Preventative antibiotic therapy for people with COPD

http://www.cochrane.org/CD009764/AIRWAYS_preventative-antibiotic-therapy-for-people-with-copd

What is COPD?

COPD is a common chronic respiratory disease mainly affecting people who smoke now or have done so previously. It could become the third leading cause of death worldwide by 2030. People with COPD experience gradually worsening shortness of breath and cough with sputum because of permanent damage to their airways and lungs. Those with COPD may have flare-ups (or exacerbations) that usually occur after respiratory infections. Exacerbations may lead to further irreversible loss of lung function with days off work, hospital admission, reduction in quality of life and they may even cause death.

Why did we do this review?

We wanted to find out if giving antibiotics to prevent a flare-up, 'prophylactic' antibiotics, would reduce the frequency of infections and improve quality of life. Studies that were taken into consideration used either continuous prophylactic antibiotics on a daily basis or prophylactic antibiotics that were used intermittently.

What evidence did we find?

We found seven randomised controlled trials (RCTs) involving 3170 patients. All studies were published between 2001 and 2011. Five studies were of continuous antibiotics and two studies were of intermittent antibiotic prophylaxis. The antibiotics investigated were azithromycin, erythromycin, clarithromycin and moxifloxacin. On average, the people involved in the trials were 66 years old and had either moderate or severe COPD. Three trials included participants with frequent exacerbations and two of the trials recruited participants requiringsystemic steroids or antibiotics, or both, or who were at the end stage of their disease and required oxygen.

Results and conclusions

We found that with the use of continuous daily antibiotics the number of patients who developed an exacerbation reduced markedly. For every eight patients treated, one person would be prevented from suffering an exacerbation. There may have been a benefit on patient-reported quality of life with the antibiotics. On the other hand, use of antibiotics did not significantly affect the number of deaths due to any cause, the frequency of hospitalisation, or the loss of lung function during the studyperiod.

Even though there may be fewer exacerbations with continuous antibiotics there are considerable drawbacks. First, there were specific adverse events associated with the antibiotics, which differed according to the antibiotic used; second, patients have to take antibiotics regularly for years or months; finally, the resulting increase in antibiotic resistance will have implications for both individual patients and the wider community through reducing the effectiveness of currently available antibiotics.

Because of concerns about antibiotic resistance and specific adverse effects, consideration of prophylactic antibiotic use should bemindful of the balance between benefits to individual patients and the potential harms to society created by antibiotic overuse.

Authors' conclusions:

Use of continuous prophylactic antibiotics results in a clinically significant benefit in reducing exacerbations in COPD patients. All trials of continuous antibiotics used macrolides hence the noted benefit applies only to the use of continuous macrolide antibiotics. The impact of pulsed antibiotics remains uncertain and requires further research.

The trials in this review included patients who were frequent exacerbators and needed treatment with antibiotics or systemic steroids, or who were on supplemental oxygen. There were also older individuals with a mean age of 66 years. The results of these trials apply only to the group of patients who were studied in these trials and may not be generalisable to other groups.

Because of concerns about antibiotic resistance and specific adverse effects, consideration of prophylactic antibiotic use should bemindful of the balance between benefits to individual patients and the potential harms to society created by antibiotic overuse.