Antibiotic prescribing for COPD acute exacerbation

Overview

Sending sputum samples for culture is not recommended in routine practice. Pulse oximetry is of value if there are clinical features of a severe exacerbation. Consider prescribing antibiotics to patients with exacerbations who have all 3 cardinal symptoms (increased dyspnea, increased sputum volume, and increased sputum purulence). Or have 2 cardinal symptoms if increased purulence of sputum is 1 of the symptoms...

1. Who require mechanical ventilation.
2. Who have pneumonia on chest x-ray.
3. Alternative treatments include bronchodilators and oral steroids

Management

Antibiotic therapy

Give antibiotics to any patient who needs ventilation (invasive or non-invasive) or patients experiencing exacerbations with increase in sputum purulence, plus Increase in sputum volume, and/or increased dyspnea.

Give antibiotics to patients who are in intensive care or hospitalized with severe COPD exacerbations where they reduce treatment failure and mortality. Consider giving antibiotics to COPD outpatients with mild-to-moderate exacerbations to reduce treatment failures. Give antibiotics for 5-7 days in COPD patients with purulent sputum and increased dyspnea or sputum production. When used appropriately, antibiotics can shorten recovery time, reduce the risk of early relapse and treatment failure and shorten the length of hospital stay. Select antibiotics based on the local bacterial resistance pattern; initial treatment is typically an aminopenicillins with or without clavulanic acid, a macrolide, or a tetracycline. See "table 1 & 2" for commonly used selected antibiotics.

Table (1). Antibiotic regimens
TYPE	DOSE
Oral regimens	Amoxicillin-clavulanate (Augmentin) 875 mg twice daily or 500 mg 3 times daily for 5 days Levofloxacin 500 mg/day for 5 days Doxycycline 100 mg twice daily for 3-14 days Clarithromycin 500 mg every 12 hours for 7 days Azithromycin (Zithromax) 500 mg once daily for 3 days, or 500 mg once on day 1 then 250 mg once daily on days 2-5 Gemifloxacin 320 mg once daily for 5 days Moxifloxacin (Avelox) 400 mg once daily for 5 days Reserve for patients without alternative treatment option
Intravenous regimens	Levofloxacin 500 mg/day for 5 days Azithromycin (Zithromax) 500 mg once daily for 3 days, or 500 mg once on day 1 then 250 mg once daily on days 2-5 Moxifloxacin (Avelox) 400 mg infused over 60 minutes once daily for 5 days, reserve for patients without alternative treatment options

Table (2). Treatment Options for Acute COPD Exacerbations
Therapy	Outpatient management	Inpatient management	Benefits	Disadvantages/common adverse effects	Typical dosage
Antibiotic, broad spectrum (e.g., amoxicillin/clavulanate [Augmentin], macrolides, second- or third-generation cephalosporins, quinolones)	Consider if sputum is purulent or after treatment failure	Use if local microbial patterns show resistance to narrow-spectrum agents	Decreases risk of treatment failure and mortality compared with narrow-spectrum agents	Antibiotic resistance, diarrhea, yeast vaginitis; side effects specific to the antibiotic prescribed	Amoxicillin/clavulanate: 875 mg orally twice daily or 500 mg orally three times daily for 5 days
	Use if local microbial patterns show resistance to narrow-spectrum agents
					Levofloxacin: 500 mg daily for 5 days
Antibiotic, narrow spectrum (e.g., amoxicillin, ampicillin, trimethoprim/sulfamethoxazole, doxycycline, tetracycline)	Consider if sputum is purulent or after treatment failure	Use if local microbial patterns show minimal resistance to these agents and if patient has not taken antibiotics recently	Believed to decrease mortality risk, but has not been tested in placebo-controlled trials	Antibiotic resistance, diarrhea, yeast vaginitis; side effects specific to the antibiotic prescribed	Amoxicillin: 500 mg orally three times daily for 3 to 14 days Doxycycline: 100 mg orally twice daily for 3 to 14 days
	Use if local microbial patterns show minimal resistance to these agents and if patient has not taken antibiotics recently

Pharmacological points

Nausea, vomiting, abdominal discomfort, and diarrhea are the most common adverse effects of macrolides. Use azithromycin with caution in people who may be predisposed to prolongation of the QT interval. This includes people with congenital or documented acquired QT prolongation and who currently receiving treatment with other active substances known to prolong the QT interval such as antiarrhythmics of classes IA and III or patients with clinically relevant bradycardia, cardiac arrhythmia, or severe cardiac insufficiency and patients with electrolyte disturbance, particularly in cases of hypokalemia and hypomagnesemia. Take care from drugs that cause hypokalemia (such as diuretics, corticosteroids, short-acting beta-2 agonists) — hypokalemia is a risk factor for QT prolongation, so prescribe suitable alternative antibiotic.

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References

1. Global Initiative for Chronic Obstructive Lung Disease - GOLD. (2016). Gold Reports for Personal Use - Global Initiative for Chronic Obstructive Lung Disease - GOLD. [online] Available at: https://goldcopd.org/gold-reports/.
2. Evensen AE. Management of COPD exacerbations. Am Fam Physician. 2010;81(5):607-613.
3. Nice (2010). Chronic obstructive pulmonary disease in over 16s: diagnosis and management. [online] Available at: https://www.nice.org.uk/Guidance/CG101.
4. Ram FS, Rodriguez-Roisin R, Granados-Navarrete A, Garcia-Aymerich J, Barnes NC. Antibiotics for exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2006;(2):CD004403.
5. Siempos II, Dimopoulos G, Korbila IP, Manta K, Falagas ME. Macrolides, quinolones and amoxicillin/clavulanate for chronic bronchitis: a meta-analysis. Eur Respir J. 2007;29(6):1127-1137.

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