Antibiotics for severe chronic obstructive pulmonary disease

• Published in: The Lancet (British edition) 2001-12, Vol.358 (9298), p.2013-2013
• Main Authors: Knaus, William A, Scheld, W Michael
• Format: Article
• Language: English
• Subjects: Aged; Anti-Bacterial Agents - therapeutic use; Antibiotics; Chronic obstructive pulmonary disease; Clinical Trials as Topic; Humans; Lung diseases; Mortality; Nosocomial infection; Nosocomial infections; Nouria; Obstructive lung disease; Pneumonia; Pneumonia - complications; Pneumonia - drug therapy; Pulmonary Disease, Chronic Obstructive - complications; Pulmonary Disease, Chronic Obstructive - drug therapy; Respiration, Artificial; Respiratory diseases; Streptococcus infections; Streptococcus pneumoniae; Systematic review; Ventilation
• ISSN: 0140-6736; 1474-547X
• DOI: 10.1016/S0140-6736(01)07136-7

The one published meta-analysis of antibiotics for the treatment of acute exacerbations of COPD, cited by the authors, does not show benefit for empirical antibiotic therapy for inpatients without pneumonia.1 By having the absence of radiological signs of pneumonia confirmed by multiple observers, Nouria and colleagues reduced the possibility of missing pneumonia. This precaution is important because there is consensus that patients with community-acquired pneumonia, especially those at high risk, such as the elderly or those with COPD, should promptly receive antimicrobial treatment.2 But this exclusion criterion, combined with the many others, resulted in a highly selected subset of patients - fewer than half of those screened. Those ultimately selected were severely ill, without obvious infection, but at high risk of acquiring additional life-threatening infections once intubated and mechanically ventilated. Such selection of severe cases and the use of a placebo gives the best possible setting for demonstrating the value of antibiotics. Thus, with the precaution taken to exclude pneumonia, the trial was ethical.