Risk Of Bias In Included Studies
Overall we found that studies had low to moderate risk of bias . Thirteen of the 19 studies correctly performed and reported random sequence generation, blinding of participants and personnel, and intentiontotreat analysis. However, information on blinding, completeness of outcome data, and selective reporting was limited.
Antibiotics And Copd Exacerbations
Antibiotics can be effective for treating your COPD exacerbation, but only if you have a bacterial infection. By definition, these medications are designed to destroy bacteria. Your medical team can identify bacteria with a sputum sample, and they may also consider some of the signs that suggest that you could have a bacterial infection, including:
- An increase in dyspnea, cough, and/or purulent sputum
- Severe exacerbations requiring non-invasive or mechanical ventilation
Antibiotics In Acute Exacerbations Of Copd: The Good The Bad And The Ugly
You may well wonder what the connection might be between the title of this editorial and the famous Western The Good, the Bad and the Ugly. Well, we know that antibiotics are effective in treating bacterial infections , are not as harmless as both clinicians and patients may think , and may have adverse effects and do not work in viral infections . There is an increasing awareness that we have to challenge the problems caused by the overuse of antibiotics. Beliefs, expectations and incentives are the drivers of antibiotic overuse among the concerned parties: patients, physicians and society. Therefore, social norms would have to be altered, resulting in a fundamental change in patients’ expectations, marketing, indications for antibiotic use and, particularly, physicians prescription behaviour. In a recent paper by the McDonnell Norms Group , some radical solutions were suggested, ranging from changes in the way physicians are paid for prescribing antibiotics and looking at accuracy and limitation of antibiotic use to patients might be reimbursed differently for antibiotic prescriptions.
Further studies should be undertaken investigating biomarkers to guide antibiotic treatment and investigate the optimal duration of antibiotic treatment.
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Study Limitations And Future Perspectives
There were several limitations in this review. Firstly, there was some notable heterogeneity in the results between studies. On the one hand, due to limited information available, we could not completely analyse and exclude the influence on outcomes of potential differences in the distribution of baseline characteristics, especially COPD severity, exacerbation history and bacterial colonization, although all included patients were relative stable and had similar COPD severity . On the other hand, heterogeneity also existed between antibiotic therapies, as regimens, dosages, durations and follow-up times of antibiotic interventions were different. Secondly, the included patients may have been concomitantly taking other therapies, such as influenza vaccines, bronchodilators or inhaled corticosteroids, which could also have a potential impact on related outcomes if these factors are not comparable between antibiotic and placebo groups. For example, the LABA/LAMA combination as a maintenance therapy of COPD could reduce the rate of exacerbation., Thirdly, the definitions and measurements of some outcomes were different, such as the varying definitions of adverse events and varying methods for identifying antibiotic resistance. Finally, due to the limited number of studies included, we could not evaluate the effects of the different doses of a specific antibiotic in COPD patients.
Red Flags: Recognizing The Signs Of Lung Infections
Individually, the symptoms of a lung infection may also be caused by other things. Nonetheless, it is important to let your doctor know if you recognize any of them, so you can be diagnosed and receive treatment as soon as possible:
- A fever if you have a temperature of 100.4 F or higher , thats a sign that your body is fighting something, including a possible lung infection.
- Your shortness of breath is worse than it usually is.
- You have rapid, shallow, breathing.
- You are coughing up more sputum usually yellow, green, with traces of blood, or an ugly tan color.
- Your heart rate has increased.
- You have chest pain or a feeling of tightness in the chest.
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Setting In Current Literature And Future Directions
Durations of 7 days remained most prominent across different situations, but index duration was not significantly associated with further prescriptions. When encountering treatment failure, the decision was to change drug rather than duration studies are needed to investigate whether this is the correct approach. There is limited evidence and guidance on ideal index duration for antibiotics. A recent meta-analysis found that adverse effects in COPD patients were more prevalent when the same index antibiotic was given for more than 7 days compared with less than 7 days with no difference in clinical outcomes. A large retrospective analysis of UK primary care data showed that respiratory infections were responsible for the majority of antibiotics prescribed for longer than guidelines suggest, with 89% of COPD exacerbations receiving more than the recommended 5 days of treatment. In primary care, asthma patients 7-day courses were also associated with fewer repeat prescriptions. Our study also supports the consideration of shorter index durations, but interventional studies are needed to confirm this.
Second-line antibiotics used for LRTI by initial antibiotic: amoxicillin and not amoxicillin. Missing data due to missing drug name . LRTI, lower respiratory tract infection.
Treatment Of Acute Copd Exacerbation
, MD, Johns Hopkins Asthma and Allergy Center
Treatment of acute exacerbations involves
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Oxygen supplementation
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Sometimes ventilatory assistance with noninvasive ventilation or intubation and ventilation
The immediate objectives are to ensure adequate oxygenation and near-normal blood pH, reverse airway obstruction, and treat any cause.
The cause of an acute exacerbation is usually unknown, although some acute exacerbations result from bacterial or viral infections. Smoking, irritative inhalational exposure, and high levels of air pollution also contribute.
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How To Decipher If Antibiotics Are Needed
The Hospitalist identifies key points in evaluating antibiotic usage. Empiric therapy is not indicated. However, antibiotics may be used in patients more likely to have a bacterial infection as studies indicate that antibiotics are associated with reduced mortality and risk of adverse outcomes.
The use of labs alone should not determine the need for antibiotics. Clinical indicators can help to identify patients who may require an antibiotic . Simple versus complicated cases can help to determine the antibiotic of choice. Typically, a five-day course of oral antibiotics is recommended.
Whats 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 < 40 mg/L.
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Why It Is Important To Do This Review
We conducted this systematic review of the literature to inform patients, healthcare providers, and clinical practice guideline developers in a transparent way about the effects of antibiotics on patientimportant outcomes. This endeavour is important because antibiotics are likely to be perceived as beneficial in clinical practice by patients and healthcare providers based on the fact that most patients recover within weeks of starting treatment. However, only placebocontrolled trials can determine the cause of such recovery, which might be attributed to natural recovery from exacerbations , effects of antibiotics, or effects of other concomitant treatments such as systemic corticosteroids. Knowledge about the effects of antibiotics compared to placebo is important if one is to appreciate the results of the many randomised trials that have compared different antibiotics. Only if antibiotics are effective at all will such headtohead trials provide useful information .
There is growing recognition that COPD is a very heterogeneous disease , and that exacerbations are heterogeneous events . Systematic reviews have been used to guide the development of strong recommendations for clinical practice, and review findings have helped researchers identify areas in which additional research is needed. In the light of uncertainties surrounding the use of antibiotics for COPD exacerbations, it is hoped that the findings presented here will prove useful.
The Use Of Prophylactic Antibiotic Therapy In Prevention Of Copd Exacerbations
Evidence shows that there are limited benefits of using antibiotics for management of symptoms in acute exacerbations for people with Chronic Obstructive Pulmonary Disease and that viral infections account for the majority of exacerbations.1,2,3
However, prophylactic antibiotics can help reduce the frequency of exacerbations and consequently the likelihood of admission to hospital in certain COPD patient population groups. Lung Foundation Australia and the Thoracic Society of Australian and New Zealand COPD-X Guidelines recommend expert advice prior to commencing long-term antibiotic therapy for patients with COPD. The primary rationale behind this recommendation is the potential for significant risk of adverse effects of such regiments, including, but not limited to, antibiotic resistance.4
A recent Cochrane review focused on quality of life and exacerbation frequency in studies that assessed use of prophylactic macrolide treatment in frequent exacerbators with moderate to severe COPD. 5
The review demonstrated that use of prophylactic antibiotic treatment resulted in marked reduction in number of patients experiencing one or more exacerbations from 61% of participants in the control group compared to 47% in the treatment group . The test for subgroup difference suggested antibiotics given at least three times per week may be more effective than pulsed antibiotics .
References
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Testing For Bacterial Infections
There are newer tests that can help doctors determine if an infection is viral or bacterial.
One of these is a blood test known as procalcitonin. Many types of cells in the body produce the substance procalcitonin in response to a bacterial infection. While this test can help distinguish whether an infection is bacterial, it will not determine the type of bacteria.
Tests on sputum can help identify specific types of bacteria and determine what antibiotic should be prescribed.
Another test, called polymerase chain reaction, looks at the genetics in sputum collected with a swab of the nose or throat to detect whether an infection is viral.
According to 2017 guidelines published by a task force of COPD experts, use of antibiotics in ambulatory patients with exacerbations of COPD reduces the treatment failure rate and increases the time to the next exacerbation. However, the guidelines add, not all exacerbations require treatment with antibiotics. They also cited some adverse effects from antibiotic treatment, including mild gastrointestinal side effects such as diarrhea.
A study published in the New England Journal of Medicine found that people with COPD benefited from treatment with the antibiotic azithromycin . However, a small percentage of subjects experienced some hearing loss.
Developing A Copd Action Plan
Doctors and other healthcare professionals develop COPD action plans specifically for an individual. When designing the plan, they should consider the severity of the persons COPD, their medications, and their overall health.
The doctor should include personalized information on when to take medications, call the doctor, or seek emergency care. The plan may also allow people to track their health, including any changes to their condition or concerns that they wish to discuss with a doctor.
It is important that people with COPD understand their action plan and feel comfortable following it.
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What Is Broad Spectrum Antibiotics
The term “broad spectrum antibiotics” was originally used to designate antibiotics that were effective against both gram-positive and gram-negative bacteria, in contrast to penicillin, which is effective chiefly against gram-positive organisms, and streptomycin, which is active primarily against gram-negative bacteria.
Antibiotics Should Be Restricted For Copd
Healthcare professionals should consider the risk of antimicrobial resistance when deciding whether antibiotics are needed for treating or preventing a flare up of symptoms of chronic obstructive pulmonary disease .
05 December 2018
These new recommendations come as NICE publishes antimicrobial prescribing guidance and a separate update to its 2010 clinical guideline on diagnosing and managing COPD in over 16s.
The antimicrobial guidance recommends that antibiotics should be offered to people who have a severe flare up of symptoms, also known as a severe acute exacerbation.
However other factors should be taken into account when considering the use of antibiotics for treating an acute exacerbation that is not severe, such as the number and severity of symptoms.
The guidance notes that acute exacerbations of COPD can be caused by a range of factors including viral infections and smoking. Only around half are caused by bacterial infections, so many exacerbations will not respond to antibiotics.
Paul Chrisp, director of the centre for guidelines at NICE, said: Evidence shows that there are limited benefits of using antibiotics for managing acute exacerbations of COPD and that it is important to take other options into account before antibiotics are prescribed.
“These recommendations will help healthcare professionals to make responsible prescribing decisions, which will not only help people manage their condition but also reduce the risk of antimicrobial resistance.
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Data Collection And Analysis
Two review authors independently screened references and extracted data from trial reports. We kept the three groups of outpatients, inpatients, and patients admitted to the intensive care unit separate for benefit outcomes and mortality because we considered them to be clinically too different to be summarised as a single group. We considered outpatients to have a mild to moderate exacerbation, inpatients to have a severe exacerbation, and ICU patients to have a very severe exacerbation. When authors of primary studies did not report outcomes or study details, we contacted them to request missing data. We calculated pooled risk ratios for treatment failure, Peto odds ratios for rare events , and mean differences for continuous outcomes using randomeffects models. We used GRADE to assess the quality of the evidence. The primary outcome was treatment failure as observed between seven days and one month after treatment initiation.
Guidelines Urge Choosing Antibiotics Wisely
Guidelines to be published in December by the National Institute for Health and Care Excellence in the United Kingdom urge doctors to think about the risk of antibiotic resistance when considering antibiotics to prevent or treat COPD exacerbations. The draft guidelines recommend that doctors consider these factors:
- Frequency of exacerbations
- Severity of exacerbations
- Indications of pneumonia, such as the results of a chest X-ray
The draft guidelines also recommend consulting with local experts on what bacteria are circulating to choose the most effective antibiotic.
Used appropriately, antibiotics can be a valuable tool in treating patients who have COPD exacerbations, says Hill. This is particularly true in those patients who are hospitalized or who have more severe disease. Contrarily, inappropriate use of antibiotics increases costs and risks. New diagnostic tools should soon be more widely available to help clinicians make appropriate therapeutic choices.
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Study Summary: Using Antibiotics Often Resolves Symptoms
Llor et al1 conducted a multicenter, double-blind placebo-controlled RCT to examine the effectiveness of antibiotic treatment for COPD exacerbations. Participants had mild to moderate COPD, defined as 10 pack-years of smoking, a forced expiratory volume in 1 second > 50%, and a FEV1-to-forced vital capacity ratio < 0.7. An exacerbation was defined as at least one of the following: increased dyspnea, increased sputum volume, or sputum purulence. Patients were randomized to receive amoxicillin/clavulanate 500/125 mg or placebo 3 times a day for 8 days. The primary endpoints were clinical cure and clinical success at Days 9 to 11 as determined by physician assessment. Secondary measures included cure and clinical success at Day 20 and time until next exacerbation. Patients were monitored for one year after the exacerbation.
The Truth About Antibiotics And Copd
Susan Russell, MD is a board-certified pulmonologist and currently the Medical Director for Northwestern Memorial Hospital’s Inpatient Pulmonary Unit.
COPD is a chronic lung disease characterized by a predisposition to recurrent COPD exacerbations, some of which are complicated by lung infections. However, the exact role of bacterial, viral, or other infections in COPD is not always clear.
Antibiotics are prescription medications used to treat bacterial infections in the body. Bacterial infections often require treatment because they may not resolve on their own. These medications can be beneficial for treating and preventing infections associated with COPD, but they can cause side effects. Experts suggest that antibiotics may be overused in COPD, and strategies are emerging for optimizing the use of antibiotics so that people living with COPD will be prescribed an antibiotic only in situations when it would be beneficial.
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Benefits And Risks Of Antibiotics To Treat Copd
There is no question that antibiotics are effective against many types of bacterial infections as long as the bacteria hasnt developed antibiotic resistance. If you have COPD and develop a respiratory infection for any reason, your doctor will almost certainly prescribe antibiotics to help you get better.
However, the role of preventative antibiotics for COPD patients are mixed, even though research shows that antibiotics can both prevent COPD exacerbations , and treat COPD exacerbations . The main topic of dispute is not whether preventative antibiotics work, but whether or not their benefits are worth their risks.
This is a question that, for now, can only be answered on a case-by-case basis. Its up to you and your doctor to decidebased on your disease severity, infection risk, and other personal health factorsif taking continuous or preventative antibiotics is right for you.
One of the main risks of taking antibiotics is antibiotic resistance this happens when bacteria mutate and become less susceptible to the effects of an antibiotic medication. This is a problem that affects everyonenot just those currently taking antibioticswhich is why antibiotic resistance is such a serious public health concern.
