Preventive Macrolide Antibiotics Recommended for COPD Patients

Internal Medicine World Report, June 2014,

The continuous use of macrolide antibiotics for prophylaxis is associated with a significant reduction in chronic obstructive pulmonary disease exacerbations.

The continuous use of macrolide antibiotics for prophylaxis is associated with a significant reduction in chronic obstructive pulmonary disease (COPD) exacerbations, according to a meta-analysis published in JAMA.

Researchers from the Montreal Chest Institute in Canada analyzed randomized clinical trials (RCTs) in the Cochrane database that examined COPD patients with lower rates of flare-ups.

“We wanted to do a systematic review and a meta-analysis of these recent trials published between 2001-2011 to see how robust the data is to support the use of antibiotics in COPD and explore the potential adverse events in a large group of patients,” lead study author Samantha C. Herath, MBBS, MPhil, FRACP, told Internal Medicine World Report.

Of the 7 eligible studies, 3 contained the appropriate data for analysis, such as whether antibiotic treatment in COPD could be just as successful as a preventive measure. The trio of studies tested prophylaxis with a macrolide, which was associated with a lower incidence of COPD exacerbations over a period of 6-12 months. The 1,262 patients enrolled across the studies were treated for COPD with antibiotics or systemic steroids, or were placed on supplemental oxygen.

The number needed to treat (NNT) in order to prevent one COPD patient from having an exacerbation was 8; however, only one study addressed the association between pulsed antibiotic prophylactic therapy and reduced exacerbation rates.

Although there were no differences in the number of adverse events among the antibiotic and placebo groups, azithromycin was associated with a significant increase in hearing loss, and moxifloxacin was linked to a significant increase in gastrointestinal (GI) symptoms.

“The individual RCTs had already pointed out a positive influence of the antibiotic use in preventing exacerbations in COPD,” Herath said of the findings. “The systematic review reinforces this finding more conclusively, although one must be careful in selecting the correct patient population to prevent unnecessary antibiotic-related adverse events, as well as antibiotic resistance in the population.”

The researchers also tracked trends in resistance to the antibiotics. In one study that utilized nasophayngeal swabs, patients identified as having no respiratory pathogens at the beginning of the study acquired new organisms throughout the course of the study. There were also higher rates of azithromycin resistance in the antibiotic treatment group (81%) as compared to the placebo group (41%), and those treated with moxifloxacin-sensitive pseudomonas at the start quickly became resistant to quinolones.

“Because of concerns about antibiotic resistance and specific antibiotic-related adverse effects, consideration of prophylactic antibiotic use should be mindful of the balance between benefits to individual patients and the potential harms to society created by antibiotic overuse,” Herath concluded. “This review supports the use of prophylactic macrolide antibiotics in COPD patients with frequent exacerbations after standard therapies for COPD have been exhausted, (but) close monitoring is advocated in this elderly, comorbid group of patients.”