COPD: exacerbation: antibiotics help recovery slightly

Clinical bottom line (level 1a)

  1. Patients with an exacerbation of COPD who take antibiotics compared with placebo are more likely to improve.
  2. Patients on antibiotics are more likely to have an increase in PEFR (roughly 11 l/min)
Saint et al: Journal of the American Medical Association 1995; 273: 957-960
Expires November 2003

The study

Systematic review of all randomised controlled trials of
  • Patients: exacerbation of chronic obstructive pulmonary disease
  • Intervention: antibiotics compared with placebo
  • Outcome: recovery, peak expiratory flow rate


    • Articles found in English using MEDline and Index Medicus, 1955 to 1994 (search terms: COPD, chronic bronchitis, exacerbation and antibiotics ) and searching reference lists of retrieved articles. Experts were contacted to identify additional studies.

    Selection criteria: see above: by 2 independent blinded reviewers
    Appraisal criteria: not detailed
    Articles excluded if:
    • follow-up for less than 5 days
    • insufficient data to calculate effect size
    • nonexperimental design
    • compared one antibiotic with another, or antibiotics given to prevent exacerbations


    9 studies found involving 1101 patients.
    The studies were not found to be heterogeneous.

    The evidence

    • summary effect size: 0.22 (95% CI: 0.10 to 0.34)
      • if 30% of treated group respond, this equates to a NNT = 14 [95% CI 10 to 30]
    • summary difference for PEFR (l/min): 10.8 (95% CI: 4.96 to 16.5)

    Comments

    1. Older antibiotics may be less effective than newer ones - consequently this meta-analysis may underestimate treatment effects.
    2. No mention was made of whether these studies also administered corticosteroids at the same time antibiotics were given. If so, the changes may have been related to corticosteroids and not antibiotics.
    3. The change in peak flow is clinically insignificant.
    4. By limiting the search to English potentially important articles may have been missed. Such small numbers in the study could reflect "no-effect" and publication bias.

    Citation

    1. Saint S, Bent S, Vittinghoff E, et al: antibiotics in chronic obstructive pulmonary disease exacerbations. Journal of the American Medical Association 1995; 273: 957-960
    Search Terms: ?
    Contributor: Bob Phillips and Chris Ball, November 1999
    Reviewer: William Stringer

    Clinical Question.
    Patient exacerbation of chronic obstructive pulmonary disease (COPD)
    Intervention or Exposure antibiotics
    Comparison placebo
    Outcome recovery