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COPD exacerbation: no systematic use of antibiotics

For episodes of moderate aggravation in patients with chronic obstructive pulmonary disease (COPD), it is preferable to prescribe antibiotics as a first-line treatment only when the suspicion of bacterial infection is reinforced by an increase in sputum purulence.

Patients with chronic obstructive pulmonary disease (COPD) are subject to exacerbations of their disease, i.e. episodes of prolonged aggravation. The known causes are mainly viral and bacterial infections. Some exacerbations justify hospitalisation: severe COPD, rapid increase in respiratory signs, presence of associated diseases (e.g. diabetes, cardiovascular diseases).

When exacerbation is moderate, the results of available trials show that seven out of ten patients recover in less than four weeks without antibiotics. About one in ten patients heals faster with antibiotic therapy, which may also extend the interval until the next exacerbation.

Antibiotic therapies expose patients to the carrying of resistant bacteria, which are sources of harder-to-treat infections. In the absence of solid evidence specifying which patients are likely to benefit, it is preferable only to prescribe antibiotics as a first-line treatment when the suspicion of bacterial infection is reinforced by the increase in sputum purulence. In the absence of any particular risk factor, a 5-day course of oral amoxicillin is the first choice. The combination of amoxicillin + clavulanic acid is an alternative. A macrolide such as spiramycin or azithromycin is an option when amoxicillin is not appropriate.

Whether or not antibiotic treatment is chosen, patient monitoring is useful during the first few days to detect any aggravation that warrants a change in treatment.

©Prescrire 1 January 2019

"Acute exacerbation of mild to moderate COPD. Antibiotic therapy rarely justified" Prescrire Int 2019; 28 (200): 19-22. (Pdf, subscribers only).

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See also:

Chronic obstructive pulmonary
disease. Useful medications for
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