From the Department of Medicine, Division of Pulmonary and Critical Care Medicine, Stony Brook University Medical Center.
Correspondence to: Jignesh K. Patel, MD, Department of Medicine, Division of Pulmonary and Critical Care Medicine, Stony Brook University Medical Center, Health Sciences Center, T17-040, Stony Brook, NY 11794-8160; e-mail: email@example.com
Financial/nonfinancial disclosures: The author has reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.
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I read with great interest the article by Stefan et al1 in CHEST (January 2013) regarding early antibiotic use and clinical outcomes in patients hospitalized with an exacerbation of COPD being concomitantly treated with systemic steroids. The authors concluded that early antibiotic use in combination with steroids is associated with lower rates of in-hospital mortality in patients admitted with COPD exacerbations. Several concerning aspects about the statistical analysis in this study require further clarification.
First, because of the nature of observational studies and their inherent selection bias, the authors performed propensity score matching such that patients in the late or no antibiotic arm are matched one to one with the nearest patient in the early antibiotic arm. Given that propensity score matching accounts for covariates that predict receiving the treatment in question, I believe that the absence of variables such as severity of disease, history of allergies and adverse events related to antibiotic use, and history of resistant bacterial infections in the propensity score analysis cannot be ignored and are integral to acknowledge in the propensity scoring and multivariate models. Moreover, the subsequent analysis examining the impact of antibiotic administration and antibiotic choice on outcomes cannot be interpreted unless patients with antibiotic allergies or antibiotic-resistant infections were excluded or if these variables were accounted for in the subsequent multivariate analysis.
Second, it is important to note that there are data to suggest that all patients with COPD do not benefit equally from corticosteroids. Analyses from the multicenter SCCOPE (Systemic Corticosteroids in COPD Exacerbations) trial performed by the Veterans Affairs Cooperative Studies Program demonstrated that prior hospitalization for COPD in the preceding 2 years is associated with a more favorable response to systemic steroid use.2 Other clinical factors suggested to have an impact on steroid responsiveness were theophylline use, lower FEV1 at admission, and prior prednisone use. The latter two baseline characteristics were not taken into account by Stefan et al1 in the multivariate analysis examining outcomes. Ultimately, the question of optimal antibiotic choice in hospitalized patients with a COPD exacerbation remains to be answered, especially in an era of increasingly prevalent antibiotic resistance.
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