A Cochrane review [Abstract] 1 on the effects of antibiotics in the management of acute COPD exacerbations included 19 studies (11 with outpatients, seven with inpatients, and one with ICU patients) with a total of 2 663 subjects. Treatment failure as the primary outcome was defined as no resolution or deterioration of symptoms after medication, additional course of antibiotics or other medication, or death due to the exacerbation. Only results from studies using current medicines are included in this summary.
In outpatients (with mild to moderate exacerbations), evidence of low quality suggests that currently available antibiotics statistically significantly reduced the risk for treatment failure between seven days and one month after treatment initiation (RR 0.72, 95% CI 0.56 to 0.94; I² = 31%; in absolute terms, reduction in treatment failures from 295 to 212 per 1000 treated participants, 95% CI 165 to 277). Evidence of low quality from one trial in outpatients suggested no effects of antibiotics on mortality (Peto OR 1.27, 95% CI 0.49 to 3.30). One trial reported no effects of antibiotics on re-exacerbations between two and six weeks after treatment initiation.
Among inpatients with severe exacerbations (i.e. for inpatients excluding ICU patients), evidence of moderate quality does not show that currently used antibiotics statistically significantly reduced the risk of treatment failure (RR 0.65, 95% CI 0.38 to 1.12; I² = 50%), but trial results remain uncertain. Evidence of moderate quality from two trials including inpatients shows no beneficial effects of antibiotics on mortality (Peto OR 2.48, 95% CI 0.94 to 6.55). Length of hospital stay (in days) was similar in antibiotic and placebo groups.
In ICU patients (1 trial, n=93), antibiotics had a statistically significant effect on mortality (Peto OR 0.21; 95% CI 0.06 to 0.72), on treatment failure (RR 0.19; 95% CI 0.08 to 0.45) and on the length of hospital stay (mean difference -9.60 days; 95% CI -12.84 to -6.36 days).
Evidence of moderate quality gathered from trials conducted in all settings shows no statistically significant effect on overall incidence of adverse events (Peto OR 1.20, 95% CI 0.89 to 1.63; moderate quality evidence) nor on diarrhoea (Peto OR 1.68, 95% CI 0.92 to 3.07; moderate quality evidence)
| Outcome | Number of participants (trials) | Control:Placebo | Intervention:Antibiotics | Effect size (95 % CI) |
|---|---|---|---|---|
| Treatment failure in outpatients within 4 weeks (current drugs only) | 1191(7) | 295 per 1000 | 212 per 1000(165 to 277) | RR 0.72 (0.56 to 0.94) |
| Treatment failure in ICU patients within 4 weeks (drugs not currently used) | 93(1) | 565 per 1000 | 107 per 1000(45 to 254) | RR 0.19(0.08 to 0.45) |
| Treatment failure in inpatients within 4 weeks (current drugs only) | 576(4) | 314 per 1000 | 204 per 1000(119 to 352) | RR 0.65(0.38 to 1.12) |
| All cause mortality in ICU patients | 93(1) | 217 per 1000 | 45 per 1000(13 to 152) | OR 0.21(0.06 to 0.72) |
| All cause mortality in inpatients | 214(2) | 31 per 1000 | 41 per 1000(18 to 90) | Peto OR 2.48(0.94 to 6.55) |
| Diarrhoea | 1099(5) | 31 per 1000 | 52 per 1000(29 to 90) | Peto OR 1.68(0.92 to 3.07) |
Comment: The quality of evidence is downgraded by inconsistency (variability in results across studies).
As only half of the exacerbations of COPD are of bacterial origin, the patients with non-severe conditions should be screened for certain clinical signs (e.g. purulent sputum) or biomarkers (e.g. C-reactive protein) before administering antibiotics.
Date of latest search: 30.04.2018
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