Antibiotics for Severe Asthma: Are They Really Necessary?

Despite guidelines stating no antibiotics for asthma patients unless there’s evidence of lung infection, doctors still prescribe them.

When someone is hospitalized for asthma, the standard of care is steroids with bronchodilators, yet many patients also end up getting antibiotics. But a growing amount of medical evidence indicates antibiotics are not only unnecessary, but can also cause side effects and increase patients’ hospital stay and expenses.

Nearly half of the patients who were hospitalized for asthma did not have signs of a lung infection, but nonetheless were given antibiotics, according to a comparative effectiveness study that examined patient medical records in 554 hospitals from the beginning of 2015 to the end of 2016.

Researchers from the University of Massachusetts Medical School-Baystate excluded patients who might need an antibiotic, such as those who are also suffering with pneumonia, sinus, emphysema and sepsis. They still found that 46% of the remaining patients — about 10,000 people — were put on antibiotics.

Given that there are established guidelines for treating asthma, and antibiotics are called for only when there is a lung infection, why do so many physicians dole out prescriptions for them?

No Studies Exploring The Issue

“There are no studies exploring this issue,” of why antibiotics are prescribed in these cases, Mihaela S. Stefan, MD, an associate professor of medicine at UMMS Baystate and lead author of the study, an abstract of which was presented at the May meeting of the American Thoracic Society.

“Potential explanations for this high rate of inappropriate treatment include the challenge of differentiating bacterial from non-bacterial infections, distinguishing asthma from COPD [chronic obstructive pulmonary disease] in the acute care setting, and gaps in knowledge about the benefits of antibiotic therapy.”

Side effects from antibiotics varied depending on class. Her team found that macrolides (a class of antibiotics that includes clarithromycin and erythromycin) had a lower risk of diarrhea compared to quinolones — such as Cipro (ciprofloxacin) and Levaquin (levofloxacin) and third-generation cephalosporins, such as Cedax (ceftibuten) and Rocephin (ceftriaxone). Macrolides had only a 1.2% risk of leading to diabetes compared to the other antibiotics at 2.2%.

This recent study is a follow-up to a 2016 JAMA Internal Medicine study Stefan co-authored in which they analyzed records of nearly 52,000 patients in 577 hospitals across the US. They found that nearly 60% of patients received antibiotics for asthma.

Dig Deeper to See What Triggered Asthma

Asthma exacerbations can be caused by a variety of factors, such as pollution, dust, tobacco smoke, outdoor allergens, pets, mold, emotional triggers, physical exercise and weather. Sinus infections, the flu and colds can also trigger asthma attacks.

“I personally rarely prescribe antibiotics for patients with asthma flare that don’t have other symptoms,” Stephen Lee, MD, a pulmonary disease specialist with Sharp Rees-Stealy Health in San Diego, said. “You look at what may have caused asthma to flare. Was there exposure to triggers?

“If someone has known asthma and is supposed to use a maintenance inhaler every single day no matter how they feel, we know that compliance with these daily inhalers is poor, people often forget to take it, or don’t want to take it daily, or wait until they’re ill to take it,” Lee explained as a possible reason for an asthma exacerbation.

Why Physicians Err on the Side of Caution

“It’s very common for patients coming in to the hospital complaining of respiratory symptoms to be given antibiotics. We’re always going to worry that we will miss an infection,” Lee said.

While Lee hardly ever prescribes antibiotics, he said physicians often feel like patients expect it, or they add it on just to be safe, so he was not surprised by the results of the study.

“There is overuse of antibiotics in the outpatient setting which can flow over to inpatient, too. A lot of doctors feel compelled to add it, just to be sure, so they err on the side of precaution,” he said.

When patients come in with respiratory complaints, one easy way to rule out pneumonia is with an X-ray, but when there’s a cough with sputum, it can be a gray area that leads doctors to hedge their bets.

When a patient is hospitalized, they’ve already progressed through the system, possibly from the ER, where attempts would have been made to manage it, so there’s a certain level of urgency related to their clinical status, Lee explained, which differs from that of an outpatient.

Stefan’s recent study also excluded patients with bronchitis — which is usually caused by a virus — who were given antibiotics, which Lee questioned, since there is no reason to prescribe them for bronchitis, which can often overlap with asthma.

“If they’re getting sicker, coughing a lot and bringing up a lot of sputum, that may be when I’m compelled to prescribe them, but it’s uncommon,” he noted. “How do you separate it out from a cough? Even if it was viral or bacterial, there’s no call to use it for bronchitis.”

The Costs of Antibiotic Prescribing for Asthma

Inappropriate use of antibiotics comes at a huge cost, both monetary and health-wise. It contributes to antibiotic resistance, which in some people can make it difficult to fight bacterial infections when they actually do have one.

“Inappropriate use of antibiotics is a public health problem, given the risk of bacterial resistance and adverse events. Antibiotic resistance adds an average of $1,383 to the cost of treating a patient with a bacterial infection, resulting in a national cost of $2.2 billion annually,” Stefan said, quoting a recent study.

“Asthma exacerbations are an important cause for recurrent hospitalizations, and although there are published guidelines, physicians are slow to adopt these guidelines,” she added

Stefan wants to dig deeper to find out why so many doctors are prescribing antibiotics that are unnecessary. Her team plans to do a qualitative study to assess providers’ attitudes and beliefs about antibiotic prescribing practices for asthma.

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