Table 3
Author, date and countryPatient groupStudy type (level of evidence)OutcomesKey resultsStudy weaknesses
Saint S et al, 1995, USA9 randomised trials (nā€Š=ā€Š1101) including npatients and outpatients with exacerbations of COPDMeta-analysisMortality benefit of antibiotics v placebo, (effect size transformed into units of standard deviation)0.22 (95% CI 0.10 to 0.34).English language search only
Change in peak expiratory flow rateSmall but significant improvementVariety of antibiotics combined to produce these figures
10.75 l/min (95% CI, 4.96 to 16.54l/min) (6 trials 836 patiens)
British Thoracic Society 1997 Initiated by the Standards of Care Committee of the British Society. A core group of individuals produced background papers that were collated into a single document. This was discussed over a two day period by a larger group which included respiratory physicians from both teaching and teaching and district general hospitals across the UK, geriatricians, general practitioners, nurses, and public health physiciansSystematic review and guidelineSituations in which antibiotics are proven to be of use in hospital and non-hospital settingsWhen two of the following three are present:Paper search strategy may not have been systematic, search methods not fully described
Duration of treatment(1) increased breathlessness
Antibiotic of choice(2) increased sputum volume
(3) development of purulent sputum
Any patient with pH<7.35 should also receive antibiotics
A maximum of 7 days should always be sufficient
Oral treatment with common antibiotics such as amoxicillin or tetracycline should be considered first choice
Mcrory DC et al, 2001Systematic review conducted by a joint panel from the American College of Physicians (ACP)-American Society for Internal Medicine (ASIM) and the American College of Chest Physicians (ACCP)Systematic reviewFindings from 11 RCTs looking at antibiotics v placebo (They found two additional papers to the meta-analysis of Saint et al)Three papers found a statistical benefit, 3 papers found a non-significant benefit and the remainder showed no benefit.Study effects were not summarised by meta-analysis
Number of days of administrationBenefits were larger, the more severe the exacerbation
Days of administration ranged from 3 to 10 days in these studies
NICE 2003 Full NICE guideline for the management of patients with COPDSystematic reviewGrade A recommendationsAntibiotics should be used to treat exacerbations of COPD associated with a history of purulent sputum
Note: currently only in its 2nd draft. 270 received antibiotics, 92 did not.Grade B recommendationsAntibiotics are more likely to be helpful in patients with more severe underlying disease
Patients with exacerbations without purulent sputum do not need antibiotic therapy unless there is consolidation on a chest radiograph or clinical signs of pneumonia