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. See Acute Exacerbation of Chronic Bronchitis for other management (e.g. Corticosteroids, Bronchodilators)
  2. Criteria
    1. Under age 65 years old
    2. FEV1 > 50% of predicted
    3. Under 4 acute exacerbations per year
    4. No significant comorbid disease
  3. Coverage
    1. Haemophilus Influenzae
    2. Streptococcus Pneumoniae
    3. Moraxella catarrhalis
    4. Chlamydia pneumoniae
    5. Mycoplasma pneumoniae
  4. 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. 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. See Acute Exacerbation of Chronic Bronchitis for other management (e.g. Corticosteroids, Bronchodilators)
  2. Criteria
    1. Uncomplicated criteria not met (see above)
  3. Coverage
    1. Uncomplicated Chronic BronchitisBacteria (see above)
    2. Gram Negative Rods (e.g. Pseudomonas)
  4. Dosing for 5 day course
    1. Amoxicillin-Clavulanate (Augmentin) 875 mg orally twice daily
    2. Second generation Macrolide
      1. Clarithromycin (Biaxin) 500 mg orally twice daily
      2. Azithromycin (Zithromax) 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. Fluoroquinolone
      1. Levofloxacin (Levaquin) 750 mg orally daily
      2. Moxifloxacin (Avelox) 400 mg orally daily
    4. Cephalosporins (alternative agents)
      1. Cefuroxime Axetil 250 to 500 mg orally every 12 hours
      2. Cefprozil 500 mg orally every 12 hours
      3. Cefdinir 300 mg every 12 hours (or 600 mg every 24 hours)
      4. Cefpodoxime Proxetil 200 mg every 12 hours

V. Management: Antibiotics for Severe Exacerbation requiring hospitalization

  1. See Acute Respiratory Failure
  2. 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)
  3. Low risk for Pseudomonas
    1. Consider Outpatient Antibiotics for Complicated Chronic Bronchitis as above
    2. Ceftriaxone (Rocephin) 1 to 2 grams IV every 24 hours
    3. Cefotaxime (Claforan) 1 gram IV every 8-12 hours
    4. Levofloxacin (Levaquin) 750 mg IV or orally every 24 hours
    5. Moxifloxacin (Avelox) 400 mg IV or orally daily
  4. Higher risk for Pseudomonas
    1. Piperacillin-Tazobactam (Zosyn) 3.375 g IV q6 hours
    2. Levofloxacin (Levaquin) 750 mg IV or orally every 24 hours
    3. Cefepime 2 g IV every 24 hours
    4. Ceftazidime (Fortaz) 1-2 grams IV every 8-12 hours
    5. Two Parenteral drug combination (older regimen, replaced by other agents)
      1. Drug 1: Cephalosporin or Antipseudomonal Penicillin
      2. Drug 2: Fluoroquinolone or Aminoglycoside
        1. Tobramycin (Tobrex)
          1. Split dosing: 1 mg/kg IV q8-12 hours
          2. Once daily: 5 mg/kg IV q24 hours

VI. Efficacy

  1. Inconsistent outcomes with and without Antibiotics in AECB
    1. Vollenweider (2018) Cochrane Database Syst Rev 10(10):CD010257 +PMID: 30371937 [PubMed]
  2. Lower COPD exacerbation treatment failure rate when Antibiotics are used in exacerbation that meets criteria
    1. Suzuki (2024) Respir Investig 62(4):663-8 +PMID: 38761481 [PubMed]

VII. References

  1. (2025) Sanford Guide, accessed on IOS, 5/1/2025
  2. Stoller and Hatipoglu (2025) COPD Exacerbation Management, UpToDate, accessed on IOS, 5/1/2025

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