A Cochrane review on the effects of antibiotics in the management of acute COPD exacerbations included 16 studies with a total of 2 068 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 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). In other inpatients there was no effect of antibiotics on mortality (Peto OR 1.02; 95% CI 0.37 to 2.79; 4 trials) or on the length of hospital stay but they significantly reduced the risk of treatment failure in severe exacerbations (RR 0.77; 95% CI 0.65 to 0.91; I2 = 47%) regardless of whether restricted to current drugs. In outpatients (mild to moderate exacerbations), antibiotics did not significantly reduce the risk for treatment failure when the meta-analysis was restricted to currently available drugs (RR 0.80; 95% CI 0.63 to 1.01; I2 = 33%). Patients treated with antibiotics experienced statistically significantly more diarrhoea (Peto OR 2.62; 95% CI 1.11 to 6.17; 3 trials).
| Outcome | Number of participants (trials) | Control: Placebo | Intervention: Antibiotics | Effect size (95 % CI) |
|---|---|---|---|---|
| Treatment failure in outpatients | 790 (5) | 20% | 15% | RR 0.75 (0.60 to 0.94) |
| Treatment failure in ICU patients | 93 (1) | 56% | 11% | RR 0.19 (0.08 to 0.45) |
| Treatment failure in inpatients | 385 (2) | 34% | 24 % | RR 0.71 (0.55 to 0.92) |
| All cause mortality in ICU patients | 93 (1) | 22% | 5% | OR 0.21 (0.06 to 0.72) |
| All cause mortality in inpatients | 223 (1) | 3% | 7% | Peto OR 2.51 (0.71 to 8.90 |
| Diarrhea | 698 (3) | 2% | 4% | Peto OR 2.62 (1.11 to 6.17) |
A systematic review including 13 studies with a total of 1 557 subjects was abstracted in DARE. Among participants with severe COPD, antibiotics were associated with lower mortality (OR 0.20, 95% CI 0.06 to 0.62; 4 studies, n=475; NNT=14, 95% CI 12 to 30) and with lower treatment failure rate (OR 0.25, 95% CI 0.16 to 0.39); NNT=4, 95% CI 3 to 5) than placebo. Among participants with mild to moderate COPD, antibiotics were not associated with a treatment failure rate (OR 1.09, 95% CI 0.75 to 1.59; 5 studies, n=581; one study causing significant heterogeneity omitted). Antibiotics were not associated with duration of hospital admission in two studies, but the length of hospital stay was reduced in a third study. Antibiotics were associated with a higher rate of adverse events than placebo (0.15 versus 0.08; significant heterogeneity between studies, I2=62%).
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: 13.09.2012
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