antibiotics in infective exacerbation of COPD

Last edited 06/2021 and last reviewed 06/2021

S. pneumoniae, H. influenzae and Moraxella cartarrhalis are the most usually identified causes of secondary bacterial infection in COPD.

Oral antibiotics should be used in patients with exacerbations of COPD if associated with purulent sputum or if there are clinical signs of pneumonia (1,2,3)

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 e xample, cardiorespiratory failure or sepsis)

Seek specialist advice if:

  • symptoms do not improve with repeated courses of antibiotics, or
  • bacteria are resistant to oral antibiotics, or
  • the person cannot take oral medicines (to explore giving intravenous antibiotics at home or in the community if appropriate)

When no antibiotic given, advise:

  • antibiotic is not currently needed
  • seeking medical help without delay if symptoms worsen rapidly or significantly, do not improve in an agreed time, or the person is systemically very unwell

When an antibiotic is given, advise:

  • possible adverse effects of antibiotics, particularly diarrhoea
  • symptoms may not be fully resolved by completion of antibiotic course
  • seeking medical help if symptoms worsen rapidly or significantly, or do not improve within 2 to 3 days (or other agreed time), or the person becomes systemically very unwell

If sputum sample sent for testing, when results available:

  • review antibiotic choice
  • only change antibiotic if bacteria resistant and symptoms not improving

Whether antibiotics are given or not:

Reassess at any time if symptoms worsen rapidly or significantly, taking account of:

  • other possible diagnoses, such as pneumonia
  • symptoms or signs of something more serious, such as cardiorespiratory failure or sepsis
  • previous antibiotic use, which may have led to resistant bacteria Send sputum sample for testing if symptoms have not improved after antibiotics
  • in general, initial empirical treatment for acute exacerbations is with an aminopenicillin, a macrolide or a tetracycline and/or to follow local microbiology guidance
    • suggested antibiotic regimes from NICE/PHE for adults 18 years or older:

      • antibiotic choice - five day course

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

          Antibiotic1,2 Dosage and course length
          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)
          • 1See BNF for appropriate use and dosing in specific populations, for example, hepatic impairment, renal impairment, and for administering intravenous antibiotics.
          • 2Where a person is receiving antibiotic prophylaxis, treatment should be with an antibiotic from a different class.

          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 failure3; guided by susceptibilities when available)

          Antibiotic1,2 Dosage and course length
          Co-amoxiclav 500/125 mg three times a day for 5 days
          Levofloxacin4 500 mg once a day for 5 days
          Co-trimoxazole5 960 mg twice a day for 5 days
          • 1See BNF for appropriate use and dosing in specific populations, for example, hepatic impairment, renal impairment, and for administering intravenous antibiotics.
          • 2Where a person is receiving antibiotic prophylaxis, treatment should be with an antibiotic from a different class.
          • 3People who may be at 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.
          • 4The 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).
          • 5Co-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)


  • virtually all strains of M. cartarrhalis, and approximately 15% of H. influenzae strains, produce beta-lactamase and show in-vitro resistance to amoxicillin

  • co-amoxiclav has good activity against beta-lactamase producing strains of M. cartarrhalis and H. influenzae, and is a reasonable choice of antibiotic where infection with these organisms is considered likely (e.g. acute infective exacerbations of COPD)

  • erythromycin has poor activity against H. influenzae

Risk factors for antibiotic resistant organisms include (2)

  • co-morbid disease,
  • severe COPD,
  • frequent exacerbations,
  • antibiotics in last 3 months

Reference:

Related pages:

COPD

prophylactic antibiotic therapy in COPD