Relationship between the GOLD combined COPD assessment staging system and bacterial isolation
Identifieur interne : 000889 ( Pmc/Corpus ); précédent : 000888; suivant : 000890Relationship between the GOLD combined COPD assessment staging system and bacterial isolation
Auteurs : Yusuf Aydemir ; Özlem Aydemir ; Fatma KalemSource :
- International Journal of Chronic Obstructive Pulmonary Disease [ 1176-9106 ] ; 2014.
Abstract
Acute exacerbations, which are a significant cause of mortality and morbidity, adversely affect chronic obstructive pulmonary disease (COPD) prognosis by accelerating loss of lung function. It is important to know the microorganisms that commonly cause exacerbations in the patient groups classified according to clinical and functional characteristics for fast and accurate treatment of acute exacerbations.
The last Global Initiative for Chronic Obstructive Lung Disease (GOLD) publication recommended a new staging system containing obstruction degree, frequency of exacerbations, and quality of life questionnaires. This study is designed to analyze the relationship between the bacteria isolated in acute exacerbations and new GOLD stages.
Potentially pathogenic bacteria (PPB) isolation with culture and polymerase chain reaction methods were obtained from 114 acute exacerbation COPD patients, classified into A, B, C, and D groups by analyzing the forced expiratory volume in 1 second (FEV1) value, COPD Assessment Test (CAT) score, and exacerbation frequency according to the new GOLD staging system.
There was a significant correlation between exacerbation frequency and PPB isolation (
Bacterial infection may cause an acute exacerbation equally in each stage for COPD. The difference in bacterial etiology is more related to exacerbation frequency than FEV1 and CAT scores for an acute exacerbation. Determining exacerbation frequency is significant for treatment success in empirical antibiotic selection.
Url:
DOI: 10.2147/COPD.S70620
PubMed: 25298733
PubMed Central: 4186572
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<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Relationship between the GOLD combined COPD assessment staging system and bacterial isolation</title><author><name sortKey="Aydemir, Yusuf" sort="Aydemir, Yusuf" uniqKey="Aydemir Y" first="Yusuf" last="Aydemir">Yusuf Aydemir</name><affiliation><nlm:aff id="af1-copd-9-1045">Department of Respiratory Medicine, Sakarya University, Sakarya, Turkey</nlm:aff></affiliation></author><author><name sortKey="Aydemir, Ozlem" sort="Aydemir, Ozlem" uniqKey="Aydemir O" first="Özlem" last="Aydemir">Özlem Aydemir</name><affiliation><nlm:aff id="af2-copd-9-1045">Department of Microbiology, Sakarya University, Sakarya, Turkey</nlm:aff></affiliation></author><author><name sortKey="Kalem, Fatma" sort="Kalem, Fatma" uniqKey="Kalem F" first="Fatma" last="Kalem">Fatma Kalem</name><affiliation><nlm:aff id="af3-copd-9-1045">Department of Microbiology, Konya Numune Hospital, Konya, Turkey</nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">25298733</idno><idno type="pmc">4186572</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4186572</idno><idno type="RBID">PMC:4186572</idno><idno type="doi">10.2147/COPD.S70620</idno><date when="2014">2014</date><idno type="wicri:Area/Pmc/Corpus">000889</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">000889</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Relationship between the GOLD combined COPD assessment staging system and bacterial isolation</title><author><name sortKey="Aydemir, Yusuf" sort="Aydemir, Yusuf" uniqKey="Aydemir Y" first="Yusuf" last="Aydemir">Yusuf Aydemir</name><affiliation><nlm:aff id="af1-copd-9-1045">Department of Respiratory Medicine, Sakarya University, Sakarya, Turkey</nlm:aff></affiliation></author><author><name sortKey="Aydemir, Ozlem" sort="Aydemir, Ozlem" uniqKey="Aydemir O" first="Özlem" last="Aydemir">Özlem Aydemir</name><affiliation><nlm:aff id="af2-copd-9-1045">Department of Microbiology, Sakarya University, Sakarya, Turkey</nlm:aff></affiliation></author><author><name sortKey="Kalem, Fatma" sort="Kalem, Fatma" uniqKey="Kalem F" first="Fatma" last="Kalem">Fatma Kalem</name><affiliation><nlm:aff id="af3-copd-9-1045">Department of Microbiology, Konya Numune Hospital, Konya, Turkey</nlm:aff></affiliation></author></analytic><series><title level="j">International Journal of Chronic Obstructive Pulmonary Disease</title><idno type="ISSN">1176-9106</idno><idno type="eISSN">1178-2005</idno><imprint><date when="2014">2014</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><sec><title>Background</title><p>Acute exacerbations, which are a significant cause of mortality and morbidity, adversely affect chronic obstructive pulmonary disease (COPD) prognosis by accelerating loss of lung function. It is important to know the microorganisms that commonly cause exacerbations in the patient groups classified according to clinical and functional characteristics for fast and accurate treatment of acute exacerbations.</p></sec><sec><title>Objectives</title><p>The last Global Initiative for Chronic Obstructive Lung Disease (GOLD) publication recommended a new staging system containing obstruction degree, frequency of exacerbations, and quality of life questionnaires. This study is designed to analyze the relationship between the bacteria isolated in acute exacerbations and new GOLD stages.</p></sec><sec><title>Methods</title><p>Potentially pathogenic bacteria (PPB) isolation with culture and polymerase chain reaction methods were obtained from 114 acute exacerbation COPD patients, classified into A, B, C, and D groups by analyzing the forced expiratory volume in 1 second (FEV<sub>1</sub>) value, COPD Assessment Test (CAT) score, and exacerbation frequency according to the new GOLD staging system.</p></sec><sec><title>Results</title><p>There was a significant correlation between exacerbation frequency and PPB isolation (<italic>P</italic>=0.002). There was no relationship between GOLD stage, FEV<sub>1</sub>, and CAT score with PPB isolation. The isolated bacteria diversity and mixed infection frequency were higher in the GOLD stage D group. <italic>Pseudomonas aeruginosa, Escherichia coli</italic>, and <italic>Acinetobacter baumannii</italic> were isolated only from D group patients.</p></sec><sec><title>Conclusion</title><p>Bacterial infection may cause an acute exacerbation equally in each stage for COPD. The difference in bacterial etiology is more related to exacerbation frequency than FEV<sub>1</sub> and CAT scores for an acute exacerbation. Determining exacerbation frequency is significant for treatment success in empirical antibiotic selection.</p></sec></div></front><back><div1 type="bibliography"><listBibl><biblStruct></biblStruct><biblStruct><analytic><author><name sortKey="Seemungal, Ta" uniqKey="Seemungal T">TA Seemungal</name></author><author><name sortKey="Donaldson, Gc" uniqKey="Donaldson G">GC Donaldson</name></author><author><name sortKey="Paul, Ea" uniqKey="Paul E">EA Paul</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Hurst, Jr" uniqKey="Hurst J">JR Hurst</name></author><author><name sortKey="Vestbo, J" uniqKey="Vestbo J">J Vestbo</name></author><author><name sortKey="Anzueto, A" uniqKey="Anzueto A">A Anzueto</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Celli, Br" uniqKey="Celli B">BR Celli</name></author><author><name sortKey="Thomas, Ne" uniqKey="Thomas N">NE Thomas</name></author><author><name sortKey="Anderson, Ja" uniqKey="Anderson J">JA Anderson</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Zhang, M" uniqKey="Zhang M">M Zhang</name></author><author><name sortKey="Li, Q" uniqKey="Li Q">Q Li</name></author><author><name sortKey="Zhang, Xy" uniqKey="Zhang X">XY Zhang</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Sethi, S" uniqKey="Sethi S">S Sethi</name></author><author><name sortKey="Murphy, Tf" uniqKey="Murphy T">TF Murphy</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Yusen, Rd" uniqKey="Yusen R">RD Yusen</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Eller, J" uniqKey="Eller J">J Eller</name></author><author><name sortKey="Ede, A" uniqKey="Ede A">A Ede</name></author><author><name sortKey="Schaberg, T" uniqKey="Schaberg T">T Schaberg</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Miravitlles, M" uniqKey="Miravitlles M">M Miravitlles</name></author><author><name sortKey="Espinosa, C" uniqKey="Espinosa C">C Espinosa</name></author><author><name sortKey="Fernandez Laso, E" uniqKey="Fernandez Laso E">E Fernández-Laso</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Soler, N" uniqKey="Soler N">N Soler</name></author><author><name sortKey="Agusti, C" uniqKey="Agusti C">C Agustí</name></author><author><name sortKey="Angrill, J" uniqKey="Angrill J">J Angrill</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Anthonisen, Nr" uniqKey="Anthonisen N">NR Anthonisen</name></author><author><name sortKey="Manfreda, J" uniqKey="Manfreda J">J Manfreda</name></author><author><name sortKey="Warren, Cp" uniqKey="Warren C">CP Warren</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Stockley, Ra" uniqKey="Stockley R">RA Stockley</name></author><author><name sortKey="O Rien, C" uniqKey="O Rien C">C O’Brien</name></author><author><name sortKey="Pye, A" uniqKey="Pye A">A Pye</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Miravittles, M" uniqKey="Miravittles M">M Miravittles</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Wedzicha, Ja" uniqKey="Wedzicha J">JA Wedzicha</name></author><author><name sortKey="Donaldson, Gc" uniqKey="Donaldson G">GC Donaldson</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Li, Xj" uniqKey="Li X">XJ Li</name></author><author><name sortKey="Li, Q" uniqKey="Li Q">Q Li</name></author><author><name sortKey="Si, Ly" uniqKey="Si L">LY Si</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Roche, N" uniqKey="Roche N">N Roche</name></author><author><name sortKey="Kouassi, B" uniqKey="Kouassi B">B Kouassi</name></author><author><name sortKey="Rabbat, A" uniqKey="Rabbat A">A Rabbat</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Huang, Yj" uniqKey="Huang Y">YJ Huang</name></author><author><name sortKey="Lynch, Sv" uniqKey="Lynch S">SV Lynch</name></author><author><name sortKey="Wiener Kronish, Jp" uniqKey="Wiener Kronish J">JP Wiener-Kronish</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Curran, T" uniqKey="Curran T">T Curran</name></author><author><name sortKey="Coyle, Pv" uniqKey="Coyle P">PV Coyle</name></author><author><name sortKey="Mcmanus, Te" uniqKey="Mcmanus T">TE McManus</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Morozumi, M" uniqKey="Morozumi M">M Morozumi</name></author><author><name sortKey="Nakayama, E" uniqKey="Nakayama E">E Nakayama</name></author><author><name sortKey="Iwata, S" uniqKey="Iwata S">S Iwata</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Str Lin, K" uniqKey="Str Lin K">K Strålin</name></author><author><name sortKey="Korsgaard, J" uniqKey="Korsgaard J">J Korsgaard</name></author><author><name sortKey="Olcen, P" uniqKey="Olcen P">P Olcén</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Brumf Tt, W" uniqKey="Brumf Tt W">W Brumfıtt</name></author><author><name sortKey="W Lloughby, Ml" uniqKey="W Lloughby M">Ml Wılloughby</name></author><author><name sortKey="Bromley, Ll" uniqKey="Bromley L">LL Bromley</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Cabello, H" uniqKey="Cabello H">H Cabello</name></author><author><name sortKey="Torres, A" uniqKey="Torres A">A Torres</name></author><author><name sortKey="Celis, R" uniqKey="Celis R">R Celis</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Rosell, A" uniqKey="Rosell A">A Rosell</name></author><author><name sortKey="Mons, E" uniqKey="Mons E">E Monsó</name></author><author><name sortKey="Soler, N" uniqKey="Soler N">N Soler</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Garcha, Ds" uniqKey="Garcha D">DS Garcha</name></author><author><name sortKey="Thurston, Sj" uniqKey="Thurston S">SJ Thurston</name></author><author><name sortKey="Patel, Ar" uniqKey="Patel A">AR Patel</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Veeramachaneni, Sb" uniqKey="Veeramachaneni S">SB Veeramachaneni</name></author><author><name sortKey="Sethi, S" uniqKey="Sethi S">S Sethi</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Patel, Is" uniqKey="Patel I">IS Patel</name></author><author><name sortKey="Seemungal, Ta" uniqKey="Seemungal T">TA Seemungal</name></author><author><name sortKey="Wilks, M" uniqKey="Wilks M">M Wilks</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Sethi, S" uniqKey="Sethi S">S Sethi</name></author><author><name sortKey="Evans, N" uniqKey="Evans N">N Evans</name></author><author><name sortKey="Grant, Bj" uniqKey="Grant B">BJ Grant</name></author><author><name sortKey="Murphy, Tf" uniqKey="Murphy T">TF Murphy</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Perotin, Jm" uniqKey="Perotin J">JM Perotin</name></author><author><name sortKey="Dury, S" uniqKey="Dury S">S Dury</name></author><author><name sortKey="Renois, F" uniqKey="Renois F">F Renois</name></author></analytic></biblStruct></listBibl></div1></back></TEI><pmc article-type="research-article"><pmc-dir>properties open_access</pmc-dir>
<front><journal-meta><journal-id journal-id-type="nlm-ta">Int J Chron Obstruct Pulmon Dis</journal-id><journal-id journal-id-type="iso-abbrev">Int J Chron Obstruct Pulmon Dis</journal-id><journal-id journal-id-type="publisher-id">International Journal of COPD</journal-id><journal-title-group><journal-title>International Journal of Chronic Obstructive Pulmonary Disease</journal-title></journal-title-group><issn pub-type="ppub">1176-9106</issn><issn pub-type="epub">1178-2005</issn><publisher><publisher-name>Dove Medical Press</publisher-name></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">25298733</article-id><article-id pub-id-type="pmc">4186572</article-id><article-id pub-id-type="doi">10.2147/COPD.S70620</article-id><article-id pub-id-type="publisher-id">copd-9-1045</article-id><article-categories><subj-group subj-group-type="heading"><subject>Original Research</subject></subj-group></article-categories><title-group><article-title>Relationship between the GOLD combined COPD assessment staging system and bacterial isolation</article-title></title-group><contrib-group><contrib contrib-type="author"><name><surname>Aydemir</surname><given-names>Yusuf</given-names></name><xref ref-type="aff" rid="af1-copd-9-1045">1</xref><xref ref-type="corresp" rid="c1-copd-9-1045"></xref></contrib><contrib contrib-type="author"><name><surname>Aydemir</surname><given-names>Özlem</given-names></name><xref ref-type="aff" rid="af2-copd-9-1045">2</xref></contrib><contrib contrib-type="author"><name><surname>Kalem</surname><given-names>Fatma</given-names></name><xref ref-type="aff" rid="af3-copd-9-1045">3</xref></contrib></contrib-group><aff id="af1-copd-9-1045"><label>1</label>Department of Respiratory Medicine, Sakarya University, Sakarya, Turkey</aff><aff id="af2-copd-9-1045"><label>2</label>Department of Microbiology, Sakarya University, Sakarya, Turkey</aff><aff id="af3-copd-9-1045"><label>3</label>Department of Microbiology, Konya Numune Hospital, Konya, Turkey</aff><author-notes><corresp id="c1-copd-9-1045">Correspondence: Yusuf Aydemir, Department of Respiratory Medicine, Sakarya University Hospital, 54100 Sakarya, Turkey, Tel +90 264 295 6630, Fax +90 264 295 6629, Email <email>dryaydemir@yahoo.com</email></corresp></author-notes><pub-date pub-type="collection"><year>2014</year></pub-date><pub-date pub-type="epub"><day>27</day><month>9</month><year>2014</year></pub-date><volume>9</volume><fpage>1045</fpage><lpage>1051</lpage><permissions><copyright-statement>© 2014 Aydemir et al. This work is published by Dove Medical Press Limited, and licensed under Creative Commons Attribution – Non Commercial (unported, v3.0) License.</copyright-statement><copyright-year>2014</copyright-year><license><license-p>The full terms of the License are available at <ext-link ext-link-type="uri" xlink:href="http://creativecommons.org/licenses/by-nc/3.0/">http://creativecommons.org/licenses/by-nc/3.0/</ext-link>. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed.</license-p></license></permissions><abstract><sec><title>Background</title><p>Acute exacerbations, which are a significant cause of mortality and morbidity, adversely affect chronic obstructive pulmonary disease (COPD) prognosis by accelerating loss of lung function. It is important to know the microorganisms that commonly cause exacerbations in the patient groups classified according to clinical and functional characteristics for fast and accurate treatment of acute exacerbations.</p></sec><sec><title>Objectives</title><p>The last Global Initiative for Chronic Obstructive Lung Disease (GOLD) publication recommended a new staging system containing obstruction degree, frequency of exacerbations, and quality of life questionnaires. This study is designed to analyze the relationship between the bacteria isolated in acute exacerbations and new GOLD stages.</p></sec><sec><title>Methods</title><p>Potentially pathogenic bacteria (PPB) isolation with culture and polymerase chain reaction methods were obtained from 114 acute exacerbation COPD patients, classified into A, B, C, and D groups by analyzing the forced expiratory volume in 1 second (FEV<sub>1</sub>) value, COPD Assessment Test (CAT) score, and exacerbation frequency according to the new GOLD staging system.</p></sec><sec><title>Results</title><p>There was a significant correlation between exacerbation frequency and PPB isolation (<italic>P</italic>=0.002). There was no relationship between GOLD stage, FEV<sub>1</sub>, and CAT score with PPB isolation. The isolated bacteria diversity and mixed infection frequency were higher in the GOLD stage D group. <italic>Pseudomonas aeruginosa, Escherichia coli</italic>, and <italic>Acinetobacter baumannii</italic> were isolated only from D group patients.</p></sec><sec><title>Conclusion</title><p>Bacterial infection may cause an acute exacerbation equally in each stage for COPD. The difference in bacterial etiology is more related to exacerbation frequency than FEV<sub>1</sub> and CAT scores for an acute exacerbation. Determining exacerbation frequency is significant for treatment success in empirical antibiotic selection.</p></sec></abstract><kwd-group><title>Keywords</title><kwd>chronic obstructive pulmonary disease</kwd><kwd>acute exacerbation</kwd><kwd>bacterial etiology</kwd><kwd>polymerase chain reaction</kwd><kwd>GOLD</kwd></kwd-group></article-meta></front><body><sec sec-type="intro"><title>Introduction</title><p>Some patients with chronic obstructive pulmonary disease (COPD) are prone to frequent exacerbations, which are a major cause of morbidity and mortality. The reduction and effective treatment of exacerbations may have significant benefits.<xref rid="b1-copd-9-1045" ref-type="bibr">1</xref>,<xref rid="b2-copd-9-1045" ref-type="bibr">2</xref> Previous studies have shown that patients with severe or very severe air flow limitation tend to be at high risk of exacerbations. Higher exacerbation rates are associated with a faster loss of forced expiratory volume in 1 second (FEV<sub>1</sub>) and greater worsening of overall health status.<xref rid="b3-copd-9-1045" ref-type="bibr">3</xref>–<xref rid="b5-copd-9-1045" ref-type="bibr">5</xref></p><p>Most exacerbations of COPD are caused by bacterial infection. Studies with conventional methods have now established that approximately 50% of exacerbations are caused by bacterial infection. Nevertheless, conventional diagnostic methods are often insufficient for etiological diagnosis, and in half of these cases the pathogen cannot be determined.<xref rid="b6-copd-9-1045" ref-type="bibr">6</xref> The use of multiplex polymerase chain reaction (PCR), which is a reliable molecular method for diagnosing lower respiratory tract infections, has increased in recent years. The prominent advantage of the PCR method compared with culture is that since PCR is a method that is based on replicating the deoxyribonucleic acid (DNA) or ribonucleic acid (RNA) of a very small amount of microorganisms, it does not require living organisms and therefore is not affected by the use of antibiotics. In addition, PCR is more sensitive for the detection of multiple microorganisms and delivers fast results.<xref rid="b6-copd-9-1045" ref-type="bibr">6</xref></p><p><italic>Streptococcus pneumoniae</italic>, <italic>Haemophilus influenzae</italic>, and <italic>Moraxella catarrhalis</italic> are the most common bacterial pathogens involved in an exacerbation.<xref rid="b1-copd-9-1045" ref-type="bibr">1</xref>,<xref rid="b6-copd-9-1045" ref-type="bibr">6</xref> This poses several questions, such as is it possible that the increased frequency of exacerbations in patients with more severe air flow limitations is related to the increase in infectious origin exacerbations? Or may the isolation of the bacterial agent be related to other clinical characteristics besides FEV<sub>1</sub>?</p><p>Previously, the Global Initiative for Chronic Obstructive Lung Disease (GOLD) publication defined and graded (stages 1, 2, 3, and 4) expiratory air flow obstruction. Because FEV<sub>1</sub> does not reliably predict the degree of breathlessness, exercise limitation, exacerbations, and health status impairment in patients with COPD, the GOLD 2011 report added symptoms, including the COPD Assessment Test (CAT) and the Modified British Medical Research Council (mMRC), and exacerbation risk to help define risk groups and a severity staging system.<xref rid="b1-copd-9-1045" ref-type="bibr">1</xref>,<xref rid="b7-copd-9-1045" ref-type="bibr">7</xref></p><p>In studies based on the previous GOLD staging system, a significant relationship between low FEV<sub>1</sub> and frequency of various organisms, including <italic>Pseudomonas aeruginosa</italic> and <italic>Enterobacteriaceae</italic>, was shown.<xref rid="b8-copd-9-1045" ref-type="bibr">8</xref>–<xref rid="b10-copd-9-1045" ref-type="bibr">10</xref> However, there have not been similar studies that have included symptom scores and exacerbation frequency in the groups classified according to the new GOLD staging system.</p><p>This study is designed to analyze the relationship of isolation frequency and the variety of potentially pathogenic bacteria (PPB) with new GOLD stages in acute exacerbations of COPD (AECOPD). PPB were obtained by conventional sputum culture and the PCR method. In addition, our study is one of the few studies comparing the highly sensitive PCR method with the culture method in AECOPD.</p></sec><sec sec-type="materials|methods"><title>Materials and methods</title><sec sec-type="methods"><title>Study design and population</title><p>Consecutive patients with AECOPD who applied to the Konya Numune Hospital Pulmonology Department, Konya, Turkey, from September 2012 to December 2013 and who were ambulatory or undergoing inpatient treatment were included in this study. The patients were diagnosed with COPD according to GOLD 2011 criteria. The existence of three criteria described previously, dyspnea, sputum volume, and increase in sputum purulence, was searched in the diagnosis of acute exacerbation.<xref rid="b11-copd-9-1045" ref-type="bibr">11</xref> Patients with a history of antibiotic use in the last 10 days, accompanying bronchiectasis (verified with high-resolution computed tomography), pneumonia, immunosuppression, malignancy, and congestive heart failure were not included in the study. CAT and a pulmonary function test, which is in accordance with the American Thoracic Society, were provided to the patients. All pulmonary function tests were performed by the same technician after the administration of 400 μg salbutamol while the patient was stable. The exacerbation history was noted. The combined COPD assessment scaling was applied according to GOLD 2011 criteria. Patients were divided into four groups, GOLD A, B, C, and D. Sputum samples were taken from patients to a sterile container after rinsing the mouth and throat and were analyzed microscopically by Gram staining without waiting. Sputum samples that were observed to have fewer than ten epithelial cells and more than 25 leukocytes in each area upon 100× magnification were included in the study as appropriate sputum samples. All patients were informed about the study. Their written consents were taken. The consent of the Selçuk University Meram Medical Faculty Ethics Committee was taken for the study.</p></sec><sec sec-type="methods"><title>Microbiological sputum analysis</title><p>After Gram staining and direct microscopic examination, sputum samples were incubated for 18–36 hours at 37°C by inoculating in eosin methylene blue agar, blood agar, Brucella agar, and chocolate agar media. The results were analyzed.</p></sec><sec sec-type="methods"><title>Multiplex PCR/reverse line blot hybridization analysis</title><p>The clinical samples, such as genomic DNA isolation, PCR step, and reverse line blot hybridization on the assay, were studied by the multiplex PCR method with a CAP-Bac-PN Mix (Gen ID<sup>®</sup>; Autoimmun Diagnostika GmbH, Straßberg, Germany) kit. In the study, detection of <italic>S. pneumoniae</italic>, <italic>H. influenzae</italic>, <italic>M. catarrhalis</italic>, <italic>Chlamydophila pneumoniae</italic>, <italic>Mycoplasma pneumoniae</italic>, <italic>Legionella pneumophila</italic>, <italic>Staphylococcus aureus</italic>, <italic>Klebsiella pneumoniae</italic>, <italic>Escherichia coli</italic>, and <italic>Enterobacter cloacae</italic> bacteria was done with an RDB 2245/RDB 2246 BAC HOSPITAL (Gen ID<sup>®</sup>; Autoimmun Diagnostika GmbH) multiplex PCR kit according to the experts’ suggestions.</p></sec><sec sec-type="methods"><title>Statistical analysis</title><p>The SPSS version 21 (IBM Corporation, Armonk, NY, USA) program was used for statistical analysis. The independent-samples <italic>t</italic>-test for comparison of parametric data among groups, the Mann–Whitney <italic>U</italic> test for comparison of nonparametric data, and the <italic>χ</italic><sup>2</sup> test for multiple nonparametric group comparisons were used. The limit for statistical significance was accepted as <italic>P</italic><0.05.</p></sec></sec><sec sec-type="results"><title>Results</title><p>A total of 114 patients, whose ages ranged from 39 years to 86 years and who consisted of 86 males and 28 females, were included in the study. Among the four groups that were divided according to GOLD stage, there was no difference in terms of age, sex, and smoking. General characteristics of the cases are presented in <xref ref-type="table" rid="t1-copd-9-1045">Table 1</xref>.</p><p>In the microscopic analysis of Gram-stained sputum samples, single or multiple bacteria were observed for 66.6% of the patients. The most frequent bacteria seen were Gram-positive cocci with 33.3%. There was a significant difference between stages in terms of bacteria observation rate with Gram staining (<italic>P</italic>=0.036). Bacterial observation in group D occurred at a greater frequency.</p><sec sec-type="results"><title>Culture results</title><p>At least one bacterial growth was detected in 42 (36.8%) patients’ culture. The most commonly grown bacteria based on the culture studies were <italic>S. pneumoniae</italic> (10.5%) and <italic>H. influenzae</italic> (8.8%) (<xref ref-type="table" rid="t2-copd-9-1045">Table 2</xref>). Bacteria reproducing in group D were elevated in terms of quantity and diversity. <italic>P. aeruginosa</italic>, <italic>E. coli</italic>, and <italic>Acinetobacter baumannii</italic> were reproduced only in group D patients (<xref ref-type="table" rid="t2-copd-9-1045">Table 2</xref>). However, there was no significant difference between GOLD stage and culture results of the patients (<italic>P</italic>=0.325). There was no difference between age, FEV<sub>1</sub>, CAT scores, and exacerbation frequency with isolation in culture (<xref ref-type="table" rid="t3-copd-9-1045">Table 3</xref>).</p></sec><sec sec-type="results"><title>PCR results</title><p>In the real-time PCR study, similar to the ratio of direct microscopy, at least one bacterial agent was obtained for 65% of the patients (<xref ref-type="table" rid="t2-copd-9-1045">Table 2</xref>).</p><p>In PCR, there was a significant difference between PPB isolation and exacerbation frequency (<italic>P</italic>=0.002). There was no significant relationship between GOLD stages, FEV<sub>1</sub>, CAT scores, and age with PCR results (<xref ref-type="table" rid="t3-copd-9-1045">Tables 3</xref> and <xref ref-type="table" rid="t4-copd-9-1045">4</xref>). As in culture, quantity and diversity of bacteria in group D were higher. Moreover, mixed infectious agent frequency was observed to be elevated in group D. The distribution of bacteria according to stage is shown in <xref ref-type="table" rid="t2-copd-9-1045">Table 2</xref>.</p></sec><sec sec-type="results"><title>PCR and culture comparison results</title><p>When we compared the PCR and culture methods in terms of bacterial detection rate, the detection rate by PCR was significantly higher (<italic>P</italic>=0.01). While bacterial growth was detected in cultures from 42 patients, the PCR method was able to detect bacteria in 74 patients. The PCR method detected bacteria in 40 out of 42 patients with positive cultures. There were only two patients who had positive cultures but did not have bacteria according to the PCR results. There was a significant difference between the culture and PCR methods in terms of detection rates of multiple pathogens (<italic>P</italic><0.001). The PCR method was able to detect multiple bacteria in 19 cases, while the culture method did not detect multiple pathogens in any of the tested cases.</p></sec></sec><sec sec-type="discussion"><title>Discussion</title><p>Our study was designed to investigate the relationship between PPB isolation frequency and GOLD stages in AECOPD. However, no relationship between stage and bacteria isolation was found. Similarly, there was no correlation between FEV<sub>1</sub> and CAT scores with PPB frequency. We have found a significant relationship between PPB isolation and exacerbation frequency only.</p><p>Acute exacerbations adversely affect the prognosis of disease and accelerate the process, resulting in severe respiratory failure. They result in a considerable load on health care expenditure of countries and a significant amount of labor force loss. However, there is controversy over which antibiotic treatment is needed for which exacerbations. The amount of sputum and evaluation of increase in its purulence seem to be the best method of indication to start antibiotic treatment.<xref rid="b12-copd-9-1045" ref-type="bibr">12</xref> The determination of factors by conventional sputum culture methods is both difficult and time consuming. For this reason, clinicians initiated an empirical antibiotic treatment without waiting for the culture results.<xref rid="b13-copd-9-1045" ref-type="bibr">13</xref> Knowing the frequency and resistance characteristics of microbiological organisms in exacerbation in that society is necessary for rational antibiotic selection and treatment success in the initiation of empirical antibiotic treatment. Many national and regional studies on agents with culture and serological methods have been conducted, and these studies have formed the foundation of empirical treatment, but there are a few studies with PCR.</p><p>In our study, similar to previous studies, <italic>S. pneumoniae</italic> and <italic>H. influenzae</italic> were the common bacteria in sputum culture, while <italic>P. aeruginosa</italic>, <italic>E. coli</italic>, and <italic>A. baumannii</italic> were isolated only in GOLD stage D patients. However, there was no significant difference between GOLD stage and culture results of the patients. In many studies of COPD acute exac-erbations, <italic>S. pneumoniae</italic>, <italic>H. influenzae</italic>, and <italic>M. catarrhalis</italic> have been found to be predominant bacterial organisms. The degree of functional respiratory impairment in COPD patients has also been associated with the presence of different bacteria in their sputum samples during the course of an exacerbation.<xref rid="b3-copd-9-1045" ref-type="bibr">3</xref>,<xref rid="b14-copd-9-1045" ref-type="bibr">14</xref> It has been shown that isolation ratios of <italic>P. aeruginosa</italic>, <italic>Enterobacteriaceae</italic>, and Gram-negative bacteria coincide with common factors in patients with severe and very severe COPD.<xref rid="b8-copd-9-1045" ref-type="bibr">8</xref> In the study of Li et al,<xref rid="b15-copd-9-1045" ref-type="bibr">15</xref><italic>S. aureus</italic>, <italic>P. aeruginosa</italic>, <italic>E. coli</italic>, and <italic>A. baumannii</italic> were only isolated in patients with a 50% FEV<sub>1</sub> value. However, <italic>S. pneumoniae</italic> was found to occur more frequently in mild and moderate COPD, and <italic>H. influenzae</italic> was found approximately equally in three groups. In the study of Eller et al,<xref rid="b8-copd-9-1045" ref-type="bibr">8</xref> a correlation between impaired lung function and bacteria isolation was obtained, and the frequency of Gram-negative organisms, including <italic>Pseudomonas</italic>, <italic>Klebsiella</italic>, and <italic>Enterobacteriaceae</italic>, was higher in severe and very severe patients.<xref rid="b16-copd-9-1045" ref-type="bibr">16</xref></p><p>It is well known that conventional culture tests have low sensitivity and specificity for detecting microorganisms. The selective environment of the culture prevents the growth and presence of more than one type of organism. The other disadvantages are a consequence of using different media for different organisms and needing at least 2 days for results. Molecular techniques developed recently maintain very fast and reliable identification of respiratory infections.<xref rid="b18-copd-9-1045" ref-type="bibr">18</xref>,<xref rid="b19-copd-9-1045" ref-type="bibr">19</xref> DNA or RNA from a very small amount of microorganisms can be isolated by PCR methods. In contrast to culture, PCR is not dependent on viable bacteria and is a valuable tool for the patients who need antibiotics. Strålin et al<xref rid="b20-copd-9-1045" ref-type="bibr">20</xref> found that the <italic>S. pneumoniae</italic> isolation rate increased from 14% to 28%, the <italic>H. influenzae</italic> isolation rate increased from 21% to 47%, and the binary detection rate of microorganisms increased from 3% to 18% in the study comparing bronchoalveolar lavage fluids, culture, and PCR.</p><p>In the present study, PCR was more discriminatory than culture (positive samples 42 vs 74, <italic>P</italic>=0.01). In 40 of 42 patients with positive cultures, the same microorganisms were detected by PCR. In only two samples was PCR negative. This situation can be explained by the presence of factors that may inhibit PCR in the samples (ie, blood, tissue, milk, or plant). Moreover, mixed infections, which cannot be found in culture, were detected by PCR (n=19). Mixed infection frequency was higher in GOLD stage D patients (n=8), but there was no significant difference between GOLD stage, FEV<sub>1</sub>, CAT scores, and PCR results. This study reveals only the relation between exacerbation frequency and bacterial isolation. Patients presenting frequent exacerbations have greater bacterial isolation, suggesting a greater degree of colonization. In fact, for many years, the existence of bacterial colonization of the airways has been known in patients with stable COPD.<xref rid="b21-copd-9-1045" ref-type="bibr">21</xref> In comparative studies with healthy control groups, colonization of <italic>H. influenzae</italic>, <italic>S. pneumoniae</italic>, <italic>M. catarrhalis</italic>, <italic>P. aeruginosa</italic>, and <italic>S. aureus</italic> in the sputum<xref rid="b5-copd-9-1045" ref-type="bibr">5</xref> and protected specimen brush<xref rid="b22-copd-9-1045" ref-type="bibr">22</xref>,<xref rid="b23-copd-9-1045" ref-type="bibr">23</xref> samples of patients with stable COPD was present. Although the impact of colonized bacteria on an acute exacerbation has not yet been clear, it has been recently presented that an increase in bacterial load during exacerbations and proliferation of new strains has a relationship with acute exacerbations.<xref rid="b24-copd-9-1045" ref-type="bibr">24</xref>,<xref rid="b25-copd-9-1045" ref-type="bibr">25</xref> When studies evaluating parameters associated with bacterial colonization are considered, Patel et al<xref rid="b26-copd-9-1045" ref-type="bibr">26</xref> observed 29 patients with COPD for 529 days and found a significant relationship between exacerbation frequency and increased colonization but did not find any relationship between airway obstruction and colonization. Similarly, Zhang et al,<xref rid="b5-copd-9-1045" ref-type="bibr">5</xref> in a study based on the observations of 46 patients with COPD for 1 year, presented a positive correlation between lower airway bacterial colonization and exacerbation frequency but could not find any relationship between FEV<sub>1</sub> and colonization. Therefore, lower airway bacterial colonization seems to be more frequent for patients with frequent exacerbations. However, whether colonization causes frequent exacerbations or vice versa is not clear.<xref rid="b3-copd-9-1045" ref-type="bibr">3</xref>,<xref rid="b14-copd-9-1045" ref-type="bibr">14</xref> In our study, PPB were isolated more frequently from patients with frequent exacerbations. Our study has not been designed for discriminating colonization or active infection. Because exacerbations were confirmed in all patients clinically, isolated PPB were considered as the cause of infection. Even if the isolated PPB reflects colonization, it can still be used as a indicator of infectious agents. This is because previous patients presenting colonization developed infections as a result of a new strain. In fact, in the Sethi et al<xref rid="b27-copd-9-1045" ref-type="bibr">27</xref> study, over a period of 56 months, sputum samples for culture were collected monthly and during exacerbations from 81 outpatients with COPD. The PPB that was isolated during the stable period versus the exacerbation period illustrates the cause of the acute exacerbations as new strains of the pathogen.</p><p>In the present study, a relationship between exacerbation frequency and bacteria isolation was found. Hence, in terms of bacterial etiology, exacerbation frequency seems to be a better indicator compared with GOLD stage and FEV<sub>1</sub>.</p><p>Viral factors are responsible for approximately 15%–30% of exacerbations.<xref rid="b9-copd-9-1045" ref-type="bibr">9</xref> Most commonly rhinoviruses, followed by metapneumovirus, influenza A and B, parainfluenza, corona-virus, adenovirus, and respiratory syncytial virus were isolated from patients with exacerbations.<xref rid="b28-copd-9-1045" ref-type="bibr">28</xref> Also, from a significant proportion of patients, both bacterial and viral agents can be isolated. Mixed infections are more frequent in patients with severe COPD. Unfortunately, because of cost, our study did not identify concurrent viral pathogens, and this situation is one of the limitations of our study. Another limitation of our study is the small number of samples, due to high cost.</p><p>This study shows that bacterial infection in COPD may be an independent cause for acute exacerbations in each stage. There may be two reasons explaining why there was no difference in group D (which had frequent exacerbations, more symptoms, and lower FEV<sub>1</sub> values) in terms of bacterial isolation frequency compared with other groups for patients classified according to the new GOLD staging. First, very severe patients with lung functions already at the lower limits are probably more sensitive to noninfectious agents such as air pollution and heart failure, and they show acute exacerbation symptoms more quickly. Air pollution and other environmental conditions that increase airway inflammation or bronchomotor tone may account for 15%–20% of exacerbations.<xref rid="b6-copd-9-1045" ref-type="bibr">6</xref> The very high air pollution rate in the region where the study was conducted also supports this thesis. In this way, the conditions may be synchronized with a mild period for COPD patients who are not affected easily by noninfectious causes. Second, the average FEV<sub>1</sub> in our study was very high (56% predicted). The average FEV<sub>1</sub> for D group patients was 42.3%. There may be differences in results for the severe COPD patients with lower FEV<sub>1</sub> values.</p></sec><sec><title>Conclusion</title><p>To our knowledge, the present study is the first to compare the new GOLD staging system and PPB isolation rate. In conclusion, isolated PPB variety and mixed infection frequency were found to be higher in GOLD group D patients. This result indicates the necessity for being cautious about the selection of empirical antibiotics for these patients. We propose the necessity of prospective studies that are based on long-term monitoring, contain groups with lower FEV<sub>1</sub> scores, and are conducted with wide patient populations.</p></sec></body><back><fn-group><fn><p><bold>Disclosure</bold></p><p>The authors report no conflicts of interest in this work.</p></fn></fn-group><ref-list><title>References</title><ref id="b1-copd-9-1045"><label>1</label><element-citation publication-type="confproc"><person-group person-group-type="author"><collab>National Heart, Lung, and Blood Institute</collab><collab>World Health Organization</collab></person-group><source>Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease</source><conf-name>NHLBI/WHO Workshop Report 2011</conf-name><publisher-name>Vestbo J. National Institutes of Health</publisher-name><year>2014</year><comment>Available from: <ext-link ext-link-type="uri" xlink:href="http://www.goldcopd.org/guidelines-global-strategy-for-diagnosis-management.html">http://www.goldcopd.org/guidelines-global-strategy-for-diagnosis-management.html</ext-link></comment><date-in-citation>Accessed August 15, 2014</date-in-citation></element-citation></ref><ref id="b2-copd-9-1045"><label>2</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Seemungal</surname><given-names>TA</given-names></name><name><surname>Donaldson</surname><given-names>GC</given-names></name><name><surname>Paul</surname><given-names>EA</given-names></name><etal></etal></person-group><article-title>Effect of exacerbation on quality of life in patients with chronic obstructive pulmonary disease</article-title><source>Am J Respir Crit Care Med</source><year>1998</year><volume>157</volume><issue>5 Pt 1</issue><fpage>1418</fpage><lpage>1422</lpage><pub-id pub-id-type="pmid">9603117</pub-id></element-citation></ref><ref id="b3-copd-9-1045"><label>3</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Hurst</surname><given-names>JR</given-names></name><name><surname>Vestbo</surname><given-names>J</given-names></name><name><surname>Anzueto</surname><given-names>A</given-names></name><etal></etal></person-group><article-title>Evaluation of COPD Longitudinally to Identify Predictive Surrogate Endpoints (ECLIPSE) investigators. Susceptibility to exacerbation in chronic obstructive pulmonary disease</article-title><source>N Engl J Med</source><year>2010</year><volume>363</volume><issue>12</issue><fpage>1128</fpage><lpage>1138</lpage><pub-id pub-id-type="pmid">20843247</pub-id></element-citation></ref><ref id="b4-copd-9-1045"><label>4</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Celli</surname><given-names>BR</given-names></name><name><surname>Thomas</surname><given-names>NE</given-names></name><name><surname>Anderson</surname><given-names>JA</given-names></name><etal></etal></person-group><article-title>Effect of pharmacotherapy on rate of decline of lung function in chronic obstructive pulmonary disease: results from the TORCH study</article-title><source>Am J Respir Crit Care Med</source><year>2008</year><volume>178</volume><issue>4</issue><fpage>332</fpage><lpage>338</lpage><pub-id pub-id-type="pmid">18511702</pub-id></element-citation></ref><ref id="b5-copd-9-1045"><label>5</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Zhang</surname><given-names>M</given-names></name><name><surname>Li</surname><given-names>Q</given-names></name><name><surname>Zhang</surname><given-names>XY</given-names></name><etal></etal></person-group><article-title>Relevance of lower airway bacterial colonization, airway inflammation, and pulmonary function in the stable stage of chronic obstructive pulmonary disease</article-title><source>Eur J Clin Microbiol Infect Dis</source><year>2010</year><volume>29</volume><issue>12</issue><fpage>1487</fpage><lpage>1493</lpage><pub-id pub-id-type="pmid">20725845</pub-id></element-citation></ref><ref id="b6-copd-9-1045"><label>6</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Sethi</surname><given-names>S</given-names></name><name><surname>Murphy</surname><given-names>TF</given-names></name></person-group><article-title>Infection in the pathogenesis and course of chronic obstructive pulmonary disease</article-title><source>N Engl J Med</source><year>2008</year><volume>359</volume><issue>22</issue><fpage>2355</fpage><lpage>2365</lpage><pub-id pub-id-type="pmid">19038881</pub-id></element-citation></ref><ref id="b7-copd-9-1045"><label>7</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Yusen</surname><given-names>RD</given-names></name></person-group><article-title>Evolution of the GOLD documents for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. Controversies and questions</article-title><source>Am J Respir Crit Care Med</source><year>2013</year><volume>188</volume><issue>1</issue><fpage>4</fpage><lpage>5</lpage><pub-id pub-id-type="pmid">23815714</pub-id></element-citation></ref><ref id="b8-copd-9-1045"><label>8</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Eller</surname><given-names>J</given-names></name><name><surname>Ede</surname><given-names>A</given-names></name><name><surname>Schaberg</surname><given-names>T</given-names></name><etal></etal></person-group><article-title>Infective exacerbations of chronic bronchitis: relation between bacteriologic etiology and lung function</article-title><source>Chest</source><year>1998</year><volume>113</volume><issue>6</issue><fpage>1542</fpage><lpage>1548</lpage><pub-id pub-id-type="pmid">9631791</pub-id></element-citation></ref><ref id="b9-copd-9-1045"><label>9</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Miravitlles</surname><given-names>M</given-names></name><name><surname>Espinosa</surname><given-names>C</given-names></name><name><surname>Fernández-Laso</surname><given-names>E</given-names></name><etal></etal></person-group><article-title>Relationship between bacterial flora in sputum and functional impairment in patients with acute exacerbations of COPD. Study Group of Bacterial Infection in COPD</article-title><source>Chest</source><year>1999</year><volume>116</volume><issue>1</issue><fpage>40</fpage><lpage>46</lpage><pub-id pub-id-type="pmid">10424501</pub-id></element-citation></ref><ref id="b10-copd-9-1045"><label>10</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Soler</surname><given-names>N</given-names></name><name><surname>Agustí</surname><given-names>C</given-names></name><name><surname>Angrill</surname><given-names>J</given-names></name><etal></etal></person-group><article-title>Bronchoscopic validation of the significance of sputum purulence in severe exacerbations of chronic obstructive pulmonary disease</article-title><source>Thorax</source><year>2007</year><volume>62</volume><issue>1</issue><fpage>29</fpage><lpage>35</lpage><pub-id pub-id-type="pmid">16928715</pub-id></element-citation></ref><ref id="b11-copd-9-1045"><label>11</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Anthonisen</surname><given-names>NR</given-names></name><name><surname>Manfreda</surname><given-names>J</given-names></name><name><surname>Warren</surname><given-names>CP</given-names></name><etal></etal></person-group><article-title>Antibiotic therapy in exacerbations of chronic obstructive pulmonary disease</article-title><source>Ann Intern Med</source><year>1987</year><volume>106</volume><issue>2</issue><fpage>196</fpage><lpage>204</lpage><pub-id pub-id-type="pmid">3492164</pub-id></element-citation></ref><ref id="b12-copd-9-1045"><label>12</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Stockley</surname><given-names>RA</given-names></name><name><surname>O’Brien</surname><given-names>C</given-names></name><name><surname>Pye</surname><given-names>A</given-names></name><etal></etal></person-group><article-title>Relationship of sputum color to nature and outpatient management of acute exacerbations of COPD. 2000</article-title><source>Chest</source><year>2009</year><volume>136</volume><issue>Suppl 5</issue><fpage>e30</fpage><pub-id pub-id-type="pmid">20162782</pub-id></element-citation></ref><ref id="b13-copd-9-1045"><label>13</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Miravittles</surname><given-names>M</given-names></name></person-group><article-title>Epidemiology of chronic obstructive pulmonary disease exacerbations</article-title><source>Clin Pulm. Med</source><year>2002</year><volume>9</volume><issue>4</issue><fpage>191</fpage><lpage>197</lpage></element-citation></ref><ref id="b14-copd-9-1045"><label>14</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Wedzicha</surname><given-names>JA</given-names></name><name><surname>Donaldson</surname><given-names>GC</given-names></name></person-group><article-title>Exacerbations of chronic obstructive pulmonary disease</article-title><source>Respir Care</source><year>2003</year><volume>48</volume><issue>12</issue><fpage>1204</fpage><lpage>1213</lpage><pub-id pub-id-type="pmid">14651761</pub-id></element-citation></ref><ref id="b15-copd-9-1045"><label>15</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Li</surname><given-names>XJ</given-names></name><name><surname>Li</surname><given-names>Q</given-names></name><name><surname>Si</surname><given-names>LY</given-names></name><etal></etal></person-group><article-title>Bacteriological differences between COPD exacerbation and community-acquired pneumonia</article-title><source>Respir Care</source><year>2011</year><volume>56</volume><issue>11</issue><fpage>1818</fpage><lpage>1824</lpage><pub-id pub-id-type="pmid">21605476</pub-id></element-citation></ref><ref id="b16-copd-9-1045"><label>16</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Roche</surname><given-names>N</given-names></name><name><surname>Kouassi</surname><given-names>B</given-names></name><name><surname>Rabbat</surname><given-names>A</given-names></name><etal></etal></person-group><article-title>Yield of sputum microbiological examination in patients hospitalized for exacerbations of chronic obstructive pulmonary disease with purulent sputum</article-title><source>Respiration</source><year>2007</year><volume>74</volume><issue>1</issue><fpage>19</fpage><lpage>25</lpage><pub-id pub-id-type="pmid">16675894</pub-id></element-citation></ref><ref id="b17-copd-9-1045"><label>17</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Huang</surname><given-names>YJ</given-names></name><name><surname>Lynch</surname><given-names>SV</given-names></name><name><surname>Wiener-Kronish</surname><given-names>JP</given-names></name></person-group><article-title>From microbe to microbiota: considering microbial community composition in infections and airway diseases</article-title><source>Am J Respir Crit Care Med</source><year>2012</year><volume>185</volume><issue>7</issue><fpage>691</fpage><lpage>692</lpage><pub-id pub-id-type="pmid">22467799</pub-id></element-citation></ref><ref id="b18-copd-9-1045"><label>18</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Curran</surname><given-names>T</given-names></name><name><surname>Coyle</surname><given-names>PV</given-names></name><name><surname>McManus</surname><given-names>TE</given-names></name><etal></etal></person-group><article-title>Evaluation of real-time PCR for the detection and quantification of bacteria in chronic obstructive pulmonary disease</article-title><source>FEMS Immunol Med Microbiol</source><year>2007</year><volume>50</volume><issue>1</issue><fpage>112</fpage><lpage>118</lpage><pub-id pub-id-type="pmid">17439541</pub-id></element-citation></ref><ref id="b19-copd-9-1045"><label>19</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Morozumi</surname><given-names>M</given-names></name><name><surname>Nakayama</surname><given-names>E</given-names></name><name><surname>Iwata</surname><given-names>S</given-names></name><etal></etal></person-group><article-title>Simultaneous detection of pathogens in clinical samples from patients with community-acquired pneumonia by real-time PCR with pathogen-specific molecular beacon probes</article-title><source>J Clin Microbiol</source><year>2006</year><volume>44</volume><issue>4</issue><fpage>1440</fpage><lpage>1446</lpage><pub-id pub-id-type="pmid">16597874</pub-id></element-citation></ref><ref id="b20-copd-9-1045"><label>20</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Strålin</surname><given-names>K</given-names></name><name><surname>Korsgaard</surname><given-names>J</given-names></name><name><surname>Olcén</surname><given-names>P</given-names></name></person-group><article-title>Evaluation of a multiplex PCR for bacterial pathogens applied to bronchoalveolar lavage</article-title><source>Eur Respir J</source><year>2006</year><volume>28</volume><issue>3</issue><fpage>568</fpage><lpage>575</lpage><pub-id pub-id-type="pmid">16737990</pub-id></element-citation></ref><ref id="b21-copd-9-1045"><label>21</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Brumfıtt</surname><given-names>W</given-names></name><name><surname>Wılloughby</surname><given-names>Ml</given-names></name><name><surname>Bromley</surname><given-names>LL</given-names></name></person-group><article-title>An evaluation of sputum examination in chronic bronchitis</article-title><source>Lancet</source><year>1957</year><volume>270</volume><issue>7009</issue><fpage>1306</fpage><lpage>1309</lpage><pub-id pub-id-type="pmid">13492632</pub-id></element-citation></ref><ref id="b22-copd-9-1045"><label>22</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Cabello</surname><given-names>H</given-names></name><name><surname>Torres</surname><given-names>A</given-names></name><name><surname>Celis</surname><given-names>R</given-names></name><etal></etal></person-group><article-title>Bacterial colonization of distal airways in healthy subjects and chronic lung disease: a bronchoscopic study</article-title><source>Eur Respir J</source><year>1997</year><volume>10</volume><issue>5</issue><fpage>1137</fpage><lpage>1144</lpage><pub-id pub-id-type="pmid">9163659</pub-id></element-citation></ref><ref id="b23-copd-9-1045"><label>23</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Rosell</surname><given-names>A</given-names></name><name><surname>Monsó</surname><given-names>E</given-names></name><name><surname>Soler</surname><given-names>N</given-names></name><etal></etal></person-group><article-title>Microbiologic determinants of exacerbation in chronic obstructive pulmonary disease</article-title><source>Arch Intern Med</source><year>2005</year><volume>165</volume><issue>8</issue><fpage>891</fpage><lpage>897</lpage><pub-id pub-id-type="pmid">15851640</pub-id></element-citation></ref><ref id="b24-copd-9-1045"><label>24</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Garcha</surname><given-names>DS</given-names></name><name><surname>Thurston</surname><given-names>SJ</given-names></name><name><surname>Patel</surname><given-names>AR</given-names></name><etal></etal></person-group><article-title>Changes in prevalence and load of airway bacteria using quantitative PCR in stable and exacerbated COPD</article-title><source>Thorax</source><year>2012</year><volume>67</volume><issue>12</issue><fpage>1075</fpage><lpage>1080</lpage><pub-id pub-id-type="pmid">22863758</pub-id></element-citation></ref><ref id="b25-copd-9-1045"><label>25</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Veeramachaneni</surname><given-names>SB</given-names></name><name><surname>Sethi</surname><given-names>S</given-names></name></person-group><article-title>Pathogenesis of bacterial exacerbations of COPD</article-title><source>COPD</source><year>2006</year><volume>3</volume><issue>2</issue><fpage>109</fpage><lpage>115</lpage><pub-id pub-id-type="pmid">17175674</pub-id></element-citation></ref><ref id="b26-copd-9-1045"><label>26</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Patel</surname><given-names>IS</given-names></name><name><surname>Seemungal</surname><given-names>TA</given-names></name><name><surname>Wilks</surname><given-names>M</given-names></name><etal></etal></person-group><article-title>Relationship between bacterial colonisation and the frequency, character, and severity of COPD exacerbations</article-title><source>Thorax</source><year>2002</year><volume>57</volume><issue>9</issue><fpage>759</fpage><lpage>764</lpage><pub-id pub-id-type="pmid">12200518</pub-id></element-citation></ref><ref id="b27-copd-9-1045"><label>27</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Sethi</surname><given-names>S</given-names></name><name><surname>Evans</surname><given-names>N</given-names></name><name><surname>Grant</surname><given-names>BJ</given-names></name><name><surname>Murphy</surname><given-names>TF</given-names></name></person-group><article-title>New strains of bacteria and exacerbations of chronic obstructive pulmonary disease</article-title><source>N Engl J Med</source><year>2002</year><volume>347</volume><issue>7</issue><fpage>465</fpage><lpage>471</lpage><pub-id pub-id-type="pmid">12181400</pub-id></element-citation></ref><ref id="b28-copd-9-1045"><label>28</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Perotin</surname><given-names>JM</given-names></name><name><surname>Dury</surname><given-names>S</given-names></name><name><surname>Renois</surname><given-names>F</given-names></name><etal></etal></person-group><article-title>Detection of multiple viral and bacterial infections in acute exacerbation of chronic obstructive pulmonary disease: a pilot prospective study</article-title><source>J Med Virol</source><year>2013</year><volume>85</volume><issue>5</issue><fpage>866</fpage><lpage>873</lpage><pub-id pub-id-type="pmid">23447038</pub-id></element-citation></ref></ref-list></back><floats-group><table-wrap id="t1-copd-9-1045" position="float"><label>Table 1</label><caption><p>General characteristics of the study population</p></caption><table frame="hsides" rules="groups"><thead><tr><th align="left" valign="top" rowspan="1" colspan="1"></th><th align="left" valign="top" rowspan="1" colspan="1">n</th><th align="left" valign="top" rowspan="1" colspan="1"></th><th align="left" valign="top" rowspan="1" colspan="1">%</th></tr></thead><tbody><tr><td align="left" valign="top" rowspan="1" colspan="1">Total patients</td><td align="left" valign="top" rowspan="1" colspan="1">140</td><td align="left" valign="top" rowspan="1" colspan="1"></td><td align="left" valign="top" rowspan="1" colspan="1"></td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1"> Excluded patients</td><td align="left" valign="top" rowspan="1" colspan="1">26</td><td align="left" valign="top" rowspan="1" colspan="1"></td><td align="left" valign="top" rowspan="1" colspan="1"></td></tr><tr><td align="left" valign="top" rowspan="4" colspan="1"> Due to</td><td align="left" valign="top" rowspan="1" colspan="1">8</td><td align="left" valign="top" rowspan="1" colspan="1">Previous antibiotic treatment</td><td align="left" valign="top" rowspan="1" colspan="1"></td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">8</td><td align="left" valign="top" rowspan="1" colspan="1">Poor cooperation PFT</td><td align="left" valign="top" rowspan="1" colspan="1"></td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">6</td><td align="left" valign="top" rowspan="1" colspan="1">Accompanying comorbidities</td><td align="left" valign="top" rowspan="1" colspan="1"></td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">4</td><td align="left" valign="top" rowspan="1" colspan="1">Not adequate quality of sputum</td><td align="left" valign="top" rowspan="1" colspan="1"></td></tr><tr><td align="left" valign="top" rowspan="3" colspan="1">Included patients</td><td align="left" valign="top" rowspan="1" colspan="1">114</td><td align="left" valign="top" rowspan="1" colspan="1"></td><td align="left" valign="top" rowspan="1" colspan="1"></td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">74</td><td align="left" valign="top" rowspan="1" colspan="1">Outpatients</td><td align="left" valign="top" rowspan="1" colspan="1"></td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">40</td><td align="left" valign="top" rowspan="1" colspan="1">Inpatients</td><td align="left" valign="top" rowspan="1" colspan="1"></td></tr><tr><td colspan="4" align="left" valign="top" rowspan="1">Sex</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1"> Male</td><td align="left" valign="top" rowspan="1" colspan="1">86</td><td align="left" valign="top" rowspan="1" colspan="1"></td><td align="left" valign="top" rowspan="1" colspan="1">75.4</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1"> Female</td><td align="left" valign="top" rowspan="1" colspan="1">28</td><td align="left" valign="top" rowspan="1" colspan="1"></td><td align="left" valign="top" rowspan="1" colspan="1">24.6</td></tr><tr><td colspan="4" align="left" valign="top" rowspan="1">GOLD class</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1"> A</td><td align="left" valign="top" rowspan="1" colspan="1">14</td><td align="left" valign="top" rowspan="1" colspan="1">All of outpatients</td><td align="left" valign="top" rowspan="1" colspan="1">12.3</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1"> B</td><td align="left" valign="top" rowspan="1" colspan="1">30</td><td align="left" valign="top" rowspan="1" colspan="1">1 inpatient</td><td align="left" valign="top" rowspan="1" colspan="1">26.3</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1"> C</td><td align="left" valign="top" rowspan="1" colspan="1">29</td><td align="left" valign="top" rowspan="1" colspan="1">9 inpatients</td><td align="left" valign="top" rowspan="1" colspan="1">25.4</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1"> D</td><td align="left" valign="top" rowspan="1" colspan="1">41</td><td align="left" valign="top" rowspan="1" colspan="1">30 inpatients</td><td align="left" valign="top" rowspan="1" colspan="1">36.0</td></tr><tr><td colspan="4" align="left" valign="top" rowspan="1">Exacerbations</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1"> 0</td><td align="left" valign="top" rowspan="1" colspan="1">27</td><td align="left" valign="top" rowspan="1" colspan="1"></td><td align="left" valign="top" rowspan="1" colspan="1">23.7</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1"> 1</td><td align="left" valign="top" rowspan="1" colspan="1">37</td><td align="left" valign="top" rowspan="1" colspan="1"></td><td align="left" valign="top" rowspan="1" colspan="1">32.4</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1"> ≥2</td><td align="left" valign="top" rowspan="1" colspan="1">50</td><td align="left" valign="top" rowspan="1" colspan="1"></td><td align="left" valign="top" rowspan="1" colspan="1">43.9</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1"> Smoking</td><td align="left" valign="top" rowspan="1" colspan="1">36</td><td align="left" valign="top" rowspan="1" colspan="1"></td><td align="left" valign="top" rowspan="1" colspan="1">31.6</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">Pneumococcal vaccination</td><td align="left" valign="top" rowspan="1" colspan="1">26</td><td align="left" valign="top" rowspan="1" colspan="1"></td><td align="left" valign="top" rowspan="1" colspan="1">22.8</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1"> Age, mean (SD)</td><td align="left" valign="top" rowspan="1" colspan="1">65 (±9)</td><td align="left" valign="top" rowspan="1" colspan="1">Minimum 39</td><td align="left" valign="top" rowspan="1" colspan="1">Maximum 86</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1"> FEV<sub>1</sub> %, mean (SD)</td><td align="left" valign="top" rowspan="1" colspan="1">56 (±15)</td><td align="left" valign="top" rowspan="1" colspan="1">Minimum 24</td><td align="left" valign="top" rowspan="1" colspan="1">Maximum 82</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1"> CAT, mean (SD)</td><td align="left" valign="top" rowspan="1" colspan="1">18 (±10)</td><td align="left" valign="top" rowspan="1" colspan="1">Minimum 3</td><td align="left" valign="top" rowspan="1" colspan="1">Maximum 40</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1"> CRP, mg/mL, mean (SD)</td><td align="left" valign="top" rowspan="1" colspan="1">38.6 (45)</td><td align="left" valign="top" rowspan="1" colspan="1">Minimum 3</td><td align="left" valign="top" rowspan="1" colspan="1">Maximum 150</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1"> Leukocytes, ×10<sup>9</sup> cells/L, mean (SD)</td><td align="left" valign="top" rowspan="1" colspan="1">11.6 (4)</td><td align="left" valign="top" rowspan="1" colspan="1">Minimum 6.1</td><td align="left" valign="top" rowspan="1" colspan="1">Maximum 22.1</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1"> Sedimentation, mm/hour, mean (SD)</td><td align="left" valign="top" rowspan="1" colspan="1">26 (15)</td><td align="left" valign="top" rowspan="1" colspan="1">Minimum 1</td><td align="left" valign="top" rowspan="1" colspan="1">Maximum 71</td></tr></tbody></table><table-wrap-foot><fn id="tfn1-copd-9-1045"><p><bold>Abbreviations:</bold> CAT, COPD Assessment Test; COPD, Chronic Obstructive Lung Disease; CRP, C-reactive protein; FEV<sub>1</sub>, forced expiratory volume in 1 second; GOLD, Global Initiative for Chronic Obstructive Lung Disease; PFT, pulmonary function test; SD, standard deviation.</p></fn></table-wrap-foot></table-wrap><table-wrap id="t2-copd-9-1045" position="float"><label>Table 2</label><caption><p>Distribution of culture and polymerase chain reaction (PCR) results according to Global Initiative for Chronic Obstructive Lung Disease stages</p></caption><table frame="hsides" rules="groups"><thead><tr><th align="left" valign="top" rowspan="1" colspan="1"></th><th align="left" valign="top" rowspan="1" colspan="1">Total (%)</th><th align="left" valign="top" rowspan="1" colspan="1">A</th><th align="left" valign="top" rowspan="1" colspan="1">B</th><th align="left" valign="top" rowspan="1" colspan="1">C</th><th align="left" valign="top" rowspan="1" colspan="1">D</th></tr></thead><tbody><tr><td colspan="6" align="left" valign="top" rowspan="1"><bold>Culture</bold></td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">Normal flora</td><td align="left" valign="top" rowspan="1" colspan="1">72 (63.1)</td><td align="left" valign="top" rowspan="1" colspan="1">10</td><td align="left" valign="top" rowspan="1" colspan="1">19</td><td align="left" valign="top" rowspan="1" colspan="1">20</td><td align="left" valign="top" rowspan="1" colspan="1">23</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1"><italic>Streptococcus pneumoniae</italic></td><td align="left" valign="top" rowspan="1" colspan="1">12 (10.5)</td><td align="left" valign="top" rowspan="1" colspan="1">1</td><td align="left" valign="top" rowspan="1" colspan="1">5</td><td align="left" valign="top" rowspan="1" colspan="1">2</td><td align="left" valign="top" rowspan="1" colspan="1">4</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1"><italic>Haemophilus influenzae</italic></td><td align="left" valign="top" rowspan="1" colspan="1">10 (8.8)</td><td align="left" valign="top" rowspan="1" colspan="1">2</td><td align="left" valign="top" rowspan="1" colspan="1">3</td><td align="left" valign="top" rowspan="1" colspan="1">3</td><td align="left" valign="top" rowspan="1" colspan="1">2</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1"><italic>Moraxella catarrhalis</italic></td><td align="left" valign="top" rowspan="1" colspan="1">5 (4.4)</td><td align="left" valign="top" rowspan="1" colspan="1">1</td><td align="left" valign="top" rowspan="1" colspan="1">2</td><td align="left" valign="top" rowspan="1" colspan="1">2</td><td align="left" valign="top" rowspan="1" colspan="1"></td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1"><italic>Klebsiella pneumoniae</italic></td><td align="left" valign="top" rowspan="1" colspan="1">5 (4.4)</td><td align="left" valign="top" rowspan="1" colspan="1"></td><td align="left" valign="top" rowspan="1" colspan="1">1</td><td align="left" valign="top" rowspan="1" colspan="1">1</td><td align="left" valign="top" rowspan="1" colspan="1">3</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1"><italic>Pseudomonas aeruginosa</italic></td><td align="left" valign="top" rowspan="1" colspan="1">5 (4.4)</td><td align="left" valign="top" rowspan="1" colspan="1"></td><td align="left" valign="top" rowspan="1" colspan="1"></td><td align="left" valign="top" rowspan="1" colspan="1"></td><td align="left" valign="top" rowspan="1" colspan="1">5</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1"><italic>Escherichia coli</italic></td><td align="left" valign="top" rowspan="1" colspan="1">2 (1.7)</td><td align="left" valign="top" rowspan="1" colspan="1"></td><td align="left" valign="top" rowspan="1" colspan="1"></td><td align="left" valign="top" rowspan="1" colspan="1"></td><td align="left" valign="top" rowspan="1" colspan="1">2</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1"><italic>Staphylococcus aureus</italic></td><td align="left" valign="top" rowspan="1" colspan="1">2 (1.7)</td><td align="left" valign="top" rowspan="1" colspan="1"></td><td align="left" valign="top" rowspan="1" colspan="1"></td><td align="left" valign="top" rowspan="1" colspan="1">1</td><td align="left" valign="top" rowspan="1" colspan="1">1</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1"><italic>Acinetobacter baumannii</italic></td><td align="left" valign="top" rowspan="1" colspan="1">1 (0.9)</td><td align="left" valign="top" rowspan="1" colspan="1"></td><td align="left" valign="top" rowspan="1" colspan="1"></td><td align="left" valign="top" rowspan="1" colspan="1"></td><td align="left" valign="top" rowspan="1" colspan="1">1</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">Bacterial isolation total (%)</td><td align="left" valign="top" rowspan="1" colspan="1">36.8</td><td align="left" valign="top" rowspan="1" colspan="1">28.5</td><td align="left" valign="top" rowspan="1" colspan="1">36.6</td><td align="left" valign="top" rowspan="1" colspan="1">31</td><td align="left" valign="top" rowspan="1" colspan="1">43.9</td></tr><tr><td colspan="6" align="left" valign="top" rowspan="1"><bold>PCR</bold><xref ref-type="table-fn" rid="tfn2-copd-9-1045">a</xref></td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">Negative</td><td align="left" valign="top" rowspan="1" colspan="1">40 (35.1)</td><td align="left" valign="top" rowspan="1" colspan="1">6</td><td align="left" valign="top" rowspan="1" colspan="1">11</td><td align="left" valign="top" rowspan="1" colspan="1">11</td><td align="left" valign="top" rowspan="1" colspan="1">12</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1"><italic>S. pneumoniae</italic></td><td align="left" valign="top" rowspan="1" colspan="1">18 (15.8)</td><td align="left" valign="top" rowspan="1" colspan="1">4</td><td align="left" valign="top" rowspan="1" colspan="1">4</td><td align="left" valign="top" rowspan="1" colspan="1">5</td><td align="left" valign="top" rowspan="1" colspan="1">5</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1"><italic>H. influenzae</italic></td><td align="left" valign="top" rowspan="1" colspan="1">18 (15.8)</td><td align="left" valign="top" rowspan="1" colspan="1">3</td><td align="left" valign="top" rowspan="1" colspan="1">4</td><td align="left" valign="top" rowspan="1" colspan="1">5</td><td align="left" valign="top" rowspan="1" colspan="1">6</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1"><italic>S. pneumoniae</italic> + <italic>H. influenzae</italic></td><td align="left" valign="top" rowspan="1" colspan="1">8 (7)</td><td align="left" valign="top" rowspan="1" colspan="1"></td><td align="left" valign="top" rowspan="1" colspan="1">2</td><td align="left" valign="top" rowspan="1" colspan="1">2</td><td align="left" valign="top" rowspan="1" colspan="1">4</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1"><italic>M. catarrhalis</italic></td><td align="left" valign="top" rowspan="1" colspan="1">7 (6.1)</td><td align="left" valign="top" rowspan="1" colspan="1">1</td><td align="left" valign="top" rowspan="1" colspan="1">3</td><td align="left" valign="top" rowspan="1" colspan="1">1</td><td align="left" valign="top" rowspan="1" colspan="1">2</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1"><italic>K. pneumoniae</italic></td><td align="left" valign="top" rowspan="1" colspan="1">7 (6.1)</td><td align="left" valign="top" rowspan="1" colspan="1"></td><td align="left" valign="top" rowspan="1" colspan="1">1</td><td align="left" valign="top" rowspan="1" colspan="1">1</td><td align="left" valign="top" rowspan="1" colspan="1">5</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1"><italic>S. pneumoniae</italic> + <italic>M. catarrhalis</italic></td><td align="left" valign="top" rowspan="1" colspan="1">6 (5.3)</td><td align="left" valign="top" rowspan="1" colspan="1"></td><td align="left" valign="top" rowspan="1" colspan="1">2</td><td align="left" valign="top" rowspan="1" colspan="1">1</td><td align="left" valign="top" rowspan="1" colspan="1">3</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1"><italic>E. coli</italic></td><td align="left" valign="top" rowspan="1" colspan="1">3 (2.6)</td><td align="left" valign="top" rowspan="1" colspan="1"></td><td align="left" valign="top" rowspan="1" colspan="1"></td><td align="left" valign="top" rowspan="1" colspan="1">1</td><td align="left" valign="top" rowspan="1" colspan="1">2</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1"><italic>H. influenzae</italic> + <italic>M. catarrhalis</italic></td><td align="left" valign="top" rowspan="1" colspan="1">3 (2.6)</td><td align="left" valign="top" rowspan="1" colspan="1"></td><td align="left" valign="top" rowspan="1" colspan="1">2</td><td align="left" valign="top" rowspan="1" colspan="1">1</td><td align="left" valign="top" rowspan="1" colspan="1"></td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1"><italic>M. pneumoniae</italic></td><td align="left" valign="top" rowspan="1" colspan="1">2 (1.8)</td><td align="left" valign="top" rowspan="1" colspan="1"></td><td align="left" valign="top" rowspan="1" colspan="1">1</td><td align="left" valign="top" rowspan="1" colspan="1"></td><td align="left" valign="top" rowspan="1" colspan="1">1</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1"><italic>S. aureus</italic> + <italic>H. influenzae</italic></td><td align="left" valign="top" rowspan="1" colspan="1">2 (1.8)</td><td align="left" valign="top" rowspan="1" colspan="1"></td><td align="left" valign="top" rowspan="1" colspan="1"></td><td align="left" valign="top" rowspan="1" colspan="1">1</td><td align="left" valign="top" rowspan="1" colspan="1">1</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">Bacterial isolation total (%)</td><td align="left" valign="top" rowspan="1" colspan="1">64.9</td><td align="left" valign="top" rowspan="1" colspan="1">57.1</td><td align="left" valign="top" rowspan="1" colspan="1">63.3</td><td align="left" valign="top" rowspan="1" colspan="1">62</td><td align="left" valign="top" rowspan="1" colspan="1">70.7</td></tr></tbody></table><table-wrap-foot><fn id="tfn10-copd-9-1045"><p><bold>Note:</bold></p></fn><fn id="tfn2-copd-9-1045"><label>a</label><p>The PCR kit has no ability to detect <italic>P. aeruginosa</italic> and <italic>A. baumanii.</italic></p></fn></table-wrap-foot></table-wrap><table-wrap id="t3-copd-9-1045" position="float"><label>Table 3</label><caption><p>Relationship between various parameters and bacterial isolation</p></caption><table frame="hsides" rules="groups"><thead><tr><th align="left" valign="top" rowspan="2" colspan="1"></th><th colspan="3" align="left" valign="top" rowspan="1">Culture
<hr></hr></th><th colspan="3" align="left" valign="top" rowspan="1">PCR
<hr></hr></th></tr><tr><th align="left" valign="top" rowspan="1" colspan="1">Bacterial isolation</th><th align="left" valign="top" rowspan="1" colspan="1">No bacterial isolation</th><th align="left" valign="top" rowspan="1" colspan="1"><italic>P</italic>-value</th><th align="left" valign="top" rowspan="1" colspan="1">Bacterial isolation</th><th align="left" valign="top" rowspan="1" colspan="1">No bacterial isolation</th><th align="left" valign="top" rowspan="1" colspan="1"><italic>P</italic>-value</th></tr></thead><tbody><tr><td align="left" valign="top" rowspan="1" colspan="1">Age (mean, years)</td><td align="left" valign="top" rowspan="1" colspan="1">66</td><td align="left" valign="top" rowspan="1" colspan="1">65</td><td align="left" valign="top" rowspan="1" colspan="1">0.483</td><td align="left" valign="top" rowspan="1" colspan="1">65.7</td><td align="left" valign="top" rowspan="1" colspan="1">64.4</td><td align="left" valign="top" rowspan="1" colspan="1">0.574</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">Sex (n, female/male)</td><td align="left" valign="top" rowspan="1" colspan="1">10/31</td><td align="left" valign="top" rowspan="1" colspan="1">18/55</td><td align="left" valign="top" rowspan="1" colspan="1">0.381</td><td align="left" valign="top" rowspan="1" colspan="1">19/58</td><td align="left" valign="top" rowspan="1" colspan="1">9/28</td><td align="left" valign="top" rowspan="1" colspan="1">0.599</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">CRP (mean, mg/mL)</td><td align="left" valign="top" rowspan="1" colspan="1">47.6</td><td align="left" valign="top" rowspan="1" colspan="1">46</td><td align="left" valign="top" rowspan="1" colspan="1">0.902</td><td align="left" valign="top" rowspan="1" colspan="1">41.2</td><td align="left" valign="top" rowspan="1" colspan="1">34.8</td><td align="left" valign="top" rowspan="1" colspan="1">0.750</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">Leukocytes (mean, ×10<sup>9</sup> cells/L)</td><td align="left" valign="top" rowspan="1" colspan="1">13.0</td><td align="left" valign="top" rowspan="1" colspan="1">10.5</td><td align="left" valign="top" rowspan="1" colspan="1">0.204</td><td align="left" valign="top" rowspan="1" colspan="1">11.6</td><td align="left" valign="top" rowspan="1" colspan="1">11.5</td><td align="left" valign="top" rowspan="1" colspan="1">0.942</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">Sedimentation (mean, mm/hour)</td><td align="left" valign="top" rowspan="1" colspan="1">32.2</td><td align="left" valign="top" rowspan="1" colspan="1">21.8</td><td align="left" valign="top" rowspan="1" colspan="1">0.114</td><td align="left" valign="top" rowspan="1" colspan="1">28.4</td><td align="left" valign="top" rowspan="1" colspan="1">23.1</td><td align="left" valign="top" rowspan="1" colspan="1">0.435</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">FEV<sub>1</sub> (mean, % predicted)</td><td align="left" valign="top" rowspan="1" colspan="1">57.8</td><td align="left" valign="top" rowspan="1" colspan="1">53.6</td><td align="left" valign="top" rowspan="1" colspan="1">0.251</td><td align="left" valign="top" rowspan="1" colspan="1">54.7</td><td align="left" valign="top" rowspan="1" colspan="1">59.5</td><td align="left" valign="top" rowspan="1" colspan="1">0.184</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">CAT (mean)</td><td align="left" valign="top" rowspan="1" colspan="1">19.8</td><td align="left" valign="top" rowspan="1" colspan="1">16.5</td><td align="left" valign="top" rowspan="1" colspan="1">0.159</td><td align="left" valign="top" rowspan="1" colspan="1">18.5</td><td align="left" valign="top" rowspan="1" colspan="1">16.0</td><td align="left" valign="top" rowspan="1" colspan="1">0.301</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">Exacerbations (mean)</td><td align="left" valign="top" rowspan="1" colspan="1">1.5</td><td align="left" valign="top" rowspan="1" colspan="1">1.0</td><td align="left" valign="top" rowspan="1" colspan="1">0.083</td><td align="left" valign="top" rowspan="1" colspan="1">1.43</td><td align="left" valign="top" rowspan="1" colspan="1">0.84</td><td align="left" valign="top" rowspan="1" colspan="1">0.002</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">GOLD class (n, groups A/B/C/D)</td><td align="left" valign="top" rowspan="1" colspan="1">4/11/9/18</td><td align="left" valign="top" rowspan="1" colspan="1">10/19/20/23</td><td align="left" valign="top" rowspan="1" colspan="1">0.325</td><td align="left" valign="top" rowspan="1" colspan="1">8/19/18/29</td><td align="left" valign="top" rowspan="1" colspan="1">6/11/11/12</td><td align="left" valign="top" rowspan="1" colspan="1">0.801</td></tr></tbody></table><table-wrap-foot><fn id="tfn3-copd-9-1045"><p><bold>Abbreviations:</bold> CAT, COPD Assessment Test; COPD, Chronic Obstructive Lung Disease; CRP, C-reactive protein; FEV<sub>1</sub>, forced expiratory volume in 1 second; GOLD, Global Initiative for Chronic Obstructive Lung Disease; PCR, polymerase chain reaction.</p></fn></table-wrap-foot></table-wrap><table-wrap id="t4-copd-9-1045" position="float"><label>Table 4</label><caption><p>Relationship between FEV<sub>1</sub>, CAT, and exacerbation frequency with positive bacterial isolation</p></caption><table frame="hsides" rules="groups"><thead><tr><th align="left" valign="top" rowspan="1" colspan="1">Positive bacterial isolation (PCR)</th><th align="left" valign="top" rowspan="1" colspan="1"><italic>P</italic>-value</th></tr></thead><tbody><tr><td align="left" valign="top" rowspan="1" colspan="1">FEV<sub>1</sub> >50% vs FEV<sub>1</sub> ≤50%</td><td align="left" valign="top" rowspan="1" colspan="1">0.817</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">CAT <10 vs CAT ≥10</td><td align="left" valign="top" rowspan="1" colspan="1">0.257</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">Exacerbations 0–1 vs ≥2</td><td align="left" valign="top" rowspan="1" colspan="1">0.028</td></tr></tbody></table><table-wrap-foot><fn id="tfn4-copd-9-1045"><p><bold>Abbreviations:</bold> CAT, COPD Assessment Test; 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