What are the indications for antibiotics in acute asthma exacerbation?

From the Guidelines

Antibiotics are not recommended for the treatment of acute asthma exacerbations except as needed for comorbid conditions. Most asthma exacerbations are triggered by viral infections or environmental factors, not bacteria, making antibiotics ineffective in these cases. If a bacterial infection is suspected (such as pneumonia or sinusitis) based on symptoms like fever, purulent sputum, or chest X-ray findings, then appropriate antibiotics may be prescribed. Common choices include amoxicillin-clavulanate (875/125 mg twice daily for 5-7 days), azithromycin (500 mg on day 1, then 250 mg daily for 4 days), or doxycycline (100 mg twice daily for 5-7 days) 1. The primary treatment for asthma exacerbations should focus on bronchodilators (like albuterol), systemic corticosteroids (such as prednisone 40-60 mg daily for 5-7 days), and addressing the underlying trigger. Unnecessary antibiotic use contributes to antibiotic resistance and may cause side effects without providing benefit. Patients should focus on their asthma action plan and seek medical attention if symptoms worsen despite appropriate asthma medication use.

Some key points to consider:

• The use of antibiotics is generally reserved for patients with fever and purulent sputum and for patients with evidence of pneumonia 1.
• Bacterial, Chlamydia, or Mycoplasma infections infrequently contribute to exacerbations of asthma 1.
• The role of sinusitis in acute exacerbations of asthma has not been truly defined 1.
• Studies of the efficacy of antibiotic treatment in asthma patients are needed to clarify the role of antibiotics in the treatment of asthma exacerbations 1.

In terms of treatment, the following are recommended:

• Bronchodilators (like albuterol) to help open up the airways
• Systemic corticosteroids (such as prednisone 40-60 mg daily for 5-7 days) to reduce inflammation
• Addressing the underlying trigger, such as avoiding allergens or irritants
• Focusing on the patient's asthma action plan and seeking medical attention if symptoms worsen despite appropriate asthma medication use.

From the Research

Antibiotics for Asthma Exacerbation

• The use of antibiotics for asthma exacerbation is a topic of ongoing debate, with some studies suggesting that they may be beneficial in certain cases 2, 3.
• A 2018 Cochrane review found that antibiotics may improve symptoms and peak expiratory flow rate (PEFR) in patients with asthma exacerbations, but the evidence was limited and of low quality 2.
• A 2001 Cochrane review found that the role of antibiotics in the treatment of acute asthma is difficult to assess due to the limited number of studies and the small sample sizes 4.
• A 2019 study found that azithromycin reduced asthma exacerbations and improved quality of life in adults with persistent uncontrolled asthma 3.
• The 2025 Chinese guidelines for the prevention and management of bronchial asthma recommend the use of antibiotics in certain cases, such as in patients with severe asthma or those who have not responded to other treatments 5.

Key Findings

• Antibiotics may be beneficial in reducing asthma exacerbations and improving quality of life in certain patients 2, 3.
• The evidence for the use of antibiotics in asthma exacerbation is limited and of low quality 2, 4.
• Azithromycin may be a useful add-on therapy in persistent asthma 3.
• The use of antibiotics should be guided by clinical judgment and should take into account the individual patient's needs and circumstances 5.

Patient Subgroups

• Patients with severe asthma or those who have not responded to other treatments may benefit from antibiotics 5.
• Patients with persistent uncontrolled asthma may benefit from azithromycin therapy 3.
• Patients with asthma-COPD overlap may require different treatment approaches 5.