Use of Antibiotics in Chronic Obstructive Pulmonary Disease: What is Their Current Role in Older Patients?
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CURRENT OPINION
Use of Antibiotics in Chronic Obstructive Pulmonary Disease: What is Their Current Role in Older Patients? Majdi N. Al‑Hasan1,2 · Mohammed J. Al‑Jaghbeer3
© Springer Nature Switzerland AG 2020
Abstract Chronic obstructive pulmonary disease (COPD) has considerable morbidity and mortality in the older adult population. The role of antibiotics in the management of acute exacerbations of COPD (AECOPD) is currently evolving. Despite only mild benefits, most patients with AECOPD in ambulatory settings receive antibiotics based on clinical criteria. Utilization of point-of-care C-reactive protein (CRP) has reduced antibiotic prescriptions by 20% without compromising clinical outcomes. A strict protocol allowing antibiotic use only in patients with clinical criteria and CRP ≥ 20 mg/L has the potential to reduce antibiotic prescriptions for AECOPD in ambulatory settings by nearly 50%. Amoxicillin and doxycycline are commonly prescribed for AECOPD based on a favorable benefit-to-risk ratio. Prophylactic antibiotics have also been used in selected patients with severe COPD and frequent exacerbations. The use of continuous or intermittent azithromycin has demonstrated efficacy in reducing the frequency of AECOPD in this population; however, this approach has potential for the development of antibiotic resistance and adverse effects. The use of azithromycin prophylaxis in older patients with frequent AECOPD should be determined on a case-by-case basis after careful review, discussion, and counseling of the potential benefits and risks. The role of continuous doxycycline and pulsed moxifloxacin prophylaxis for frequent AECOPD remains controversial.
1 Introduction Chronic obstructive pulmonary disease (COPD) is a progressive disease that affects 12% of the US population older than 65 years of age [1]. It is the fourth leading cause of death in the US and a common reason for office visits [2]. It has a significant economic burden that is one of the highest among chronic diseases [3, 4]. In addition, COPD is associated with multiple comorbidities, including muscle weakness, osteoporosis, and worsening in quality of life and cognitive function in older adults [5–8]. Acute exacerbation of COPD (AECOPD) is an acute worsening of respiratory symptoms that results in additional therapy [9]. AECOPD has a detrimental effect on pulmonary function, comorbidities, and quality of life * Majdi N. Al‑Hasan [email protected] 1
Department of Medicine, Division of Infectious Diseases, University of South Carolina School of Medicine, Columbia, SC, USA
2
Prisma Health University of South Carolina Medical Group, Columbia, SC, USA
3
Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
Key Points Antibiotics have only mild benefits in ambulatory settings and should be reserved for patients with clinical criteria suggestive of bacterial etiology for acute exacerbations of chronic obstructive pulmonary disease (COPD) and C-reactive protein ≥ 20 mg/L. When indicated, a short course of a narrow spectru
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