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. 2021 Jul 1;58(1):2003599.
doi: 10.1183/13993003.03599-2020. Print 2021 Jul.

A real-life comparative effectiveness study into the addition of antibiotics to the management of asthma exacerbations in primary care

Clare S Murray  1 , Sarah J Lucas  2 , John Blakey  3   4 , Alan Kaplan  5 , Alberto Papi  6 , James Paton  7 , Wanda Phipatanakul  8 , David Price  9   10 , Oon Hoe Teoh  11 , Mike Thomas  12 , Steve Turner  13 , Nikolaos G Papadopoulos  14   15
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Free article

A real-life comparative effectiveness study into the addition of antibiotics to the management of asthma exacerbations in primary care

Clare S Murray et al. Eur Respir J. .
Free article

Abstract

Background: Asthma exacerbations are major contributors to asthma morbidity and mortality. They are usually managed with bronchodilators and oral corticosteroids (OCS), but clinical trial evidence suggests that antibiotics could be beneficial. We aimed to assess whether treatment of asthma exacerbations with antibiotics in addition to OCS improved outcomes in larger, more representative routine-care populations.

Method: A retrospective comparative effectiveness study into managing asthma exacerbations with OCS alone versus OCS plus antibiotics was conducted using the Optimum Patient Care Research Database. The dataset included 28 637 patients; following propensity score matching 20 024 adults and 4184 children were analysed.

Results: Antibiotics in addition to OCS were prescribed for the treatment of asthma exacerbations in 45% of adults and 32% of children. Compared to OCS alone, OCS plus antibiotics was associated with reduced risk of having an asthma/wheeze consultation in the following 2 weeks (children hazard ratio (HR) 0.84 (95% CI 0.73-0.96), p=0.012; adults HR 0.86 (95% CI 0.81-0.91), p<0.001), but an increase in risk of a further OCS prescription for a new/ongoing exacerbation within 6 weeks in adults (HR 1.11 (95% CI 1.01-1.21), p=0.030), but not children. Penicillins, but not macrolides, were associated with a reduction in the odds of a subsequent asthma/wheeze consultation compared to OCS alone, in both adults and children.

Conclusion: Antibiotics were frequently prescribed in relation to asthma exacerbations, contrary to guideline recommendations. Overall, the routine addition of antibiotics to OCS in the management of asthma exacerbations appeared to confer little clinical benefit, especially when considering the risks of antibiotic overuse.

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Conflict of interest statement

Conflict of interest: C.S. Murray reports personal fees from AstraZeneca, Thermo Fisher, Boehringer Ingelheim, GSK and Novartis, outside the submitted work. Conflict of interest: S.J. Lucas has nothing to disclose. Conflict of interest: J. Blakey reports personal fees and non-financial support from AstraZeneca and Boehringer Ingelheim, personal fees from TEVA, non-financial support from GSK, grants from Novartis, outside the submitted work. Conflict of interest: A. Kaplan reports personal fees from AstraZeneca, Behring, Boehringer Ingelheim, GSK, Novartis, Reva, Covis, Merck, Trudell, Pfizer, Purdue, NovoNordisk and Griffols, outside the submitted work. Conflict of interest: A. Papi reports grants, personal fees for advisory board work, lectures and consultancy, and non-financial support (travel expenses reimbursement) from GlaxoSmithKline, AstraZeneca, Boehringer Ingelheim, Chiesi Farmaceutici and TEVA, personal fees for advisory board work, lectures and consultancy, and non-financial support (travel expenses reimbursement) from Mundipharma, Zambon, Novartis and Sanofi/Regeneron, grants, personal fees for lectures and non-financial support (travel expenses reimbursement) from Menarini, personal fees for advisory board work and non-financial support (travel expenses reimbursement) from Roche, grants from Fondazione Maugeri and Chiesi, personal fees for consultancy from Edmondpharma, outside the submitted work. Conflict of interest: J. Paton has nothing to disclose. Conflict of interest: W. Phipatanakul reports grants and personal fees for consultancy from Genentech/Novartis and Regeneron/Sanofi, other (reagent support) from Thermo Fisher, other (clinical trial/medication support) from GSK and Kaleo, other (clinical trial support) from Lincoln Diagnostics and Monaghen, during the conduct of the study. Conflict of interest: D. Price reports grants and personal fees for advisory board work, consultancy and lectures from AstraZeneca, Chiesi, Boehringer Ingelheim, Teva Pharmaceuticals, Novartis, Mylan and Mundipharma, grants and personal fees for advisory board work from Circassia, grants and personal fees for advisory board work and lectures from Regeneron Pharmaceuticals and Sanofi Genzyme, grants and personal fees for consultancy from Pfizer and Theravance, grants from Respiratory Effectiveness Group and UK National Health Service, personal fees for advisory board work and consultancy from Amgen, personal fees for advisory board work, consultancy and lectures from GSK, personal fees for lectures from Cipla and Kyorin, personal fees for advisory board work and travel to meetings from Thermofisher, outside the submitted work; and has stock/stock options from AKL Research and Development Ltd, which produces phytopharmaceuticals; owns 74% of the social enterprise Optimum Patient Care Ltd (Australia and UK) and 74% of Observational and Pragmatic Research Institute Pte Ltd (Singapore); is peer reviewer for grant committees of the Efficacy and Mechanism Evaluation programme, and Health Technology Assessment; and was an expert witness for GlaxoSmithKline. Conflict of interest: O.H. Teoh has nothing to disclose. Conflict of interest: M. Thomas reports personal fees from GSK, Novartis and Boehringer Ingelheim, outside the submitted work. Conflict of interest: S. Turner has nothing to disclose. Conflict of interest: N.G. Papadopoulos reports personal fees for advisory board work and lectures from Novartis, Nutricia, HAL, Menarini/Faes Farma and Mylan/Meda, personal fees lectures from Sanofi, Biomay, MSD, Asit Biotech and Boehringer Ingelheim, personal fees for advisory board work from AstraZeneca and GSK, grants from Gerolymatos International SA and Capricare, outside the submitted work.

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