Objectifs - reevaluer le traitement des exacerbations de bronchite chronique a la lumiere des recommandations, des essais cliniques et de l'evolution des resistances bacteriennes. L'evaluation devait porter sur les antibiotiques mis sur le marche depuis 1991, en terme d'efficacite, de duree de traitement, d'impact ecologique, de cout/efficacite.Methodologie - recherche sur Medline et a partir des references citees dans chaque article si besoin de 1991 a juin 1999. Selection des essais cliniques randomises, en aveugle ou ouvert, et selon les criteres d'une grille preetablie (nombre de patients, criteres d'inclusion - exclusion, criteres d'analyse, tests statistiques).Resultats - les sept articles enoncant des recommandations selectionnees different sur les choix des antibiotiques (mais s'accordent pour choisir les plus anciens) dits de premiere ligne. Sur les 34 essais randomises de type equivalence [fluoroquinolones (12), macrolides (14), betalactamines (8)], aucun ne montre de difference avec les comparateurs. L'impact ecologique est rarement recherche. Deux etudes sur les couts sont en faveur des nouvelles molecules, mais elles sont retrospectives.Conclusion - On ne peut conclure a une superiorite des nouvelles molecules sur les anciennes, les desseins des etudes ne le permettant pas. De ce fait on ne peut les proposer en premiere intention meme si leur efficacite intrinseque est superieure a celle des molecules anciennes et si le taux de succes depasse celui decrit habituellement avec les antibiotiques dits de premiere ligne. Des etudes sont necessaires pour preciser les impacts economiques et ecologiques selon le choix des antibiotiques et leur efficacite a moyen terme.
Objective - The authors had for aim to assess the treatment of chronic bronchitis exacerbation, considering the recommendations or guidelines, clinical studies, and the evolution of bacterial resistance since 1991. The assessment was performed on antibiotics put on the market since 1991, considering their efficacy, treatment duration, the bacteriological impact, and the cost-effectiveness ratio.Method - Research was performed on Medline and on references quoted in various papers when needed, from 1991 to 1999. We selected randomized studies only, whether open or blind, and various items were collected such as the number of patients involved, selection and exclusion criteria, judgement criteria, statistical analysis, methodology.Results - For the seven recommendations or guidelines, the first choice treatment usually concerned old and low price molecules. 34 equivalence, randomized studies were selected (fluoroquinolones (12), macrolides (14), and betalactams (8)). No difference was demonstrated with the comparators. The ecological impact was not analyzed on an individual basis. The shortest duration treatment was as effective as the longest. The cost-effectiveness analysis was made in 2 retrospective studies, and seemed to be in favor of the new drugs.Conclusion - we cannot prove the superiority of new molecules: the clinical assessment were not meant for that but to assess equivalence. So, these new antibiotics cannot be recommended as the first line treatment despite a superior intrinsic activity as shown by their spectrum, and their efficacy rate, superior to that generally shown with first line antibiotics. More studies are needed to assess economical and ecological impact.