Prophylactic antibiotics for adults with chronic obstructive pulmonary disease: a network meta‐analysis

Background Chronic obstructive pulmonary disease (COPD) is a chronic respiratory condition characterised by persistent respiratory symptoms and airflow limitation. Acute exacerbations punctuate the natural history of COPD and are associated with increased morbidity and mortality and disease progression. Chronic airflow limitation is caused by a combination of small airways (bronchitis) and parenchymal destruction (emphysema), which can impact day‐to‐day activities and overall quality of life. In carefully selected patients with COPD, long‐term, prophylactic use of antibiotics may reduce bacterial load, inflammation of the airways, and the frequency of exacerbations. Objectives To assess effects of different prophylactic antibiotics on exacerbations, quality of life, and serious adverse events in people with COPD in three separate network meta‐analyses (NMAs), and to provide rankings of identified antibiotics. Search methods To identify eligible randomised controlled trials (RCTs), we searched the Cochrane Airways Group Specialised Register of trials and clinical trials registries. We conducted the most recent search on 22 January 2020. Selection criteria We included RCTs with a parallel design of at least 12 weeks' duration evaluating long‐term administration of antibiotics prophylactically compared with other antibiotics, or placebo, for patients with COPD. Data collection and analysis This Cochrane Review collected and updated pair‐wise data from two previous Cochrane Reviews. Searches were updated and additional studies included. We conducted three separate network meta‐analyses (NMAs) within a Bayesian framework to assess three outcomes: exacerbations, quality of life, and serious adverse events. For quality of life, we collected data from St George's Respiratory Questionnaire (SGRQ). Using previously validated methods, we selected the simplest model that could adequately fit the data for every analysis. We used threshold analysis to indicate which results were robust to potential biases, taking into account each study’s contributions to the overall results and network structure. Probability ranking was performed for each antibiotic class for exacerbations, quality of life, and serious adverse events. Main results Characteristics of studies and participants Eight trials were conducted at multiple sites that included hospital clinics or academic health centres. Seven were single‐centre trials conducted in hospital clinics. Two trials did not report sett