October 22, 2019
By Marilynn Larkin
NEW YORK (Reuters Health) - Antibiotics are overprescribed for chronic obstructive pulmonary disease (COPD), and particularly for mild-to-moderate disease, a large observational study reveals.
"Antibiotic treatment brings both risks and benefits for patients," study coauthor Dr. Laura Shallcross of University College London told Reuters Health by email. "Balancing these risks is particularly difficult in primary care, where doctors have limited information, and delaying antibiotics could cause a COPD exacerbation."
"A recent multicenter trial showed that antibiotic prescribing can be reduced safely in COPD patients by using a rapid diagnostic (C-reactive protein) test," she noted. [https://www.nejm.org/doi/10.1056/NEJMoa1803185 ]. "But changing prescribing practice in the absence of rapid diagnostics is challenging, as COPD patients often expect antibiotic treatment, and again, clinicians are keen to avoid triggering exacerbations by delaying antibiotics."
Using a large English primary care database, Dr. Shallcross and colleagues analyzed data from 19,594 COPD patients (mean age, 71; 46% women) from 157 practices who were followed for a year (2015). Approximately 70%-80% had mild-to-moderate disease (GOLD 1-2 or MRC 1-3).
As reported online October 9 in the Journal of Antimicrobial Chemotherapy, this cohort represented 2.6% of all patients in those practices, and 11.5% of all prescribed antibiotics.
More specifically, 833 patients (4.5%) with severe COPD and frequent acute exacerbations were prescribed six to nine prescriptions per year and accounted for 13% of antibiotics. However, individuals with mild-to-moderate COPD and no more than one acute exacerbation received one to three prescriptions per year, accounting for 42.5% of all prescriptions.
In adjusted analyses, factors associated with higher rates of antibiotic prescribing were: increasing age (>60 years); female sex (rate ratio, 1.29); and comorbidities including asthma (RR, 1.22;), coronary heart disease (RR, 1.08), diabetes (RR, 1.07), and heart failure (RR, 1.17).
Rates were also higher in patients who had received an influenza vaccination (RR, 1.23). By contrast, current smokers received 9% fewer antibiotics on average (RR, 0.91).
Dr. Shallcross said, "Quantifying the harms of unnecessary antibiotic use in patients with chronic disease, as well as the benefits, could help clinicians balance prescribing decisions."
Dr. Joanna Beros, Assistant Professor of Thoracic Medicine and Surgery at the Lewis Katz School of Medicine at Temple University in Philadelphia said, "These (observational) findings are...what I would expect to see."
"It was interesting that individuals with asthma as well as COPD are getting more antibiotics, which shows me this may be an area we can educate primary care providers more (about), as there is not good evidence to support the use of antibiotics in asthma exacerbations," she said. "Smokers received less antibiotics, which I would hope is because they are instead getting counseled on the benefits of smoking cessation as opposed to being given a prescription for antibiotics."
"I would hesitate to make the conclusion that the use of antibiotics in the treatment of COPD exacerbations is wrong," she noted. "Currently, guidelines support using them in individuals who have increased dyspnea, increased sputum volume and change in quality - i.e., more purulent sputum - along with certain risk factors."
"For now," she said, "I would encourage clinicians to follow what the guidelines say in the management of acute exacerbations of COPD and to not inappropriately stop utilizing a potentially helpful intervention in the appropriate patient."
"At Temple, we try to identify high-risk patients and work on interventions that will help to reduce the risk of exacerbations," she said. "We have a smoking cessation program...and utilize medications outside of the antimicrobial class, such as roflumilast, which has been shown to reduce exacerbations."
"We work closely with our gastroenterologists and ear, nose and throat specialists to treat co-morbidities such as gastroesophageal reflux and sinus disease that will increase risk for exacerbations and need for antibiotics," she added," and we coach people on good oral hygiene."
"We regularly do not use antibiotics in low-risk individuals and instead counsel more on appropriate inhaler use or try to adjust inhaled therapies," she said.
J Antimicrob Chemother 2019.
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