Comparative effectiveness of macrolides and quinolones for patients hospitalized with acute exacerbations of chronic obstructive pulmonary disease (AECOPD).

BACKGROUND

Meta-analyses of randomized trials have found that antibiotics are effective in acute exacerbations of chronic obstructive pulmonary disease (AECOPD), but there is insufficient evidence to guide antibiotic selection. Current guidelines offer conflicting recommendations.

OBJECTIVE

To compare the effectiveness of macrolides and quinolones for AECOPD DESIGN: Retrospective cohort study using logistic regression, propensity score-matching, and grouped treatment models.

SETTING

A total of 375 acute care hospitals throughout the United States.

PATIENTS

Age > or =40 years and hospitalized for AECOPD.

INTERVENTION

Macrolide or quinolone antibiotic begun in the first 2 hospital days.

MEASUREMENTS

Treatment failure (defined as the initiation of mechanical ventilation after hospital day 2, inpatient mortality, or readmission for AECOPD within 30 days), length of stay, and hospital costs.

RESULTS

Of the 19,608 patients who met the inclusion criteria, 6139 (31%) were treated initially with a macrolide and 13,469 (69%) with a quinolone. Compared to patients treated initially with a quinolone, those who received macrolides had a lower risk of treatment failure (6.8% vs. 8.1%; P < 0.01), a finding that was attenuated after multivariable adjustment (odds ratio [OR], 0.89; 95% confidence interval [CI], 0.78-1.01), and disappeared in a grouped-treatment analysis (OR, 1.01; 95% CI, 0.75-1.35). There were no differences in adjusted length of stay (ratio, 0.98; 95% CI, 0.97-1.00) or adjusted cost (ratio, 1.00; 95% CI, 0.99-1.02). After propensity score-matching, antibiotic-associated diarrhea was more common with quinolones (1.2% vs. 0.6%; P < 0.001).

CONCLUSIONS

Macrolide and quinolone antibiotics are associated with similar rates of treatment failure in AECOPD; however, macrolides are less frequently associated with diarrhea.