Click here for guidance on COPD and for further information on the management of acute exacerbations (including prescription of corticosteroids), rescue packs and self-management plans.

If clinical evidence of pneumonia, follow community-acquired pneumonia advice.

The information below is based on NICE Guideline 114: Chronic obstructive pulmonary disease (acute exacerbation): antimicrobial prescribing (December 2018), unless otherwise stated.

Many exacerbations (including some severe exacerbations) are not caused by bacterial infections so will not respond to antibiotics. Symptoms usually last between 7 – 10 days, but some events may last longer.

The severity of the exacerbation and severity of the underlying disease will determine if it is managed in the inpatient or outpatient setting.

Consider an antibiotic for people with an acute exacerbation of COPD, 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
• 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.

The GOLD 2019 Report for the Global Strategy for the Diagnosis, Management, and Prevention of COPD states that antibiotics should be used in patients who have three cardinal symptoms: increased dyspnoea, sputum volume and sputum purulence.

GOLD 2019 recommends that antibiotics may also be considered if only two of the above symptoms are present, if sputum purulence is one of the symptoms.

GOLD 2019 also recommends that antibiotics should be given if patients require mechanical ventilation (invasive or non-invasive).

If a sputum sample has been sent for culture and susceptibility testing 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).

NICE Guideline 115 recommends that for patients who have their exacerbation managed in primary care – sending sputum samples for culture is not recommended in routine practice however NICE Guideline 114 states that sputum samples should be sent if symptoms have not improved following antibiotic treatment.

Advise the patient:

• about possible adverse effects of antibiotics, particularly diarrhoea
• that symptoms may not be fully resolved when the antibiotic course has been completed
• to seek medical help without delay 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 (with or without antibiotics)

Reassess at any time if symptoms worsen rapidly or significantly, 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

Refer patients with an acute exacerbation of COPD to hospital if they have any symptoms or signs suggesting a more serious illness or condition.

Oral antibiotics

If patient is unable to take oral antibiotics, or is severely unwell, consider intravenous treatment (see below).

First line

• Empirical treatment or guided by most recent sputum sample results
• If patient is taking prophylactic antibiotic then ensure treatment is with an antibiotic from a different class

Amoxicillin

• 500mg three times a day for 5 days (1g three times a day if severe)
• See section 5.1.1 Penicillins

OR

Doxycycline

• 200mg single dose on day one, then 100mg once daily, for a total of 5 days (200mg once daily if severe)
• See section 5.1.3 Tetracyclines

OR

Clarithromycin

• 500mg twice a day for 5 days
• Use with caution if predisposition to QT prolongation
• See section 5.1.5 Macrolides

Second line

• If no improvement in symptoms on first choice taken for at least 2-3 days, send a sputum sample for culture and susceptibility testing if this has not been done already.
• Try alternative first line choice but from a different class.
• Seek microbiology advice if symptoms are not improving with repeated courses of antibiotics or if bacteria are resistant to oral antibiotics.

Patients at high risk of treatment failure

• E.g. Repeat courses of antibiotics; previous or current sputum culture with resistant bacteria; patients at high risk of complication
• To be guided by susceptibilities when available

Co-amoxiclav

• 625mg three times a day for 5 days
• See section 5.1.1 Penicillins

OR

Seek specialist advice

Intravenous antibiotics

If patient is unable to take oral antibiotics, or is severely unwell, admit to secondary care for consideration of intravenous antibiotics, via outpatient or home parenteral antibiotic therapy service where available (for Plymouth referrals, contact Livewell Acute Care at Home Team on 01752 435567 or 07795 505578).

Review intravenous antibiotics by 48 hours and consider stepping down to oral antibiotics when patients are stabilised.