What is the UK management of Lower Respiratory Tract Infections (LRTI) and exacerbation of Chronic Obstructive Pulmonary Disease (COPD)?

From the Guidelines

Management of lower respiratory tract infections (LRTI) and COPD exacerbations in the UK should follow a structured approach focusing on prompt assessment and appropriate antimicrobial therapy, with the goal of reducing morbidity, mortality, and improving quality of life. For uncomplicated LRTI in adults, amoxicillin 500mg three times daily for 5 days is the first-line treatment, as recommended by recent guidelines 1. Alternatives for penicillin-allergic patients include doxycycline 200mg on day 1, then 100mg daily for 4 days, or clarithromycin 500mg twice daily for 5 days.

For COPD exacerbations, treatment depends on severity but typically includes:

• Bronchodilators (salbutamol 100-200mcg via spacer or 2.5-5mg via nebulizer)
• Oral corticosteroids (prednisolone 30mg daily for 5 days)
• Antibiotics if purulent sputum is present, with amoxicillin 500mg three times daily for 5 days being the preferred antibiotic, and doxycycline or clarithromycin as alternatives 1. Severe exacerbations may require hospital admission for oxygen therapy (target saturation 88-92% for those at risk of hypercapnic respiratory failure), nebulized bronchodilators, intravenous corticosteroids, and potentially non-invasive ventilation.

Preventive strategies include:

• Smoking cessation
• Influenza and pneumococcal vaccinations
• Optimizing maintenance therapy with appropriate inhalers Early pulmonary rehabilitation following exacerbations has been shown to reduce readmission rates and improve quality of life, as supported by the European Respiratory Society/American Thoracic Society guideline 1. Prompt treatment is essential as delays can lead to disease progression and increased mortality. The most recent and highest quality study, the 2017 European Respiratory Society/American Thoracic Society guideline 1, provides the best evidence for the management of COPD exacerbations.

From the FDA Drug Label

Adults Acute bacterial exacerbations of chronic obstructive pulmonary disease (mild to moderate) 500 mg QD × 3 days OR 500 mg as a single dose on Day 1, followed by 250 mg once daily on Days 2 through 5

The recommended dose of azithromycin for the treatment of acute bacterial exacerbations of chronic obstructive pulmonary disease (COPD) in adults is 500 mg once daily for 3 days or 500 mg as a single dose on Day 1, followed by 250 mg once daily on Days 2 through 5 2.

• Key points:
  • The dosage is for mild to moderate COPD exacerbations
  • Azithromycin can be taken with or without food
  • No dosage adjustment is recommended for subjects with renal impairment (GFR ≤80 mL/min)
  • Caution should be exercised when azithromycin is administered to subjects with severe renal impairment 2.

From the Research

Management of LRTI and Exacerbation of COPD in the UK

• The management of lower respiratory tract infection (LRTI) and exacerbation of chronic obstructive pulmonary disease (COPD) in the UK involves the use of antibiotics, with amoxicillin being the most commonly prescribed index drug 3.
• A study found that 8.4% of patients with COPD exacerbations received further antibiotics for LRTI within 14 days, and 15.5% received further courses for any indication 3.
• The use of antibiotics for COPD exacerbations is a common practice, but the choice of antibiotic and duration of treatment can vary 3, 4.
• A review of prophylactic antibiotic therapy for COPD found that there is no clear difference in efficacy or safety between different classes or regimens of antibiotics 5.
• A study on amoxicillin for acute LRTI in primary care found that there is no clear evidence of clinically meaningful benefit from antibiotics in high-risk groups, such as those with comorbidities or producing colored sputum 6.
• A Delphi-based approach to determine the most appropriate therapeutic strategy for acute LRTIs found that oral cephalosporins, such as cefditoren, may be appropriate for first-line treatments of LRTIs 7.

Antibiotic Prescribing Habits

• The prescription of multiple antibiotic courses for COPD exacerbations is relatively common, with one in twelve patients receiving antibiotics for LRTI having a further course within two weeks 3.
• The choice of antibiotic and duration of treatment can vary, with amoxicillin and doxycycline being the most common index and second-line drugs, respectively 3.
• The use of antibiotics for COPD exacerbations is often based on clinical judgment, rather than a clear understanding of the underlying pathophysiology 4, 5.

Future Research Directions

• Further clinical trials are needed to determine the best practice for managing LRTI and COPD exacerbations in the UK 3, 5.
• Research is needed to understand the optimal choice and duration of antibiotic therapy for COPD exacerbations, as well as the potential risks and benefits of different treatment strategies 4, 6.
• The development of evidence-based guidelines for the management of LRTI and COPD exacerbations is essential to improve patient outcomes and reduce the risk of antibiotic resistance 7.