In Reply: We agree with Dr Hurley that unrecognized pneumonia might explain the observed difference in mortality between patients who did and did not receive early antibiotics. In clinical practice this would make little difference. Pneumonia can be difficult to diagnose in COPD, and the physicians in our study did not make the diagnosis, so this distinction cannot be used to guide therapy. Although we have no information about do-not-resuscitate orders, in our experience antibiotics are considered a noninvasive intervention and are usually continued even for hospice patients. The finding that patients not given antibiotics were more likely to be intubated also argues against withholding of antibiotics out of preference. We lacked reliable information about smoking status, but it is not clear why smokers would be less likely than nonsmokers to receive antibiotics. Moreover, although readmissions constituted the majority of outcomes, mortality and late ventilation were also significantly lower in the treatment group.
Rothberg MB, Pekow PS, Lindenauer PK. Antibiotic Therapy in Patients Hospitalized With Acute Chronic Obstructive Pulmonary Disease—Reply. JAMA. 2010;304(12):1325-1327. doi:10.1001/jama.2010.1340