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This summary is in the process of being updated. In the meantime, please refer to the most up-to-date guideline on the NICE website

Fluoroquinolone antibiotics: In September 2019, this guideline was updated to reflect MHRA restrictions and precautions for the use of fluoroquinolone antibiotics following rare reports of disabling and potentially long-lasting or irreversible side effects (see Drug Safety Update and update information for details).

In this summary

COPD (acute exacerbation)- antimicrobial prescribing

COPD (acute exacerbation): antimicrobial prescribing. Download a PDF of this visual summary.

Managing an acute exacerbation of COPD with antibiotics

  • Be aware that:

Treatment

  • Consider an antibiotic (see the recommendations on choice of antibiotic) for people with an acute exacerbation of COPD, but only after taking into account:
    • the severity of symptoms, particularly sputum colour changes and increases in volume or thickness beyond the person’s normal day-to-day variation
    • whether they may need to go into hospital for treatment (see the NICE guideline on COPD in over 16s)
    • previous exacerbation and hospital admission history, and the risk of developing complications
    • previous sputum culture and susceptibility results
    • the risk of antimicrobial resistance with repeated courses of antibiotics
  • If a sputum sample has been sent for culture and susceptibility testing (in line with the NICE guideline on COPD in over 16s) and an antibiotic has been given:
    • review the choice of antibiotic when results are available and
    • only change the antibiotic according to susceptibility results if bacteria are resistant and symptoms are not already improving (using a narrow-spectrum antibiotic wherever possible)
  • If an antibiotic is given, give advice:
    • about possible adverse effects of the antibiotic, particularly diarrhoea
    • that symptoms may not be fully resolved when the antibiotic course has been completed
    • about seeking medical help if:
      • symptoms worsen rapidly or significantly or
      • symptoms do not start to improve within 2–3 days (or other agreed time) or
      • the person becomes systemically very unwell
  • If no antibiotic is given, give advice about:
    • an antibiotic not being needed currently
    • seeking medical help without delay if:
      • symptoms (such as sputum colour changes and increases in volume or thickness) worsen rapidly or significantly or
      • symptoms do not start to improve within an agreed time or
      • the person becomes systemically very unwell

Reassessment

  • Reassess people with an acute exacerbation of COPD if their symptoms worsen rapidly or significantly at any time, taking account of:
    • other possible diagnoses, such as pneumonia
    • any symptoms or signs suggesting a more serious illness or condition, such as cardiorespiratory failure or sepsis
    • previous antibiotic use, which may have led to resistant bacteria

      Send a sputum sample for culture and susceptibility testing if symptoms have not improved following antibiotic treatment and this has not been done already

Referral and seeking specialist advice

  • 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) and in line with the NICE guideline on COPD in over 16s
  • Seek specialist advice for people with an acute exacerbation of COPD if they:
    • have symptoms that are not improving with repeated courses of antibiotics or
    • have bacteria that are resistant to oral antibiotics or
    • cannot take oral medicines (to explore locally available options for giving intravenous antibiotics at home or in the community, rather than in hospital, where appropriate)

Choice of antibiotic

  • When prescribing an antibiotic for an acute exacerbation of COPD, follow table 1 for adults aged 18 years and over
  • Give oral antibiotics first line if the person can take oral medicines, and the severity of their exacerbation does not require intravenous antibiotics
  • Review intravenous antibiotics by 48 hours and consider stepping down to oral antibiotics where possible
Table 1: Antibiotic treatment for adults aged 18 years and over
Antibiotic*,Dosage and course length

First-choice oral antibiotics (empirical treatment or guided by most recent sputum culture and susceptibilities)

Amoxicillin

500 mg three times a day for 5 days (see BNF for dosage in severe infections)

Doxycycline

200 mg on first day, then 100 mg once a day for 5‑day course in total (see BNF for dosage in severe infections)

Clarithromycin

500 mg twice a day for 5 days (see BNF for dosage in severe infections)

Second-choice oral antibiotics (no improvement in symptoms on first choice taken for at least 2 to 3 days; guided by susceptibilities when available)

Use alternative first choice (from a different class)

as above

Alternative choice oral antibiotics (if person at higher risk of treatment failure; guided by susceptibilities when available)

Co-amoxiclav

500/125 mg three times a day for 5 days

Levofloxacin§

500 mg once a day for 5 days

Co-trimoxazole

960 mg twice a day for 5 days

First-choice intravenous antibiotic (if unable to take oral antibiotics or severely unwell; guided by susceptibilities when available)**

Amoxicillin

500 mg three times a day (see BNF for dosage in severe infections)

Co-amoxiclav

1.2 g three times a day

Clarithromycin

500 mg twice a day

Co-trimoxazole

960 mg twice a day (see BNF for dosage in severe infections)

Piperacillin with tazobactam

4.5 g three times a day (see BNF for dosage in severe infections)

Second-choice intravenous antibiotic

Consult local microbiologist; guided by susceptibilities

* See the British national formulary (BNF) for appropriate use and dosing in specific populations, for example, hepatic impairment, renal impairment, and administering intravenous antibiotics
If a person is receiving antibiotic prophylaxis, treatment should be with an antibiotic from a different class
People who may be at a higher risk of treatment failure include people who have had repeated courses of antibiotics, a previous or current sputum culture with resistant bacteria, or people at higher risk of developing complications
§  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 (press release October 2018)
Co-trimoxazole should only be considered for use in acute exacerbations of COPD when there is bacteriological evidence of sensitivity and good reason to prefer this combination to a single antibiotic (BNF, October 2018)
** Review intravenous antibiotics by 48 hours and consider stepping down to oral antibiotics where possible.

Terms used in this guideline

Acute exacerbation of COPD

  • An exacerbation is a sustained worsening of the person’s symptoms from their usual stable state, which is beyond normal day-to-day variations, and is acute in onset. Commonly reported symptoms are worsening breathlessness, cough, increased sputum production and change in sputum colour (NICE gu ideline on COPD in over 16s)

Severity of exacerbation

  • A general classification of the severity of an acute exacerbation is:
    • mild exacerbation: the person has an increased need for medication, which they can manage in their own normal environment
    • moderate exacerbation: the person has a sustained worsening of respiratory status that requires treatment with systemic corticosteroids and/or antibiotics
    • severe exacerbation: the person experiences a rapid deterioration in respiratory status that requires hospitalisation
  • Anthonisen et al. (1987) classified the type of an acute exacerbation based on 3 cardinal exacerbation symptoms:
    • increased breathlessness
    • increased sputum volume
    • sputum purulence
  • The presence of all 3 symptoms was defined as type 1 exacerbation; 2 of the 3 symptoms was defined as type 2 exacerbation; and 1 of the 3 symptoms with the presence of 1 or more supporting symptoms and signs was defined as type 3 exacerbation. This classification has been widely used to determine the severity of exacerbation in research studies, with more symptoms indicating a more severe exacerbation
  • Supporting symptoms were:
    • cough
    • wheezing
    • fever without an obvious source
    • upper respiratory tract infection in the past 5 days
    • respiratory rate increase or heart rate increase 20% above baseline

© NICE 2018. Chronic obstructive pulmonary disease (acute exacerbation): antimicrobial prescribing.  Available from: www.nice.org.uk/guidance/NG114. All rights reserved. Subject to Notice of rights.

NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication.

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