Antibiotics in asthma exacerbations-a harmful practice: JAMA

USA: According to a retrospective cohort study of nearly 20,000 adult patients, treatment with Antibiotics in asthma exacerbations is an inappropriate and harmful practice. Providing antibiotic treatment to patients hospitalized for asthma exacerbation results in higher hospital cost, a longer hospital length of stay, and risk of treatment failure.

The results, published in the journal JAMA Internal Medicine, highlight the need to reduce inappropriate antibiotic prescribing among patients hospitalized for asthma.

Mihaela Stefan, University of Massachusetts Medical School, Baystate, Springfield, and colleagues conducted the study to determine the association of antibiotic treatment with outcomes among patients hospitalized for asthma and treated with corticosteroids.

The study holds importance as, despite professional society guidelines recommending against the use of empirical antibiotics for treatment of asthma exacerbation, high antibiotic prescribing rates have been recorded in the United States and elsewhere.

The team conducted the retrospective cohort study using data collected from 543 hospitals across the U.S. participating in the Premier Inpatient Database, which is an inpatient, enhanced administrative database developed to measure healthcare quality and use.

Participating hospitals were generally small to medium-sized non-teaching hospitals located mostly in cities, and the cohort included 19,811 adults hospitalized for acute asthma exacerbations in 2015 and 2016. All patients were treated with systemic corticosteroids.

Early antibiotic treatment was defined as treatment with an antibiotic initiated during the first 2 days of hospitalization and prescribed for a minimum of 2 days.

The primary outcome was hospital length of stay, and other measures included treatment failure (initiation of mechanical ventilation, transfer to the intensive care unit after hospital day 2, in-hospital mortality, or readmission for asthma) within 30 days of discharge, hospital costs, and antibiotic-related diarrhea.

Multivariable adjustment, propensity score matching, propensity weighting, and instrumental variable analysis were used to assess the association of antibiotic treatment with outcomes.

Of the 19,811 patients, the median (interquartile range [IQR]) age was 46 (34-59), 14,389 (72.6%) were women, 8,771 (44.3%) were white, and Medicare was the primary form of health insurance for 5,120 (25.8%). Antibiotics were prescribed for 8,788 patients (44.4%).

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Key Findings:

• Compared with patients not treated with antibiotics, those who did receive antibiotics were older (median [IQR] age, 48 [36-61] vs 45 [32-57]), more likely to be white (48.6% vs 40.9%) and smokers (6.6% vs 5.3%), and had a higher number of comorbidities (e.g., congestive heart failure, 6.2% vs 5.8%).


• Compared with patients in the cohort not treated with antibiotics, those prescribed the antimicrobial therapies had higher rates of diarrhoea and similar rates of treatment failure.


• Patients treated with antibiotics had significantly longer hospital stays (median [IQR], 4 [3-5] vs 3 [2-4] days) and a similar rate of treatment failure (5.4% vs 5.8%).


• In propensity score-matched analysis, receipt of antibiotics was associated with a 29% longer hospital stay (length of stay ratio, 1.29; 95% CI, 1.27-1.31) and higher cost of hospitalization (median [IQR] cost, $4,776 [$3,219-$7,373] vs $3,641 [$2,346-$5,942]) but with no difference in the risk of treatment failure (propensity score–matched OR, 0.95; 95% CI, 0.82-1.11).


• Multivariable adjustment, propensity score weighting, and instrumental variable analysis, as well as several sensitivity analyses, yielded similar results.

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"Antibiotic treatment in patients with asthma exacerbations is an appropriate practice for de-implementation because it lacks evidence for effectiveness and it may be harmful," the team wrote. Validating known biomarkers, such as the procalcitonin level, for guiding targeted antibiotic therapy is one strategy that could influence clinicians' willingness to refrain from prescribing antibiotics for patients with asthma.

For further reference log on to 10.1001/jamainternmed.2018.5394