COPD exacerbation
Acute worsening of respiratory symptoms (dyspnea, cough, sputum volume and purulence) in a patient with COPD that needs additional therapy. Bacterial etiology is likely with purulent sputum and two or more Anthonisen criteria. GOLD 2024 foundation therapy: short-acting bronchodilators, a short course of systemic steroids (prednisolone 40 mg for 5 days), and antibiotics in confirmed bacterial flares (amoxicillin/clavulanate, cefuroxime, cefditoren, levofloxacin).
ICD-10 J44.15 drugs
Also known as: Acute exacerbation of COPD, AECOPD
Drugs used for this condition
- AAmoxicillin + Clavulanic AcidFirst line · Fixed-dose combination: aminopenicillin plus beta-lactamase inhibitorCOPD exacerbation when an antibiotic is indicated: increased sputum purulence together with more dyspnea or more sputum, or an exacerbation requiring hospitalization or ventilation (GOLD, GesEPOC 2021). Per GOLD, initial empirical therapy is an aminopenicillin with clavulanic acid, a macrolide or a tetracycline, chosen by local resistance patterns; the Spanish GesEPOC 2021 places amoxicillin-clavulanate as first choice in mild and moderate exacerbations without Pseudomonas risk. NICE NG114 (2018) narrows the frame: first choices are amoxicillin, doxycycline or clarithromycin, with co-amoxiclav for a high risk of treatment failure. Per Cochrane 2018, antibiotics in outpatients reduce the risk of treatment failure (RR 0.72, 95% CI 0.56–0.94, low certainty) without affecting mortality, with a large effect in the ICU. Exacerbation of chronic bronchitis is listed in the Spanish SmPC (4.1). Adult dose: 875/125 mg every 8–12 h, usually 5–7 days (GOLD: 5–7 days). With Pseudomonas risk factors (frequent antibiotic courses, severe airflow limitation, previous isolation) a different drug is needed. The 875/125 mg tablets are not recommended when creatinine clearance is below 30 ml/min. Contraindications (AEMPS SmPC, 4.3): penicillin allergy, anaphylaxis to other beta-lactams, and a history of jaundice or liver injury with the drug. Possible cholestatic hepatitis (more often in older adults and with prolonged courses) and diarrhea up to C. difficile colitis. Interactions: oral anticoagulants (higher INR), methotrexate, mycophenolate, allopurinol.
- BCefditoren pivoxilSecond line · Third-generation oral cephalosporinUsed in bacterial COPD exacerbations meeting two or more Anthonisen criteria (worsening dyspnea, increased sputum volume and purulence). Cefditoren is listed in Spanish GesEPOC 2021 as an alternative to amoxicillin/clavulanate. Dose 400 mg twice daily for 5–7 days. Not used in severe COPD with risk factors for Pseudomonas aeruginosa – ciprofloxacin or levofloxacin is preferred.
- BCefuroxime axetilSecond line · Second-generation oral cephalosporinUsed in bacterial COPD exacerbations meeting Anthonisen criteria. Dose 500 mg twice daily for 5–7 days. GOLD 2024 and Spanish GesEPOC 2021 place it among alternatives to amoxicillin/clavulanate and cefditoren.
- BLevofloxacinSecond line · Third-generation fluoroquinoloneUsed in severe COPD exacerbation with Pseudomonas aeruginosa risk (severe COPD with bronchiectasis, frequent antibiotic courses) per GOLD 2024 and GesEPOC 2021. Dose 500 mg once daily for 5–7 days.
- BMoxifloxacinSecond line · Fourth-generation fluoroquinoloneIn severe bacterial COPD exacerbation in patients at Pseudomonas aeruginosa risk or after first-line failure (amoxicillin/clavulanate, cefuroxime). GesEPOC 2021 considers moxifloxacin an alternative with Anthonisen criteria and first-line failure or intolerance. Dose 400 mg once daily for 5 days.
How to read tiers A–F
Evidence tiers belong to the drug-indication pair, not to the drug as a whole: the same substance can be A for one condition and F for another.
- AStrong evidence – first or second line in international guidelines
- BRecommended in selected cases
- CStudy data contradict each other
- DBenefit not proven, no documented harm
- FDocumented harm, or risk without benefit