Evidence shows that there are limited benefits of using antibiotics for management of symptoms in acute exacerbations (flare-ups) for people with Chronic Obstructive Pulmonary Disease (COPD) and that viral infections account for the majority of exacerbations.1,2,3
However, prophylactic antibiotics can help reduce the frequency of exacerbations and consequently the likelihood of admission to hospital in certain COPD patient population groups. Lung Foundation Australia and the Thoracic Society of Australian and New Zealand COPD-X Guidelines recommend expert advice prior to commencing long-term antibiotic therapy for patients with COPD. The primary rationale behind this recommendation is the potential for significant risk of adverse effects of such regiments, including, but not limited to, antibiotic resistance.4
A recent Cochrane review focused on quality of life and exacerbation frequency in studies (14 key publications, 3932 participants) that assessed use of prophylactic macrolide treatment in frequent exacerbators with moderate to severe COPD. 5
The review demonstrated that use of prophylactic antibiotic treatment resulted in marked reduction in number of patients experiencing one or more exacerbations; from 61% of participants in the control group compared to 47% in the treatment group (95% CI 39% to 55%). The test for subgroup difference suggested antibiotics given at least three times per week may be more effective than pulsed antibiotics (P = 0.02, I² = 73.3%).
Although a statistically significant improvement in quality of life was observed with prophylactic treatment, clinical significance of a four-unit improvement could not be demonstrated (measured by St George’s Respiratory Questionnaire, SGRQ).
Frequency of hospital admissions, change in forced expiratory volume in one second (FEV1), serious adverse events and all‐cause mortality were also assessed; however, there was no evidence of prophylactic antibiotic treatment having a statistically significant impact on these outcomes.
In line with current guidelines and due to the risk of antibiotic resistance and other adverse effects, a balance between prophylactic antibiotic use and benefits to COPD patients should be considered.
1 VOLLENWEIDER, D. J., JARRETT, H., STEURER-STEY, C. A., GARCIA-AYMERICH, J. & PUHAN, M. A. 2012. Antibiotics for exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev, 12, CD010257.
2 Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease (2018 report). https://goldcopd.org/wp-content/uploads/2018/11/GOLD-2019-v1.7-FINAL-14Nov2018-WMS.pdf (accessed prior to 14 January 2019).
- WOODHEAD M, BLASI F, EWIG S, GARAU J, HUCHON G, LEVEN M, ET AL. Guidelines for the management of adult lower respiratory tract infections. Clinical Microbiology and Infection 2011;17(6):E1‐E59.
4 YANG IA, BROWN JL, GEORGE J, JENKINS S, MCDONALD CF, MCDONALD V, SMITH B, ZWAR N, DABSCHECK E. The COPD-X Plan: Australian and New Zealand Guidelines for the management of Chronic Obstructive Pulmonary Disease 2018. Version 2.55, August 2018.
5 HERATH SC, NORMANSELL R, MAISEY S, Poole P. Prophylactic antibiotic therapy for chronic obstructive pulmonary disease (COPD). Cochrane Database of Systematic Reviews 2018, Issue 10. Art. No.: CD009764.