Division of General Medicine and Geriatrics, Baystate Medical Center, 759 Chestnut St, Springfield, MA 01199, USA.
JAMA. 2010 May 26;303(20):2035-42. doi: 10.1001/jama.2010.672.
Guidelines recommend antibiotic therapy for acute exacerbations of chronic obstructive pulmonary disease (COPD), but the evidence is based on small, heterogeneous trials, few of which include hospitalized patients.
To compare the outcomes of patients treated with antibiotics in the first 2 hospital days with those treated later or not at all.
DESIGN, SETTING, AND PATIENTS: Retrospective cohort of patients aged 40 years or older who were hospitalized from January 1, 2006, through December 31, 2007, for acute exacerbations of COPD at 413 acute care facilities throughout the United States.
A composite measure of treatment failure, defined as the initiation of mechanical ventilation after the second hospital day, inpatient mortality, or readmission for acute exacerbations of COPD within 30 days of discharge; length of stay, and hospital costs.
Of 84,621 patients, 79% received at least 2 consecutive days of antibiotic treatment. Treated patients were less likely than nontreated patients to receive mechanical ventilation after the second hospital day (1.07%; 95% confidence interval [CI], 1.06%-1.08% vs 1.80%; 95% CI, 1.78%-1.82%), had lower rates of inpatient mortality (1.04%; 95% CI, 1.03%-1.05% vs 1.59%; 95% CI, 1.57%-1.61%), and had lower rates of readmission for acute exacerbations of COPD (7.91%; 95% CI, 7.89%-7.94% vs 8.79%; 95% CI, 8.74%-8.83%). Patients treated with antibiotic agents had a higher rate of readmissions for Clostridium difficile (0.19%; 95% CI, 0.187%-0.193%) than those who were not treated (0.09%; 95% CI, 0.086%-0.094%). After multivariable adjustment, including the propensity for antibiotic treatment, the risk of treatment failure was lower in antibiotic-treated patients (odds ratio, 0.87; 95% CI, 0.82-0.92). A grouped treatment approach and hierarchical modeling to account for potential confounding of hospital effects yielded similar results. Analysis stratified by risk of treatment failure found similar magnitudes of benefit across all subgroups.
Early antibiotic administration was associated with improved outcomes among patients hospitalized for acute exacerbations of COPD regardless of the risk of treatment failure.
指南建议对慢性阻塞性肺疾病（COPD）急性加重患者进行抗生素治疗，但这些证据基于小型、异质性的试验，其中很少有试验纳入住院患者。
比较抗生素治疗开始于前 2 天与治疗开始于后 2 天或根本不治疗的患者的结局。
设计、场所和患者：回顾性队列研究，纳入 2006 年 1 月 1 日至 2007 年 12 月 31 日期间在美国 413 家急性护理机构住院的年龄 40 岁或以上的 COPD 急性加重患者。
治疗失败的综合指标，定义为第 2 天以后开始使用机械通气、住院期间死亡或出院后 30 天内因 COPD 急性加重再次入院；住院时间和住院费用。
在 84621 例患者中，79%的患者至少接受了连续 2 天的抗生素治疗。与未接受治疗的患者相比，接受治疗的患者在第 2 天以后使用机械通气的可能性较小（1.07%；95%置信区间，1.06%-1.08%比 1.80%；95%置信区间，1.78%-1.82%）、住院期间死亡率较低（1.04%；95%置信区间，1.03%-1.05%比 1.59%；95%置信区间，1.57%-1.61%）、因 COPD 急性加重再次入院的发生率较低（7.91%；95%置信区间，7.89%-7.94%比 8.79%；95%置信区间，8.74%-8.83%）。接受抗生素治疗的患者因艰难梭菌（Clostridium difficile）而再次入院的发生率较高（0.19%；95%置信区间，0.187%-0.193%），而未接受治疗的患者为 0.09%（95%置信区间，0.086%-0.094%）。在多变量调整包括抗生素治疗的倾向性后，抗生素治疗组的治疗失败风险较低（比值比，0.87；95%置信区间，0.82-0.92）。采用分组治疗方法和分层模型来考虑医院效应的潜在混杂因素，得到了类似的结果。根据治疗失败的风险进行分层分析，发现所有亚组的获益幅度相似。
对于因 COPD 急性加重而住院的患者，无论治疗失败的风险如何，早期给予抗生素治疗均与结局改善相关。
