Clinical Question

Can prophylactic antibiotics decrease chronic obstructive pulmonary disease (COPD) exacerbations in a 67-year-old man with a history of frequent exacerbations?

Evidence-Based Answer

Continuous prophylactic antibiotic therapy significantly decreases COPD exacerbations for up to three years. However, it does not decrease mortality, and it puts the patient at risk of antibiotic-resistant colonization and infection. (Strength of Recommendation: B, based on inconsistent or limited-quality patient-oriented evidence.)

Practice Pointers

COPD occurs in approximately 40% of smokers, affects more men than women, and is more common among those living in urban areas.¹ The economic burden in the United States is as much as $49.5 billion annually, with most of this cost devoted to treating exacerbations.¹ Current guidelines recommend preventive measures to limit exacerbations, including smoking cessation, immunization against pneumococcus and the influenza virus, maintenance therapy (e.g., use of inhaled steroids), and treatment of comorbid conditions.¹

This systematic review analyzed seven randomized controlled trials involving 3,170 patients with a mean age of 66 years and at least moderate COPD. Patients were followed for three to 36 months. In five studies, patients were given continuous antibiotic therapy; in the other two, they received intermittent antibiotic therapy. All of the patients treated continuously were given macrolide antibiotics—azithromycin (Zithromax), clarithromycin (Biaxin), or erythromycin. Moxifloxacin (Avelox) was the only nonmacrolide antibiotic studied and was used only intermittently.

The number of patients with exacerbations was significantly reduced in those treated continuously (54% vs. 69% in the placebo group; number needed to treat = 8). Intermittent antibiotic use also reduced the number of exacerbations, but this result was not significant. Although continuous and intermittent regimens yielded a statistically significant improvement in quality of life, neither reduced important secondary outcomes such as frequency of hospital admission or all-cause mortality.

Adverse effects such as hearing loss were noted in patients taking azithromycin, and there was a statistically significant increase in the number of gastrointestinal symptoms among those taking moxifloxacin. Notably, patients treated with moxifloxacin experienced rapid development of antibiotic-resistant Pseudomonas infections.

The authors of this Cochrane review are hesitant to recommend continuous antibiotic therapy for all patients with COPD, given the cost, risks to each individual patient, and potential for increasing antibiotic resistance. In January 2014, the Global Initiative for Chronic Obstructive Lung Disease released updated guidelines on the management and prevention of COPD. These guidelines do not advocate use of prophylactic antibiotics.¹ Although the use of prophylactic antibiotic regimens to prevent exacerbations shows promise, for now they should be used only for carefully selected patients (e.g., those with frequent exacerbations), if at all.