Pharmacological and pharmaeconomic considerations

The GIARIR study group has made a critical analysis of the most recent scientific literature on acute bacterial exacerbations of chronic bronchitis (ABECB) with the aim of proposing therapeutic recommendations applicable to the current epidemiological situation in Italy. The international literature has indicated the scarcity of studies on the treatment of ABECB compared to an abundance of information regarding chronic obstructive pulmonary disease (COPD), of which ABECB is often considered the initial ore predisposing stage, even though a precise evolutionary correlation between these pathologies has not yet been demonstrated. ABECB is the principle cause of doctor visits, hospitalization and death in COPD patients. The natural course of the disease is characterized by the appearance of exacerbation episodes (a mean of two yearly). for this reason it is indispensable to prevent exacerbations, to treat them as quickly as possible, in order to minimize their negative effects on the respiratory tract and the patient’s general health. The routine use of antibiotic therapy is controversial because at least 20% of exacerbations do not have an infectious origin and about 30% are viral. in most cases the choice of antibiotic is empiric, in both ABECB patients without risk factors (mild form) and in those with risk factors such as cigarette smoking or constant exposure to air pollutants (moderate form). for these reasons it is necessary to keep up to date on the local and regional bacteria etiological situation and to be aware of antibiotic resistance patterns for the most commonly involved pathogens. An analysis of the most recent information in italy has confirmed the involvement of the terrible three bacterial species—Haemophilus influenzae, Moraxella catarrhalis and Streptococcus pneumoniae—as the cause of 85-95% of ABECB cases, as well as an increase in resistance to various classes of molecules by all the respiratory pathogens. On the basis of the known resistance patterns in italy, some antibiotics are no longer considered first choice for empiric therapy such as the unprotected betalactams, tetracycline, trimethoprim/sulfamethoxazole and the macrolides) which should be used only after antibiotic susceptibility testing indicates they are still active against the pathogens. The epidemiological picture of bacterial resistance in Italy has greatly restricted the choice of antibiotics which can be used for this type of infection, justifying interest in the oral beta-lactams which have the highest therapeutic index and are first choice therapy against bacterial exacerbations of chronic bronchitis. included in this group are amoxicillin-clavulanate and the new cephem molecule, cefditoren, which has been available in italy since 2008. Thanks to its good pharmacokinetics and pharmacodynamics as well as clinical performance, cefditoren may be considered a drug of choice against exacerbations of chronic bronchitis.