High levels of inappropriate prescribing of antibiotics in patients with COPD exacerbations can be improved with efforts such as multidisciplinary input into clinical guidelines and shared decision-making with patients, experts say.
As highlighted in Antimicrobial use and Resistance in Australia 2019 (AURA) and previously reported in the limbic, COPD ranks at the bottom of the list for the appropriateness of antibiotic prescribing in the 20 most common hospital indications.
Clinical director of AURA and infectious diseases physician Dr Kathryn Daveson told the limbic COPD was admittedly a difficult situation for clinicians faced with patients with distressing symptoms such as breathlessness.
“The issue is that the longer term outcomes of antibiotic therapy in COPD exacerbations are less favourable than the shorter term outcomes,” she said.
“We make a arbitrary assessment around day 3 or day 5 of therapy about whether somebody is getting better or worse and then we decide to prescribe or change antibiotics but the literature says we can’t really assess if they are going to get better or not without them until 30 days.”
She said there was however some “low-lying fruit” where prescribers could do better.
“We can do better in dose, duration and choice to start. And that is completely consistent within available guidelines whether you are using Therapeutic Guidelines or the COPD-X guidelines. There are a lot of choices made that really aren’t consistent with current guidelines.”
She said a shared decision making tool could help patients better understand their individual risk versus benefit of taking antibiotics.
“It’s an extra layer when you talk about the number of patients who will get better at 30 days or not or if in x months you will have a resistant organism in your sputum that is going to be harder to treat.”
She added there needed to be more multidisciplinary discussion about the issues of antimicrobial resistance.
“I would suggest that people developing the guidelines have different assessments of risks versus benefits and what emphasis we should place on that.
“There is no right answer but I think in every circumstance, whenever we are developing guidelines, we should endeavour to have the expert and key opinion leaders together making the combined decisions, weighing up all the risks and benefits, and then providing advice to the busy clinician at the front end of care to make decisions quickly.”
Professor Ian Yang, chair of the COPD Guidelines Committee for Lung Foundation Australia, told the limbic the COPD-X Concise Guide was currently in the final stages of its latest update.
“Our guidelines continue to recommend appropriate and targeted therapy for people with COPD. In particular, the exacerbation section has been updated to reflect Therapeutic Guidelines recommendations for antibiotic therapy in patients with exacerbations of COPD.”
“Antimicrobial stewardship is an important principle, and our guidelines will recommend oral amoxycillin or doxycycline for five days, for patients with exacerbations and clinical features of infection such as increased volume and change in colour of sputum and/or fever. If pneumonia is present, then pneumonia-specific guidelines should be followed.”
He said proposed practice tips include that intravenous antibiotics were generally not required.
As well, chest X-ray and sputum culture, were not routinely recommended in community-based management of people with COPD exacerbations, unless there were issues with severe or repeated exacerbations, or lack of response.