COPD Exacerbation Antibiotics

Aka: COPD Exacerbation Antibiotics, Antibiotic Use in COPD Exacerbation

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II. Indications: Antibiotic indications if 3 criteria met

  1. Increased Dyspnea (or requiring NIPPV or Intubation)
  2. Increased Sputum
  3. Purulent Sputum

III. Management: Antibiotics for Uncomplicated Chronic Bronchitis

  1. Criteria
    1. Under age 65 years old
    2. FEV1 > 50% of predicted
    3. Under 4 acute exacerbations per year
    4. No significant comorbid disease
  2. Coverage
    1. HaemophilusInfluenzae
    2. Streptococcus Pneumoniae
    3. Moraxella catarrhalis
    4. Chlamydia pneumoniae
    5. Mycoplasma pneumoniae
  3. Antibiotics (5 day course)
    1. First-Line
      1. Trimethoprim-Sulfamethoxazole (Bactrim DS, Septra DS) one tablet orally twice daily
      2. Amoxicillin 1000 mg orally twice daily
        1. Equivalent to Moxifloxacin in clinical outcome
        2. Wilson (2004) Chest 125:953-64 [PubMed]
    2. Alternative Antibiotics
      1. Augmentin 875 mg orally twice daily
      2. Second generation Macrolide
        1. Clarithromycin 500 mg PO bid
        2. Azithromycin 500 mg day 1, then 250 mg PO x4 days
          1. Also available as 3 day preparation
          2. Similar outcomes to Levofloxacin for 7 days
          3. Amsden (2003) Chest 123:772-7 [PubMed]
    3. Other Antibiotics
      1. Doxycycline 100 mg orally twice daily
        1. No longer recommended in COPD exacerbation due to lack of efficacy
        2. Sethi and Murphy in Ramirez, Management of infection in exacerbations of COPD, UpToDate, accessed 11/24/2022
        3. van Velzen (2017) Lancet Respir Med 5(6):492-9 +PMID: 28483402 [PubMed]

IV. Management: Antibiotics for Complicated Chronic Bronchitis

  1. Criteria
    1. Uncomplicated criteria not met (see above)
  2. Coverage
    1. Uncomplicated Chronic BronchitisBacteria (see above)
    2. Gram Negative Rods (e.g. Pseudomonas)
  3. Dosing for 5 day course
    1. Augmentin 875 mg PO bid
    2. Fluoroquinolone
      1. Levofloxacin (Levaquin) 250 mg po qd
      2. Moxifloxacin (Avelox) 400 mg PO qd

V. Management: Antibiotics for Severe Exacerbation requiring hospitalization

  1. Co-administer Corticosteroids
    1. Initially use intravenous Corticosteroids
      1. Methylprednisolone (Solumedrol) 60 mg IV every 6 hours
      2. Avoid high doses (e.g. 125 mg) as they offer no added benefit
    2. Transition to oral Corticosteroids as soon as prudent
      1. Prednisone 30-40 mg orally daily
      2. Taper off over 2 weeks (no benefit to previously used longer taper over 8 weeks)
  2. Protocol: Two Parenteral drug combination
    1. Drug 1: Cephalosporin or Antipseudomonal Penicillin
    2. Drug 2: Fluoroquinolone or Aminoglycoside
  3. Cephalosporins
    1. Ceftriaxone (Rocephin) 1 to 2 grams IV q24 hours
    2. Cefotaxime (Claforan) 1 gram IV q8-12 hours
    3. Ceftazidime (Fortaz) 1-2 grams IV q8-12 hours
  4. Antipseudomonal Penicillins
    1. Piperacillin-Tazobactam (Zosyn) 3.375 g IV q6 hours
    2. Ticarcillin-Clavulanate (Timentin) 3.1 g IV q4-6 hour
  5. Fluoroquinolones
    1. Levofloxacin (Levaquin) 500 mg IV q24 hours
    2. Gatifloxacin (Tequin) 400 mg IV q24 hours
  6. Aminoglycoside
    1. Tobramycin (Tobrex)
      1. Split dosing: 1 mg/kg IV q8-12 hours
      2. Once daily: 5 mg/kg IV q24 hours

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