Choice of antibiotic in infective exacerbation of COPD

S. pneumoniae, H. influenzae and Moraxella cartarrhalis are the most usually identified causes of secondary bacterial infection in COPD.

Oral antibiotics should be used in patients with exacerbations of COPD if associated with purulent sputum or if there are clinical signs of pneumonia (1,2,3)

Refer people with an acute exacerbation of COPD to hospital if they have any symptoms or signs suggesting a more serious illness or condition (for example, cardiorespiratory failure or sepsis)

Seek specialist advice if:

• symptoms do not improve with repeated courses of antibiotics, or
• bacteria are resistant to oral antibiotics, or
• the person cannot take oral medicines (to explore giving intravenous antibiotics at home or in the community if appropriate)

When no antibiotic given, advise:

• antibiotic is not currently needed
• seeking medical help without delay if symptoms worsen rapidly or significantly, do not improve in an agreed time, or the person is systemically very unwell

When an antibiotic is given, advise:

• possible adverse effects of antibiotics, particularly diarrhoea
• symptoms may not be fully resolved by completion of antibiotic course
• seeking medical help if symptoms worsen rapidly or significantly, or do not improve within 2 to 3 days (or other agreed time), or the person becomes systemically very unwell

If sputum sample sent for testing, when results available:

• review antibiotic choice
• only change antibiotic if bacteria resistant and symptoms not improving

Whether antibiotics are given or not:

Reassess at any time if symptoms worsen rapidly or significantly, taking account of:

• other possible diagnoses, such as pneumonia
• symptoms or signs of something more serious, such as cardiorespiratory failure or sepsis
• previous antibiotic use, which may have led to resistant bacteria
  • Send sputum sample for testing if symptoms have not improved after antibiotics
• in general, initial empirical treatment for acute exacerbations is with an aminopenicillin, a macrolide or a tetracycline and/or to follow local microbiology guidance
  • suggested antibiotic regimes from NICE/PHE for adults 18 years or older:
    • antibiotic choice - five day course

• virtually all strains of M. cartarrhalis, and approximately 15% of H. influenzae strains, produce beta-lactamase and show in-vitro resistance to amoxicillin
• co-amoxiclav has good activity against beta-lactamase producing strains of M. cartarrhalis and H. influenzae, and is a reasonable choice of antibiotic where infection with these organisms is considered likely (e.g. acute infective exacerbations of COPD)
• erythromycin has poor activity against H. influenzae

Risk factors for antibiotic resistant organisms include (2)

• co-morbid disease,
• severe COPD,
• frequent exacerbations,
• antibiotics in last 3 months

Reference:

• (1) NICE (December 2018). Chronic obstructive pulmonary disease (acute exacerbation): antimicrobial prescribing
• (2) Public Health England (October 2014). Management of infection guidance for primary care for consultation and local adaptation
• (3) Public Health England (June 2021). Managing common infections: guidance for primary care