title: Comparison of first-line with second-line antibiotics for acute exacerbations of chronic bronchitis: a metaanalysis of randomized controlled trials.
abstract: BACKGROUND
  Although acute exacerbations of chronic bronchitis (AECBs) are common, there has been no metaanalysis that focused on the optimum regimen.
  
  
  METHODS
  To evaluate the comparative effectiveness and safety of first-line antimicrobial agents (ie, amoxicillin, ampicillin, pivampicillin, trimethoprim/sulfamethoxazole, and doxycycline) and second-line antimicrobial agents (ie, amoxicillin/clavulanic acid, macrolides, second-generation or third-generation cephalosporins, and quinolones) for the treatment of patients with AECB, in an era of increasing antimicrobial resistance among the microbes responsible for AECB, we performed a metaanalysis of randomized controlled trials (RCTs) retrieved through searches of the PubMed and the Cochrane databases.
  
  
  RESULTS
  Twelve RCTs were included in the metaanalysis. First-line antibiotics were associated with lower treatment success compared to second-line antibiotics in the clinically evaluable patients (odds ratio [OR], 0.51; 95% confidence interval [CI], 0.34 to 0.75). There were no differences among the compared regimens regarding mortality (OR, 0.64; 95% CI, 0.25 to 1.66) or treatment success (OR, 0.56; 95% CI, 0.22 to 1.43) in microbiologically evaluable patients, or adverse effects in general (OR, 0.75; 95% CI, 0.39 to 1.45) or diarrhea in particular (OR, 1.58; 95% CI, 0.74 to 3.35).
  
  
  CONCLUSIONS
  Compared to first-line antibiotics, second-line antibiotics are more effective, but not less safe, when administered to patients with AECB. The available data did not allow for stratified analyses according to the presence of risk factors for poor outcome, such as increased age, impaired lung function, airway obstruction, and frequency of exacerbations; this fact should be taken into consideration when interpreting the findings of this metaanalysis.
authors.affiliation: Alfa Institute of Biomedical Sciences (AIBS), 9 Neapoleos St, 151 23 Marousi, Greece.
authors.forename: George
authors.initials: G
authors.lastname: Dimopoulos
authors.forename: Ilias I
authors.initials: II
authors.lastname: Siempos
authors.forename: Ioanna P
authors.initials: IP
authors.lastname: Korbila
authors.forename: Katerina G
authors.initials: KG
authors.lastname: Manta
authors.forename: Matthew E
authors.initials: ME
authors.lastname: Falagas
mesh_terms: D029481:Bronchitis, Chronic / Q000188:drug therapy*; D016001:Confidence Intervals; D006801:Humans; D018942:Macrolides / Q000145:classification / Q000627:therapeutic use*; D016017:Odds Ratio; D010406:Penicillins / Q000145:classification / Q000627:therapeutic use*; D016032:Randomized Controlled Trials as Topic; D012008:Recurrence; D016896:Treatment Outcome
chemical_list: D018942:Macrolides; D010406:Penicillins