On SAGE Insight: Does antibiotic treatment duration affect the outcomes of exacerbations of asthma and pulmonary disease?

Article title: Does antibiotic treatment duration affect the outcomes of exacerbations of asthma and COPD? A systematic review

From Chronic Respiratory Disease

Antibiotic resistance is a major public health crisis facing the world today and in part caused by inappropriately prescribed antibiotics. Evidence for their optimal use, e.g. how long to give a course of antibiotics for, is often missing. The advantages of shorter courses (less resistance, fewer side effects etc.) need to be balanced carefully with treatment failure. This balance is particularly difficult in those with chronic respiratory conditions such as asthma or chronic obstructive pulmonary disease (COPD) as most of their exacerbations are not caused by bacteria, yet in reality they are normally given antibiotics to treat exacerbations.

We hence undertook this systematic review and meta-analysis to investigate the optimal antibiotic duration to treat COPD and asthma exacerbations. Disappointingly, no work has been done in asthma. The ten studies included for COPD showed that courses of 7 days or longer of the same antibiotic were associated with increased adverse events compared to shorter courses. Shorter courses did not cause more treatment failure or failed at eradicating bacteria from sputum. Fluoroquinolones were the commonest antibiotic class studied, yet these are not usually given in clinical practice. All studies were carried out in high income countries.

Considering that more than 200 million people suffer from asthma globally and e.g. the UK National Health Service (NHS) spends more than £250 million per year on COPD, more work needs to be done. We need to establish what is happening in primary care as most antibiotics are prescribed here (our group is working on this currently). Interventional studies are needed to compare different classes and establish whether shorter durations are safe in reality. This may link in with biomarker studies and form the basis for developing guidelines. Finally, the burden of respiratory non-communicable diseases in lower- and middle-income countries is rising due to increased microbial resistance, limited access to follow up, malnutrition, air pollution, smoking and industrial exposures. Populations there are particularly vulnerable to treatment failure and adverse effects, and as a scientific community we need to create a stronger evidence base. Hopefully this study will point us in the right direction.

By Marie Stolbrink

Dr Marie Stolbrink is a National Institute for Health Research Academic Clinical Fellow at University of Liverpool.
Twitter: @M_Stolbrink



Asthma and chronic obstructive pulmonary disease (COPD) cause significant morbidity and mortality worldwide, primarily through exacerbations. Exacerbations are often treated with antibiotics but their optimal course duration is uncertain. Reducing antibiotic duration may influence antimicrobial resistance but risks treatment failure. The objective of this article is to review published literature to investigate whether shorter antibiotic therapy duration affects clinical outcomes in the treatment of asthma and COPD exacerbations. We systematically searched electronic databases (MEDLINE, EMBASE, CINAHL, World Health Organisation International Clinical Trial Registry Platform, the Cochrane library, and ISRCTN) with no language, location, or time restrictions. We retrieved observational and controlled trials comparing different durations of the same oral antibiotic therapy in the treatment of acute exacerbations of asthma or COPD in adults. We found no applicable studies for asthma exacerbations. We included 10 randomized, placebo-controlled trials for COPD patients, all from high-income countries. The commonest studied antibiotic class was fluoroquinolones. Antibiotic courses shorter than 6 days were associated with significantly fewer overall adverse events (risk ratio (RR): 0.84, 95% confidence interval (CI): 0.75–0.93, p = 0.001) when compared with those of 7 or more days. There was no statistically significant difference for clinical success or bacteriological eradication in sputum (RR: 1.00, 95% CI: 0.88–1.13 and RR: 1.06, 95% CI: 0.79–1.44, respectively). Shorter durations of antibiotics for COPD exacerbations do not seem to confer a higher risk of treatment failure but are associated with fewer adverse events. This is in keeping with previous studies in community acquired pneumonia, but studies were heterogeneous and differed from usual clinical practice. Further observational and prospective work is needed to explore the significance of antibiotic duration in the treatment of asthma and COPD exacerbations.

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Article details
Does antibiotic treatment duration affect the outcomes of exacerbations of asthma and COPD? A systematic review
Marie Stolbrink, Jack Amiry, John D Blakey
First Published December 12, 2017
DOI: 10.1177/1479972317745734
From Chronic Respiratory Disease

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