Acute bacterial exacerbation of chronic bronchitis: Introduction:

Chronic bronchitis is said to be the excessive secretion of mucus in bronchi. Which accompanied by cough, expectoration of mucus. The basic cause for the bronchitis is said to be the tobacco use. The obvious nature of COPD is sometime cause as Acute bacterial exacerbation of chronic bronchitis, (ABECB).that play a major role in the decline of quality and quantity of life. Sometime is considering the leading cause of death in COPD 1.

Definition:
According to American thoracic society: Chronic bronchitis is the presence of chronic productive cough for 3 months in each of the 2 successive years in a patient. In whom the other disease state can be cause similar symptoms 2. The most common and precise definition for Acute bacterial exacerbation of chronic bronchitis is: Subjective increase in dyspnoea, increased sputum volume and increase sputum purulence. On the basis of severity we categories the Acute bacterial exacerbation of chronic bronchitis, (ABECB) in 3 following stages. According to Anthonisen work 3: Type 1: sever episode containing all 3 clinical findings. Type 2: moderate episode containing only 2 clinical findings. Type 3: mild episode contains only 1 clinical findings and having history of urinary tract infection of 5 days and fever with high cough 3.

Epidemiology:
Worldwide prevalence is not very well documented because of the variable statements in definition of COPD. In past we believe that basic 85% of the patients of COPD have Acute bacterial exacerbation of chronic bronchitis, (ABECB). In USA out of 16 million people with COPD, only 12 million people suffer with chronic bronchitis symptoms 2. Out of 12 million about 50 % again admitted to the hospital having symptoms of Acute bacterial exacerbation of chronic bronchitis, (ABECB). So the major point at which the clinician emphasises is to manage COPD to cope with the severity and lessens the number of patients having Exacerbation. Acute bacterial exacerbation of chronic bronchitis, (ABECB) cost up to 5 billion dollar per year for hospitalization which is double to the cost of money used to treat ASTHAMA. Acute bacterial exacerbation of chronic bronchitis, (ABECB) is the major cause of death in the patients suffering with COPD 4.

Pathology:
Morphologic changes in the large and small air passages is said to be the leading cause for the pathologic lesions in the chronic bronchitis. The air passage have a large number of monocytes , lymphocyte , and CD8 cells accompanied by neutrophillis. Inflammation causes the metaplasis of columnar and goblet cells which are present in the epithelium lining, causes the hypertrophy of mucous glands, which present in the smooth muscle and connective tissues. Finally leads to the degeneration of air ways 1. Now a day it is evidences that Acute bacterial exacerbation of chronic bronchitis, (ABECB) is caused by the increased inflammation of the airways. There is a firm association between the inflammation degree and severity of the exacerbation. The specimen taken by the bronchoalveolar lavage constitute with large number of neutrophills 5. By culturing the sputum it is come to know that there is markedly increase in the pathogenic bacteria in 50 % cases. The main pathogens are H.influenza, catarrhillis Morixella and S.pneumonae. These organisms cause the inflammation that leads to the malfunctioning of local defenses. Apart from the above organisms many other species are found in the sputum culture but these have the higher colonial count in the culture 1, 5.

Diagnosis:
For the clinical diagnosis of Acute bacterial exacerbation of chronic bronchitis,(ABECB) we use the Antonisen criteria, that discussed in the start. According to the symptoms variability we grade the Acute bacterial exacerbation of chronic bronchitis, (ABECB). Still there is no clinical lab or any other radiological diagnostic procedure develops for Acute bacterial exacerbation of chronic bronchitis, (ABECB). For the Anthonisen criteria, some clinician further categories it in the major and minor classes. In major, we considered all 3 clinical findings of Anthonisen but for the minor they consider only wheezing and cough with common old symptoms. According to them, some patients having 2 major symptoms or 1 major symptom with one minor , for at least 2 consecutive days.chest radiograph only diagnosed pneumonia but in case of Acute bacterial exacerbation of chronic bronchitis,(ABECB) it fails.sputum culture also not very much helpful in the case of Acute bacterial exacerbation of chronic bronchitis,(ABECB) 4,6.

Treatment:
The major point of emphasise in the treatment plan is to: To restore the normal pulmonary function by reducing the disease effect . First the patient is ask to keep away from allergic substances ( dust , dirt , any other allergen). Antimicrobial therapy is also not very authentic approach for Acute bacterial exacerbation of chronic bronchitis,(ABECB) and remain controversial as it was applied for more than one decade . The major use of the antibiotics Symptomatic treatment is against the 3 basic pathogens 6 .

Antimicrobial therapy:
Major classes that include in the treatment plan of Acute bacterial exacerbation of chronic bronchitis,(ABECB) are written as follow: Class Penicilins Drug Amoxicillin Amoxicillin + clavulanate 1st generation 2nd generation: Cefprozil cefuroxime 3rd generation: Cefixime Cefdinir Azithromycin clarithromycin Moxifloxacin Gemifloxacin Activity Active against H. influenza

Cephalosporins

Active against H. influenza, Morixella catarrhillis

Macrolids

Good activity against H. influenza, S.pneumonia Active against streptococcus pneumonia

Flourquinolones

Role of Floroquinolone in treating Acute bacterial exacerbation of chronic bronchitis,(ABECB):

Several recent trial show the great activity of flouroqinolones against the pathogenic organisim against Acute bacterial exacerbation of chronic bronchitis,(ABECB). Council of appropriate and rational antibiotic therapy issued in the 2005 , guidline to aid the physician, according to the guideline the respiratory flouroquinolone use as 1st line therapy for Acute bacterial exacerbation of chronic

bronchitis,(ABECB). There are two main strategy approaches used for appropriate response of the resistant rates for S. pneumonae against flouroquinolones. Not to use flouroquinolone in beta lactamase sensitive patient. To use most poent quinolone as 1st line so to reduce the risk of therapy failure.

Gemifloxacin for the treatment of Acute bacterial exacerbation of chronic bronchitis, (ABECB): That drug shows much hopeful results to reduce the duration of exacerbation. The Willson study in 2002 shows that the 5 day therapy of Gemifloxacin 320 mg daily have such better results as compared with 7 6 days course of Glarithromycin 7 days course . Random patient selected and given Gemifloxacin 320mg daily for 5 day and Clarithromycin 500 m for 7 days. While therapy monitor the patient sign and symptoms while bacteriological monitoring done by sputum culturing. At end Gemifloxacin show 85% results as compared with 79.8% with Claritromycin 7.

Conclusion:
Gemifloxacin show markedly results while treating Acute bacterial exacerbation of chronic bronchitis, (ABECB). In pathogenic eradication it has 85% rate and also very cost effective then other antibiotics.

Community acquired pneumonia:

Among the common types of pneumonia, the sever community acquired pneumonia is the type that cause hospitalization of patient. It is associated with the morbidity and mortality rate. That is the most common cause disease that occurs in all ages group in all over the world.

Definition:
It is defined as acute lower respiratory tract inflammation acquired by an immunocompromised individual in community. The most common pathogen involved in Community acquired pneumonia, is S.pneumonae along with that S.aureus, legionella pneumophillia. The pneumonia is accompanied with fever and muscular pain. The main point of emphasize is to differentiate it from hospital acquired pneumonia 8.

Etiology:
As discussed earlier, the main causative agents are sated as follow:

Pathogen
Streptococcus aureus

Description:
Gram positive, effect at nasophyrynx, and skin ,grape like clusterous shape , and produce penicillinase that inactive penicillins and cause resistence against penicillins. Anerobic, gram negative bacteria present in the ponds, mainly causative agent in younger patients. Gram positive bacteria, present in the nasophyrynx and main causative agent in the elderly ones.

Ligeonella pneumophlia

Streptococcus pneumonae

Clinical features:
Major clinical features associated with the Community acquired pneumonia are high grade fever , chest pain breath shortness and productive cough. With the passage of time patient may develop features like renal function failure , hypotension, respiratory dysfunction which said to be the identification feature of sepsis 8.

Diagnosis:
Pathological investigation can clear the picture that helps in the proper diagnosis of the Community acquired pneumonia. While in general the hematological in investigation involves the white blood cell count, the value of the W.B.C is more than 15 x 109 per liter indicates the bacterial infection if we

observes the increase more than 20 x 109 per liter or less the 4 x 109 per liter it indicates the sever form of disease. Another parameter is PLASMA C REACTIVE PROTIEN. If its value is more than 100mg per liter then it shows the sever form of pneumonia or in the other words that is the marker for pneumonia to monitor the results of the therapy efficacy, serial evaluation of C-REACTIVE PROTIEN results play an important role. If its value not decreased up to 50 % within 4 consecutive days monitoring that indicates the therapy failure. As far as microbiology concerns, we can use staining, culture techniques, BAL techniques that help in the diagnosis of Community acquired pneumonia. Most commonly used is bacterial isolation from blood and antigen evaluation that secretes through urine. This method favorable for detection of pneumococcal infection. Most important and most precise method for the diagnosis is radiological method. Chest x-ray and ultrasound 9.

Severity assurance:
Sever Community acquired pneumonia have high rate of mortality. For optimization of antibiotic therapy assessment of severity is very much critical. For that purpose we use pneumonia severity index, that is very useful and have high success rate.

PSI: Type of variable

Patient characteristics

Specific variable
Age more than 50 years Male sex Nursing home residence Congestive cardiac failure Neoplasia Coronary artery disease Cerebrovascular disease Renal disease Liver disease Ventilator frequency more the 30 bpm Systolic arterial pressure less the 90 mm of Hg Altered mental status Altered body temperature Heart rate more then 125 beats per min Arterial pH less the 7.35 Plasma sod. Less the 130mmol/L BUN > 11 mmol / L Haematocrit < 30% Blood glucose >14 mmol/ L Pleural effusion

Score
10 10 10 10 30 10 10 10 10 20 20 20 25 10 30 20 20 10 10 10

Co-existing illness

Physical examination findings

Laboratory findings

Radiological findings

Risk stratification based on PSI:

Class
I II III IV V

PSI score
0 10 11- 70 71 90 91 130 >130

Risk
Low Low Intermediate High High

Management
Suitable for out patient treatment Consider inpatient treatment Need agreesive treatment Prefer ICU setting

Management:
Immediate action:
To ensure the breathing of the patient. Check the circulation by administration of fluids to the patient. Maintain arterial and venous pressure

Antibiotic therapy:
In sever Community acquired pneumonia; initial treatment will be empirical and broad spectrum. Most of the antibiotics that have excellent action against S. aureus will be administered during Community 7 acquired pneumonia .

Role of gemifloxacin tin the treatment of Community acquired pneumonia:

According to the LODE study, that conducted in 2002, it was observed that Gemifloxacin have much higher rate in the treatment of Community acquired pneumonia. During the random trails it was observed the Gemifloxacin 320 mg dose for 7 to 14 days is much effective then the I.V administration of Ceftiaxone 2 gm along with the Macrolid for 14 days. The successive rate of Gemifloxacin was 95 % as 8,10 compared with the 45% of the I.V admisitration of Cefriaxone 2 gm along with any Macrolid . References: 1. Stoller JK. Acuter exercabation of chronic obstructive pulmonary disease. N Engal J Med (2002)(397-404) 2. Standards for the diagnosis and care of patients with chronic obstructive pulmonary disease . Am .J respire Crit Care Med(1995)(77-121) 3. Anthonisen NR, Manfred. Antibiotic therapy in exacerbation of chronic obstructive pulmonary disease (1987)((196-204). 4. McCrory DC, Brown C, Gelfand SE. Management of acute exacerbation of COPD (2001)(11901209). 5. Burrows B, Earle RH, course and prognosis of chronic obstructive lung disease.(1969)(397-404) 6. Dever LL,Shashikumar K, Johanson WG. Antibiotic in the treatment of acute exacerbation of chronic bronchitis. (2002)(922-925). 7. Larisa chagan, Gemifloxacin for the treatment of acute bacterial exacerbation of chronic bronchitis, and CAP.(drug forecast 2003,(769-771). 8. British thoracic society , Guideline for the management of CAP in Adults,2001,(1-64) 9. Lims WS, van der Erden MM, A prediction rule to identify patient with CAP,1997,(243-250). 10. Lode H, File T.M Jr,Mandell, the 185 Gemifloxacin study group,2002,(*1995-1936).