Antibiotic benefits COPD patients

Hyperinflated lungs consistent with COPD caused by emphysema or bronchitis
Hyperinflated lungs consistent with COPD caused by emphysema or bronchitis
Macrolide therapy apparently reduces both the frequency and severity of exacerbations in patients with moderate-to-severe chronic pulmonary obstructive disease (COPD), according to a preliminary British study.

Jadwiga Wedzicha, MD, and colleagues at University College London randomized 109 patients to erythromycin 250 mg or placebo twice daily. During the 12-month trial, the treated group had 35% fewer exacerbations.

Of 206 moderate-to-severe episodes, 81 were in the treatment arm. These episodes also resolved more quickly; the median duration was nine days for the erythromycin group vs. 13 for those on placebo.

No differences were observed in forced expiratory volume in one second, myeloperoxidase, bacterial flora, or serum C-reactive protein (Am J Respir Crit Care Med. 2008;178:1139-1147).

The study acknowledges several drawbacks, including small size and the fact that some patients also used inhaled corticosteroids or inhaled long-acting bronchodilators. Consequently, the degree of added benefit from macrolide therapy is murky.

Prolonged antibiotic use also raises questions about eventual bacterial resistance. An accompanying editorial states, “Balancing benefit against harm could pose a dilemma for which there might be no clear answers.”

Meanwhile, pulmonary experts at Johns Hopkins University urge clinicians to use caution when prescribing inhaled corticosteroids (ICS). Their meta-analysis showed these drugs can increase the risk of pneumonia by a third (JAMA. 2008;300:2407-2416).

The team looked at 11 randomized controlled trials with 14,426 COPD patients to determine associations of ICS for six or more months with death from any cause and the risk of pneumonia.

Trials that included mortality data found no significant difference in all-cause mortality (risk ratio [RR] 0.86) between patients who took ICS medication and those who did not. But the seven trials that looked at pneumonia risk found a definite association: 777 events among 5,405 patients in the treatment groups vs. 561 events among 5,371 in the controls for an RR of 1.34.

“Our evidence is not conclusive…only hypothesis-generating,” the researchers write, but it should spur clinicians to screen and monitor their patients to find the lowest possible steroid dose that works.
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