A draft guideline issued today by the United Kingdom's National Institute for Health and Care Excellence (NICE) recommends that providers take into account the risk of antimicrobial resistance when considering antibiotics for acute but non-severe flare-ups of chronic obstructive pulmonary disease (COPD).
The recommendation is based on evidence suggesting a limited benefit from antibiotics in patients who experience acute exacerbations of COPD, and the recognition that COPD patients often have multiple exacerbations and receive multiple courses of antibiotics, which may not always be appropriate and can contribute to antibiotic resistance.
The guideline, written by an independent committee of experts, also suggests that antibiotics should be considered for acute exacerbations only after factoring in the number and severity of a patient's symptoms, whether he or she needs to go into the hospital for treatment, and previous exacerbations and hospital admission history.
COPD is an inflammatory lung condition that makes it difficult to breathe. Acute exacerbation is characterized by either increasing shortness of breath, increased sputum production, or a change in sputum color. But acute flare-ups of the condition are caused by bacterial infections only about half the time, with viral infections and environmental factors, such as smoking, as other common causes.
The committee agreed that patients with severe exacerbations, which are marked by the presence of all three symptoms and frequently require hospitalization, should be offered an antibiotic.
"The new guideline will help healthcare professionals make responsible prescribing decisions to not only help people manage their condition but also reduce the risk of resistant infections," Mark Baker, MD, director of the Centre for Guidelines at NICE, said in a press release.
Weighing evidence, symptoms, risks
The recommendations are based on a review of 16 placebo-controlled randomized controlled trials of more than 2,000 adults over the age of 40.
In its analysis, the committee found that while significantly fewer patients on antibiotics showed no improvement in symptoms compared with placebo, the result was influenced by a large positive effect observed in one study conducted among patients in intensive care; when that study was removed from the analysis, the benefit of antibiotics was reduced. In addition, when antibiotics not currently used in practice were excluded, the differences between antibiotics and placebo were not significant.
Overall, the committee concluded that the evidence suggested that antibiotics had uncertain benefit in patients with acute exacerbations of COPD, but appeared to be more effective in patients with more severe symptoms. They agreed that an antibiotic should be considered only for non-severe worsening of symptoms on an individual patient basis.
"This should take into account the uncertain benefit of antibiotics and the risk of antimicrobial resistance with repeated courses, balanced against the number and severity of their symptoms, their need for hospital treatment, their exacerbation and hospitalisation history, their risk of complications, and previous sputum culture results," the committee wrote.
The guideline recommends that when no antibiotic is prescribed for acute COPD flare-ups, providers should explain to patients why an antibiotic is not needed and advise them to seek medical attention if symptoms worsen significantly. But if an antibiotic is prescribed, clinicians should warn patients about possible side-effects, especially diarrhea. The experts also encouraged clinicians to review the choice of antibiotics based on results of sputum sample testing.
In a separate draft update of the clinical guideline for diagnosing and managing COPD in patients over the age of 16, NICE also provides criteria on the use of prophylactic antibiotics. While the reviewed evidence showed that prophylactic antibiotics reduce the risk of having an exacerbation and the number of exacerbations, to minimize the risk of antibiotic resistance, the committee recommended that antibiotics be offered only to patients who don't smoke, have optimized other management strategies, and have frequent, prolonged exacerbations with sputum production.
Both draft guidelines are open for public comment through Aug 6.
Jul 9 NICE guideline on COPD diagnosis and management
Jul 9 NICE press release