NICE publishes antimicrobial prescribing guidance for COPD

NICE has published new guidance on prescribing antibiotics for acute exacerbations of chronic obstructive pulmonary disease (COPD) (NG114).

An acute exacerbation of COPD is a sustained worsening of symptoms from a person’s stable disease state. NICE notes that a range of factors can trigger a COPD exacerbation (including viral infections and smoking) and only about half are caused by bacterial infections, and thus many exacerbations will not respond to antibiotics. Therefore, in patients with an acute exacerbation, antibiotics should be considered but only after taking into account other factors, such as the severity of symptoms (in particular sputum changes), the need for hospital admission, exacerbation history, the risk of developing complications and the risk of antibiotic resistance.

NICE adds that if a patient’s sputum sample has been sent for culture and susceptibility testing and an antibiotic has already been given, the antibiotic should only be changed if susceptibility results show that bacteria are resistant and symptoms are not improving.

Patients prescribed antibiotics should be advised about possible adverse effects, in particular diarrhoea, and that the antibiotic may not fully resolve symptoms. The first choice of antibiotic in patients over 18 years of age should be oral amoxicillin, doxycycline or clarithromycin. A different antibiotic from this list should be tried if there is no improvement in symptoms after two to three days. In patients at high risk of treatment failure, co-amoxiclav, levofloxacin and co-trimoxazole are alternative oral antibiotics. If the patient is unable to take oral antibiotics or is severely unwell, IV antibiotics can be given, but their use should be reviewed after 48 hours and stepped down to oral antibiotics where possible.

Whether or not an antibiotic is offered, the patient should be told to seek medical help if symptoms do not start to improve within an agreed time, if they worsen rapidly or significantly, or if they become systemically very unwell. If symptoms worsen significantly, more serious conditions such as pneumonia, cardiorespiratory failure or sepsis should be considered and the patient should be referred to hospital. Specialist advice should be sought in patients who have symptoms that are not improving with repeated courses of antibiotics, are infected with bacteria that are resistant to oral antibiotics or if they cannot take oral antibiotics.

NICE has also published a separate update to its 2010 clinical guideline on diagnosing and managing COPD in patients aged 16 and older. The new guideline (NG115) provides new recommendations on prognosis, inhaled therapies, prophylactic antibiotics, oxygen therapy, managing pulmonary hypertension and self-management plans.

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