Prophylactic antibiotic therapy in COPD

Prophylactic antibiotic therapy for chronic obstructive pulmonary disease (COPD)

• a systematic review investigated the use of prophylactic antibiotic therapy in COPD
  • study duration varied from three months to 36 months and all used intention-to-treat analysis
• use of continuous and intermittent prophylactic antibiotics results in a clinically significant benefit in reducing exacerbations in COPD patients
• implications for practice
  • "..use of prophylactic macrolide antibiotics for a period of up to 12 months is likely to reduce the number of patients with one or more exacerbations, exacerbation frequency, increase the median time to first exacerbation and improve health-related quality of life. Benefits appear to be driven by continuous and intermittent macrolide regimens, with pulsed regimens being less effective." (1)
    
• antibiotic regimes (1):
  • example adult regimes used in clinical trials include:
    • Azithromycin 250 mg daily or
    • Azithromycin 250 mg 3 times a week

NICE have issued guidance regarding the use of prophylactic antibiotics in COPD:

• oral prophylactic antibiotic therapy
  • before starting prophylactic antibiotic therapy in a person with COPD, think about whether respiratory specialist input is needed
  • azithromycin (usually 250 mg 3 times a week) should be considered for people with COPD if they:
    • do not smoke and have optimised non-pharmacological management and inhaled therapies, relevant vaccinations and (if appropriate) have been referred for pulmonary rehabilitation and
    • continue to have 1 or more of the following, particularly if they have significant daily sputum production:
      • frequent (typically 4 or more per year)
      • exacerbations with sputum production
      • prolonged exacerbations with sputum production exacerbations resulting in hospitalisation
  • before the patient is offered prophylactic antibiotics, then ensure that the person has had:
    • sputum culture and sensitivity (including tuberculosis culture), to identify other possible causes of persistent or recurrent infection that may need specific treatment (for example, antibiotic-resistant organisms, atypical mycobacteria or Pseudomonas aeruginosa)
    • training in airway clearance techniques to optimise sputum clearance
    • a CT scan of the thorax to rule out bronchiectasis and other lung pathologies
  • before starting azithromycin, ensure the person has had:
    • an electrocardiogram (ECG) to rule out prolonged QT interval and
    • baseline liver function tests
  • when prescribing azithromycin, advise people about the small risk of hearing loss and tinnitus, and tell them to contact a healthcare professional if this occurs
  • review:
    • prophylactic azithromycin should be reviewed after the first 3 months, and then at least every 6months
    • only continue treatment if the continued benefits outweigh the risks - be aware that there are no long-term studies on the use of prophylactic antibiotics in people with COPD
  • for people who are taking prophylactic azithromycin and are still at risk of exacerbations, provide a non-macrolide antibiotic to keep at home as part of their exacerbation action plan
  • be aware that it is not necessary to stop prophylactic azithromycin during an acute exacerbation of COPD

Reference:

• (1) Herath SC, Normansell R, Maisey S, Poole P. Prophylactic antibiotic therapy for chronic obstructive pulmonary disease (COPD). Cochrane Database of Systematic Reviews 2018, Issue 10. Art. No.: CD009764. DOI: 10.1002/14651858.CD009764.pub3
• (2) National Institute for Health and Clinical Excellence (NICE) 2018. Chronic obstructive pulmonary disease: Management of chronic obstructive pulmonary disease in adults in primary and secondary care