NICE has released its 2018 guideline on Antimicrobial prescribing in acute exacerbation of the chronic obstructive pulmonary disease, COPD in adults. It covers diagnosing and managing exacerbation of chronic obstructive pulmonary disease (COPD) and aims to optimize antibiotic use to reduce symptoms taking care of antibiotic resistance and improve quality of life and keep them healthy for longer.
The guideline includes recommendations on
- referral and seeking specialist advice
- choice of antibiotic
Following are the major recommendations:
Managing an acute exacerbation of COPD with antibiotics
1. Be aware that:
- an acute exacerbation of chronic obstructive pulmonary disease (COPD) is a sustained worsening of symptoms from a person’s stable state
- a range of factors (including viral infections and smoking) can trigger an exacerbation
- many exacerbations (including some severe exacerbations) are not caused by bacterial infections so will not respond to antibiotics
- some people at risk of exacerbations may have antibiotics to keep at home as part of their exacerbation action plan.
2. Consider an antibiotic for people with an acute exacerbation of COPD, but only 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.
3 If a sputum sample has been sent for culture and susceptibility testing (in line with the NICE guideline on COPD in over 16s) 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).
4. If an antibiotic is given, give advice:
- about possible adverse effects of the antibiotic, particularly diarrhoea
- that symptom may not be fully resolved when the antibiotic course has been completed
- about seeking medical help 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.
5. If no antibiotic is given, give advice about:
- an antibiotic not being needed currently
- seeking medical help without delay if:
- symptoms (such as sputum colour changes and increases in volume or thickness) worsen rapidly or significantly or
- symptoms do not start to improve within an agreed time or
- the person becomes systemically very unwell.
6. Reassess people with an acute exacerbation of COPD if their symptoms worsen rapidly or significantly at any time, 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. Send a sputum sample for culture and susceptibility testing if symptoms have not improved following antibiotic treatment and this has not been done already.
Referral and seeking specialist advice
7. Refer people with an acute exacerbation of COPD to the hospital if they have any symptoms or signs suggesting a more serious illness or condition (for example, cardiorespiratory failure or sepsis) and in line with the NICE guideline on COPD in over 16s.
8. Seek specialist advice for people with an acute exacerbation of COPD if they:
- have symptoms that are not improving with repeated courses of antibiotics or
- have bacteria that are resistant to oral antibiotics or
- cannot take oral medicines (to explore locally available options for giving intravenous antibiotics at home or in the community, rather than in hospital, where appropriate).
See the evidence and committee discussion on antibiotics.
Choice of antibiotic
1. When prescribing an antibiotic for an acute exacerbation of COPD, give oral antibiotics first line if the person can take oral medicines, and the severity of their exacerbation does not require intravenous antibiotics.
2. Review intravenous antibiotics by 48 hours and consider stepping down to oral antibiotics where possible.
Antibiotic treatment for adults aged 18 years and over
|Antibiotic||Dosage and course length|
|First-choice oral antibiotics (empirical treatment or guided by most recent sputum culture and susceptibilities)|
|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)|
|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 failure; guided by susceptibilities when available)|
|Co-amoxiclav||500/125 mg three times a day for 5 days|
|Levofloxacin||500 mg once a day for 5 days|
|Co-trimoxazole||960 mg twice a day for 5 days|
|First-choice intravenous antibiotic (if unable to take oral antibiotics or severely unwell; guided by susceptibilities when available)|
|Amoxicillin||500 mg three times a day (see BNF for dosage in severe infections)|
|Co-amoxiclav||1.2 g three times a day|
|Clarithromycin||500 mg twice a day|
|Co-trimoxazole||960 mg twice a day (see BNF for dosage in severe infections)|
|Piperacillin with tazobactam||4.5 g three times a day (see BNF for dosage in severe infections)|
|Second-choice intravenous antibiotic|
|Consult local microbiologist; guided by susceptibilities|
|1 See the British national formulary (BNF) for appropriate use and dosing in specific populations, for example, hepatic impairment, renal impairment, and administering intravenous antibiotics.
2 If a person is receiving antibiotic prophylaxis, treatment should be with an antibiotic from a different class.
3 People who may be at a 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.
4 The 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).
5 Co-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).
6 Review intravenous antibiotics by 48 hours and consider stepping down to oral antibiotics where possible.
It’s fairly common for symptoms of COPD to suddenly get worse than usual leading to exacerbation but antibiotics should be used only when they are not needed so that antibiotic resistances has taken care of.
For more details click on the link: www.nice.org