Our approach to empiric antibacterial treatment of COPD exacerbations in hospitalized patients*

Prompt and appropriate antibiotic use has been associated with improved clinical outcomes in patients hospitalized for COPD exacerbations. Empiric regimens are designed to target the most likely pathogens (Haemophilus influenzae, Moraxella catarrhalis, and Streptococcus pneumoniae). Pseudomonas should be targeted in those with risk factors for infection with this pathogen. Generally, a sputum Gram stain and culture with susceptibility testing should be obtained for hospitalized patients. Modifications to the empiric regimen may be needed based on sputum Gram stain and culture results, particularly for patients who do not respond to the initial empiric regimen within 48 to 72 hours of starting treatment. Modifications to this approach may be needed for patients with a history of colonization or infection with drug-resistant pathogens (including Pseudomonas) or when a specific pathogen is suspected.

COPD: chronic obstructive pulmonary disease; FEV₁: forced expiratory volume in 1 second.

* Antiviral therapy for influenza is also indicated for exacerbations triggered by influenza infection.

¶ Selection among antibiotic choices is based on local microbial sensitivity patterns, patient comorbidities, prior infecting organisms, potential adverse events and drug interactions, and also provider and patient preferences. Modifications to these regimens may be needed for patients with suspicion for specific pathogens and/or history of drug-resistant organisms (eg, drug-resistant Pseudomonas).

Δ For those who cannot tolerate these agents, alternatives include ciprofloxacin, aztreonam, certain carbapenems (eg, meropenem, imipenem), and aminoglycosides. We generally select among them based on local epidemiology, prior susceptibility testing results, drug interactions, and patient comorbidities or intolerances. Two agents are often needed for empiric treatment. Refer to the UpToDate content for detail.

◊ If recent antibiotic exposure (eg, within the past 3 months), select an antibiotic from a different class than the most recent agent used.

References:

Sethi S, Murphy TF. Acute exacerbations of chronic bronchitis: New developments concerning microbiology and pathophysiology--impact on approaches to risk stratification and therapy. Infect Dis Clin N Am 2004; 18:861.
Sethi S, Anzueto A, Miravitlles M, et al. Determinants of bacteriological outcomes in exacerbations of chronic obstructive pulmonary disease. Infection 2016; 44:65.
Gallego M, Pomares X, Espasa M, et al. Pseudomonas aeruginosa isolates in severe chronic obstructive pulmonary disease: characterization and risk factors. BMC Pulm Med 2014; 14:103.

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Our approach to empiric antibacterial treatment of COPD exacerbations in hospitalized patients*