Is it appropriate to start antibiotics for an acute COPD exacerbation?
Most exacerbations of COPD are caused by viral or bacterial infection. The clinical manifestations of exacerbations result from direct effects of viruses and bacteria from the host response. Antibiotics are not beneficial for a mild exacerbation but are beneficial in the treatment of moderate and severe COPD exacerbations, especially when purulent sputum is one of the presenting symptoms. Initial antibiotic choice (before any specific infectious agent is identified) should be based on the patient's age, risk factors, FEV1, number of exacerbations per year, recent antibiotic exposure, and presence of cardiac disease. Observational studies have identified advanced age, severe airflow obstruction, recurrent exacerbations, and coexisting cardiac disease as predictive factors for poor clinical outcomes after a COPD exacerbation.
Hint 1: The most prevalent bacterial pathogens in COPD are Haemophilus influenza and Pseudomonas aeruginosa. These pathogens enhance mucous secretion, disrupt normal ciliary activity, and cause airway epithelial injury, thereby further impairing mucociliary clearance.
Hint 2: Air pollution and other environmental conditions that increase airway inflammation or bronchomotor tone probably account for 15 to 20% of exacerbations. Increased respiratory symptoms resulting from coexisting conditions such as congestive heart failure and pulmonary emboli should be clinically ruled out in the evaluation of exacerbations.
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NEJM - Vol. 359, No. 22, November 27, 2008
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