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Antibiotic Use in COPD ExacerbationAka: Acute Exacerbation of Chronic Bronchitis

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  1. See Also
    1. COPD
    2. COPD Management
  2. General Measures
    1. Low Flow Oxygen to keep Arterial PaO2 > 60mmHg
    2. Systemic Corticosteroids (oral or intravenous)
      1. Consider in all significant COPD exacerbations
      2. Prednisone 30-40 mg/day PO tapered over 2 weeks
  3. Antibiotic indications if 3 criteria met
    1. Increased Dyspnea
    2. Increased Sputum
    3. Purulent Sputum
  4. Uncomplicated Chronic Bronchitis Management
    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. Haemophilus Influenzae
      2. Streptococcus Pneumoniae
      3. Moraxella catarrhalis
      4. Chlamydia pneumoniae
      5. Mycoplasma pneumoniae
    3. Antibiotics (5 day course)
      1. First-Line
        1. Bactrim DS one tablet PO bid
        2. Doxycycline 100 mg PO bid
        3. Amoxicillin 500 mg PO tid
          1. Equivalent to Moxifloxacin in clinical outcome
          2. Wilson (2004) Chest 125:953
      2. Alternative Antibiotics
        1. Augmentin 875 mg PO bid
        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
  5. Complicated Chronic Bronchitis Management
    1. Criteria
      1. Uncomplicated criteria not met (see above)
    2. Coverage
      1. Uncomplicated Chronic Bronchitis bacteria (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. Gatifloxacin (Tequin) 400 mg PO qd
        3. Moxifloxacin (Avelox) 400 mg PO qd
  6. Severe Exacerbation requiring hospitalization
    1. Co-administer intravenous Corticosteroids
    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
  7. References
    1. Fein (2000) Curr Opin Pulm Med 6:122
    2. Saint (1995) JAMA 273:957
    3. Sethi (2000) Chest 117(5 suppl 2):S380

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