Acute Exacerbation of COPD
Treatment Criteria & Considerations
The use of antibiotics in acute exacerbations of chronic obstructive pulmonary disease (AECOPD) is controversial
Antimicrobial therapy is only recommended when AECOPD is accompanied by an acute change in all 3 cardinal symptoms or at least 2 of the 3 cardinal symptoms, if increased sputum purulence is one of the 2 symptoms.
Cardinal symptoms include: 1. Increased dyspnea 2. Increased sputum volume 3. Increased sputum purulence
See link below for evaluation and treatment algorithm
Patients receiving invasive or non-invasive ventilation for AECOPD should be initiated on intravenous antimicrobial therapy
If infiltrate on chest x-ray consistent with infection or pneumonia suspected, then treat as per pneumonia treatment guidelines (see Community Acquired Pneumonia below)
Consider nasopharyngeal swab for influenza if seasonal influenza is circulating within the community.
If swab positive: consider stopping antibacterial therapy
If swab negative: stop antiviral therapy if started
Evaluation and Treatment Algorithm
Patients presenting with only:
1 of the 3 cardinal symptoms
ONLY increased dyspnea and increased sputum volume
- Less than 4 exacerbations per year
At least one of:
Forced expiratory volume in 1 second (FEV₁) less than 50% predicted
Greater than or equal to 4 exacerbations per year
Ischemic heart disease
Use of home oxygen
Chronic steroid use
Guideline content derived from:
- NB Provincial Health Authorities Anti-Infective Stewardship Committee. Antimicrobial Therapy for Acute Exacerbation of Chronic Obstructive Pulmonary Disease. 05-2019.
- O’Donnel DE, Hernandez P, Kaplan A et al. Canadian Thoracic Society Recommendations for Management of Chronic Obstructive Pulmonary Disease – 2008 update – Highlights for primary care. Can Respir J 2008; 15(Suppl A):1A – 8A.
- O’Donnel DE, Aaron S, Bourbeau J et al. Canadian Thoracic Society Recommendations for Management of Chronic Obstructive Pulmonary Disease – 2007 update. Can Respir J 2007; 14(Suppl B):5B – 32B.
- Wilson R, Sethi S, Anzueto A et al. Antibiotics for treatment and preventions of exacerbations of chronic obstructive pulmonary disease. Journal of Infection (2013) 67, 497 – 515
- Stockley RA, O’Brien C, Pye A et al. Relationship of Sputum Color to Nature and Outpatient Management of Acute Exacerbations of COPD. Chest 2000;117:1638 – 1645.
- Moussaoui RE, Roede BM, Speelman P et al. Short-course antibiotic treatment in acute exacerbations of chronic bronchitis and COPD: a meta-analysis of double-blind studies. Thorax 2008; 63:415-422
- Falagas ME, Avgeri SG, Matthaiou DK et al. Short- versus long-duration antimicrobial treatment for exacerbations of chronic bronchitis: a meta-analysis. J Antimicrob Chemother. 2008 May; 62: 442 – 450.
- Siempos II, Dimopoulos G, Korbila IP et al. Macrolides, Quinolones and amoxicillin/clavulanate for chronic bronchitis: a meta-analysis. Eur Respir J 2007; 29:1127 – 1137
- Wilson R, Anzueto A, Miravitlles M et al. Moxifloxacin versus amoxicillin/clavulanic acid in outpatient acute exacerbations of COPD: Maestral results. Eur Respir J 2012; 40:17 – 27
- Miravitlles M, Llor C, Molina J et al. Antbiotic treatment of exacerbations of COPD in general practice: long-term impact on health-related quality of life. Int J COPD 2010;5:11 – 19
- Dimopoulos G, Siempos II, Korbila IP et al. Comparison of First-Line with Second-Line Antibiotics for Acute Exacerbations of Chronic Bronchitis A Metaanalysis of Randomized Controle Trials. Chest 2007; 132:447 – 455
- Leuppi JD, Schuetz P, Bingisser R et al. Short-term vs Conventional Glucocorticoid Therapy in Acute Exacerbations of Chronic Obstructive Pulmonary Disease The REDUCE Randomized Clinical Trial. JAMA 2013; 309(21):2223-2231
- Walters JAE, Gibson PG, Wood-baker R, et al. Systemic corticosteroids for acute exacerbations of chronic obstructive pulmonary disease. Cochrane Database of Systemic Reviews 2009, Issue 1. Art. No.:CD001288. DOI”10.1002/14561858.CD001288.pub3
- Anthonisen NR, Manfreda J, Warren CPW et al. Antibiotic Therapy in Exacerbations of Chronic Obstructive Pulmonary Disease. Ann Int Med 1987; 106:196-204
- Walters JAE, Tan DJ, Whit CJ, Wood-Baker R. Different durations of corticosteroid therapy for exacerbations of chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews 2014, Issue 12. Art. No.: CD006897. DOI:10.1002/14651858.CD006897.pub3.
- Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease (2018 Report)
- Wedzicha JA, Miravitlles M, Hurst JR, et al. Management of COPD exacerbations: a European Respiratory Society/American Thoracic Society guideline. Eur Respir J 2017; 49: 1600791 https://doi.org/10.1183/13993003.00791-2016