Our approach to empiric antibacterial treatment of COPD exacerbations in outpatients*

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.

¶ Suspicion for other cardiopulmonary disorders (heart failure, pneumothorax) and more severe infections (eg, pneumonia) should be absent for the diagnosis of an acute COPD exacerbation.

Δ Age alone is not a strict risk factor but should be considered as additive to other risk factors.

◊ 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. In particularly, modifications to this regimen may be needed for patients with a history of drug-resistant Pseudomonas based on severity of illness, degree of suspicion for Pseudomonas, and prior susceptibility profiles of pseudomonal isolates.

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

¥ Trimethoprim-sulfamethoxazole is a reasonable alternative when macrolides and cephalosporins cannot be used due to allergy, potential adverse effects, or availability.

‡ Some experts add amoxicillin or another agent with better activity against S. pneumoniae to ciprofloxacin for broader empiric treatment.

† Because fluoroquinolone resistance is prevalent among Pseudomonas aeruginosa strains, we obtain a sputum Gram stain and culture with susceptibility testing for these patients to help guide subsequent management decisions. For most other outpatients, obtaining a sputum culture is not needed unless the patient fails to respond to empiric treatment.