Antibiotic Treatment In Acute Bronchitis and Exacerbations of COPD ...

Türk Toraks Derneği
Turkish Thoracic Society
Turkish
Thoracic
Society
Pocket Books Series
Antibiotic Treatment In
Acute Bronchitis and
Exacerbations of COPD and
Bronchiectasis
Short Version (Handbook)
in English
www.toraks.org.tr

This report was prepared and written by
Abdullah Sayıner, Mehmet Polatlı, Lütfü Çöplü
The full text of the report is published in Turkish in
Turkish Thoracic Journal 2009;10 (Supplement 3)
Türk Toraks Derneği
Turkish Thoracic Society
Turkish Thoracic Society
Turan Güneş Boulevard, No: 175/19 Oran-Ankara-Turkey
Telephone Number: +90 312 490 40 50
Fax Number: +90 312 490 41 42
E-mail address: toraks@toraks.org.tr
Website: www.toraks.org.tr

Treatment approach in acute bronchitis
• Basically symptomatic. A great majority is viral.
Indications of antibiotic treatment in COPD
exacerbations
• The presence of all three of the following symptoms:
increased dyspnea, increase in amount of sputum and
purulent sputum (Anthonisen Type 1)
• The presence of two of the three cardinal symptoms,
with the condition that one of the symptoms is
purulent sputum (Anthonisen Type 2)
Risk factors for P. aeruginosa infection in exacerbations
of COPD and bronchiectasis
• Hospitalization within the last month
• Antibiotic use, four times or more in the preceding year
or once within the last month
• Severe exacerbation (associated with respiratory
failure)
• Detection of P. aeruginosa in sputum in previous
exacerbation or in stable period
Risk factors for treatment failure or early relapse in
COPD exacerbations (criteria for complicated
exacerbation)
• The presence of comorbidity (especially heart disease)
• Severe COPD (FEV 1
< 50%)
• History of four or more exacerbations in the preceding
year
• Antibiotic use within the last 3 months
5

Recommendations for antibiotic treatment in infective COPD exacerbations
Group
A
B
C
Features of exacerbation and of
the patient
Mild and simple exacerbation
(No respiratory failure, non- severe
obstruction, no comorbidity, three
or fewer exacerbations in the
preceding year, no antibiotic use
within the last 3 months)
Moderate-severe, complicated
exacerbation
(Risk factors for treatment failure
present – Table 2; no risk factor for
P. aeruginosa – Table 3)
Severe exacerbation with risk of
Pseudomonas infection
(Table 3)
Possible pathogens First-line oral antibiotics 1 Alternative agents 1 Parenteral treatment
options
H. influenzae
S. pneumoniae
M. catarrhalis
C. pneumoniae 2
Viruses
Group A bacteria
Bacteria producing
beta-lactamase
Enteric Gram (-)
bacteria
(K. pneumoniae, E. coli
etc.)
Group B bacteria
P. aeruginosa
ESBL(+) EGNB
Amoxicillin 3
Beta-lactam + betalactamase
inhibitor
2 nd generation
cephalosporin 4 Macrolide
2 5
Beta-lactam + betalactamase
inhibitor or
2 nd and 3 rd generation
cephalosporin 6
Fluoroquinolone effective
against P. aeruginosa 8
(ciprofloxacin)
Respiratory
fluoroquinolones
(gemifloxacin,
levofloxacin,
moxifloxacin) 7
Beta-lactam + betalactamase
inhibitor
2 nd and 3 rd generation
cephalosporin
Respiratory
fluoroquinolones
Fluoroquinolone effective
against P. aeruginosa
(ciprofloxacin) 8
Anti-Pseudomonas betalactam
antibiotics 8
1
No priority in the order.
2
As it is stated within the text, although these have been detected with serological methods in exacerbations, it is not certain whether atypical bacteria are really the causative agents
or not; there is not enough evidence justifying the use of antimicrobials covering the atypical bacteria.
3
Amoxicillin should be given if penicillin-sensitive S.pneumoniae or beta lactamase (-) bacteria are identified in sputum culture . The bioavailability of ampicillin is lower than that of
Amoxicillin.
4
The 2 nd generation cephalosporins that are most effective against H. influenzae are cefuroxime axetil and cefprozil
5
The most effective macrolides against H. influenzae and S. pneumoniae are azithromycin and clarithromycin, respectively.
6
3 rd generation non-pseudomonal cephalosporins are ceftriaxone and cefotaxime.
7
They are the first-line antibiotics in patients who have used a beta-lactam within the last 3 months or who are allergic to penicillin. These fluoroquinolones can be considered as first
choice by virtue of their effectiveness in exacerbations, their high concentrations in lung tissue and respiratory tract secretions and their achievement of good bacterial eradication.
However, it should not be forgotten that any increase in their use may increase the risk of resistance development.
8
Sputum cultures are recommended in these patients. The empiric treatment may be modified and a regimen with a narrower spectrum may be chosen based on culture and
susceptibility results,.
6
7

8
Antibiotic recommendations in exacerbations of bronchiectasis
Oral treatment Parenteral treatment
Beta-lactam + beta-lactamase inhibitor
3. generation non-pseudomonal cephalosporin
Respiratory fluoroquinolone
Beta-lactam +
beta-lactamase
inhibitor
Respiratory
fluoroquinolone
Patients without
any risk factor for
Pseudomonas
Ciprofloxacin * Ciprofloxacin
3. or 4. generation anti-pseudomonal cephalosporin
Carbapenem
Piperacillin-tazobactam
Anti-pseudomonal beta-lactam +
FQ or aminoglycoside
Patients with
risk factor for
Pseudomonas
* In exacerbations of patients with bronchiectasis due to IgG insufficiency, an antibiotic effective against gram +bacteria
(e.g. a beta-lactam) should be given together with ciprofloxacin with the aim to cover S. pneumoniae
Türk Toraks Derneği
Turkish Thoracic Society