Prophylactic Antibiotics Reduce COPD Exacerbations in Stable Disease

In patients with stable moderate to severe chronic obstructive pulmonary disease (COPD), treatment with prophylactic antibiotics was effective in preventing exacerbations and improving quality of life, according to a study published in the Journal of Antimicrobial Chemotherapy.

Researchers systematically reviewed several clinical trials databases for randomized controlled trials focused on the use of prophylactic antibiotics in patients with stable COPD. A total of 12 randomized controlled trials comprising 3683 patients with COPD were included in the analysis. Antibiotics included in the analysis were azithromycin, erythromycin, moxifloxacin, clarithromycin, roxithromycin, and doxycycline. Exacerbations of COPD as well as overall quality of life were the primary outcome measures. The investigators also conducted a subgroup analysis that focused on the duration and schedule of antibiotics.

In the pooled analysis, treatment with prophylactic antibiotics was associated with a reduction in the frequency of COPD exacerbations (risk ratio [RR] 0.74; 95% CI, 0.60-0.92). Additionally, prophylactic antibiotics were associated with a reduction in the number of patients in the overall cohort with ≥1 COPD exacerbation (RR 0.82; 95% CI, 0.74-0.90). Two antibiotics — azithromycin and erythromycin — were most effective in the prevention of exacerbations. The number of antibiotics needed to treat patients ranged from approximately 4 to 7.

Prophylactic antibiotics were also associated with significant improvements in quality of life (mean difference, –1.55; 95% CI, –2.59 to –0.51). A total of 6 studies showed that antibiotic use was associated with prolongation of time to first exacerbation. No significant changes were observed in the hospitalization rate (RR 0.94; 95% CI, 0.83-1.06) or the rate of adverse events (RR 1.09; 95% CI, 0.84-1.42) compared with placebo in the pooled analysis of 5 and 8 studies, respectively. There was an observable increase in the number of antibiotic-resistant isolates following initiation of prophylactic antibiotics (odds ratio 4.49; 95% CI, 2.48-8.12).

Heterogeneity between studies, lack of data on concomitant therapies, inclusion of only patients with stable COPD, and the relatively small number of studies included in the analysis were potential limitations of the study.

The researchers added that, based on current evidence, physicians “should pay particular attention to the long and continuous use of antibiotics, considering the potential risk [for] bacterial resistance for future treatment of infections.”

Reference

Wang Y, Zijp TR, Bahar MA, Kocks JWH, Wilffert B, Hak E. Effects of prophylactic antibiotics on patients with stable COPD: a systematic review and meta-analysis of randomized controlled trials [published online September 4, 2018]. J Antimicrob Chemother. doi:10.1093/jac/dky326