FPIN's Clinical Inquiries

Antibiotic Prophylaxis for COPD Exacerbations

 

Am Fam Physician. 2018 Apr 15;97(8):527-528.

Clinical Question

Are prophylactic antibiotics effective in reducing chronic obstructive pulmonary disease (COPD) exacerbations?

Evidence-Based Answer

Prophylactic antibiotics may be used to reduce the overall rate of COPD exacerbations and delay their onset. (Strength of Recommendation: A, based on a high-quality systematic review of randomized controlled trials [RCTs].) However, the appropriate antibiotic regimen and target population are unclear.

Evidence Summary

A 2013 Cochrane review of seven RCTs (N = 3,170) examined whether the use of prophylactic antibiotics in patients with COPD reduces exacerbations or improves quality of life.1 The trials compared prophylactic oral antibiotics with placebo over three to 36 months. Five trials (N = 1,438) studied continuous prophylaxis with oral macrolide antibiotics (azithromycin [Zithromax], erythromycin, or clarithromycin [Biaxin]) vs. placebo. Two trials (N = 1,732) studied pulsed prophylaxis with oral moxifloxacin (Avelox) or azithromycin vs. placebo. Both regimens demonstrated an overall reduction in the number of treated patients who had one or more COPD exacerbations (four trials; N = 2,411; odds ratio [OR] = 0.64; 95% confidence interval [CI], 0.45 to 0.90; number needed to treat [NNT] = 13). Continuous prophylaxis with macrolides resulted in a decrease in the number of patients with one or more exacerbations (three trials; N = 1,262; OR = 0.55; 95% CI, 0.39 to 0.77; NNT = 8). Pulsed prophylaxis with moxifloxacin did not reduce the risk of exacerbations compared with placebo (one trial; n = 1,149; OR = 0.87; 95% CI, 0.69 to 1.09). Continuous prophylaxis with macrolide antibiotics resulted in a significant reduction in the rate of COPD exacerbations per patient-year (three trials; N = 1,262; rate ratio [RR] = 0.73; 95% CI, 0.58 to 0.91). One trial of azithromycin found that macrolide resistance was significantly higher in the treatment group (81% vs. 41%, P < .001), although only 15% of participants were able to give sputum for a culture. There were

Address correspondence to Corey Lyon, DO, at corey.lyon@ucdenver.edu. Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

References

show all references

1. Herath SC, Poole P. Prophylactic antibiotic therapy for chronic obstructive pulmonary disease (COPD). Cochrane Database Syst Rev. 2013;(11):CD009764....

2. Uzun S, Djamin RS, Kluytmans JA, et al. Azithromycin maintenance treatment in patients with frequent exacerbations of chronic obstructive pulmonary disease (COLUMBUS): a randomised, double-blind, placebo-controlled trial. Lancet Respir Med. 2014;2(5):361–368.

3. Shafuddin E, Mills GD, Holmes MD, Poole PJ, Mullins PR, Black PN. A double-blind, randomised, placebo-controlled study of roxithromycin and doxycycline combination, roxithromycin alone, or matching placebo for 12 weeks in adults with frequent exacerbations of chronic obstructive pulmonary disease. J Negat Results Biomed. 2015;14:15.

4. Celli BR, Decramer M, Wedzicha JA, et al.; ATS/ERS Task Force for COPD Research. An official American Thoracic Society/European Respiratory Society statement: research questions in chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2015;191(7):e4–e27.

Clinical Inquiries provides answers to questions submitted by practicing family physicians to the Family Physicians Inquiries Network (FPIN). Members of the network select questions based on their relevance to family medicine. Answers are drawn from an approved set of evidence-based resources and undergo peer review. The strength of recommendations and the level of evidence for individual studies are rated using criteria developed by the Evidence-Based Medicine Working Group (http://www.cebm.net).

The complete database of evidence-based questions and answers is copyrighted by FPIN. If interested in submitting questions or writing answers for this series, go to http://www.fpin.org or e-mail: questions@fpin.org.

This series is coordinated by John E. Delzell Jr., MD, MSPH, Associate Medical Editor.

A collection of FPIN's Clinical Inquiries published in AFP is available at http://www.aafp.org/afp/fpin.

 

 

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