COPD acute exacerbation


Change antibiotic when sputum culture becomes available -only if bacteria are resistant and symptoms are not readily improving Chronic obstructive pulmonary disease -management of acute exacerbation antimicrobial prescribing.  This a very useful guideline from 
NICE which has looked into the
 current evidence base of management
 of COPD exacerbation.NICE has set in definite terms what an exacerbation means. This will help clinicians recognize the event . In brief an exacerbation is Deterioration from baseline state
 It can manifest as
○ worsening breathlessness
○ cough
○ increased sputum production
○ change in sputum colour
 Various factors can cause an exacerbation for eg viral infections and smoking
 Not all exacerbations are caused by bacteria so will not respond to antibiotics

Severity-Mild- ↑ ed need for medication but can be managed at home Moderate -sustained worsening that requires Rx with steroids and or antibiotics Severe – rapid deterioration which requires hospital admission ( Oba Y et al 2017 ).Also based on symptoms 
( ↑ed breathlessness ,↑ ed sputum , sputum purulence ) – 
can be classified as Type1 , Type 2 or
 Type 3.supporting symptoms include- cough , wheeze , fever without an obvious source , URTI in past 5 D’s, ↑ ed RR or HR above 20 % of baseline
(Anthonisen et al 1987 )

Once a diagnosis of COPD-Exacerbation has been reached 
NICE recommends using the checklist to identify patients 
who would need hospital admission

Arterial pH and PaO2 have been excluded as they are
 currently not available in primary care

. able to cope, breathlessness, general condition, level of activity, cyanosis, worsening peripheral oedema , level of consciousness, Long term oxygen therapy, social, acute confusion, rapid onset, significant comorbidity particularly cardiac disease and insulin dependent diabetes , oxygen saturation , chest x ray changes

Sputum investigation- NICE does not recommend sending sputum sample in routine practice
 Send a sample if no improvement following antibiotic Rx

inhaled therapy-Increased doses of short acting bronchodilators
 Both hand held inhalers and nebulizers can be used

systemic steroids-If no significant contraindications consider oral steroids Advice people who are likely to need to start early for maximum benefit Prednisolone 30 mg orally for 7 to 14 days
ie issue 42 X 5 mg for 1 week or 
84 x 5 mg for 2 weeks

Limit the duration to 14 days as there is no advantage in prolonged therapy
 Consider osteoporosis prophylaxis in people requiring frequent steroids
 Discuss long term SEs of steroid therapy

Antibiotics-NICE is urging caution with antibiotic prescribing and wants us to take into account severity of symptoms and to judge that by change in sputum colour , volume or thickness look into patient history and note – this helps with decision making

previous exacerbations
hospital admissions
risk of developing complications 
 Previous sputum culture and sensitivity Aim is to reduce antimicrobial resistance and NICE reminds us about the risk of resistance with repeated courses of antibiotics

Change antibiotic when sputum culture becomes available -only if bacteria are resistant and symptoms are not readily improving.If antibiotic given adv about
 SEs particularly diarrhoea Prescribed course may not lead to complete resolution of symptoms Seek help if situation deteriorates rapidly and significantly or no improvement within 2-3 days Patient becomes systemically unwell.
If not issuing antibiotics- explain that Not indicated currently This may change if clinical situation changes and to seek help if-

symptoms worsen rapidly or significantly
no improvement within agreed time
person becomes systemically very unwell

First choice-Amoxicillin 500 mg x tds for 5 days Doxycyline 200 mg day 1 then 100 mg once a day for a 5 day course Clarithromycin 500 mg x bd for 5 days.If person at high risk of treatment failure-
Alternative choice 
( use sensitivity when available ).Co-amoxiclav 500/125 x tds for 5 days Levofloxacin 500 mg x OD for 5 days Co-trimoxazole 960 mg x bd for 5 days

( BNF advices that co-trimoxazole should only be considered for use in acute exacerbation when there is bacteriological evidence of senstitivity and good reason to prefer this combination to a single antibiotic )

Reassess-If symptoms worsen rapidly or significantly. NICE advices to suspect other conditions as

○ pneumonia
○ cardiorespiratory failure
○ sepsis
 Fails to respond due to ? resistance refer-A serious condition suspected
( as per NICE guidance on COPD )
 During an acute exacerbation – get specialist adv if
○ repeated antibiotic courses and no improvement
○ bacteria not sensitive to oral Rx
○ patient unable to take oral medications ( explore options for IV antibiotic at home via eg community outreach , rapid response , fraility , continuing care teams )

Based on Chronic obstructive pulmonary disease ( acute exacerbation ) : antimicrobial prescribing NICE guideline NG-114 December 2018

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