WHAT’S NEW?
Evidence supports antibiotics for mild to moderate COPD
Few placebo-controlled trials have addressed antibiotic use for exacerbations in patients with mild to moderate COPD.2,8,9 This study demonstrated that, compared with placebo, symptom resolution and clinical success is greater with amoxicillin/clavulanate and that antibiotic treatment also may increase time until next exacerbation.
The study also looked at the relationship of CRP and exacerbations in the placebo group. Higher spontaneous clinical cure rates were noted when the CRP was lower than 40 mg/L.
CAVEATS
Effects of concomitant medications are unclear
In both the placebo and antibiotic groups, patients were taking other medications (including short- and long-acting β-agonists, anticholinergics, theophyllines, and oral or inhaled corticosteroids). Roughly the same number of patients in each group took additional medications, but researchers did not conduct a subgroup analysis to see if patients treated with these medications responded differently from those who received antibiotics alone.
GOLD guidelines already suggest antibiotics for exacerbations in patients with moderate COPD.2 In this study, 89% of patients met criteria for moderate COPD and 11% for mild COPD. Though the percentage of patients who had mild COPD was small, we believe the results of this study warrant consideration of antibiotic use in patients with mild disease. Local antibiograms may show increased resistance to amoxicillin/clavulanate; this study did not address the use of other antibiotics.
CHALLENGES TO IMPLEMENTATION
Antibiotic overuse may be a concern
Concerns about antibiotic resistance may make clinicians reluctant to prescribe the drugs for those with mild to moderate COPD.
REFERENCES
1. Llor C, Moragas A, Hernández S, et al. Efficacy of antibiotic therapy for acute exacerbations of mild to moderate chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2012;186(8):716-723.
2. Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. January 2014. www.goldcopd.org/guidelines-global-strategy-for-diagnosis-management.html. Accessed April 15, 2014.
3. Donaldson GC, Seemungal TA, Bhowmik A, et al. Relationship between exacerbation frequency and lung function decline in chronic obstructive pulmonary disease. Thorax. 2002;57(10):847-852.
4. Soler-Cataluña JJ, Martínez-García MA, Román Sánchez P, et al. Severe acute exacerbations and mortality in patients with chronic obstructive pulmonary disease. Thorax. 2005;60(11):925-931.
5. Vollenweider DJ, Jarrett H, Steurer-Stey CA, et al. Antibiotics for exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2012;12:CD010257.
6. Bartlett, JG, Sethi S. Management of infection in acute exacerbations of chronic obstructive pulmonary disease. In: Basow DS, ed. UpToDate. www.uptodate.com. Last updated March 27, 2012. Accessed January 2, 2013.
7. Lacoma A, Prat C, Andreo F, et al. Value of procalcitonin, C-reactive protein, and neopterin in exacerbations of chronic obstructive pulmonary disease. Int J Chron Obstruct Pulmon Dis. 2011;6:157-169.
8. Antonescu-Turcu AL, Tomic R. C-reactive protein and copeptin: prognostic predictors in chronic obstructive pulmonary disease exacerbations. Curr Opin Pulm Med. 2009;15(2):120-125.
9. Thomsen M, Ingebrigtsen TS, Marott JL, et al. Inflammatory biomarkers and exacerbations in chronic obstructive pulmonary disease. JAMA. 2013;309(22):2353-2361.
ACKNOWLEDGEMENT
The PURLs Surveillance System was supported in part by Grant Number UL1RR024999 from the National Center for Research Resources, a Clinical Translational Science Award to the University of Chicago. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Center for Research Resources or the National Institutes of Health.
Copyright © 2014. The Family Physicians Inquiries Network. All rights reserved.
Reprinted with permission from the Family Physicians Inquiries Network and The Journal of Family Practice. 2014;63(4):E11-E13.