Antibiotic Selection for COPD Exacerbations

Introduction to Antibiotic Use

The European Respiratory Society recommends prescribing a single antibiotic based on severity and risk factors for COPD exacerbations, not both azithromycin and doxycycline together 1, 2

Antibiotics should be prescribed in patients with all three cardinal symptoms: increased dyspnea, increased sputum volume, AND increased sputum purulence (Type I Anthonisen exacerbation) 1, 2
Antibiotics should be prescribed in patients with two of the above symptoms when one is increased sputum purulence (Type II Anthonisen exacerbation with purulence) 1, 2
Antibiotics should be prescribed in patients with severe exacerbations requiring invasive or non-invasive mechanical ventilation 1, 2

For mild to moderate exacerbations without risk factors for Pseudomonas aeruginosa, the first choice for outpatient treatment is Amoxicillin or tetracycline (doxycycline) 1, 3
For mild to moderate exacerbations without risk factors for Pseudomonas aeruginosa, alternatives for outpatient treatment include Co-amoxiclav (amoxicillin-clavulanate), macrolide (azithromycin), or respiratory fluoroquinolone (levofloxacin, moxifloxacin) 3, 4
For hospital treatment of moderate-severe exacerbation, the first choice is Co-amoxiclav (amoxicillin-clavulanate) 2, 3
For patients with risk factors for Pseudomonas aeruginosa, the first choice for oral treatment is Ciprofloxacin 2, 3
For patients with risk factors for Pseudomonas aeruginosa, alternatives for oral treatment include Levofloxacin 750 mg/day or 500 mg twice daily 2, 5

The recommended duration for antibiotic therapy is 5-7 days 6, 7
Switch from IV to oral therapy by day 3 of hospitalization if the patient is clinically stable 2, 3

Obtain sputum cultures before starting antibiotics in patients with severe exacerbations, risk factors for P. aeruginosa, or frequent exacerbations 2, 5
Consider local resistance patterns when selecting antibiotics 3, 5
For non-responding patients, re-evaluate for non-infectious causes of failure and consider changing to an antibiotic with good coverage against P. aeruginosa and drug-resistant S. pneumoniae 2, 8

Antibiotics have been shown to shorten recovery time and reduce the risk of early relapse in COPD exacerbations 6

The European Respiratory Society recommends against using both azithromycin and doxycycline together for COPD exacerbations 1, 2, 3
The European Respiratory Society recommends against prescribing antibiotics for all COPD exacerbations - use the criteria above to determine when antibiotics are indicated 1, 2
The European Respiratory Society recommends considering local resistance patterns when selecting antibiotics 3, 5
The European Respiratory Society recommends switching from IV to oral therapy when the patient is clinically stable 2, 3