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Short- Versus Standard-Course Nonmacrolide Antibiotic Treatment in Acute Exacerbations of Chronic Obstructive
Kevin D Betthauser1, Lindsey N Eble2, Paul Juang3
1Department of Pharmacy, Barnes-Jewish Hospital, St. Louis, Missouri; Division of Specialty Care Pharmacy, St. Louis College of Pharmacy, St. Louis, Missouri; The Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, Missouri.
Purpose:
In critically ill patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) and without positive microbiological data, the efficacy and tolerability of short-course nonmacrolide antibiotics are ill-described and have pertinent implications in antimicrobial stewardship. This study compared the efficacy and tolerability of nonmacrolide antibiotic strategies in critically ill patients with AECOPD and without pertinent positive microbiological testing.
Methods:
This single-center, retrospective cohort study was conducted in culture-negative critically ill adults admitted to an intensive care unit (ICU) between July 1, 2014, and July 1, 2019, for the treatment of AECOPD. Included patients received treatment with an empiric corticosteroid, azithromycin, and/or a nonmacrolide antibiotic. Patients treated with a nonmacrolide antibiotic for ≤3 and >3 days made up the short- and standard-course groups, respectively. The prevalence of in-hospital mortality, progression to the need for ventilation, and/or readmission for AECOPD within 30 days (primary composite end point) was compared between the two groups. Additional end points included hospital and ICU lengths of stay (LOS), all-cause 30-day readmission, and prevalence of antibiotic-related adverse events.
Findings:
A total of 135 patients were included (short course, 66; standard course, 69). The differences in the primary composite end point (short vs standard, 24.2% vs 39.1%; P = 0.06) and its individual components were not significant. The median ICU LOS (2 vs 3 days) and hospital LOS (4 vs 6 days) were shorter in the short-course group (both, P < 0.01). Multivariate logistic regression confirmed no association between group assignment and the primary end point.
Implications:
Short-course nonmacrolide therapy in patients with AECOPD and no positive microbiological testing was not associated with differences in mortality, progression to ventilation, readmission rate, or prevalence of adverse drug events. Larger-scale prospective studies are needed to validate these findings.
Insights
Short-course nonmacrolide antibiotics for culture-negative acute exacerbation of chronic obstructive pulmonary disease (AECOPD) showed similar outcomes to standard courses. This approach may support antimicrobial stewardship without compromising patient safety.
Area of Science:
- Critical Care Medicine
- Pulmonology
- Infectious Diseases
Background:
- Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) in critically ill patients often lacks clear microbiological data.
- The optimal duration of nonmacrolide antibiotic therapy in these culture-negative cases is not well-defined, impacting antimicrobial stewardship efforts.
Purpose of the Study:
- To compare the efficacy and tolerability of short-course versus standard-course nonmacrolide antibiotic strategies in critically ill patients with culture-negative AECOPD.
- To evaluate the impact of antibiotic course duration on clinical outcomes and adverse events.
Main Methods:
- A retrospective cohort study of 135 critically ill adults with culture-negative AECOPD treated between 2014 and 2019.
- Patients were divided into short-course (≤3 days) and standard-course (>3 days) nonmacrolide antibiotic groups.
- Primary composite endpoint included in-hospital mortality, need for ventilation, or 30-day readmission for AECOPD. Secondary endpoints included length of stay and adverse events.
Main Results:
- No significant difference was observed in the primary composite endpoint between the short-course (24.2%) and standard-course (39.1%) groups (P=0.06).
- The short-course group experienced significantly shorter median ICU length of stay (2 vs 3 days) and hospital length of stay (4 vs 6 days) (P < 0.01).
- Multivariate analysis confirmed no association between short-course therapy and the primary endpoint, nor significant differences in adverse drug events.
Conclusions:
- Short-course nonmacrolide antibiotic therapy is a viable option for critically ill patients with culture-negative AECOPD, demonstrating comparable efficacy and tolerability to standard courses.
- This approach may contribute to effective antimicrobial stewardship by reducing antibiotic exposure without negatively impacting key clinical outcomes.
- Further validation through larger prospective studies is recommended to confirm these findings.
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