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  • Journal article
    Johnston SL, Szigeti M, Cross M, Brightling C, Chaudhuri R, Harrison T, Mansur A, Robison L, Sattar Z, Jackson D, Mallia P, Wong E, Corrigan C, Higgins B, Ind P, Singh D, Thomson NC, Ashby D, Chauhan Aet al., 2016,

    Azithromycin for Acute Exacerbations of Asthma The AZALEA Randomized Clinical Trial

    , JAMA INTERNAL MEDICINE, Vol: 176, Pages: 1630-1637
  • Journal article
    Westwood JP, Mackay AJ, Donaldson G, Machin SJ, Wedzicha JA, Scully Met al., 2016,

    The role of complement activation in COPD exacerbation recovery.

    , ERJ Open Research, Vol: 2, ISSN: 2312-0541
  • Journal article
    Al-Ahmari A, Kowlessar BS, Patel ARC, Mackay AJ, Allinson JP, Wedzicha JA, Donaldson GCet al., 2016,

    Physical activity and exercise capacity in patients with moderate COPD exacerbations

    , European Respiratory Journal, Vol: 48, Pages: 340-349, ISSN: 1399-3003

    Introduction: Little is known about changes in physical activity during moderate (out-patient managed) exacerbations. Methods: Six minute walking distance (6MWD) was measured during 50 exacerbations when the patients were stable, and at 3 and 7 days post exacerbation presentation. At similar time points, quadriceps maximum voluntary contraction (QMVC) was measured during 47 different exacerbations. Physical activity (SenseWear) was recorded over two consecutive week periods post presentation. Results: 6MWD fell from a median 422 metres when stable to 373 metres on day 3 (p=0.001). Similarly, QMVC fell from 32.6 vs. 29.7 kg (p=0.026). Falls in 6MWD were associated with rise in C-Reactive Protein (r=-0.364; p=0.041) and increased FACIT fatigue (r=-0.44; p=0.013). Light physical activity was 2.18 hours/day during the first week post exacerbation and was less over week 2, 1.98 hours/day (p=0.009). Patients who had attended pulmonary rehabilitation (PR) had smaller changes in 6MWD than those who had not attended (-35.0 vs. -114.9 meters; p=0.013). Falls in physical activity were correlated with higher depression scores (rho=-0.51; p=0.006).Conclusion: These findings indicate that exercise capacity and muscle strength falls at exacerbation in COPD patients treated at home and free to maintain normal activity.

  • Journal article
    Allinson JP, Hardy R, Donaldson GC, Shaheen SO, Kuh D, Wedzicha JAet al., 2015,

    The presence of chronic mucus hypersecretion across Adult life in relation to COPD development

    , American Journal of Respiratory and Critical Care Medicine, Vol: 193, Pages: 662-672, ISSN: 1073-449X

    RATIONALE: Chronic Mucus Hypersecretion(CMH) is common amongst smokers and is associated with Chronic Obstructive Pulmonary Disease(COPD) development and progression. Understanding how the relationships between smoking, CMH and COPD develop during adult life could facilitate earlier disease detection and intervention. METHODS: We analysed data on CMH, smoking and lung function prospectively collected by the MRC National Survey of Health and Development, a nationally representative British cohort followed since birth in 1946. We analysed the longitudinal relationships between smoking and CMH, how symptoms during life related to airflow limitation at 60-64 years and how CMH duration between ages 43 to 60-64 years related to concurrent FEV1 decline. RESULTS: From 5362 individuals enrolled at birth, 4427 contributed data between ages 20 and 64 years (52%male;63%ever-smoker). Amongst smokers CMH prevalence escalated between ages 36 and 43 from 7.6±2.0% to 13.0±2.6%. At these ages symptoms were associated with a higher risk of subsequent airflow limitation (OR(95%CI):3.70(1.62-8.45);4.11(1.85-9.13) respectively). Across adult life, CMH followed a dynamic remitting-relapsing course. Symptom prevalence following smoking cessation returned to levels seen amongst never-smokers. The longer CMH was present across 3 occasions (ages 43, 53 and 60-64), the greater the concurrent FEV1 decline, corresponding to an additional decrement of 3.6±2.5ml/year per occasion that CMH was present(p=0.005). CONCLUSIONS: CMH amongst middle-aged smokers represents an early developmental phase of COPD. Smoking-related CMH usually resolves following smoking cessation but the longer its duration the greater the FEV1 lost, suggesting the course of CMH across adult life may reflect the underlying course of airway disease activity.

  • Journal article
    Pavord ID, Lettis S, Locantore N, Pascoe S, Jones PW, Wedzicha JA, Barnes NCet al., 2015,

    Blood eosinophils and inhaled corticosteroid/long-acting β-2 agonist efficacy in COPD

    , Thorax, Vol: 71, Pages: 118-125, ISSN: 1468-3296

    Objective We performed a review of studies offluticasone propionate (FP)/salmeterol (SAL) (combinationinhaled corticosteroid (ICS)/long-acting β2-agonist(LABA)) in patients with COPD, which measured baseline(pretreatment) blood eosinophil levels, to test whetherblood eosinophil levels ≥2% were associated with agreater reduction in exacerbation rates with ICS therapy.Methods Three studies of ≥1-year duration met theinclusion criteria. Moderate and severe exacerbation rateswere analysed according to baseline blood eosinophillevels (<2% vs ≥2%). At baseline, 57–75% of patientshad ≥2% blood eosinophils. Changes in FEV1 and StGeorge’s Respiratory Questionnaire (SGRQ) scores werecompared by eosinophil level.Results For patients with ≥2% eosinophils, FP/SALwas associated with significant reductions inexacerbation rates versus tiotropium (INSPIRE: n=719,rate ratio (RR)=0.75, 95% CI 0.60 to 0.92, p=0.006)and versus placebo (TRISTAN: n=1049, RR=0.63, 95%CI 0.50 to 0.79, p<0.001). No significant difference wasseen in the <2% eosinophil subgroup in either study(INSPIRE: n=550, RR=1.18, 95% CI 0.92 to 1.51,p=0.186; TRISTAN: n=354, RR=0.99, 95% CI 0.67 to1.47, p=0.957, respectively). In SCO30002 (n=373), nosignificant effects were observed (FP or FP/SAL vsplacebo). No relationship was observed in any studybetween eosinophil subgroup and treatment effect onFEV1 and SGRQ.Discussion Baseline blood eosinophil levels mayrepresent an informative marker for exacerbationreduction with ICS/LABA in patients with COPD and ahistory of moderate/severe exacerbations.

  • Journal article
    Benson VS, Mullerova H, Vestbo J, Wedzicha JA, Patel A, Hurst JRet al., 2015,

    Associations between gastro-oesophageal reflux, its management and exacerbations of chronic obstructive pulmonary disease

    , RESPIRATORY MEDICINE, Vol: 109, Pages: 1147-1154, ISSN: 0954-6111
  • Journal article
    Brill S, Law M, El-Emir E, Allinson JP, James PL, Maddox V, Donaldson GC, McHugh TD, Cookson WO, Moffatt MF, Nazareth I, Hurst JR, Calverley PMA, Sweeting MJ, Wedzicha JAet al., 2015,

    Effects of different antibiotic classes on airwaybacteria in stable COPD using culture and molecularQ1 techniques: a randomised controlled trial

    , Thorax, Vol: 70, Pages: 930-938, ISSN: 1468-3296

    BackgroundLong term antibiotic therapy is used to prevent exacerbations of chronic obstructive pulmonary disease (COPD) but there is uncertainty over whether this reduces airway bacteria. The optimum antibiotic choice remains unknown. We conducted an exploratory trial in stable patients with COPD comparing three antibiotic regimens against placebo. MethodsThis was a single-centre, single-blind, randomised placebo-controlled trial (clinicaltrials.gov number NCT01398072). Patients ≥45 years with COPD, FEV1<80% predicted and chronic productive cough were randomised to receive either moxifloxacin 400mg daily for 5 days/4 weeks, doxycycline 100mg/day, azithromycin 250mg 3x/week or one placebo tablet daily for 13 weeks. The primary outcome was the change in total cultured bacterial load in sputum from baseline; secondary outcomes included bacterial load by 16S qPCR, sputum inflammation and antibiotic resistance. Results99 patients were randomised; 86 completed follow-up, were able to expectorate sputum and were analysed. After adjustment, there was a mean reduction in bacterial load of 0.42 log10 cfu/ml (95% CI -0.08, 0.91, p=0.10) with moxifloxacin, 0.11 (-0.33, 0.55, p=0.62) with doxycycline, and 0.08 (-0.38, 0.54, p=0.73) with azithromycin from placebo, respectively. There were also no significant changes in bacterial load measured by 16S qPCR or in airway inflammation. More treatment-related adverse events occurred with moxifloxacin. Of note, mean inhibitory concentrations of cultured isolates increased by at least 3 times over placebo in all treatment arms.ConclusionsTotal airway bacterial load did not decrease significantly after three months of antibiotic therapy. Large increases in antibiotic resistance were seen in all treatment groups and this has important implications for future studies.

  • Journal article
    Donaldson GC, Law M, Kowlessar B, Singh R, Brill SE, Allinson JP, Wedzicha JAet al., 2015,

    Impact of Prolonged Exacerbation Recovery in Chronic Obstructive Pulmonary Disease.

    , American Journal of Respiratory and Critical Care Medicine, Vol: 192, Pages: 943-950, ISSN: 1535-4970

    INTRODUCTION: COPD exacerbations are important and heterogeneous events, but the consequences of prolonged exacerbation recovery are unknown. METHODS: A cohort of 384 COPD patients (FEV1 % predicted 45.8 (SD 16.6) and a median exacerbation rate of 2.13 per year (IQR 1.0-3.2)) were followed for 1039 days (IQR 660-1814) between October 1995 and January 2013. Patients recorded daily worsening of respiratory symptoms and peak expiratory flow (PEF), and when stable underwent 3-monthly spirometry, and completed the St. George's Respiratory Questionnaire (SGRQ) annually. Exacerbations were diagnosed as two consecutive days with one major symptom plus another respiratory symptom. Exacerbation duration was defined as the time from onset to the day preceding two consecutive symptom-free and recovery in PEF as return to pre-exacerbation levels. RESULTS: 351 patients had 1 or more exacerbations. Patients with a longer symptom duration (mean 14.5 days) had a worse SGRQ total score (0.2 units per 1 day; p=0.040). A longer symptomatic duration was associated with a shorter interval between exacerbation recovery and onset of the next exacerbation (Hazard Ratio=1.004; p=0.013). For 257 (7.3%) exacerbations, PEF did not recover within 99 days. These exacerbations were associated with symptoms of a viral infection (cold and sore throat). Patients with these non-recovered exacerbations showed a 10.8 ml/year (p<0.001) faster decline in FEV1. CONCLUSION: Prolonged exacerbation symptomatic duration is associated with poorer health status and a greater risk of a new event. Exacerbations where lung function does not recover are associated with symptoms of viral infections and accelerated decline in FEV1.

  • Journal article
    Beale J, Jayaraman A, Jackson DJ, Macintyre JDR, Edwards MR, Walton RP, Zhu J, Ching YM, Shamji B, Edwards M, Westwick J, Cousins DJ, Hwang YY, McKenzie A, Johnston SL, Bartlett NWet al., 2014,

    Rhinovirus-induced IL-25 in asthma exacerbation drives type 2 immunity and allergic pulmonary inflammation

    , SCIENCE TRANSLATIONAL MEDICINE, Vol: 6, ISSN: 1946-6234
  • Journal article
    Ic-Jusufagic AS, Belgrave D, Pickles A, Telcian AG, Bakhsoliani E, Sykes A, Simpson A, Johnston SL, Custovic Aet al., 2014,

    Assessing the association of early life antibiotic prescription with asthma exacerbations, impaired antiviral immunity, and genetic variants in 17q21: a population-based birth cohort study

    , LANCET RESPIRATORY MEDICINE, Vol: 2, Pages: 621-630, ISSN: 2213-2600
  • Journal article
    James GD, Donaldson GC, Wedzicha JA, Nazareth Iet al., 2014,

    Trends in management and outcomes of COPD patients in primary care, 2000-2009: a retrospective cohort study

    , npj Primary Care Respiratory Medicine, Vol: 24, Pages: 14015-14015, ISSN: 2055-1010

    Background:Since the introduction of the Quality and Outcomes framework, there has been some evidence of improvement in the management of chronic obstructive pulmonary disease (COPD) patients in the United Kingdom through increasing rates of smoking cessation advice and immunisations against influenza. However, it is unknown whether disease-specific management criteria, disease outcomes and diagnosis have improved.Aims:To describe changes in the management and outcomes of patients with COPD in UK general practice between 2000 and 2009.Methods:The study was done on a retrospective cohort using data from The Health Improvement Network UK primary care database. We calculated age at diagnosis of COPD and death, total number of short-term oral corticosteroid courses and consultations, and proportion of patients with very severe COPD and on triple inhaled therapy for each year between 2000 and 2009.Results:We identified 92,576 patients with COPD. The mean age at COPD diagnosis decreased from 68.1 years in 2000 to 66.7 years in 2009. The mean age at death increased from 78.2 years in 2000 to 78.8 years in 2009. The number of prescribed courses of oral corticosteroids increased from 0.6 in 2000 to 0.8 in 2009. The number of consultations increased from 9.4 in 2004 to 11.3 in 2009. The risk of having very severe COPD decreased from 9.4% in 2004 to 6.8% in 2009. The likelihood of patients with very severe COPD receiving triple therapy increased from 25% in 2004 to 59% in 2009.Conclusions:The trends suggest that management and outcomes observed in patients with COPD may have improved since the year 2000.

  • Journal article
    Alahmari AD, Patel AR, Kowlessar BS, Mackay AJ, Singh R, Wedzicha JA, Donaldson GCet al., 2014,

    Daily activity during stability and exacerbation of chronic obstructive pulmonary disease

    , BMC Pulmonary Medicine, Vol: 14, Pages: 98-98, ISSN: 1471-2466

    BACKGROUND: During most COPD exacerbations, patients continue to live in the community but there is little information on changes in activity during exacerbations due to the difficulties of obtaining recent, prospective baseline data. METHODS: Patients recorded on daily diary cards any worsening in respiratory symptoms, peak expiratory flow (PEF) and the number of steps taken per day measured with a Yamax Digi-walker pedometer. Exacerbations were defined by increased respiratory symptoms and the number of exacerbations experienced in the 12 months preceding the recording of daily step count used to divide patients into frequent (> = 2/year) or infrequent exacerbators. RESULTS: The 73 COPD patients (88% male) had a mean (+/-SD) age 71(+/-8) years and FEV1 53(+/-16)% predicted. They recorded pedometer data on a median 198 days (IQR 134-353). At exacerbation onset, symptom count rose by 1.9(+/-1.3) and PEF fell by 7(+/-13) l/min. Mean daily step count fell from 4154(+/-2586) steps/day during a preceding baseline week to 3673(+/-2258) step/day during the initial 7 days of exacerbation (p = 0.045). Patients with larger falls in activity at exacerbation took longer to recover to stable level (rho = -0.56; p < 0.001). Recovery in daily step count was faster (median 3.5 days) than for exacerbation symptoms (median 11 days; p < 0.001). Recovery in step count was also faster in untreated compared to treated exacerbation (p = 0.030).Daily step count fell faster over time in the 40 frequent exacerbators, by 708 steps/year, compared to 338 steps/year in 33 infrequent exacerbators (p = 0.002). CONCLUSIONS: COPD exacerbations reduced physical activity and frequent exacerbations accelerate decline in activity over time.

  • Journal article
    Allinson JP, Donaldson GC, 2014,

    Long-term antibiotic therapy reduces exacerbation frequency in patients with COPD but it remains unclear which patients to target

    , Evid Based Med, Vol: 19, ISSN: 1473-6810
  • Journal article
    George SN, Garcha DS, Mackay AJ, Patel AR, Singh R, Sapsford RJ, Donaldson GC, Wedzicha JAet al., 2014,

    Human rhinovirus infection during naturally occurring COPD exacerbations

    , Eur Respir J, Vol: 44, Pages: 87-96, ISSN: 1399-3003

    Human rhinovirus (HRV) infection is an important trigger of exacerbations of chronic obstructive pulmonary disease (COPD) but its role in determining exacerbation frequency phenotype or the time-course of HRV infection in naturally occurring exacerbations is unknown. Sputum samples from 77 patients were analysed by real-time quantitative PCR for both HRV (388 samples), and Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis (89 samples). Patients recorded worsening of respiratory symptoms on daily diary cards, from which exacerbations were identified. HRV prevalence and load at exacerbation presentation were significantly higher than in the stable state (prevalence 53.3% versus 17.2%, respectively; p<0.001) but 0% by day 35 post-exacerbation. HRV load was higher in patients with cold symptoms (p=0.046) or sore throats (p=0.006) than those without. 73% of bacterium-negative but HRV-positive exacerbations were bacterium-positive by day 14. Patients with HRV detected at exacerbation had a higher exacerbation frequency (interquartile range) of 3.01 (2.02-5.30) per year compared with patients without HRV (2.51 (2.00-3.51)) (p=0.038). HRV prevalence and load increased at COPD exacerbation, and resolved during recovery. Frequent exacerbators were more likely to experience HRV infection. Secondary bacterial infection is common after HRV infection, and provides a possible mechanism for exacerbation recurrence and a potential target for novel therapies.

  • Journal article
    Donaldson GC, Mullerova H, Locantore N, Hurst JR, Calverley PM, Vestbo J, Anzueto A, Wedzicha JAet al., 2013,

    Factors associated with change in exacerbation frequency in COPD

    , Respiratory Research, Vol: 14, Pages: 79-79, ISSN: 1465-9921

    BACKGROUND: Patients with chronic obstructive pulmonary disease (COPD) can be categorized as having frequent (FE) or infrequent (IE) exacerbations depending on whether they respectively experience two or more, or one or zero exacerbations per year. Although most patients do not change category from year to year, some will, and the factors associated with this behaviour have not been examined. METHODS: 1832 patients completing two year follow-up in the Evaluation of COPD Longitudinally to Identify Predictive Surrogate End-points (ECLIPSE) study were examined at baseline and then yearly. Exacerbations were defined by health care utilisation. Patient characteristics compared between those patients who did or did not change exacerbation category from year 1 to year 2. FINDINGS: Between years 1 and 2, 221 patients (17%) changed from IE to FE and 210 patients (39%) from FE to IE. More severe disease was associated with changing from IE to FE and less severe disease from FE to IE. Over the preceding year, small falls in FEV1 and 6-minute walking distance were associated with changing from IE to FE, and small falls in platelet count associated with changing from FE to IE. CONCLUSION: No parameter clearly predicts an imminent change in exacerbation frequency category. TRIAL REGISTRATION: SCO104960, clinicaltrials.gov identifier NCT00292552.

  • Journal article
    Wedzicha JA, Decramer M, Ficker JH, Niewoehner DE, Sandstrom T, Taylor AF, D'Andrea P, Arrasate C, Chen H, Banerji Det al., 2013,

    Analysis of chronic obstructive pulmonary disease exacerbations with the dual bronchodilator QVA149 compared with glycopyrronium and tiotropium (SPARK): a randomised, double-blind, parallel-group study

    , LANCET RESPIRATORY MEDICINE, Vol: 1, Pages: 199-209, ISSN: 2213-2600
  • Journal article
    Wedzicha JA, Rabe KF, Martinez FJ, Bredenbroeker D, Brose M, Goehring U-M, Calverley PMAet al., 2013,

    Efficacy of Roflumilast in the COPD Frequent Exacerbator Phenotype

    , CHEST, Vol: 143, Pages: 1302-1311, ISSN: 0012-3692
  • Journal article
    Mackay AJ, Donaldson GC, Patel AR, Singh R, Kowlessar B, Wedzicha JAet al., 2013,

    Detection and severity grading of COPD exacerbations using the exacerbations of Chronic Obstructive Pulmonary Disease Tool (EXACT)

    , Eur Respir J, Vol: 43, Pages: 735-744, ISSN: 1399-3003

    Uncertainty exists over the ability of the Exacerbations of Chronic Obstructive Pulmonary Disease Tool (EXACT) patient-reported outcome diary to quantify exacerbation severity and frequency. To clarify this we investigated the ability of the EXACT to assess severity of exacerbations and examined the relationship between exacerbations diagnosed using London COPD cohort diary cards, physician review and symptom-defined events using the EXACT.58 patients enrolled in the London COPD cohort prospectively completed the EXACT during 128 cohort diary card-defined exacerbations between January 2010 and April 2012.Mean EXACT scores increased from 42.6 (SD 8.6) at baseline to 48.0 (8.6) at exacerbation onset (p<0.001), and rose further to a maximum score of 54.1 (8.9). Maximum EXACT scores were significantly higher in treated than untreated events. Time taken for EXACT scores to return to baseline was significantly related to symptom recovery time as judged by London COPD cohort diary cards, and to PEFR recovery. Approximately 50% of both diary card-defined and HCU exacerbations crossed the EXACT event threshold.However, only 27.9% of diary-card defined and 34.6% of HCU exacerbations fully met the criteria for an EXACT event. Patients exhibited smaller rises in EXACT score at exacerbation as baseline disease severity increased.The EXACT is an effective method of evaluating COPD exacerbation severity. However, concerns remain about the ability of the EXACT to accurately detect exacerbations.

  • Journal article
    Patel AR, Kowlessar BS, Donaldson GC, Mackay AJ, Singh R, George SN, Garcha DS, Wedzicha JA, Hurst JRet al., 2013,

    Cardiovascular risk, myocardial injury, and exacerbations of chronic obstructive pulmonary disease

    , Am J Respir Crit Care Med, Vol: 188, Pages: 1091-1099, ISSN: 1535-4970

    RATIONALE: Patients with chronic obstructive pulmonary disease (COPD) have elevated cardiovascular risk, and myocardial injury is common during severe exacerbations. Little is known about the prevalence, magnitude, and underlying mechanisms of cardiovascular risk in community-treated exacerbations. OBJECTIVES: To investigate how COPD exacerbations and exacerbation frequency impact cardiovascular risk and myocardial injury, and whether this is related to airway infection and inflammation. METHODS: We prospectively measured arterial stiffness (aortic pulse wave velocity [aPWV]) and cardiac biomarkers in 98 patients with stable COPD. Fifty-five patients had paired stable and exacerbation assessments, repeated at Days 3, 7, 14, and 35 during recovery. Airway infection was identified using polymerase chain reaction. MEASUREMENTS AND MAIN RESULTS: COPD exacerbation frequency was related to stable-state arterial stiffness (rho = 0.209; P = 0.040). Frequent exacerbators had greater aPWV than infrequent exacerbators (mean +/- SD aPWV, 11.4 +/- 2.1 vs. 10.3 +/- 2.0 ms(-1); P = 0.025). Arterial stiffness rose by an average of 1.2 ms(-1) (11.1%) from stable state to exacerbation (n = 55) and fell slowly during recovery. In those with airway infection at exacerbation (n = 24) this rise was greater (1.4 +/- 1.6 vs. 0.7 +/- 1.3 ms(-1); P = 0.048); prolonged; and related to sputum IL-6 (rho = 0.753; P < 0.001). Increases in cardiac biomarkers at exacerbation were higher in those with ischemic heart disease (n = 12) than those without (n = 43) (mean +/- SD increase in troponin T, 0.011 +/- 0.009 vs. 0.003 +/- 0.006 mug/L, P = 0.003; N-terminal pro-brain natriuretic peptide, 38.1 +/- 37.7 vs. 5.9 +/- 12.3 pg/ml, P < 0.001). CONCLUSIONS: Frequent COPD exacerbators have greater arterial stiffness than infrequent exacerbators. Arterial stiffness rises acutely during COPD exacerbations, particularly with airway infection. Increases in arterial stiffness are related to inflammation

  • Journal article
    James GD, Petersen I, Nazareth I, Wedzicha JA, Donaldson GCet al., 2013,

    Use of long-term antibiotic treatment in COPD patients in the UK: a retrospective cohort study

    , Prim Care Respir J, Vol: 22, Pages: 271-277, ISSN: 1475-1534

    BACKGROUND: Exacerbations of chronic obstructive pulmonary disease (COPD) are a burden to patients and impose a major cost on health services. Long-term antibiotic therapy may prevent exacerbations, but at present it is not recommended by management guidelines. AIMS: To identify the type and prevalence of long-term oral antibiotic treatments prescribed to patients with COPD and to assess the patient characteristics associated with long-term antibiotic use. METHODS: A retrospective cohort using all eligible practices in The Health Improvement Network (THIN) UK primary care database between 2000 and 2009 was studied. We identified patients with COPD and then those who received a course of long-term antibiotics. Long-term courses were defined as >6 months in duration with <50% concomitant oral corticosteroid treatment. RESULTS: We identified 92,576 patients with COPD, but only 567 patients (0.61%) who received 998 long-term antibiotic courses. Mean follow-up time was 3 years and 10 months. The median long-term antibiotic course length was 280 days (interquartile range 224, 394) and 58 patients (0.06%) were continuously prescribed antibiotics for >2 years. The most commonly used long-term antibiotics were oxytetracycline, doxycycline, and penicillin. Azithromycin, erythromycin, and clarithromycin were less frequently used. There was little evidence of the use of rotating courses of antibiotics. Men, people aged 50-79 years, non-smokers, and patients with poorer lung function were more likely to receive long-term antibiotic treatment. CONCLUSIONS: Relatively few COPD patients are currently prescribed long-term antibiotics. Further clinical trials are required to determine the efficacy of this therapy. If beneficial, the use of such treatments should be incorporated into clinical guidelines.

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