Association Between Antibiotic Treatment and Outcomes in Patients Hospitalized With Acute Exacerbation of COPD Treated With Systemic Steroids

doi:10.1378/chest.12-0649

Chest

Volume 143, Issue 1, January 2013, Pages 82-90

https://doi.org/10.1378/chest.12-0649 Get rights and content

Background

Antibiotics are widely used in acute exacerbations of COPD (AE-COPD), but their additional benefit to a therapeutic regimen that already includes steroids is uncertain. We evaluated the association between antibiotic therapy and outcomes among a large cohort of patients treated with steroids who were hospitalized with AE-COPD and compared the effectiveness of three commonly used antibiotic regimens.

Methods

We conducted a retrospective cohort study of patients aged ≥ 40 years hospitalized for AE-COPD from January 1, 2006, through December 1, 2007, at 410 acute care hospitals throughout the United States.

Results

Of the 53,900 patients who met the inclusion criteria, 85% were treated with antibiotics in the first 2 hospital days; 50% were treated with a quinolone, 22% with macrolides plus cephalosporin, and 9% with macrolide monotherapy. Compared with patients not treated with antibiotics, those who received antibiotics had lower mortality (1% vs 1.8%, P < .0001). In multivariable analysis, receipt of antibiotics was associated with a 40% reduction in the risk of in-hospital mortality (RR, 0.60; 95% CI, 0.50-0.73) and a 13% reduction in the risk of 30-day readmission for COPD (RR, 0.87; 95% CI, 0.79-0.96). The risk of late ventilation and readmission for Clostridium difficile colitis was not significantly different between the two groups. We found little difference in the outcomes associated with three common antibiotic treatment choices.

Conclusions

Our results suggest that the addition of antibiotics to a regimen that includes steroids may have a beneficial effect on short-term outcomes for patients hospitalized with AE-COPD.

Section snippets

Materials and Methods

We conducted a retrospective cohort study using data from 410 hospitals that participate in Perspective, an inpatient administrative database. The information available includes patient demographics, principal and secondary diagnoses, discharge status, source of admission, date of service, medications dispensed, diagnostic tests, and physician and hospital characteristics.

Patients were included if they were aged ≥ 40 years and were discharged between January 1, 2006, and December 1, 2007, with

Results

A total of 53,900 patients were included in the analysis (Fig 1). The median age was 70 years, 58% were women, and 76% were white. Eighty-five percent of the patients received antibiotics within the first 2 hospital days; 50% received a quinolone, 22% a macrolide combined with a cephalosporin, and 9% macrolide monotherapy. An additional 1,662 patients (3.1%) received an antibiotic starting after day 3 and were analyzed in the group of patients who did not receive early antibiotics. The median

Discussion

In this study of > 50,000 patients hospitalized with AE-COPD, we observed that the addition of antibiotic therapy to a treatment regimen that included systemic corticosteroids was associated with a substantial reduction in the risk of hospital death and readmission. These findings were robust to a variety of analytic approaches and in sensitivity analyses. At the same time, antibiotic choice was not associated with in-hospital mortality.

Acute exacerbations are a major contributor to the

Acknowledgments

Authors contributions: Dr Stefan had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Dr Stefan: contributed to study conception and design, analysis and interpretation of data, drafting the manuscript for important intellectual content, and reading and approving the final manuscript.

Dr Rothberg: contributed to study conception and design, analysis and interpretation of data, drafting the manuscript for

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This single-center, retrospective cohort study was conducted in culture-negative critically ill adults admitted to an intensive care unit (ICU) between July 1, 2014, and July 1, 2019, for the treatment of AECOPD. Included patients received treatment with an empiric corticosteroid, azithromycin, and/or a nonmacrolide antibiotic. Patients treated with a nonmacrolide antibiotic for ≤3 and >3 days made up the short- and standard-course groups, respectively. The prevalence of in-hospital mortality, progression to the need for ventilation, and/or readmission for AECOPD within 30 days (primary composite end point) was compared between the two groups. Additional end points included hospital and ICU lengths of stay (LOS), all-cause 30-day readmission, and prevalence of antibiotic-related adverse events.
A total of 135 patients were included (short course, 66; standard course, 69). The differences in the primary composite end point (short vs standard, 24.2% vs 39.1%; P = 0.06) and its individual components were not significant. The median ICU LOS (2 vs 3 days) and hospital LOS (4 vs 6 days) were shorter in the short-course group (both, P < 0.01). Multivariate logistic regression confirmed no association between group assignment and the primary end point.
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In the 2018 meta-analysis of placebo-controlled randomized trials, 5 trials in 803 hospitalized patients showed reduced treatment failure with a relative risk of 0.76 (95% confidence interval [CI] 0.58–1.00) favoring antibiotic use.25 Two large database studies from the United States also strongly support the benefit of antibiotics in hospitalized AECOPD, demonstrating less treatment failure in antibiotic-treated patients (odds ratio [OR], 0.87; 95% CI, 0.82–0.92),39 as well as reductions in in-hospital mortality (relative risk [RR], 0.60; 95% CI, 0.50–0.73) and 30-day readmission for COPD (RR, 0.87; 95% CI, 0.79–0.96).40 Whether all hospitalized patients should be treated with antibiotics is unclear, with 1 study suggesting that it is safe to withhold antibiotics in patients who are milder and do not have any clinical signs of bacterial infection.
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Antibiotics Use among Patients with Acute Exacerbation of Chronic Obstructive Pulmonary Disease in the Department of Internal Medicine of a Tertiary Care Centre: A Descriptive Cross-sectional Study
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Funding/Support: Dr Stefan is supported by the National Cancer Institute [Grant KM1 CA156726] and by the National Center for Research Resources and the National Center for Advancing Translational Sciences, National Institutes of Health [Grant UL1 RR025752].

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.

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Chest

Original ResearchCOPDAssociation Between Antibiotic Treatment and Outcomes in Patients Hospitalized With Acute Exacerbation of COPD Treated With Systemic Steroids

Background

Methods

Results

Conclusions

Section snippets

Materials and Methods

Results

Discussion

Acknowledgments

Clin Chest Med

Chest

Chest

Lancet

Chest

Chest

Chest

Am J Prev Med

Clin Chest Med

Clin Ther

Chest

Characteristics and long-term outcome of acute exacerbations in chronic obstructive pulmonary disease: an analysis of cases in the Swedish Intensive Care Registry during 2002-2006

Acta Anaesthesiol Scand

NHLBI morbidity and mortality chartbook. National Heart, Lung and Blood Institute website

Effect of exacerbation on quality of life in patients with chronic obstructive pulmonary disease

Am J Respir Crit Care Med

Evidence base for management of acute exacerbations of chronic obstructive pulmonary disease

Ann Intern Med

Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary

Am J Respir Crit Care Med

Antibiotic therapy in exacerbations of chronic obstructive pulmonary disease

Ann Intern Med

Systemic corticosteroids for acute exacerbations of chronic obstructive pulmonary disease

Cochrane Database Syst Rev

Original Research
COPD
Association Between Antibiotic Treatment and Outcomes in Patients Hospitalized With Acute Exacerbation of COPD Treated With Systemic Steroids