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Examining ED Antibiotic Trends in Acute Exacerbations of COPD

Allison Inserro
Current guidelines for chronic obstructive pulmonary disease (COPD) call for using antibiotics in the emergency department (ED) when presented with acute exacerbations of COPD (AECOPD). A recent study sought to determine the rate at which patients with AECOPD are treated with antibiotics and also looked at the proportions of antibiotic classes prescribed, trends of antibiotic treatment, and identified independent predictors of antibiotic therapy.
 
Current guidelines for chronic obstructive pulmonary disease (COPD) call for using antibiotics in the emergency department (ED) when presented with acute exacerbations of COPD (AECOPD). A recent study sought to determine the rate at which patients with AECOPD are treated with antibiotics and also looked at the proportions of antibiotic classes prescribed, trends of antibiotic treatment, and identified independent predictors of antibiotic therapy.

The researchers wrote that the utility of antibiotics in this population is unclear, but there’s an assumption that the exacerbations are caused by a bacterial infection, and providers want to avoid complications. There has been no recent research examining prescribing practices of antibiotics specific to this population. "The trials which have demonstrated a reduction in treatment failure showed small and inconsistent effects and did not enroll patients from the ED," the authors wrote. 

AECOPD treatment includes inhaled short-acting bronchodilators and systemic corticosteroids; administration of antibiotics has been previously identified as a quality indicator.

This study was a secondary analysis of the National Hospital Ambulatory Medical Care Survey, conducted by the CDC as well as the National Center for Health Statistics. The study looked at ED visits between 2009 in 2014 by patients over the age of 24. The majority of visits occurred in the South, among patients who are female, and among those who are middle-aged (aged 45 to 64). Most did not have private commercial insurance and they did not arrive by ambulance. Most resulted in discharge.

The primary outcome was antibiotic treatment using cephalosporins, macrolides, penicillins, quinolones, sulfonamides, tetracyclines, aminoglycosides, glycopeptide antibiotics, and miscellaneous antibiotics. Antibiotic treatment occurred at an estimated rate of 39.07%. When an antibiotic was given, macrolides and quinolones were used most of the time.

After adjusting for age gender, race/ethnicity, insurance status, region, means of arrival, triage level, temperature, and disposition, there was no significant associate association between the year of the ED visit and whether or not the patient was treated with antibiotics. The researchers said there was no significant change in antibiotic use between 2009 to 2014.

Characteristics associated with antibiotic treatment included being triaged as emergent or immediate, and having an elevated temperature.

In explaining the results, the researchers noted that the odds of an antibiotics prescription was nearly 8 times higher among peptide patients with a temperature greater than or equal to 100.4, compared with those without a fever. The researchers theorized that providers, being aware of public health campaigns to use antibiotics judiciously, reserved them for cases where infection already existed.

They also noted that patients admitted to the intensive care unit were treated with antibiotics at the same rate as those who went home.

The results matched guidelines that recommend macrolides as the first choice of antibiotic in this population. What was different, however, is that in a real-world setting, quinolones were used most frequently by ED providers, rather than tetracyclines or aminopenicillins as recommended by the guidelines.

Reference

Tichter AM, Ostrovskiy G. Emergency department antibiotic use for exacerbations of COPD. [published online December 5, 2018]. Open Access Emerg Med. doi: 10.2147/OAEM.S178134.

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