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Mihaela S. Stefan, MD; Peter K. Lindenauer, MD
Author and Funding Information

From the Department of Medicine and Center for Quality of Care Research, Baystate Medical Center; and Tufts University School of Medicine, Boston, MA.

Correspondence: Mihaela S. Stefan, MD, Baystate Medical Center, 759 Chestnut St, Springfield, MA 01199; e-mail: Mihaela.stefan@bhs.org


Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2013;144(2):716-717. doi:10.1378/chest.13-1066
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To the Editor:

We read the comments by Dr Patel regarding our recent article1 with great interest. Although we agree that severity of illness is an important variable for propensity score analysis, our administrative database does not include data on spirometry or other physiologic measures. While we were unable to use specific measures to assess severity of illness, we did control for multiple confounders that serve as markers for disease severity, including admissions in the year prior, multiple treatments and tests performed, comorbidities, and principal diagnosis of acute respiratory failure or COPD. In addition, our sensitivity analysis demonstrated that for a strong unmeasured confounder (eg, severe reduced FEV1), the difference in prevalence between treated and untreated patients has to be >40% to negate our findings.1

Dr Patel notes our lack of information on history of allergy, adverse events to antibiotics, and resistant infection. This data, however, would impact antibiotic selection, not treatment. In addition, allergic reactions to macrolide and fluoroquinolone appear to be relatively uncommon (0.4%-3%) and most likely had little, if any, effect on the observed results. Our analysis also excluded patients treated with antibiotics not recommended by GOLD (Global Initiative for Chronic Obstructive Lung Disease) guidelines (eg, vancomycin, third and fourth generation of cephalosporine) and patients with other infection (like pneumonia).

Concerns were expressed by Dr Patel regarding the impact of other factors on the response to steroids. While we did not include theophylline use prior to hospitalization as a variable in the propensity score, we adjusted for theophylline utilization on day 1 to day 2 of hospitalization as we believe its use on the first days of hospitalization would most likely reflect prior prescription. In the study cited by Dr Patel, there was an interaction between prior hospitalization and the responsiveness to steroid,2 and we adjusted for prior admission in our study.

Dr Patel states that “ultimately, the question of optimal antibiotic choice in hospitalized patients with a COPD exacerbation remains to be answered.” We agree; however, our results suggest that trials to answer this question would need to be extremely large. In addition, these trials are not likely to take place soon, given a recent Cochrane review showing that antibiotics significantly reduce the risk of treatment failure in hospitalized patients with severe COPD exacerbations.3 Although more research is needed, antibiotics do appear to be useful for patients with acute exacerbations of COPD requiring hospitalization.

References

Stefan MS, Rothberg MB, Shieh M-S, Pekow PS, Lindenauer PK. Association between antibiotic treatment and outcomes in patients hospitalized with acute exacerbation of COPD treated with systemic steroids. Chest. 2013;143(1):82-90. [CrossRef]
 
Niewoehner DE, Erbland ML, Deupree RH, et al; Department of Veterans Affairs Cooperative Study Group. Effect of systemic glucocorticoids on exacerbations of chronic obstructive pulmonary disease. N Engl J Med. 1999;340(25):1941-1947. [CrossRef]
 
Vollenweider DJ, Jarrett H, Steurer-Stey CA, Garcia-Aymerich J, Puhan MA. Antibiotics for exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2012;12:CD010257.
 

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References

Stefan MS, Rothberg MB, Shieh M-S, Pekow PS, Lindenauer PK. Association between antibiotic treatment and outcomes in patients hospitalized with acute exacerbation of COPD treated with systemic steroids. Chest. 2013;143(1):82-90. [CrossRef]
 
Niewoehner DE, Erbland ML, Deupree RH, et al; Department of Veterans Affairs Cooperative Study Group. Effect of systemic glucocorticoids on exacerbations of chronic obstructive pulmonary disease. N Engl J Med. 1999;340(25):1941-1947. [CrossRef]
 
Vollenweider DJ, Jarrett H, Steurer-Stey CA, Garcia-Aymerich J, Puhan MA. Antibiotics for exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2012;12:CD010257.
 
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