Infective Exacerbation of COPD

Comments from Expert Advisory Group

Acute exacerbations of COPD may be triggered by viral as well as bacterial infections therefore many exacerbations (including some severe exacerbations) will not respond to antibiotics, in addition some exacerbations may be caused by non-infective triggers e.g. environmental pollution.
Initiate short-acting bronchodilator therapy and 5 day course oral prednisolone 30 mg per day.
Ensure all patients are up to date with influenza vaccine, COVID-19 vaccine and pneumococcal vaccine.
Consider prescribing antibiotics if exacerbation is associated with increased dyspnoea and increased sputum volume or purulence.
Consider sending sputum for culture especially if frequent exacerbations or if symptoms have not improved following antibiotic treatment.
If patient colonised with multidrug resistant organisms, empiric first line antibiotics may not be effective or appropriate. Contact consultant microbiologist, consultant respiratory physician or infectious diseases specialist, according to local referral pathways.
In penicillin allergy, doxycycline is the preferred choice. Macrolide warning.
Azithromycin should not be used for prevention of exacerbations of COPD except under the direction of a respiratory physician. It is effective in a very select subgroup of COPD patients.
Consider pulse oximetry to assess oxygenation.

Treatment

Infective Exacerbation of COPD Empiric Antibiotic Treatment Table

Drug

Dose

Duration

Notes

1st choice options

Amoxicillin

500mg every 8 hours.

Consider 1g every 8 hours for severe infection.

5 days

Avoid in penicillin allergy.

OR Doxycycline

(First choice in penicillin allergy)

200mg every 24 hours.

OR 100mg every 12 hours.

OR in non-severe infection, Doxycycline 200mg stat then 100mg every 24 hours can be considered.

5 days

Avoid in pregnancy.

Advise to take with a glass of water and sit upright for 30 minutes after taking.

Can take with food or milk if gastritis is an issue.

Absorption of doxycycline significantly impaired by antacids, iron/calcium/magnesium/zinc-containing products.

OR Clarithromycin

(Second line in penicillin allergy)

500mg every 12 hours.

5 days

Avoid if on azithromycin prophylaxis.

See Macrolide warning and check drug interactions before prescribing.

Macrolides should be used with caution in pregnancy. Clarithromycin suitable only in 2nd and 3rd trimester in pregnancy. Alternative macrolide for all trimesters of pregnancy: Azithromycin 500mg stat then 250mg every 24 hours from Day 2 to Day 5.

2nd choice options or high risk of treatment failure

Consider hospital admission.

Check for consultant guidance from previous consultation.

Consider choosing antibiotic from a different class to previous antibiotic.

Consider consultation with respiratory physician / microbiologist / infectious diseases if treatment options are limited.

Co-amoxiclav

500/125mg every 8 hours.

In some cases, 875/125mg every 8 hours may be advised by microbiology or infectious diseases.

5 days

Avoid in penicillin allergy.

If patient has a penicillin allergy and options below previously prescribed consider consultation with respiratory physician / microbiologist / infectious diseases.

Doxycycline

(suitable in penicillin allergy)

200mg every 24 hours.

OR 100mg every 12 hours. 

5 days

Avoid in pregnancy.

Advise to take with a glass of water and sit upright for 30 minutes after taking.

Can take with food or milk if gastritis is an issue.

Absorption of doxycycline significantly impaired by antacids, iron/calcium/magnesium/zinc-containing products.

OR Clarithromycin

(suitable in penicillin allergy)

500mg every 12 hours.

5 days

Avoid if on azithromycin prophylaxis.

See Macrolide warning and check drug interactions before prescribing.

Patient Information

For more information on COPD see COPD Overview
Patient COPD Communication Card available from NCPC
COPD Self Care plan
COPD Support Ireland

Useful Link

National Clinical Guideline: Management of COPD (3.09 MB, PDF)

Safe Prescribing (visit the safe prescribing page)

Doses are oral and for adults unless otherwise stated
Clarithromycin and other macrolides warning
Penicillin allergy – tips on prescribing in penicillin allergy
Renal impairment dosing table
Safety in Pregnancy and Lactation
Drug interactions table. Extensive drug interactions for clarithromycin, fluoroquinolones, azole antifungals and rifampicin. Many antibiotics increase the risk of bleeding with anticoagulants.
Visit the Health Products Regulatory Authority (HPRA) website for detailed drug information (summary of product characteristics and patient information leaflets). Dosing details, contraindications and drug interactions can also be found in the Irish Medicines Formulary (IMF) or other reference sources such as British National Formulary (BNF) / BNF for children (BNFC).

Reviewed September 2024