title: Antibiotic therapy and treatment failure in patients hospitalized for acute exacerbations of chronic obstructive pulmonary disease.
abstract: BACKGROUND
  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.
  
  
  OBJECTIVE
  To compare the outcomes of patients treated with antibiotics in the first 2 hospital days with those treated later or not at all.
  
  
  METHODS
  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.
  
  
  METHODS
  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.
  
  
  RESULTS
  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.
  
  
  CONCLUSIONS
  Early antibiotic administration was associated with improved outcomes among patients hospitalized for acute exacerbations of COPD regardless of the risk of treatment failure.
authors.affiliation: Division of General Medicine and Geriatrics, Baystate Medical Center, 759 Chestnut St, Springfield, MA 01199, USA. michael.rothberg@bhs.org
authors.forename: Michael B
authors.initials: MB
authors.lastname: Rothberg
authors.forename: Penelope S
authors.initials: PS
authors.lastname: Pekow
authors.forename: Maureen
authors.initials: M
authors.lastname: Lahti
authors.forename: Oren
authors.initials: O
authors.lastname: Brody
authors.forename: Daniel J
authors.initials: DJ
authors.lastname: Skiest
authors.forename: Peter K
authors.initials: PK
authors.lastname: Lindenauer
mesh_terms: D000368:Aged; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D016360:Clostridioides difficile; D015331:Cohort Studies; D004761:Enterocolitis, Pseudomembranous; D005260:Female; D017048:Health Care Costs / Q000706:statistics & numerical data; D017052:Hospital Mortality; D006801:Humans; D007297:Inpatients; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D010359:Patient Readmission / Q000706:statistics & numerical data; D029424:Pulmonary Disease, Chronic Obstructive / Q000150:complications / Q000188:drug therapy*; D012121:Respiration, Artificial; D012189:Retrospective Studies; D017211:Treatment Failure; D014481:United States
chemical_list: D000900:Anti-Bacterial Agents