US guidance recommends limiting antibiotic treatment to 5 days in patients with bronchitis and acute exacerbations of COPD
Short-course antibiotics are preferable to longer treatment durations for patients with acute uncomplicated bronchitis and COPD exacerbations, according to new best practice advice from the American College of Physicians (ACP).
The ACP recommends a 5-day course in patients with an exacerbation of COPD and acute uncomplicated bronchitis presenting with increased purulent sputum plus increased dyspnea, sputum volume, or both.
This contrasts with the 5- to 7-day course proposed by the Global Initiative for Chronic Obstructive Lung Disease for patients with COPD exacerbations in general.[1]
The ACP recommendation is underpinned by a meta-analysis (21 randomized controlled trials; n=10,698 patients) of short-course antibiotic use in patients with acute exacerbations of chronic bronchitis and COPD, which showed no difference in clinical improvement between groups that included patients receiving short-course antibiotics (mean 4.9 days) and those receiving long treatment (mean 8.3 days).[139]
The ACP notes that unnecessarily long durations of antibiotic therapy in patients with common bacterial infections such as acute bronchitis with COPD exacerbation contribute to antibiotic resistance and other adverse events.
Clinicians should reassess patients who do not improve with appropriate antibiotics for other causes of symptoms rather than defaulting to a longer duration of antibiotic therapy.
See Management: treatment algorithm
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Summary
Definition
History and exam
Key diagnostic factors
- dyspnea
- cough
- wheeze
- changes in sputum volume/color/thickness
- tachypnea
- cyanosis
Other diagnostic factors
- past medical history of COPD
- tobacco use
- past medical history of gastroesophageal reflux/swallowing dysfunction
- malaise and fatigue
- chest tightness
- features of cor pulmonale
- environmental/occupational exposure to pollutants or dust
- change in mental status
- fever
- accessory muscle use
- paradoxical movements of abdomen
Risk factors
- viral infection
- bacterial infection
- gastroesophageal reflux/swallowing dysfunction
- smoking
- atypical bacterial infection
- air pollutants
- change in weather
Diagnostic investigations
1st investigations to order
- oxygen saturation on pulse oximetry
- chest x-ray
- ECG
- ABG
- CBC with platelets
- electrolytes, BUN, + creatinine
Investigations to consider
- sputum culture + Gram stain
- respiratory virus diagnostics
- cardiac troponin
- CT scan of chest
Treatment algorithm
Contributors
Authors
Carolyn L. Rochester, MD
Professor of Medicine
Yale School of Medicine
New Haven
VA Connecticut Healthcare System
West Haven
CT
Disclosures
CLR serves on the COPD scientific advisory board for GlaxoSmithKline Pharmaceuticals but has no competing interests pertaining to this publication.
Richard A. Martinello, MD
Associate Professor
Yale School of Medicine
New Haven
CT
Disclosures
RAM declares that he has no competing interests.
Peer reviewers
Sanjay Sethi, MD
Professor of Medicine
Division Chief
Pulmonary/Critical Care/Sleep Medicine
University at Buffalo
State University of New York
Section Chief
Pulmonary/Critical Care/Sleep Medicine
VA Western New York Healthcare System
Buffalo
NY
Disclosures
SS declares that he has no competing interests.
Francis Thien, MD, FRACP, FCCP
Professor
Box Hill Hospital and Monash University
Victoria
Australia
Disclosures
FT declares that he has no competing interests.
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