COPD exacerbations

TL;DR: The presence of a single bacterial strain on sputum culture at exacerbation is associated with increased systemic and airway neutrophilic inflammation and a lower airway IL6. Dual bacterial strains are associated with less systemic inflammation than single bacterial strains.

Abstract: P107 Table 1 Inflammatory markers 0 PPM n 1 PPM n 2 PPM n CRP (g/dl) 10.0 (4.2–26.0) 81 19.5 (5.0–96.0)* 38 3.0 (2.0–8.0){ 6 Serum IL6 (pg/ml) 6.6 (3.1–12.3) 78 15.1 (8.5–50.5)* 40 4.0 (3.1–6.2){ 12 Sputum IL6 (pg/ml) 192 (82–537) 84 116 (43–271)* 45 133 (57–268) 12 Sputum IL8 (pg/ml) 3608 (2343–4996) 86 4284 (3274–6200)* 43 4001 (3600–4791) 12 Values are median (interquartile range). CRP, C-reactive protein; IL, interleukin; PPM, potentially pathogenic microbe. *p(0.05 compared to 0 PPM, {p(0.05 compared to 1 PPM using Mann-Whitney U test. Poster sessions Thorax 2009;64(Suppl IV):A75–A174 A119 interleukin-6 (IL6) and C-reactive protein (CRP). Spontaneously expectorated sputum was collected for standard microbiological culture and a subset was also assayed for IL8, a marker of neutrophilic inflammation and IL6. Results There were 196 patients with 266 sputum samples (52% 0 PPM, 38% 1 PPM, 10% 2 PPM). Their mean age was 68.0 years (SD 8.1); 61% were male; forced expiratory volume in 1 s (FEV1)% predicted 47.1 (18.3) and 49.8 (36.7) pack years smoking history. Conclusions The presence of a single PPM on sputum culture at exacerbation is associated with an increase in systemic and airway neutrophilic inflammation and a lower airway IL6 (table 1). Unexpectedly, dual PPMs are associated with less systemic inflammation than single PPMs and they share the same inflammatory profile as non-bacterial exacerbations. This suggests that dual PPMs may be non-contributory to exacerbations. Inhibitory competition arising from the acquisition of a second bacterial strain might explain their relative non-pathogenicity. Screening and treatment of tuberculosis P108 THE NATIONAL MULTIDRUG RESISTANT TB SERVICE PDO Davies, DM Cullen. Liverpool Heart and Chest Hospital, Liverpool, UK doi:10.1136/thx.2009.127167d Introduction The low incidence of multidrug resistant tuberculosis (MDRTB) in the UK means that few specialists treating tuberculosis have much experience of managing patients with MDRTB and no mechanism for collecting data on the progress of such patients exists. To attempt to overcome this gap, with the support of relevant professional bodies and a grant from Genus Pharma, the MDRTB Service was established at the Liverpool Heart and Chest Hospital in January 2008. Method The Service offers ready access to expert advice on the management of patients with MDRTB via an electronic committee of TB experts. The second function of the Service is to collect data on all MDRTB cases identified in the UK, to record outcomes and develop a consensus on the most effective methods of treatment. Results This submission is an update to the report which was presented at the 2008 BTS winter meeting. Since its founding, the MDRTB Service has been approached with 62 TB cases. Of these, 48 were confirmed as MDR and 3 XDRTB while the remainder could not be confirmed as MDR, were isoniazid mono-resistant or were more general requests for advice. Regular updates on these cases are being sought and treatment patterns and results recorded. An analysis of the initial data shows that 69% of cases had received no previous treatment for TB. Over half were likely to have been infectious, with 57% of the cases being sputum smear positive at diagnosis. The majority of the cases were of a non-white ethnic background, the highest number being Asian (40%). The split between male and female was 65% male to 35% female, while 78% of cases were aged between 24 and 44. Drug resistance patterns revealed that MDRTB is associated with high levels of resistance to other drugs: streptomycin (56%), ethambutol (42%) and pyrazinamide (36%) (fig 1). For a total of 37.5 patient-years of follow-up, only one death has been recorded. 1. Cullen DM, Davies PDO. The national multi-drug resistant tuberculosis service: the first six months. Thorax 2008;63(Suppl VII):A147. P109 TREATMENT INTERRUPTIONS AND INCONSISTENT SUPPLY OF ANTI-TUBERCULOSIS DRUGS IN THE UK: A NATIONAL REVIEW TGD Capstick, D Laycock, MCI Lipman, on behalf of the UK Coalition to Stop TB. Pharmacy Department, St James’s University Hospital, Leeds, UK; Results UK, London, UK; Department of Thoracic Medicine, The Royal Free Hospital, London, UK doi:10.1136/thx.2009.127167e Introduction The 2004 Department of Health TB Action plan highlighted the need to provide ‘‘high quality treatment and care for all people with TB’’. Anecdotal evidence suggests that there are problems in obtaining anti-tuberculosis drugs in the UK for both adults and children. We report the first UK survey to evaluate antituberculosis drug supply and its impact on patient care within TB treatment services. Methods A questionnaire was sent to pharmacists with a specialist interest in respiratory medicine or infectious diseases working at UK centres providing TB treatment. This asked whether they had experienced difficulties obtaining anti-tuberculosis drugs over a 2year period and whether this resulted in unintentional interruption or alteration of treatment. Abstract P108 Figure 1 MDRTB drug resistance pattern. Poster sessionsP108 Figure 1 MDRTB drug resistance pattern. Poster sessions A120 Thorax 2009;64(Suppl IV):A75–A174 Results Responses were received from 67 UK NHS hospital trusts who account for approximately 40% of all UK TB notifications. 42 (63%) trusts reported difficulties in obtaining anti-tuberculosis drugs in the previous 2 years. This was not restricted to any one group of drug or licensing status in the UK (table 1). One in 4 trusts reported problems with isoniazid drug supplies, 1 in 5 with pyrazinamide and 1 in 10 with ethambutol. At least 10% of trusts using rifabutin, capreomycin, streptomycin, ofloxacin, prothionamide, ethionamide, cycloserine, PAS or clofazimine had difficulty in obtaining these. At least 5% of trusts using isoniazid, pyrazinamide, rifabutin, capreomycin, ofloxacin, prothionamide, PAS or clofazimine reported that they had to interrupt the prescribed treatment regimen in at least one patient because of difficulties obtaining supplies. The treatment regimen had to be altered in more than 5% of trusts using isoniazid, rifabutin, capreomycin or PAS, although the numbers using some of these drugs were small. Conclusions A large number of UK trusts have experienced difficulties obtaining a wide range of anti-tuberculosis drugs. The actual number of patients affected by interruptions or alterations in their treatment regimen is fairly low, but this may have had a significant clinical impact on the treatment of both sensitive and drug-resistant TB. Our data argue for national strategic guidance to ensure a consistent and reliable supply of anti-tuberculosis drugs through improved drug information which can promptly alert treatment centres to potential supply issues. P110 DOES A SPECIALIST TB NURSE SERVICE IMPROVE OUTCOME? R King, MJ Carter, SB Mungall, MR Hetzel. Bristol Royal Infirmary, Bristol, UK doi:10.1136/thx.2009.127167f Introduction and Objectives Poor compliance is the pre-eminent obstacle to successful treatment of patients with tuberculosis (TB). Following national guidelines, 2 our primary care trust appointed two community-based TB nurses aiming to improve compliance, outcome and cost of treatment. We audited the effectiveness of our previous hospital-based system of monthly clinic visits (2006) versus a nurse-led system (2008). Methods We retrospectively examined case notes for all patients referred to the TB nurses during 2008. We excluded those who were partially treated before referral, given chemoprophylaxis, changed diagnosis or died within the first month of treatment. Using the same exclusion criteria, we compared these results with our last audit of a clinic-based TB service (31/8/05–28/2/06; denoted ‘‘2006a’’) and information from cases notified to the Health Protection Agency (HPA) in 2006 (‘‘2006b’’). We present the data for the key standards measured. A priori exception was applied. We also present financial data for the nurse-led service from April 2008 to March 2009. Statistical analysis was carried out with STATA. The Fisher exact test and the Student t test were used. Abstract P109 Table 1 Drug Number of trusts with experience of using drug Problems with drug supply encountered Number (%) of trusts affected Number (%) of trusts having to interrupt treatment Number (%) of trusts having to alter treatment regimen Isoniazid 66 19 (29%) 4 (6%) 4 (6%) Rifampicin 65 3 (5%) 0 (0%) 0 (0%) Pyrazinamide 65 13 (20%) 4 (6%) 1 (2%) Ethambutol 65 7 (11%) 2 (3%) 1 (2%) Amikacin 47 4 (9%) 0 (0%) 0 (0%) Streptomycin 44 12 (27%) 2 (5%) 2 (5%) Moxifloxacin 51 3 (6%) 0 (0%) 0 (0%) Prothionamide 34 5 (15%) 3 (9%) 1 (3%) Abstract P110 Table 1 Percentage of patients achieving key standards or key measurements, in 2006a, 2006b and 2008P110 Table 1 Percentage of patients achieving key standards or key measurements, in 2006a, 2006b and 2008