What is the recommended antibiotic treatment for a patient with Chronic Obstructive Pulmonary Disease (COPD) infective exacerbation?

Antibiotic Prescription for COPD Infective Exacerbation in Ward Admission

For hospitalized patients with COPD exacerbation without risk factors for Pseudomonas, prescribe amoxicillin-clavulanate (co-amoxiclav) 875/125 mg orally twice daily for 7-10 days, or alternatively levofloxacin 500 mg daily or moxifloxacin 400 mg daily for 5-7 days. 1

Patient Stratification and Antibiotic Selection

Confirm Antibiotic Indication

Antibiotics are indicated when patients present with:

• All three cardinal symptoms (Type I Anthonisen): increased dyspnea, increased sputum volume, AND increased sputum purulence 1
• Two cardinal symptoms (Type II Anthonisen) when purulent sputum is one of them 1
• Severe exacerbation requiring mechanical ventilation (invasive or non-invasive) 1

Assess Risk Factors for Pseudomonas aeruginosa

Pseudomonas coverage is needed when at least TWO of the following are present: 1

• Recent hospitalization
• Frequent antibiotic use (>4 courses/year or within last 3 months)
• Severe COPD (FEV1 <30% predicted)
• Oral steroid use (>10 mg prednisolone daily in last 2 weeks) 1

Specific Antibiotic Regimens

For Patients WITHOUT Pseudomonas Risk Factors (Group B)

First-line choice:

• Amoxicillin-clavulanate 875/125 mg orally twice daily (or 2000/125 mg twice daily formulation for better coverage) for 7-10 days 1

Alternative options:

• Levofloxacin 500 mg orally once daily for 5-7 days 1
• Moxifloxacin 400 mg orally once daily for 5 days 1

Parenteral options (if patient cannot take oral medications):

• Amoxicillin-clavulanate IV 1
• Ceftriaxone 1-2 g IV once daily 1
• Cefotaxime IV 1
• Levofloxacin 500 mg IV once daily 1
• Moxifloxacin 400 mg IV once daily 1

For Patients WITH Pseudomonas Risk Factors (Group C)

Oral regimen:

• Ciprofloxacin 750 mg orally twice daily for 7-10 days 1
• Alternative: Levofloxacin 750 mg orally once daily (or 500 mg twice daily) 1

Parenteral regimen:

• Ciprofloxacin IV 1
• OR an anti-pseudomonal β-lactam (cefepime, piperacillin-tazobactam, or carbapenem) 1
• Addition of aminoglycosides is optional (though evidence for combination therapy benefit is limited) 1

Route of Administration and Switching

• Start with oral route if patient can tolerate oral intake 1
• Use IV route if: patient cannot eat, severe illness, or ICU admission 1
• Switch from IV to oral by day 3 if patient is clinically stable 1

Microbiological Testing

Obtain sputum culture or endotracheal aspirate (in mechanically ventilated patients) in: 1

• Severe exacerbations (Group C patients)
• Suspected Pseudomonas infection
• Prior antibiotic or oral steroid treatment
• Prolonged disease course
• More than 4 exacerbations per year
• FEV1 <30% predicted

Important Clinical Considerations

Avoid These Common Pitfalls:

• Plain amoxicillin is NOT recommended due to higher relapse rates and β-lactamase-producing H. influenzae resistance (20-30% of strains) 1
• Macrolides are generally NOT recommended due to high S. pneumoniae resistance (30-50% in some European countries) and H. influenzae resistance to clarithromycin 1
• Ciprofloxacin has poor S. pneumoniae coverage, but this is acceptable in Group C patients where Pseudomonas is the concern 1

Duration of Therapy:

• Standard duration: 7-10 days 1
• Shorter courses (5 days) with fluoroquinolones (levofloxacin or moxifloxacin) are as effective as 10-day β-lactam courses 1, 2

Evidence Quality Notes:

The European Respiratory Society guidelines 1 provide the strongest evidence base for these recommendations. Recent research supports moxifloxacin as equally effective to amoxicillin-clavulanate with lower clinical failure rates in confirmed bacterial AECOPD 2. However, amoxicillin remains the preferred first-line agent in UK primary care with acceptable outcomes 3.

Non-Responding Patients:

If no clinical improvement within 72 hours: 1

• Re-evaluate for non-infectious causes (pulmonary embolism, heart failure, pneumothorax)
• Obtain microbiological reassessment
• Switch to antibiotic with broader coverage against Pseudomonas, resistant S. pneumoniae, and non-fermenters
• Adjust based on culture results