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Antibiotics in acute exacerbations of chronic obstructive pulmonary disease
  1. Ross Murphy, Specialist Registrar,
  2. Martin McKechnie, Specialist Registrar,
  3. Joel Dunning, RCS Fellow
  1. Department of Emergency Medicine, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK; kevin.mackway-jonesman.ac.uk

    Abstract

    A short cut review was carried out to establish whether antibiotics improve recovery in patients with acute exacerbations of COPD. Altogether 200 papers were found using the reported search, of which four presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these best papers are tabulated. A clinical bottom line is stated

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    Report by Ross Murphy, Specialist RegistrarChecked by Martin McKechnie, Specialist RegistrarJoel Dunning, RCS Fellow

    Clinical scenario

    A 78 year old man with a history of COPD attends the emergency department with a recent increase in shortness of breath, cough, and wheeze. You diagnose him as suffering from an exacerbation of COPD and treat him with oxygen, nebulised salbutamol, and corticosteroids. You wonder if a course of antibiotics would also be of benefit.

    Three part question

    In [a patient with an acute exacerbation of COPD] does [administration of a course of antibiotics] improve [outcome and hasten recovery]?

    Search strategy

    Medline 1966-11/03 using the Ovid interface. In addition the Cochrane Database of Systematic Reviews was searched and the National Institute of Clinical Excellence web site was searched for relevant guidelines. [{(exp chronic disease OR exp hospitals, chronic disease OR chronic.mp) AND (exp lung disease, obstructive OR obstructive.mp)} OR exp emphysema OR exp pulmonary emphysema OR emphysema.mp OR exp bronchitis OR bronchitis.mp OR exp COPD.mp OR COAD.mp OR airway obstruction.mp] AND [exp acute disease OR acute.mp OR exacerbation.mp] AND [exp antibiotics OR antibiotic$.mp] AND [exp Meta-analysis OR meta-analysis.mp OR exp review literature OR Review.mp OR systematic review.mp OR guideline$.mp OR exp clinical protocol OR protocol.mp]

    Search outcome

    Altogether 200 papers were found of which four meta-analyses or systematic reviews provided the highest level of evidence (see table 3).

    Table 3

    Comment(s)

    A large number of papers have addressed this question in hospital and community settings. A well conducted meta-analysis by Saint et al found nine randomised controlled trials in this area and found a statistically significant mortality benefit in patients receiving antibiotics. In addition they showed a significant benefit in terms of peak expiratory flow rate. Several large groups have published guidelines. The American Colleges joint statement found an additional two papers to Saint et al, and concluded that antibiotics were of benefit and that the more severe the exacerbation the greater the benefit.

    The British Thoracic Society Guidelines state that antibiotics should be used for anyone with two of: increased breathlessness, increased production of sputum, or purulent sputum.

    NICE are currently in their second draft for producing new guidelines in this area.In addition to the 11 papers used above they have found three more studies of interest. They recommend that all patients with purulent sputum should have antibiotics and that there is greater benefit in patients with more severe underlying disease.

    CLINICAL BOTTOM LINE

    Antibiotics improve outcome in acute exacerbations of COPD, especially when associated with purulent sputum, more severe exacerbations, or severe underlying disease.

    Report by Ross Murphy, Specialist RegistrarChecked by Martin McKechnie, Specialist RegistrarJoel Dunning, RCS Fellow

    References

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