People with chronic obstructive pulmonary disease (COPD) may have exacerbations or flare-ups of symptoms, such as breathlessness, increased coughing, or excessive sputum production. Doctors may prescribe antibiotics to help manage exacerbations.

COPD is a progressive lung disorder that includes emphysema and chronic bronchitis. It causes irreversible damage to the airways and lungs, making breathing difficult.

Exacerbations of COPD are common and often have a trigger, such as an infection or environmental irritant. During this time, doctors may recommend medications to reduce inflammation of the airways and treat the infection.

Antibiotics, such as amoxicillin with clavulanic acid (Amoclav), macrolides, or tetracyclines, can help treat COPD exacerbations. They work by killing the bacteria that cause symptoms.

Keep reading to learn more about antibiotics for COPD exacerbations and what doctors might consider before prescribing them.

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Doctors may prescribe antibiotics for COPD exacerbations if they suspect a bacterial infection is causing the flare-up of symptoms. Respiratory tract infections cause most exacerbations, with bacterial infections accounting for around half of cases.

The Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines recommend antibiotics for exacerbations in people with moderate to severe COPD. However, research from 2014 suggests that antibiotics may also help people with mild COPD.

Under the GOLD guidelines, doctors may prescribe antibiotics to treat COPD exacerbations for people with moderate or severe COPD who experience three primary symptoms:

  • increased breathing problems
  • excessive sputum production
  • sputum with a purulent (this means it contains pus) that is a yellow or green color

However, if purulent sputum is one of the symptoms, doctors may recommend antibiotics if the person presents with one more symptom. Doctors also prescribe antibiotics if the person is on a ventilator.

What else can help doctors determine whether antibiotics are necessary?

Doctors may measure the C-reactive protein (CRP) levels in the blood to determine the extent of the exacerbation. CRP is a protein that the body releases in response to inflammation.

An older 2012 study found that antibiotics may be useful for people with mild or moderate COPD with an exacerbation and CRP above 40 milligrams per liter.

The choice of antibiotic does not typically depend on the severity of the exacerbation. For example, doctors do not prescribe different antibiotics for mild versus severe exacerbations.

Rather, doctors prescribe the antibiotic based on local experience with bacterial infections that have become resistant to certain antibiotics. This requires lab testing and data patterns of bacterial resistance from local areas to determine which antibiotic can best treat the specific bacteria causing the infection.

Sometimes, doctors wait for the results of sputum samples from a lab before prescribing antibiotic treatment. The lab cultures the sample and identifies the bacteria causing the exacerbation. A healthcare professional then selects an appropriate antibiotic to treat it.

This step may be unnecessary if a person has frequent exacerbations, severe airflow obstruction, or requires mechanical ventilation.

Doctors usually begin COPD exacerbation treatment with the following:

Often, gram-negative bacteria such as Pseudomonas species or resistant bacteria are not sensitive to commonly used antibiotics. This means the antibiotic will not be useful in treating the symptoms.

How long is the antibiotic treatment?

Evidence suggests that 5 days or fewer of antibiotic treatment can be as effective as longer courses in people experiencing COPD exacerbations.

A major advantage of shorter courses of antibiotics is that they can help decrease the risk of developing antimicrobial resistance and other complications.

Antimicrobial resistance can occur when the bacteria are no longer sensitive to an antibiotic. This can limit the choice of antibiotics a person can receive.

Learn more about antibiotic resistance.

People should receive oral antibiotics whenever possible, although this may depend on the person’s ability to eat. The route of administering the drug also depends on the pharmacokinetics of the antibiotic, which refers to how the body processes the medication.

When antibiotics are necessary, doctors usually consider:

  • local resistance patterns to antibiotics
  • the person’s medical history
  • other health conditions the person may have
  • known allergies
  • previous antibiotic use
  • adverse effects of antibiotics
  • drug interactions
  • cost

When antibiotics are necessary, doctors will also consider the most appropriate dose and duration of treatment. Many factors can influence that decision, such as whether the person has kidney issues.

If a person is not responding to antibiotics or has frequent exacerbations, they may need further tests. Antibiotics will not work if the cause of the exacerbation is not due to a bacterial infection.

In addition to antibiotics, people with COPD exacerbations may require other treatments. These can include:

  • corticosteroids, medications that help to reduce inflammation
  • bronchodilators, medications that can open the airways
  • mucolytics, medications that help reduce mucus
  • oxygen therapy for those with low oxygen levels
  • fluid replacement
  • mechanical ventilation

Doctors may also recommend pulmonary rehabilitation to prevent further exacerbations. This program teaches people with COPD about breathing exercises, exercise, and lifestyle changes they may consider. Healthcare professionals will tailor a program on an individual basis.

Pulmonary rehabilitation can help people with COPD:

  • manage their condition better
  • build endurance
  • reduce symptoms

Antibiotics are an important part of treatment for COPD exacerbations. The choice of antibiotics depends on the symptoms a person presents with, the bacteria causing the symptoms, and other factors.

However, doctors usually begin with amoxicillin with clavulanic acid, macrolides such as azithromycin and erythromycin, or tetracyclines such as doxycycline.

Evidence suggests that 5 days or fewer of antibiotics are as effective as longer courses for people with COPD exacerbations. Other treatments, such as corticosteroids, bronchodilators, and pulmonary rehabilitation, may also help people manage COPD exacerbation symptoms.