Clinical question: What is the relative efficacy of trimethoprim/sulfamethoxazole (TMP/sulfa) versus ciprofloxacin for the treatment of severe exacerbations of COPD?
Background: The use of antimicrobials in the treatment of COPD exacerbations is well accepted, with the original studies using amoxicillin, TMP/sulfa, and tetracyclines. Whether newer antimicrobial agents offer greater efficacy versus these standard agents remains uncertain.
Study design: Randomized, double-blind, placebo-controlled (double-dummy), noninferiority trial.
Setting: Two academic medical ICUs in Tunisia.
Synopsis: Consecutive patients (n=170) with severe exacerbations of COPD requiring mechanical ventilation were randomized to standard medical therapy plus either TMP/sulfa or ciprofloxacin. Patients had a prior diagnosis of COPD and the clinical presence of purulent sputum and respiratory failure. The study excluded those who were immunosuppressed, had significant hepatic or renal disease, pneumonia, recent antibiotic use, active cancer, or inability to take oral medications.
The primary endpoint of hospital death and the need for an additional course of antibiotics was no different between the groups (16.4% with TMP/sulfa versus 15.3% with ciprofloxacin). The mean exacerbation-free interval, days of mechanical ventilation, and length of stay were no different. Noninferiority was defined as <10% relative difference.
Bottom line: TMP/sulfa was noninferior to ciprofloxacin in the treatment of severe exacerbations of COPD requiring mechanical ventilation.
Citation: Nouira S, Marghli S, Besbes L, et al. Standard versus newer antibacterial agents in the treatment of severe acute exacerbations of chronic obstructive pulmonary disease: a randomized trial of trimethoprim-sulfamethoxazole versus ciprofloxacin. Clin Inf Dis. 2010;51:143-149.
For more physician reviews of HM-related research, visit our website.