Associations with antibiotic prescribing for acute exacerbation of COPD in primary care: secondary analysis of a randomised controlled trial

Gillespie, David; Butler, Christopher Collett; Bates, Janine; Hood, Kerenza; Melbye, Hasse; Phillips, Rhiannon; Stanton, Helen; Alam, M Fasihul; Cals, Jochen; Cochrane, Ann; Kirby, Nigel; Llor, Carl; Lowe, Rachel; Naik, Gurudutt; Riga, Evgenia; Sewell, Bernadette; Thomas-Jones, Emma; White, Patrick; Francis, Nick

doi:10.3399/bjgp.2020.0823

Cited by 9 publications

(7 citation statements)

References 27 publications

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“…The observed increase can hardly be explained by a corresponding increase in more severe RTIs. Evidence shows that CRP testing reduce antibiotic prescribing for patients with acute RTIs and acute exacerbations of chronic obstructive pulmonary disease in primary care [ 22 , 23 ]. However, there is a concern that CRP testing might also have negative effects, for instance on costs of management or re-consultation, but there is limited measurement of these outcomes [ 22 ].…”

Section: Discussionmentioning

confidence: 99%

Respiratory tract infections in Norwegian primary care 2006–2015: a registry-based study

Larsen

Wensaas

Emberland

et al. 2022

Scandinavian Journal of Primary Health Care

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Objective Examine characteristics and time trends of respiratory tract infection (RTI) consultations in Norwegian primary care and compare consultations in daytime general practice and out-of-hours (OOH) services. Design Registry-based study using reimbursement claims data. Setting All in-person primary care consultations during 2006–2015. Patients All patients visiting primary care during the study period. Main outcome measures The main outcome variable was RTI consultations. Differences regarding service type (general practice or OOH services) and changes over time were investigated. We report associations with patient age and sex, season, point-of-care C-reactive protein (CRP) test use, and sickness certificate issuing. Results RTI consultations ( n = 16 304 777) represented 11.6% of all consultations ( N = 140 199 637) in primary care over the ten-year period. The annual number of RTI consultations per 1000 inhabitants decreased from 335 to 314, while the number of consultations for any reason increased. Of RTI consultations, 83.2% occurred in general practice. OOH services had a higher proportion of RTI consultations (21.4%) compared with general practice (10.6%). Young children (0–4 years) represented 18.9% of all patients in RTI consultations. CRP testing was used in 56.2% of RTI consultations, and use increased over time. Sickness certificates were issued in 31.9% of RTI consultations with patients of working age (20–67 years). Conclusion Most RTI consultations occurred in general practice, although the proportion was higher in OOH services. Laboratory testing and/or issuing of sickness certificates were part of most consultations. This could be an important reason for seeking health care. Key Points Patients with a respiratory tract infection (RTI) are mostly managed in primary care, where they represent much of the workload. Most consultations for RTIs took place in daytime general practice, but out-of-hours services had a higher proportion of RTI consultations. RTIs were the dominating reason for encounter among young children both in out-of-hours services and daytime general practice. CRP tests were used in over half of RTI consultations, and their use expanded over time.

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Section: Discussionmentioning

confidence: 99%

Respiratory tract infections in Norwegian primary care 2006–2015: a registry-based study

Larsen

Wensaas

Emberland

et al. 2022

Scandinavian Journal of Primary Health Care

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“…Sputum purulence and sputum volume were associated with in-hospital antibiotic use, while no association was observed with dyspnea. This finding may indicate that sputum volume is used as an indicator to start antibiotics, although sputum purulence is the strongest predictor of bacterial infection among the Anthonisen criteria [ 15 ]. CRP level was the strongest determinant of in-hospital antibiotic use for which there is moderate evidence to differentiate bacterial AECOPD [ 11 ].…”

Section: Discussionmentioning

confidence: 99%

“…To the best of our knowledge, studies that investigated the determinants of antibiotic use for AECOPD were performed in primary care [ 14 , 15 ], or did not investigate laboratory results such as CRP [ 16 ]. Only two retrospective studies investigated the real-life effect of (guideline-recommended) antibiotics in patients hospitalized with AECOPD on outcomes, both performed in the United States [ 17 , 18 ].…”

Section: Introductionmentioning

confidence: 99%

In-hospital antibiotic use for severe chronic obstructive pulmonary disease exacerbations: a retrospective observational study

et al. 2023

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Background The use of antibiotics in mild to severe acute exacerbations of chronic obstructive pulmonary disease (COPD) remains controversial. Aim To explore in-hospital antibiotic use in severe acute exacerbations of COPD (AECOPD), to analyze determinants of in-hospital antibiotic use, and to investigate its association with hospital length of stay (LOS) and in-hospital mortality. Methods A retrospective, observational study was conducted in Ghent University Hospital. Severe AECOPD were defined as hospitalizations for AECOPD (ICD-10 J44.0 and J44.1) discharged between 2016 and 2021. Patients with a concomitant diagnosis of pneumonia or ‘pure’ asthma were excluded. An alluvial plot was used to describe antibiotic treatment patterns. Logistic regression analyses identified determinants of in-hospital antibiotic use. Cox proportional hazards regression analyses were used to compare time to discharge alive and time to in-hospital death between antibiotic-treated and non-antibiotic-treated AECOPD patients. Results In total, 431 AECOPD patients (mean age 70 years, 63% males) were included. More than two-thirds (68%) of patients were treated with antibiotics, mainly amoxicillin-clavulanic acid. In multivariable analysis, several patient-related variables (age, body mass index (BMI), cancer), treatment-related variables (maintenance azithromycin, theophylline), clinical variables (sputum volume and body temperature) and laboratory results (C-reactive protein (CRP) levels) were associated with in-hospital antibiotic use independent of sputum purulence, neutrophil counts, inhaled corticosteroids and intensive care unit of which CRP level was the strongest determinant. The median hospital LOS was significantly longer in antibiotic-treated patients (6 days [4–10]) compared to non-antibiotic-treated patients (4 days [2–7]) (p < 0.001, Log rank test). This was indicated by a reduced probability of hospital discharge even after adjustment for age, sputum purulence, BMI, in-hospital systemic corticosteroid use and forced expiratory volume in one second (FEV1) (adjusted hazard ratio 0.60; 95% CI 0.43; 0.84). In-hospital antibiotic use was not significantly associated with in-hospital mortality. Conclusions In this observational study in a Belgian tertiary hospital, in-hospital antibiotic use among patients with severe AECOPD was determined by the symptom severity of the exacerbation and the underlying COPD severity as recommended by the guidelines, but also by patient-related variables. Moreover, in-hospital antibiotic use was associated with a longer hospital stay, which may be linked to their disease severity, slower response to treatment or 'harm' due to antibiotics. Trial registration Number: B670201939030; date of registration: March 5, 2019.

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“…Selective and narrow-spectrum antibiotics can be applied in some cases, but broad-spectrum antibiotics are inevitable in most clinical situations because causative organisms are not definite at initial presentation. In addition to antibiotic resistance and unnecessary side effects due to their overuse 15 , it should also be acknowledged that antibiotics are the representative treatment causing an imbalance in the intestinal microbiota. It has already been documented that the imbalance and depletion of microbiota can aggravate pulmonary infection from both bacteria 16 and viruses 17 .…”

Section: Introductionmentioning

confidence: 99%

Systemic antibiotics cause deterioration of emphysema associated with exaggerated inflammation and autophagy

Kim,

Choi,

Kim

et al. 2023

Exp Mol Med

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The interaction between the microbial environment and the host is important for immune homeostasis. Recent research suggests that microbiota dysbiosis can be involved in respiratory diseases. Emphysema is a chronic inflammatory disease, but it is unclear whether dysbiosis caused by antibiotics can affect disease progression. Here, we tried to elucidate the effect of systemic antibiotics on smoking-exposed emphysema models. In this study, the antibiotic mixture caused more alveolar destruction and airspace expansion in the smoking group than in the smoking only or control groups. This emphysema aggravation as a result of antibiotic exposure was associated with increased levels of inflammatory cells, IL-6, IFNγ and protein concentrations in bronchoalveolar lavage fluid. Proteomics analysis indicated that autophagy could be involved in antibiotic-associated emphysema aggravation, and increased protein levels of LC3B, atg3, and atg7 were identified by Western blotting. In microbiome and metabolome analyses, the composition of the gut microbiota was different with smoking and antibiotic exposure, and the levels of short-chain fatty acids (SCFAs), including acetate and propionate, were reduced by antibiotic exposure. SCFA administration restored emphysema development with reduced inflammatory cells, IL-6, and IFNγ and decreased LC3B, atg3, and atg7 levels. In conclusion, antibiotics can aggravate emphysema, and inflammation and autophagy may be associated with this aggravation. This study provides important insight into the systemic impact of microbial dysbiosis and the therapeutic potential of utilizing the gut microbiota in emphysema.

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Associations with antibiotic prescribing for acute exacerbation of COPD in primary care: secondary analysis of a randomised controlled trial

Cited by 9 publications

References 27 publications

Respiratory tract infections in Norwegian primary care 2006–2015: a registry-based study

Respiratory tract infections in Norwegian primary care 2006–2015: a registry-based study

In-hospital antibiotic use for severe chronic obstructive pulmonary disease exacerbations: a retrospective observational study

Systemic antibiotics cause deterioration of emphysema associated with exaggerated inflammation and autophagy

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