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Am Fam Physician. 2019;100(3):185

Clinical Question

Does the use of antibiotics in patients hospitalized with an asthma exacerbation result in better outcomes?

Bottom Line

Antibiotics do not benefit patients hospitalized with an asthma exacerbation. Evidence from this study suggests worse outcomes with antibiotic use, including a longer hospital stay, higher costs, and greater risk of diarrhea. Antibiotic use was not associated with a decreased risk of treatment failure. Although findings were not unexpected, it is surprising that almost one-half of the patients in this study were receiving antibiotics, despite current guidelines. (Level of Evidence = 2b)


Although current evidence does not support the use of antibiotics for the management of acute asthma exacerbations, patients continue to receive them. Using an administrative database that includes 543 nonteaching hospitals in the United States, the investigators identified patients who were hospitalized during a two-year period with a principal diagnosis of asthma being treated with systemic corticosteroids. Those with a potential indication for antibiotic treatment, such as a secondary diagnosis of chronic obstructive pulmonary disease, were excluded, leaving a total of 19,811 patients. The median age of the cohort was 46 years, and 73% were women. The exposure of interest was the use of antibiotics within the first two days of hospitalization for a minimum of two days, which was noted in 44% of the overall cohort. The comparison was the subset of patients who either did not receive any antibiotics or did not receive antibiotics within the first two days. The primary outcome was hospital length of stay. Patients treated with early antibiotics were older and more likely to be white. They were also more likely to have comorbidities, including congestive heart failure, diabetes mellitus, and renal failure. The most common antibiotic class used was macrolides. In a propensity-matched cohort of 13,666 patients, exposure to early antibiotics was associated with a longer length of stay (four days vs. three days) and higher hospitalization costs ($4,776 vs. $3,641). The risks of treatment failure and 30-day mortality were similar in the two groups. In a sensitivity analysis that compared patients who received early antibiotics with those who received no antibiotics at all, the risk of diarrhea was 2.6 times higher. However, in patients treated only with macrolides compared with those treated with other antibiotics, the incidence of antibiotic-related diarrhea was lower (1.1% vs. 2.0%; P < .001).

Study design: Cohort (retrospective)

Funding source: Unknown/not stated

Setting: Inpatient (any location) with outpatient follow-up

Reference: StefanMSShiehMSpitzerKAet alAssociation of antibiotic treatment with outcomes in patients hospitalized for an asthma exacerbation treated with systemic corticosteroids. JAMA Intern Med2019;179(3):333–339.

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