Antibiotic prescribing for COPD acute exacerbation

byAbdelwahab Ward, BS Pharm, PharmD - last updated
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OVERVIEW ã…¡  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

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.

REFERENCES

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