Thursday, June 1, 2023

When To Give Antibiotics For Copd Exacerbation

Red Flags: Recognizing The Signs Of Lung Infections

When should antibiotics be used for COPD exacerbations?

Individually, the symptoms of a lung infection may also be caused by other things. Nonetheless, it is important to let your doctor know if you recognize any of them, so you can be diagnosed and receive treatment as soon as possible:

  • A fever if you have a temperature of 100.4 F or higher , that’s a sign that your body is fighting something, including a possible lung infection.
  • Your shortness of breath is worse than it usually is.
  • You have rapid, shallow, breathing.
  • You are coughing up more sputum usually yellow, green, with traces of blood, or an ugly tan color.
  • Your heart rate has increased.
  • You have chest pain or a feeling of tightness in the chest.

Description Of The Condition

Acute exacerbations of COPD are an important cause of morbidity, mortality, hospital admission, impaired health status, reduced physical activity, and increased costs. AECOPD is defined as an acute worsening of respiratory symptoms that results in additional therapy. Definitions of AECOPD may be symptombased or eventbased. Criteria from Anthonisen 1987 are most commonly used to define the severity of an exacerbation based on symptoms sputum production). The eventbased definition refers to the setting and intensity of treatment as prescribed by the treating physician. Mild AECOPDs are those treated at home by the patient, most often using shortacting bronchodilators. Moderate AECOPDs are those treated on an outpatient basis with oral corticosteroids and/or antibiotics. An AECOPD is severe if the patient requires inpatient treatment with antibiotics and/or oral corticosteroids and/or additional treatments , and very severe if treatment in an intensive care unit is required because of acute respiratory failure.

Guidelines Urge Choosing Antibiotics Wisely

Guidelines to be published in December by the National Institute for Health and Care Excellence in the United Kingdom urge doctors to think about the risk of antibiotic resistance when considering antibiotics to prevent or treat COPD exacerbations. The draft guidelines recommend that doctors consider these factors:

  • Frequency of exacerbations
  • Severity of exacerbations
  • Indications of pneumonia, such as the results of a chest X-ray

The draft guidelines also recommend consulting with local experts on what bacteria are circulating to choose the most effective antibiotic.

Used appropriately, antibiotics can be a valuable tool in treating patients who have COPD exacerbations, says Hill. This is particularly true in those patients who are hospitalized or who have more severe disease. Contrarily, inappropriate use of antibiotics increases costs and risks. New diagnostic tools should soon be more widely available to help clinicians make appropriate therapeutic choices.

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Antibiotics And Copd Exacerbations

Antibiotics can be effective for treating your COPD exacerbation, but only if you have a bacterial infection. By definition, these medications are designed to destroy bacteria. Your medical team can identify bacteria with a sputum sample, and they may also consider some of the signs that suggest that you could have a bacterial infection, including:

Copd When To Take Antibiotics

Gold Guidelines Copd Exacerbation Antibiotics

The guidelines recommend antibiotics for exacerbations in patients with moderate to severe COPD, and evidence shows that they may be effective for those with mild COPD. With increased awareness of the inappropriate use of antibiotics, doctors may have concerns about the emergence of antibiotic resistance as a result of antibiotic use for exacerbations of mild to moderate COPD.

The guidelines recommend antibiotics for exacerbations in patients with moderate to severe COPD, and evidence shows that they may be effective for those with mild COPD. With increased awareness of the inappropriate use of antibiotics, doctors may have concerns about the emergence of antibiotic resistance as a result of antibiotic use for exacerbations of mild to moderate COPD. Antibiotics are generally reserved for use in episodes of acute exacerbations of chronic bronchitis and emphysema. Theophylline may induce a short-term improvement in FEV1, but the benefits of methylxanthine therapy should be weighed against potential side effects and potential toxicity.

In fact, the Australian Therapeutic Guidelines, a guide for doctors on how best to treat different diseases, recommend antibiotics to treat respiratory tract infections in people with COPD.

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Developing A Copd Action Plan

Doctors and other healthcare professionals develop COPD action plans specifically for an individual. When designing the plan, they should consider the severity of the persons COPD, their medications, and their overall health.

The doctor should include personalized information on when to take medications, call the doctor, or seek emergency care. The plan may also allow people to track their health, including any changes to their condition or concerns that they wish to discuss with a doctor.

It is important that people with COPD understand their action plan and feel comfortable following it.

Risk Of Bias In Included Studies

Overall we found that studies had low to moderate risk of bias . Thirteen of the 19 studies correctly performed and reported random sequence generation, blinding of participants and personnel, and intentiontotreat analysis. However, information on blinding, completeness of outcome data, and selective reporting was limited.

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Why It Is Important To Do This Review

We conducted this systematic review of the literature to inform patients, healthcare providers, and clinical practice guideline developers in a transparent way about the effects of antibiotics on patientimportant outcomes. This endeavour is important because antibiotics are likely to be perceived as beneficial in clinical practice by patients and healthcare providers based on the fact that most patients recover within weeks of starting treatment. However, only placebocontrolled trials can determine the cause of such recovery, which might be attributed to natural recovery from exacerbations , effects of antibiotics, or effects of other concomitant treatments such as systemic corticosteroids. Knowledge about the effects of antibiotics compared to placebo is important if one is to appreciate the results of the many randomised trials that have compared different antibiotics. Only if antibiotics are effective at all will such headtohead trials provide useful information .

There is growing recognition that COPD is a very heterogeneous disease , and that exacerbations are heterogeneous events . Systematic reviews have been used to guide the development of strong recommendations for clinical practice, and review findings have helped researchers identify areas in which additional research is needed. In the light of uncertainties surrounding the use of antibiotics for COPD exacerbations, it is hoped that the findings presented here will prove useful.

The Role Of Antibiotics In Copd Treatment

COPD Exacerbations – Treatment with antibiotics

Research has shown that taking antibiotics greatly improves the outcome for moderate to severe exacerbations, which means that you’ll have at least two of these symptoms:

  • Increased shortness of breath
  • More sputum than usual
  • Purulent sputum this means pus is present, usually signified by a notorious green or yellow color

If you have only of these three symptoms, meanwhile, your doctor will probably advise you to use your bronchodilator more often, as well as offering relief for other symptoms you may be experiencing.

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Intubation & Ventilator Management

  • These are explored in more detail above. To summarize:
  • Indications for immediate intubation
  • Multiorgan failure .
  • The patient is really not protecting airway .
  • Respiratory/cardiac arrest.
  • Indications for delayed intubation
  • Patient clinically deteriorating despite optimized BiPAP/HFNC support.
  • Patient stabilizes on BiPAP but is completely BiPAP-dependent for > 48 hours.
  • intubation procedure itself
    • Consider use of a relatively large-size ETT . Use of a small ETT may increase airway resistance, hindering your ability to ventilate.
    • Resist the urge to aggressively bag patients following intubation. COPD patients may rapidly trap gas in their lungs , leading to pneumothorax or hypotension. Bag these patients gently and slowly.
    ventilator settings
    • Ventilating COPD patients is generally much easier than ventilating asthmatic patients, despite the fact that both have airflow limitation.
    • COPD patients: Respiratory failure is usually due to a combination of diaphragmatic fatigue and bronchospasm. Once they are on the ventilator, diaphragmatic fatigue isn’t a problem so ventilation is fairly easy.
    • Asthmatic patients: Respiratory failure is due primarily to intense bronchospasm. The degree of bronchospasm is more severe, which can create major challenges in ventilator management.
  • The major concern with ventilation is autoPEEP
  • Patients have difficulty with expiration. If the tidal volume and/or respiratory rate are too high, this causes gas trapping inside the chest at end-expiration .
  • Simple Ways To Prevent Infection

    Research has shown there are some very simple but very effective ways to avoid catching, or spreading, a respiratory tract infection even serious ones.

    • Stay at home if you are unwell.
    • Use a tissue when coughing or sneezing then throw it away.
    • Wash your hands with soap and running water, particularly after coughing or blowing your nose, and before preparing or eating food.
    • Avoid touching your eyes, nose and mouth.
    • Dont share cups, glasses and cutlery.
    • Keep household surfaces clean.

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    In Copd Exacerbations 5 Days Steroids Seem As Good As 14

    For COPD Exacerbations, 5 Days Corticosteroids As Good as 2+ Weeks

    COPD exacerbations — worsening of shortness of breath and cough, often requiring medical treatment — are a major problem for many people living with COPD. People with moderate or severe emphysema and chronic bronchitis experience an average of 1-2 COPD exacerbations a year, often feeling poorly for weeks and sometimes requiring hospitalization. People with frequent exacerbations tend to have a faster decline in lung function proper treatment, it’s hoped, could help slow this deterioration, and improve hundreds of thousands of people’s daily lives.

    But “proper treatment” for COPD exacerbations has never been definitively established. It’s known that the anti-inflammatory effects of systemic corticosteroids help people recover from COPD flares — but at a cost of increased blood sugar and other side effects.

    Expert guidelines recommend 10-14 days systemic corticosteroids for treatment of COPD exacerbations. But this is based largely on one clinical trial done at the VA more than a decade ago, which did not examine shorter treatment courses. An underpowered Cochrane analysis of a few randomized trials could not establish equivalence between shorter and longer courses of steroids for COPD exacerbations, but a large observational database analysis in JAMA suggested patients treated with lower-dose oral steroids did just as well as those treated with higher-dose intravenous steroids.

    What They Did
    What It Means

    How Antibiotics Are Used To Treat Copd

    What Is the Appropriate Use of Antibiotics In Acute Exacerbations of ...

    As we’ve discussed briefly so far, antibiotics are used quite often in COPD treatment, especially when someone with COPD is hospitalized or has a severe exacerbation. We’ve mentioned their use as a preventative treatment, as well, to prevent exacerbations and infections before they ever occur.

    Now, let’s take a closer look at each of these different antibiotic treatments to better understand how they’re administered and how they work. Then, we’ll discuss some of the major risks and side-effects of using antibiotics to treat COPD, and how frequent antibiotic use can contribute to antibiotic-resistant infections.

    Antibiotics are pretty much always used to treat illnesses caused by bacteria, including respiratory infections like pneumonia that are common in people with COPD. If you develop such an infection, taking antibiotics directly treats the cause and gives you the best chance of recovery.

    However, figuring out whether or not a respiratory illness is caused by bacteria is not exactly simple it can be difficult and expensive to test for the cause of an illnesses that’s deep inside the lungs. Because of this, when COPD patients get sick, doctors often have to rely on making educated guesses about whether the exacerbation is more likely caused by a virus or bacteria.

    X-ray of lung with Haemophilus influenzae .

    Here are some of the most common types of bacteria that cause lung infections in people with COPD:

    • Streptococcus pneumoniae

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    Caveats: Effects Of Concomitant Medications Are Unclear

    In both the placebo and antibiotic groups, patients were taking other medications . Roughly the same number of patients in each group took additional medications, but researchers did not conduct a subgroup analysis to see if patients treated with these medications responded differently than those who received antibiotics alone.

    Whats New: Evidence Supports Antibiotics For Mild To Moderate Copd

    Few placebo-controlled trials have addressed antibiotic use for exacerbations in patients with mild to moderate COPD.2,8,9 This study demonstrated that compared with placebo, symptom resolution and clinical success is greater with amoxicillin/clavulanate, and that antibiotic treatment also may increase time until next exacerbation.

    The study also looked at the relationship of CRP and exacerbations in the placebo group. Higher spontaneous clinical cure rates were noted when the CRP was < 40 mg/L.

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    Benefits And Risks Of Antibiotics To Treat Copd

    There is no question that antibiotics are effective against many types of bacterial infections as long as the bacteria hasn’t developed antibiotic resistance. If you have COPD and develop a respiratory infection for any reason, your doctor will almost certainly prescribe antibiotics to help you get better.

    However, the role of preventative antibiotics for COPD patients are mixed, even though research shows that antibiotics can both prevent COPD exacerbations , and treat COPD exacerbations . The main topic of dispute is not whether preventative antibiotics work, but whether or not their benefits are worth their risks.

    This is a question that, for now, can only be answered on a case-by-case basis. It’s up to you and your doctor to decidebased on your disease severity, infection risk, and other personal health factorsif taking continuous or preventative antibiotics is right for you.

    One of the main risks of taking antibiotics is antibiotic resistance this happens when bacteria mutate and become less susceptible to the effects of an antibiotic medication. This is a problem that affects everyonenot just those currently taking antibioticswhich is why antibiotic resistance is such a serious public health concern.

    Preventative Antibiotic Therapy For People With Copd

    COPD exacerbation – Treatment with corticosteroids

    What is COPD?

    COPD is a common chronic respiratory disease mainly affecting people who smoke now or have done so previously. It could become the third leading cause of death worldwide by 2020. People with COPD experience gradually worsening shortness of breath and cough with sputum because of permanent damage to their airways and lungs. Those with COPD may have flare-ups most commonly with respiratory infections. Exacerbations may lead to further irreversible loss of lung function, as well as days off work, hospital admission, reduction in quality of life, or even death.

    Why did we do this review?

    We wanted to find out if giving antibiotics to prevent a flare-up would reduce the frequency of flare-ups and improve quality of life. Studies that were taken into consideration used either continuous prophylactic antibiotics , or antibiotics that were used intermittently or pulsed

    What evidence did we find?

    Results and conclusions

    Even though there may be fewer exacerbations with antibiotics, there are considerable drawbacks of taking antibiotics. First, there were specific adverse events associated with the antibiotics, which differed according to the antibiotic used second, patients have to take antibiotics regularly for months or years finally, the resulting increase in antibiotic resistance will have implications for both individual patients and the wider community through reducing the effectiveness of currently available antibiotics.

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    Antibiotic Use Characteristics Of Included Aecopd Patients Receiving Antibiotic Treatment

    Among the 1663 AECOPD patients enrolled, 1434 received antibiotic treatment. Approximately 85.6% and 86.3% of patients in the secondary and tertiary hospital groups, respectively, received such treatment. Overall, 1102 patients were treated with monotherapy, while 332 received combination therapy with 2 antibiotics. In addition, the proportion of patients in the secondary hospital group receiving combination therapy with 2 antibiotics was significantly lower than that in the tertiary hospital group . As for the duration of antibiotic use, the median time in the overall population was 9.0 °days. Compared with the secondary hospital group, the tertiary hospital group demonstrated a significantly longer median duration of therapy . With regard to the routes of antibiotic use, 1400 patients received intravenous antibiotics, 18 received oral antibiotics, 15 received both intravenous and oral antibiotics, and one patient received both oral and nebulized antibiotic treatment .

    TABLE 2. Antibiotic using characteristics of included AECOPD patients receiving antibiotic treatment.

    Outcomes And Data Analysis

    The primary outcomes were as follows: number of patients with exacerbations frequency of exacerbation and health-related quality of life assessed by the St Georges Respiratory Questionnaire . The secondary outcomes were as follows: median time to first exacerbation frequency of hospitalization all-cause mortality adverse events antibiotic resistance and change in lung functions, bacterial load and airway inflammation. The influences of different schedules and durations of prophylactic antibiotic use on exacerbations and quality of life in COPD patients were explored. Because the standard deviation of the SGRQ score change was missing in two studies,, we calculated it according to the Cochrane guideline . All analyses were done in accordance with the ITT principle using Review Manager Version 5.3. Risk ratio or OR was calculated for binary outcomes, while mean difference was calculated for continuous outcomes. Generic inverse variance methods were used for non-standard types of both dichotomous and continuous data. Summary measures were pooled using random-effects models. If data could not be combined, we performed a descriptive analysis. Statistical heterogeneity among studies was assessed using the conventional 2 test and the I2 statistic of inconsistency. Sensitivity analysis was performed by removing studies with a high risk of bias or deviation. A funnel plot was used to assess publication bias.

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    Oxygen Supplementation In Acute Copd Exacerbation

    Many patients require oxygen supplementation during a COPD exacerbation, even those who do not need it chronically. Hypercapnia may worsen in patients given oxygen. This worsening has traditionally been thought to result from an attenuation of hypoxic respiratory drive. However, increased ventilation/perfusion mismatch probably is a more important factor.

    Before oxygen administration, pulmonary vasoconstriction minimizes V/Q mismatch by decreasing perfusion of the most poorly ventilated areas of the lungs. Increased V/Q mismatch occurs because oxygen administration attenuates this hypoxic pulmonary vasoconstriction.

    The Haldane effect may also contribute to worsening hypercapnia, although this theory is controversial. The Haldane effect is a decrease in hemoglobin’s affinity for carbon dioxide, which results in increased amounts of carbon dioxide dissolved in plasma. Oxygen administration, even though it may worsen hypercapnia, is recommended many patients with COPD have chronic as well as acute hypercapnia and thus severe central nervous system depression is unlikely unless PaCO2 is > 85 mm Hg. The target level for PaO2 is about 60 mm Hg higher levels offer little advantage and increase the risk of hypercapnia.

    In patients who are prone to hypercarbia , oxygen is given via nasal prongs or Venturi mask so it can be closely regulated, and the patient is closely monitored. Patients whose condition deteriorates with oxygen therapy require ventilatory assistance.

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