Credits Earned (2024) Crédits obtenus

Redeem Prepaid Membership

Tools for Practice Outils pour la pratique


#62 Daily Prophylactic Antibiotics in COPD? If so, who?


CLINICAL QUESTION
QUESTION CLINIQUE
Are daily prophylactic antibiotics reasonable for preventing acute exacerbations of COPD (and if so, in which patients)?


BOTTOM LINE
RÉSULTAT FINAL
In select patients with severe COPD and recurrent exacerbations, prophylactic antibiotics may reduce exacerbations for about one in 10. Balanced against possible increased resistance and adverse events, present use should be very limited.  



CFPCLearn Logo

Reading Tools for Practice Article can earn you MainPro+ Credits

La lecture d'articles d'outils de pratique peut vous permettre de gagner des crédits MainPro+

Join Now S’inscrire maintenant

Already a CFPCLearn Member? Log in

Déjà abonné à CMFCApprendre? Ouvrir une session



EVIDENCE
DONNÉES PROBANTES
Three randomized controlled trials (RCTs):    
  • 1,142 severe COPD patients (60% on O2, 48% on all three puffers), randomized to azithromycin 250 mg daily or placebo:1 
    • At one year, azithromycin: 
      • Decreased exacerbations, hazard ratio 0.73 (0.63-0.84).   
      • Decreased patients ≥1 exacerbation: 57% versus 68%, Number Needed to Treat (NNT)=10. 
      • Clinically important improved quality of life, NNT=15. 
    • Harms: 5% more had decreased hearing and macrolide resistance from nasopharyngeal swabs increased (81% versus 41%).  
  • 109 COPD patients, 35% had ≥3 exacerbations last year, randomized to erythromycin 250 mg BID or placebo:2 
    • Erythromycin reduced exacerbations, rate ratio 0.65 (0.49-0.86). 
    • No difference in adverse events. 
  • 1,157 COPD patients with ≥2 exacerbations last year, randomized to moxifloxacin 400 mg daily x 5 days every 8 weeks or placebo for 48 weeks:3   
    • Non-significant trend to reduced exacerbation (odds ratio 0.81, 0.65-1.01).  
      • No impact on hospitalization, mortality, or quality of life.  
    • Harms: More adverse events (primarily GI) from treatment, 9.3% versus 3.8%, Number Needed to Harm (NNH)=19. 
  • Systematic review of seven RCTs (3170 patients):4 
    • Decreased patients ≥1 exacerbation, Odds Ratio 0.64 (results inconsistent). 
      • Subgroup analysis of studies that used continuous antibiotics: OR 0.55, NNT=8 over 10 months. 
    • Rate of exacerbations, time to first exacerbation, and quality of life improved with prophylaxis.   
    • No effect on admissions or mortality. 
    • Resistance not consistently defined/reported. 
  • Other systematic reviews found similar,5-7 although one found a reduction in admissions (RR=0.79).5   
Context:   
  • Recent guidelines either suggest use of prophylaxis in patients with moderate-severe COPD with ≥1 moderate-severe exacerbation/year despite optimal inhalers8 or state benefits do not outweigh risks.9 
  • The reduction in exacerbation is similar to long-acting inhaled therapies.10,11 
  • Macrolide antibiotics are used chronically in respiratory disorders such as cystic fibrosis and diffuse panbronchiolitis.12  
    • Effect may be anti-inflammatory more than antimicrobial.  
updated june 30 2015


Latest Tools for Practice
Derniers outils pour la pratique

#369 Remind me, do medications that target brain amyloid improve my dementia?

Are amyloid-targeting monoclonal antibodies safe and effective for mild cognitive impairment or Alzheimer’s dementia?
Read Lire 0.25 credits available Crédits disponibles

#368 Sodium Restriction in Heart Failure: Beneficial or pouring salt in the wound?

Does sodium restriction improve outcomes in patients with chronic heart failure?
Read Lire 0.25 credits available Crédits disponibles

#367 Oral Calcitonin Gene-related Peptide Antagonists: A painfully long name for the acute treatment of migraines

What are the risks and benefits of ubrogepant for the acute treatment of episodic migraines?
Read Lire 0.25 credits available Crédits disponibles

This content is certified for MainPro+ Credits, log in to access

Ce contenu est certifié pour les crédits MainPro+, Ouvrir une session


Author(s)
Auteur(s)
  • G. Michael Allan MD CCFP
  • Geetika Verma MD FRCPC

1. Albert RK, Connett J, Bailey WC, et al. N Engl J Med. 2011; 365 (8):689-98.

2. Seemungal TA, Wilkinson TM, Hurst JR, et al. Am J Respir Crit Care Med. 2008; 178:1139-47.

3. Sethi S, Jones PW, Theron MS, et al. Respir Res. 2010; 11:10.

4. Herath SC, Poole P. Cochrane Database System Rev. 2013; 11:CD009764.

5. Donath E, Chaudhry A, Hernandez-Aya LF, et al. Respir Med. 2013; 107(9):1385-92.

6. Lee JS, Park DA, Hong Y, et al. Int J Tuberc Lung Dis. 2013; 17(2):153-62.

7. Ni W, Shao X, Cai X, et al. PLoS One. 2015 Mar 26; 10(3):e0121257.

8. Criner GJ, Bourbeau J, Diekemper RL, et al. Chest. 2015; 147(4):894-942.

9. Global Initiative for Chronic Obstructive Lung Disease. Global Strategy for the Diagnosis, Management and Prevention of COPD, 2015. Available at: www.goldcopd.org. Last accessed June 30, 2015.

10. Wilt TJ, Niewoehner D, MacDonald R, et al. Ann Intern Med. 2007; 147:639-53.

11. McDonald C. ACP J Club. 2008; 148(2):49.

12. Martinez FJ, Curtis JL, Albert R. Int J Chron Obstruct Pulmon Dis. 2008; 3:331-50.

Authors do not have any conflicts of interest to declare.

Les auteurs n’ont aucun conflit d’intérêts à déclarer.

Most recent review: 30/06/2015

By: Adrienne J Lindblad BSP ACPR PharmD

Comments:

Evidence Updated: 4 systematic reviews added, context updated; Bottom Line: Unchanged.

Learning at a glance
Yearly credits
Acquired ()
Your content by topic
Cardiology Dermatology Emergency
My Bookmarks