To the Editor: We have a number of concerns about the message to indiscriminately prescribe antibiotics to any hospitalized patient with exacerbation of COPD conveyed in the study by Dr Rothberg and colleagues.1 First, even after propensity matching, significant heterogeneity in comorbidities remained between patients who did and who did not receive antibiotics, indicating residual confounding.
Second, use of data only from the United States, where medical practice may be heavily influenced by legal pressure to prescribe antibiotics, limits generalizability because of the small proportion of the no-antibiotic group. This raises concerns about performance bias.
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