Acute Infective Exacerbations of Chronic Obstructive Pulmonary Disease - Management of Infection Guidance for Primary Care

Publication: 30/09/2010  
Last review: 19/09/2017  
Next review: 19/09/2020  
Clinical Guideline
CURRENT 
ID: 2231 
Approved By: LAPC 
Copyright© Leeds Teaching Hospitals NHS Trust 2017  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

The European Medicines Agency’s Pharmacovigilance Risk Assessment Committee has recommended restricting the use of fluoroquinolone antibiotics following a review of disabling and potentially long-lasting side effects mainly involving muscles, tendons, bones and the nervous system. This includes a recommendation not to use them for mild or moderately severe infections unless other antibiotics cannot be used (MHRA advice November 2018).

Acute Infective Exacerbations of COPD in Primary Care

Patients with exacerbations without more purulent sputum do not need antibiotic therapy unless there is consolidation on a chest radiograph or clinical signs of pneumonia. If CAP is suspected, see relevant guideline.

Preferred Option*

Alternative Option *

Notes

Amoxicillin 500mg 8-hourly for
5 days

Clarithromycin 500mg 12-hourly for 5 days
OR
Doxycycline 200mg stat then 100mg OD for 5 days. May be increased to 200mg od in severe infection

Clarithromycin and ciprofloxacin may interact with theophylline / aminophylline and cause theophylline toxicity. Common practice is to halve the theophylline dose (eg omit pm dose) for duration of antibiotic course. Alternatively theophylline level may be taken on day 2 of treatment and dose adjusted accordingly. Theophylline monitoring guideline

 

If risk factors for antibiotic resistance:
Co-amoxiclav 625mg 8-hourly x 5 days

Resistance risk factors include: severe underlying COPD, age >65yrs, multiple co-morbidities (especially cardiac disease), frequent exacerbations and antibiotics in last 3 months.

 

If Pseudomonas risk factors present, send sputum cultures and consider use of ciprofloxacin pending culture results.
Ciprofloxacin 750mg 12- hourly x 5 days

Pseudomonas risk factors include:

  • advanced COPD
  • previous isolation of Pseudomonas from sputum
  • bronchiectasis
  • frequent/recent antibiotics
  • frequent hospital admissions
  • systemic steroid use
    Note: use of ciprofloxacin is associated with C difficile infection and may select for resistant bacteria.
    Theophylline interactions see above.

Empiric choice of antibiotic should be guided by previous sputum culture results if available.

Consider prescribing a supply of rescue antibiotics and provide written information advising the patient when to take them (these should be reviewed regularly to take account of recent sputum culture results)

Antibiotic prophylaxis is is generally not recommended in COPD because of an unfavourable balance between benefits and side effects.

NICE 101, GOLD For latest recommendation on prescribing in pregnancy see point 10 below.

Exacerbations of COPD

  • exacerbation of COPD is an acute event characterized by a worsening of the patient’s respiratory symptoms that is beyond normal day-to-day variations and leads to a change in medication. Commonly reported symptoms of acute exacerbations of COPD are worsening breathlessness, cough, increased volume of sputum production and change in sputum colour.
  • exacerbations can be precipitated by several factors; common causes include viral upper respiratory tract infections and infections of the tracheobronchial tree but exacerbations may also occur due to non-infective factors eg environmental pollution.

The diagnosis of an exacerbation relies exclusively on the clinical presentation of the patient complaining of an acute change of symptoms that is beyond normal day-to-day variation. In addition, some signs and tests may be useful in assessing the patient and the severity of an exacerbation:

Signs of severity that may be useful in assessing patients include:

  • use of accessory respiratory muscles
  • paradoxical chest wall movements
  • worsening or new onset central cyanosis
  • development of peripheral oedema
  • haemodynamic instability
  • deterioration in mental status

Potential Indications for Hospital Assessment or Admission

  • marked increase in intensity of symptoms, such as sudden development of resting dyspnoea
  • severe underlying COPD
  • onset of new physical signs (e.g., cyanosis, peripheral oedema)
  • failure of an exacerbation to respond to initial medical management
  • presence of serious comorbidities (e.g., heart failure or newly occurring arrhythmias)
  • frequent exacerbations
  • older age
  • insufficient home support

Tests that may be considered to assess the severity of an exacerbation include:
pulse oximetry, CXR, ECG, FBC

Acute Infective Exacerbations:

  • Antibiotics are indicated in the treatment of COPD if there is an infective exacerbation: antibiotics should be used to treat exacerbations of COPD associated with a history of more purulent sputum plus at least one other indicator (see below).
  • Patients with exacerbations without more purulent sputum do not need antibiotic therapy unless there is consolidation on a chest radiograph or clinical signs of pneumonia. If CAP is suspected, see relevant guideline.

Sputum cultures:

  • sputum cultures are not routinely required.
  • In primary care, sputum cultures are generally not feasible as they take too long (at least 2 days) and frequently do not give reliable results for technical reasons.
  • sputum culture and sensitivity should be requested if an infectious exacerbation does not respond to the initial antibiotic treatment
  • sputum culture and sensitivity may also be indicated in patients with frequent exacerbations, severe airflow limitation, and/or past exacerbations requiring mechanical ventilation as gram-negative bacteria (e.g., Pseudomonas species) or resistant pathogens that are not sensitive to the normal empirical antibiotic choices may be implicated

Antibiotics

Antibiotics should be given to moderately or severely ill patients with exacerbations of COPD who

  • have three cardinal symptoms – increase in dyspnea, increase sputum volume, and sputum purulence
    or
  • have two of the cardinal symptoms, if increased purulence of sputum is one of the two symptoms
    or
  • require mechanical ventilation (invasive or noninvasive)

Antibiotics are not routinely indicated for patients with mild exacerbations ie only 1 of the 3 cardinal symptoms, who do not require hospitalisation or ventilator assistance (invasive or noninvasive).

General Principles for Treating Infections

  1. This guidance is based on the best available evidence but its application must be modified by professional judgement.
  2. A dose and duration of treatment is suggested. In severe or recurrent cases consider a larger dose or longer course
  3. Choices are given as Preferred option or Alternative for patients intolerant of the preferred option and 2nd Line for when an alternative is required because of treatment failure
  4. Only send microbiology specimens if there is a clinical suspicion of infection. Inappropriate specimens (e.g. routine ulcer swab or routine catheter specimen of urine) lead to inappropriate antibiotic prescribing.
  5. Prescribe an antibiotic only when there is likely to be a clear clinical benefit.
  6. Consider a no, or delayed, antibiotic strategy for acute self-limiting upper respiratory tract infections 1,A+
  7. Limit prescribing over the telephone to exceptional cases.
  8. Use simple generic antibiotics if possible. Avoid broad spectrum antibiotics (e.g. co-amoxiclav, quinolones and cephalosporins) when narrow spectrum antibiotics remain effective, as they increase risk of Clostridium difficile, MRSA and resistant UTI's.
  9. Avoid widespread use of topical antibiotics (especially those agents also available as systemic preparations).
  10. In pregnancy, take specimens to inform treatment, use this guidance alternative or seek expert advice. Penicillins, cephalosporins and erythromycin are not associated with increased risks. If possible, avoid tetracyclines, quinolones, aminoglycosides, azithromycin, clarithromycin, high dose metronidazole (2g stat) unless the benefits outweigh the risks. Short-term use of nitrofurantoin is not expected to cause foetal problems (theoretical risk of neonatal haemolysis). Trimethoprim is also unlikely to cause problems unless poor dietary folate intake, or taking another folate antagonist.
  11. We recommend clarithromycin as it has less side-effects than erythromycin, greater compliance as twice rather than four times daily & generic medicines are similar cost. Where a ‘best guess’ therapy has failed or special circumstances exist, microbiological advice can be obtained from LTHT Microbiology (Mon-Fri 9am-5pm and Sat and Sun 9am-1pm: 0113 39 23962/28580; Otherwise via LTHT switchboard - ask for the On call Microbiology Registrar)

Note
Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information.
Letters indicate strength of evidence:
A+ = systematic review: D = expert opinion

Provenance

Record: 2231
Objective:
Clinical condition:

Acute Infective Exacerbations of Chronic Obstructive Pulmonary Disease

Target patient group:
Target professional group(s): Primary Care Doctors
Pharmacists
Primary Care Nurses
Adapted from:

Evidence base

Not supplied

Approved By

LAPC

Document history

LHP version 1.0

Related information

Not supplied