adecuado de las mismas así como implementar medidas de prevención. En este apartado haremos recomendaciones respecto al manejo del componente infeccioso de las exacerbaciones. Le sugerimos revise las secciones previas de este consenso donde se tratan otros aspectos relevantes del manejo integral de esta complicación.

PALABRAS CLAVE

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REFERENCIAS

1. Combivent Inhalation Aerosol Study Group. In chronic obstructive pulmonary disease, a combination of ipratropium and albuterol is more effective than either agent alone. Chest 1994; 105: 1411-1419.

2. Warren PM, Flenley DC, Millar JS, Avery A. Respiratory failure revisited: acute exacerbations of chronic bronchitis between 1961-68 and 1970-76. Lancet 1980; 1:467-470.

3. Wilson R. Bacterial infection and chronic obstructive pulmonary disease. Eur Respir J 1999; 13: 233-235.

4. Sethi S, Muscarella K, Evans N, Klingman K, Grant BJB, et al. Airway inflammation and etiology of acute exacerbations of chronic bronchitis. Chest 2000; 3: 1557-1565.

5. Eller J, Ede A, Schaberg T, Niederman MS, Mauch H, et al. Infective exacerbations of chronic bronchitis. Relation between bacteriologic etiology and lung function. Chest 1998; 113: 1542-1548.

6. Recomendaciones ALAT sobre la exacerbación infecciosa de la EPOC. Arch Bronch 2001; 37: 349-357.

7. Martinez FJ, Anzueto A. Appropriate outpatient treatment of acute bacterial exacerbations of chronic bronchitis. Am J Med 2005; 118 Suppl 7A: 39S-44S.

8. Seemungal T, Harper-Owen R, Bhowmik A, Moric I, Wedzicha J, et al. Respiratory viruses, symptoms, and inflammatory markers in acute exacerbations and stable chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2001; 164: 1618-1623.

9. Rohde G, Wiethege A, Borg I, Kauth M, Bauer TT, et al. Respiratory viruses in exacerbations of chronic obstructive pulmonary disease requiring hospitalization: a case control study. Thorax 2003; 58: 37-42.

10. Papi A, Bellettato CM, Braccioni F, Romagnoli M, et al. Infections and airway inflammation in chronic obstructive pulmonary disease Severe exacerbations. Am J Respir Crit Care Med 2006; 173: 114-120.

11. Wilkinson TMA, Hurst JR, Perera WR, Wilks M, Donaldson GC, et al. Effect of: interactions between lower airway bacterial and rhinoviral infection in exacerbations of COPD. Chest 2005; 129: 317-324.

12. Pauwels RA, Buist S, Calvery PMA, Jenkins C, Hurd S. Global Strategy for the diagnosis, management and prevention of chronic obstructive pulmonary disease. NHLB/WHO Global Initiative for Chronic Obstructive Lung Disease (GOLD). Am J Respir Crit Care Med 2001; 163: 1256-1276.

13. Zalacain R, Sobradillo V, Amilibia J, Barrón J, Achótegui V, et al. Predisposing factors to bacterial colonization in chronic obstructive pulmonary disease. Eur Respir J 1999; 13: 343-348.

14. Monso E, Rosell AT, Boret G, Manterola J, Cardona PJ, et al. Risk factors of lower airway bacterial colonization in chronic bronchitis. Eur Respir J 1999; 13: 338-342.

15. Luna JM, Jardim JR y ALAT. Update to the Latin American Association (ALAT) Recommendations on Infectious exacerbations of chronic obstructive pulmonary disease. Arch Bronch 2004; 40: 315-325.

16. Miravitlles M. El fracaso en el tratamiento de las agudizaciones de la enfermedad pulmonar obstructiva crónica. Factores de riesgo e importancia clínica. Med Clin (Barc) 2002; 5: 304-314.

17. Dewan NA, Rafique S, Kanwar B, Satpathy H, Ryschon K, et al. Acute exacerbations of COPD. Factors associated with poor treatment outcome. Chest 2000; 2: 662-671.

18. Miravitlles M, Murio C, Guerrero T, on behalf of the DAFNE Group. Factors associated with relapse after ambulatory treatment of acute exacerbations of chronic bronchitis. A prospective multicenter study in the community. Eur Respir J 2001; 17: 928-933.

19. Miravitlles M, Espinosa C, Fernández-Laso E, Martos JA, Maldonado JA, et al and Study Group of Bacterial Infection in COPD. Relationship between bacterial flora in sputum and functional impairment in patients with acute exacerbations of COPD. Chest 1999; 116: 40-46.

20. Ball P. Epidemiology and treatment of chronic bronchitis and exacerbations. Chest 1995; 108: 43S-52S.

21. Jacobs MR. Streptococcus pneumoniae: Epidemiology and Paterns of Resistance. Am J Med 2004; 117, 3s.

22. Guzmán-Blanco M, Casellas JM, Sader HS. Bacterial resistance to antimicrobial agents in Latin America. The giant is awakening. Infect Dis Clin North Am 2000; 14: 67-81.

23. Castanheira M, Gales AC, Mendes RE, Jones RN, Sader HS. Antimicrobial susceptibility of Streptococcus pneumoniae in Latin America: results from five years of the SENTRY Antimicrobial Surveillance Program. Clin Microbiol Infect 2004; 10: 645-51.

24. Quiñones-Falconi F, Calva JJ, Lopez-Vidal Y, Galicia-Velazco M, Jimenez-Martinez ME, et al. Antimicrobial susceptibility patterns of Streptococcus pneumoniae in Mexico. Diagn Microbiol Infect Dis 2004; 49: 53-58.

25. Calva-Mercado, Castillo G, López-Vidal Y. Actividad de las fluoroquinolonas en aislamientos clínicos de Streptococcus pneumoniae con diferente susceptibilidad a la penicilina: Estudio epidemiológico en cinco ciudades de la república mexicana. Gac Med Mex 2005; 141: 253-258.

26. Yoo BK, Triller DM, Yong CS, Lodise TP. Gemifloxacin: a new fluoroquinolone approved for treatment of respiratory infections. Ann Pharmacother 2004; 38: 1226-1235.

27. Sohy C, Pilette C, Niederman MS, Sibille Y. Acute exacerbation of chronic obstructive pulmonary disease and antibiotics: what studies are still needed? Eur Respir J 2002; 19: 966-975.

28. Wilson R. Bacteria, antibiotics and COPD. Eur Respir J 2001; 17: 995-1007.

29. McCrory DC, Brown C, Gelfand SE, Bach PB. Management of acute exacerbations of COPD: a summary and appraisal of published evidence. Chest 2001; 119: 1190-1209.

30. Murphy TF, Sethi S, Niederman MS. The role of bacteria in exacerbations of COPD. A constructive view. Chest 2000; 118: 204-209.

31. Hirschmann JV. Do bacteria cause exacerbations of COPD? Chest 2000; 118: 193-203.

32. Adams SG, Melo J, Luther M, Anzueto A. Antibiotics are associated with lower relapse rates in outpatients with acute exacerbations of COPD. Chest 2000; 117: 1345-352.

33. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. Document 2006. NHLB/WHO Global initiative for chronic lung Disease. www.goldcopd.org

34. Stockley RA, O´Brien C, Pye A, Hill SL. Relationship of sputum color to nature and outpatient management of acute exacerbations of COPD. Chest 200; 2: 1638-1645.

35. Shams WE, Evans ME. Guide to Selection of fluoquinolones in patients with low respiratory tract infections. Drugs 2005; 65: 949-991.

36. Miravitlles M, Murio C, Guerrero T, Segú JL. Tratamiento de la bronquitis crónica y la EPOC en atención primaria. Arch Bronconeumol 1999; 35: 173-178.

37. Kesten S, Chapman KR. Physician perceptions and management of COPD. Chest 1993; 104: 254-258.

38. Celli BR, MacNee W; ATS/ERS Task Force. Standards for the diagnosis and treatment of patients with COPD: a summary of the ATS/ERS position paper. Eur Respir J 2004; 23: 932-46.

39. Lieberman D, Gelfer Y, Varshavsky R, Dvoskin B, Friedman MG, et al. Pneumonic vs nonpneumonic acute exacerbations of COPD. Chest 2002; 122: 1264-1270.

40. Appelbaum PC, Gillespie SH, Burley CJ, Tillotson GS. Antimicrobial selection for community-acquired lower respiratory tract infections in the 21st century: a review of gemifloxacin. Int J Antimicrob Agents 2004; 23: 533-546.

41. Williams JH Jr. Fluoroquinolones for respiratory infections: too valuable to overuse. Chest 2001; 120: 1771-1775.

42. Sethi S, Fogarty C, Fulambarker A. A randomized, double-blind study comparing 5 days oral gemifloxacin with 7 days oral levofloxacin in patients with acute exacerbation of chronic bronchitis. Respir Med 2004; 98: 697-707.

43. Wilson R, Allegra L, Huchon G, Izquierdo JL, Jones P, Schaberg T, et al. MOSAIC Study Group. Short-term and long-term outcomes of moxifloxacin compared to standard antibiotic treatment in acute exacerbations of chronic bronchitis. Chest 2004; 125: 953-964.

44. Wilson R, Schentag JJ, Ball P, Mandell L; 068 Study Group. A comparison of gemifloxacin and clarithromycin in acute exacerbations of chronic bronchitis and long-term clinical outcomes. Clin Ther 2002; 24: 639-652.

45. Amsden GW, Baird IM, Simon S, Treadway G. Efficacy and safety of azithromycin vs levofloxacin in the outpatient treatment of acute bacterial exacerbations of chronic bronchitis. Chest 2003; 123: 772-777.