Clinical Practice Research Datalink, Medicines and Healthcare products Regulatory Agency, 151 Buckingham Palace Road, London SW1W 9SZ, UK.
BMC Pulm Med. 2013 May 31;13:32. doi: 10.1186/1471-2466-13-32.
The role of antibiotics in treating mild or moderate exacerbations in patients with acute chronic obstructive pulmonary disease (COPD) is unclear. The aims were to: (i) describe patient characteristics associated with acute exacerbations amongst a representative COPD population, (ii) explore the relationship between COPD severity and outcomes amongst patients with exacerbations, and (iii) quantify variability by general practice in prescribing of antibiotics for COPD exacerbations.
A cohort of 62,747 patients with COPD was identified from primary care general practices (GP) in England, and linked to hospital admission and death certificate data. Exacerbation cases were matched to three controls and characteristics compared using conditional logistic regression. Outcomes were compared using incidence rates and Cox regression, stratified by disease severity. Variability of prescribing at the GP level was evaluated graphically and by using multilevel models.
COPD severity was found to be associated with exacerbation and subsequent mortality (very severe vs. mild, odds ratio for exacerbation 2.12 [95%CI 19.5-2.32]), hazard ratio for mortality 2.14 [95%CI 1.59-2.88]). Whilst 61% of exacerbation cases were prescribed antibiotics, this proportion varied considerably between GP practices (interquartile range, 48-73%). This variation is greater than can be explained by patient characteristics alone.
There is significant variability between GP practices in the prescribing of antibiotics to COPD patients experiencing exacerbations. Combined with a lack of evidence on the effects of treatment, this supports the need and opportunity for a large scale pragmatic randomised trial of the prescribing of antibiotics for COPD patients with exacerbations, in order to clarify their effectiveness and long term outcomes whilst ensuring the representativeness of subjects.
抗生素在治疗慢性阻塞性肺疾病（COPD）轻度或中度加重患者中的作用尚不清楚。目的是：（i）描述具有代表性的 COPD 人群中与急性加重相关的患者特征，（ii）探讨 COPD 严重程度与加重患者结局之间的关系，以及（iii）量化全科医生处方 COPD 加重抗生素的变异性。
从英格兰的基层医疗全科医生（GP）中确定了 62747 例 COPD 患者队列，并与住院和死亡证明数据相关联。使用条件逻辑回归比较了加重病例与 3 个对照的特征。使用发病率和 Cox 回归，根据疾病严重程度分层比较了结局。通过图形和多水平模型评估了 GP 水平处方的变异性。
发现 COPD 严重程度与加重和随后的死亡率相关（非常严重与轻度相比，加重的比值比为 2.12[95%CI 19.5-2.32]，死亡率的危险比为 2.14[95%CI 1.59-2.88]）。尽管 61%的加重病例开了抗生素，但这种比例在 GP 实践之间差异很大（四分位间距，48-73%）。这种变异性大于仅由患者特征解释的变异性。
在为经历加重的 COPD 患者开具抗生素方面，GP 实践之间存在很大的变异性。结合缺乏关于治疗效果的证据，这支持了对 COPD 加重患者开具抗生素进行大规模实用随机试验的必要性和机会，以阐明其疗效和长期结局，同时确保研究对象的代表性。
