Preferred Option*

Alternative Option*

Notes

Amoxicillin 500mg 8-hourly PO for
5 days
May be increased to 1g 8-hourly PO in severe infections.

Clarithromycin  ** 500mg 12-hourly PO for 5 days
OR
Doxycycline 200mg stat then 100mg OD PO 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 (e.g. omit pm dose) for duration of antibiotic course. Alternatively theophylline level may be taken on day 2 of treatment and dose adjusted accordingly. See Theophylline monitoring guideline

Second-choice options:

If no response to first-line option taken at least 2-3 days, guided by culture results if available:
Use alternative from above first choices.

If risk factors for treatment failure :

Co-Amoxiclav 625mg 8-hourly PO x 5 days

Alternatives based on culture susceptibilities:
Co-trimoxazole 960mg BD PO x 5 days
OR    
Levofloxacin 500mg OD PO x 5 days

Risk factors for treatment failure include: multiple co-morbidities with high risk of complications, frequent exacerbations and repeated antibiotic courses, current or previous sputum culture with resistant organisms.

(consider safety issues with levofloxacin- see MHRA advicefor restrictions and precautions for using fluoroquinolone antibiotics due to very rare reports of disabling and potentially long-lasting or irreversible side effects affecting musculoskeletal and nervous systems. Warnings include: stopping treatment at first signs of a serious adverse reaction (such as tendonitis), prescribing with special caution in people over 60 years and avoiding coadministration with a corticosteroid (March 2019).)

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

(consider safety issues with ciprofloxacin- see MHRA advice for restrictions and precautions for using fluoroquinolone antibiotics due to very rare reports of disabling and potentially long-lasting or irreversible side effects affecting musculoskeletal and nervous systems. Warnings include: stopping treatment at first signs of a serious adverse reaction (such as tendonitis), prescribing with special caution in people over 60 years and avoiding coadministration with a corticosteroid (March 2019).)

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. 
Note Theophylline interactions -  see above.

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

Use a narrow spectrum agent whenever possible.

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).

Seek specialist advice if patient unable to take oral antibiotics, or if no oral options are available due to antibiotic resistance; intravenous antibiotics at home/in the community may be possible.

Seek specialist advice if patient with infective exacerbation of COPD is not improving with repeated courses of  antibiotics

** Do not prescribe a macrolide if patient is already on azithromycin prophylaxis.

Antibiotic prophylaxis is generally not recommended  in COPD patients because of an unfavourable balance between benefits and side effects. See NG115 for azithromycin prophylaxis in COPD patients (specialist advice). Patients on azithromycin prophylaxis should not be given a macrolide rescue antibiotic.

For latest recommendation on prescribing in pregnancy see point 10 below.

NICE NG114, NG115
GOLD COPD guidelines
LTHT COPD guideline

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. 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 and will not respond to antibiotics.

The diagnosis of an exacerbation relies exclusively on the clinical presentation of the patient complaining of an acute sustained change of symptoms. 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
• pulse oximetry

Potential Indications for Hospital Assessment or Admission

• sepsis
• 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

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
• if sputum culture is performed, the choice of empirically prescribed antibiotics should be reviewed with the culture results and changed based on the results if bacteria are resistant and symptoms not already improving.

Antibiotics

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

• have three cardinal symptoms – increase in dyspnoea, 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 non-invasive)

If antibiotics are given, advise patient on possible side-effects, especially diarrhoea, and that symptoms may not have fully resolved when antibiotic course has completed. Advise patient to seek prompt medical help if symptoms worsen or do not start to improve in an agreed time, or if patient becomes systemically unwell.

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

If antibiotics are not given, advise patient to seek prompt medical help if symptoms worsen or do not start to improve in an agreed time, or if patient becomes systemically unwell.

Reassess patients with worsening symptoms of acute exacerbation of COPD, considering other diagnoses  and antibacterial resistance; send sputum culture if not already done so and symptoms not improving on empirical antibiotics (see above)

Immunisations:

Patients with COPD should have annual pneumococcal and influenza vaccinations (CMO recommendation 2004)

See influenza guideline for advice on antivirals for  treatment and  prevention of flu in primary care