Should All Patients with COPD Exacerbations Be Treated with Antibiotics?

December 26, 2013

Should All Patients with COPD Exacerbations Be Treated with Antibiotics?

  1. Patricia Kritek, MD

In those with mild-to-moderate chronic obstructive pulmonary disease, only purulent sputum and high C-reactive protein levels predicted need for antibiotics.

  1. Patricia Kritek, MD

Patients with severe chronic obstructive pulmonary disease (COPD) exacerbations are treated with antibiotics, but do patients with less-severe disease also need them? In a 2012 trial of outpatients with mild-to-moderate COPD exacerbations (forced expiratory volume in 1 second, >50% of predicted) who received either amoxicillin/clavulanate or placebo, 80% of 152 placebo patients had satisfactory outcomes in the absence of antibiotic therapy (Am J Respir Crit Care Med 2012; 186:716).

To predict which patients would do well without antibiotics, investigators examined the data from the placebo group of this trial. COPD exacerbations were defined by the classical symptoms of increased dyspnea, increased volume of sputum, and increased purulence of sputum. Using multivariate analyses, the researchers determined which factors were associated with potential response to antibiotics. The only symptom that predicted potential benefit from antibiotics was increased purulence of sputum; patients with dyspnea, increased sputum volume (but not increasing purulence), or both did well without receiving antibiotics. The two best predictors of potential benefit from antibiotics were purulent sputum and C-reactive protein (CRP) level >40 mg/L.


This study's finding about use of point-of-care C-reactive protein testing will have limited clinical relevance in settings where such testing is not available. However, this study does support forgoing antibiotics in patients who have mild-to-moderate COPD exacerbations without purulent sputum.

Editor Disclosures at Time of Publication

  • Disclosures for Patricia Kritek, MD at time of publication Editorial boards ACP Medicine; New England Journal of Medicine


Reader Comments (3)

Peter Hakim Resident, Emergency Medicine

This study used amox/clav, but I know a lot of people are using azithromycin as their antimicrobial. I'm not sure this can be applied in those settings.

RAMAKRISHNAN SIVARAMAN SUMAITHANGI Physician, Internal Medicine, rural health care unit

systemic symptoms of infection such as fever, headache ,body ache,weakness, nausea bowel disturbance etc.should also be considered before prescribing antibiotics in a pt. with exacerbation of copd.

JESUS ARTURO FLORES Physician, Pulmonary Medicine, IMSS and private practice

Certanly I stop giving antibiotics in acute exacerbations , only paciente on ICU sould recive. Not as a norm , but close .

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