Infectious Disease Compendium

COPD Exacerbation

Diagnosis

Increase in color and production of sputum with increased dyspnea.

Epidemiologic Risks

COPD.

Microbiology

There is microbiome of the lung and in COPD may in part be due to alternation in the microbiome. There is an increase in Firmicutes and Proteobacteria and a decrease in Bacteroidetes(Pubmed).

H. influenza, S. pneumoniae and M. catarrhalis predominate, but it may a generalized increase in bacteria and not any one specific organism. However, acquisition of new bacterial strains is associated with exacerbations. Pseudomonas is increasingly identified in as a cause of progression of COPD (PubMed) and doubles the mortality (PubMed).

Pneumocystis (Pubmed) may have a role in the pathogenesis combined with a change in the microbiome, especially in HIV patients.

Empiric Therapy

The worser the exacerbation, the better the response to antibiotics. Anything will do and there is no data to suggest that newer, broad spectrum or more expensive antibiotics will lead to a better outcome. Worry about H. influenza, S. pneumoniae and M. catarrhalis, but probably not their resistance to antibiotics, no matter what the drug rep says.

Try amoxicillin OR tmp/sulfa OR doxycycline orally, probably any po or iv antibiotic for 5 to 10 days, depending on how ill they are.

Patient who receive early antibiotics are less likely to receive mechanical ventilation after the second hospital day, have lower death rates during hospitalization and lower readmission rates for acute COPD exacerbations but more Clostridium difficile (PubMed). No good deed ever goes unpunished, huh?

Antibiotics for COPD is the perfect example of Newtons Second Law of the Medical Literature: for every study there is an equal and opposite study. The Cochran review finds benefit for patients admitted to an ICU but for outpatients and inpatients the results were inconsistent. (PubMed).

From the NEJM review (PubMed).

- Uncomplicated COPD (No risk factors: Age <65 years, FEV1 >50% predicted,<3 exacerbations per year, no cardiac disease) Advanced macrolide (azithromycin, clarithromycin) Cephalosporin (cefuroxime, cefpodoxime, cefdinir) doxycycline, TMP/Sulfa. If recent antibiotic exposure (<3 months), use alternative class.

- Complicated COPD (1 or More risk factors: Age ≥65 years, FEV1 ≤50% predicted, ≥3 exacerbations per year, cardiac disease) Fluoroquinolone (moxifloxacin, , levofloxacin) amoxicillin/clavulanate.

- even in patients severe to end up on a vent, ciprofloxacin is no better than trimethoprim/sulfamethoxisole (PubMed).

- If at risk for Pseudomonas infection, consider ciprofloxacin and obtain sputum culture.

If recent antibiotic exposure (<3months), use alternative class.

Doxycycline does not work for prolonging the interval to next exacerbation (PubMed).

Pearls

COPD exacerbations may be decreased by azithromycin, perhaps due to its immune modulating effects ( PubMed).

Clarithromycin for acute exacerbations of chronic obstructive pulmonary disease or community acquired pneumonia may be associated with increased cardiovascular events (PubMed).

Rants

It is probably vital so give the most expensive, newest antibiotic you have recently been detailed on. Not.