CHEST Guidelines-COUNTERPOINT--Is-Chronic-Bacterial-Infection-Clini

COUNTERPOINT--Is-Chronic-Bacterial-Infection-Clini

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In a counterpoint article by Holly R. Keir and James D. Chalmers, the authors challenge the traditional view of chronic bronchial infection in chronic obstructive pulmonary disease (COPD) as clinically relevant. The article suggests that the outdated notion of chronic infection in COPD should be replaced with a more nuanced understanding of microbial dysbiosis, which accounts for the dynamic and complex interactions between host and pathogens. The traditional view sees bacterial isolation in sputum cultures as an indication of infection requiring antibiotics. However, this fails to capture the reality of the diverse microbial communities found in the airways, even during health, that change in composition during both stable and exacerbating COPD.<br /><br />Modern molecular techniques have demonstrated that the healthy airway is not sterile, revealing microbial diversity undetected by traditional sputum cultures. Keir and Chalmers argue that positive bacterial cultures often misrepresent the clinical significance of the bacterial load and its impact on airway inflammation, leading to potential overuse of antibiotics. Instead, they advocate for a focus on "microbial dysbiosis" and suggest that treatment should address various "treatable traits" associated with dysbiosis rather than indiscriminate antibiotic use.<br /><br />Furthermore, the article emphasizes the need for a comprehensive consideration of factors like microbial immigration from the upper airway, conditions enhancing local microbial growth, and impaired clearance due to COPD-related anatomical changes. The authors argue that this dysbiosis-centered approach in COPD necessitates both pharmacologic and nonpharmacologic interventions aimed at these underlying factors. <br /><br />The article concludes by calling for a shift towards using molecular methods for microbial detection in COPD, which promise greater sensitivity and the ability to better guide treatment. They highlight that while antibiotics remain useful, their role should be limited to certain conditions where microbial dysbiosis is significantly impacting the patient's condition.

Keywords

chronic bronchial infection

COPD

microbial dysbiosis

sputum cultures

antibiotic overuse

microbial diversity

airway inflammation

molecular techniques

treatable traits

pharmacologic interventions