Acute Infective Exacerbation of Chronic Obstructive Pulmonary Disease (COPD) in Secondary Care

Publication: 14/08/2020

Next review: 11/08/2024

Clinical Guideline

CURRENT

ID: 6604

Approved By: Improving Antimicrobial Prescribing Group

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.

Guideline for the Management of Acute Infective Exacerbation of Chronic Obstructive Pulmonary Disease (COPD) in Secondary Care

Diagnostics
Empirical Treatment
Review by 72 Hours
Directed Therapy

DIAGNOSTICS

For patients with a presumed diagnosis of infective exacerbation of COPD the following diagnostic tests should be taken to confirm diagnosis#:

All patients^#	Respiratory secretions for culture: sputum* (if productive cough or produced after physiotherapy). Strongly recommended especially if recurrent infections.
	Procalcitonin
	CRP
	Consider respiratory samples for viral PCR if clinically indicated.
Patients who require IV antibiotics	Blood cultures (prior to starting IV antibiotics /if systemically unwell).

^# Note - if patient is being considered for discharge from the ED/acute care areas, blood tests may not be required for all patients
*Send only if sputum colour changes and increases in volume/thickness OR failing to respond to antibiotics

EMPIRICAL TREATMENT

Antimicrobials are not always indicated - many exacerbations (including some severe exacerbations) are not caused by bacterial infections so will not respond to antibiotics. See management of exacerbation section in Full Guidelines for the Diagnosis and Management of Chronic Obstructive Pulmonary Disease

Before antimicrobial treatment is initiated, the following should be considered:

Symptom severity – sputum colour changes and increases in volume or thickness (outside of patient’s normal variation), worsening breathlessness, cough
Previous exacerbation and hospital admission
Previous sputum culture and susceptibility results
Increased risk of antimicrobial resistance with repeated courses of antibiotics
Where a person is receiving antibiotic prophylaxis, use alternative treatment from a different class.
Consider delaying antibiotics until procalcitonin result is back. For procalcitonin levels below 0.25nanogram/L, antibiotics are discouraged and strongly discouraged where levels are below 0.1nanogram/L.

Empirical treatment	First line	Penicillin Allergy	Duration
Oral antibiotics (CHECK most recent sputum culture and susceptibilities before prescribing empirical antibiotics)	Amoxicillin PO 1g 8-hourly	Doxycycline PO 200mg loading dose followed by 100mg 24-hourly OR Clarithromycin PO 500mg 12-hourly	5 days
If Pseudomonas risk factors* present	Ciprofloxacin PO 750mg 12- hourly		7 days
Intravenous antibiotics (ONLY if unable to take oral antibiotics or severely unwell; guided by susceptibilities when available)	Co-amoxiclav IV 1.2g 8 hourly	Levofloxacin IV 500mg 12-hourly	5 days in total (IV and PO)

*Pseudomonas risk factors - previous two consecutive positive respiratory cultures for P. aeruginosa in last 12 months and no response to other antibiotics, chronic lung disease and inpatient on respiratory ward (within the last month), admission to ICU this episode, immune-compromised.

REVIEW BY 72 HOURS

By 72 hours of antibiotic treatment, diagnostics should have proven your initial diagnosis or guided to a new diagnosis. If your patient is prescribed IV antibiotics then they should be reviewed daily.

The review, outcome and future plans (where appropriate) should be documented in the medical notes.

IVOS	If your initial diagnosis is correct and the patient is prescribed IV antibiotics, review whether an oral switch is appropriate using the ACED criteria (see below). If they meet all 4 criteria (note: this is not a deep seated infection) consider switching using the oral options listed in the table above. A - Afebrile for 24 hours C - Clinically improving E - Eating and drinking D - not Deep seated infection
Stop	If no signs of infection and diagnostics support this decision - procalcitonin is less than 0.25 nanogram/L
Change	If the patient is not clinically responding, check microbiology results to see if directed therapy is required or you may need to consider an alternative diagnosis.
Continue	If the patient is improving but does not fully meet ACED criteria. Review daily until ready to switch.

DIRECTED THERAPY

Follow microbiology advice from culture and susceptibility results.

Provenance

Record:	6604
Objective:
Clinical condition:
Target patient group:
Target professional group(s):	Secondary Care Doctors Pharmacists
Adapted from:

Evidence base

NICE guideline [NG114]: Chronic obstructive pulmonary disease (acute exacerbation): antimicrobial prescribing. December 2018
Global Initiative for Chronic Obstructive Lung Disease. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease 2020 Report

Approved By

Improving Antimicrobial Prescribing Group

Document history

LHP version 1.0

Related information

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