Chronic obstructive pulmonary disease (COPD) (acute infective exacerbation)

Last updated: Tuesday, June 20, 2017

These guidelines are based upon a range of information resources and may not represent your local policy. Check if your Trust has local guidelines for acute infective exacerbations of COPD before reading on.

Case definition 
An acute infective exacerbation of COPD presents as a rapid, sustained worsening of the patient’s symptoms that is beyond their normal day-to-day variations. Click to learn more.
Common symptoms include worsening breathlessness, cough, increased sputum production and change in sputum colour.
More than one third of COPD exacerbations that result in admission are not related to infection.
Exclusions: severe sepsis, immunocompromised, pneumonia or predominant bronchiectasis.
Typical pathogen profile
H.influenzae is the most common pathogen but a range of Gram positive, Gram negative and atypicals may be responsible. Click to learn more.
Gram positive
Streptococcus pneumoniae (10-15%)

Gram negative
H. influenzae (20-30%)
Moraxella catarrhalis (10-15%)
P. aeruginosa (5-10%)

Anaerobes N/A

Chlamydophila pneumoniae (3-5%)
Mycoplasma pneumoniae (1-2%)
Microbiology investigations
Blood and sputum samples may be required. Click to learn more.
If sputum is purulent, send sample for microscopy and culture.
Consider nasopharyngeal aspirate or combined nose and throat swap for virus detection if the patient’s presentation suggests a viral infection (in HiGuide, NICE does not include)
Take blood cultures if patient pyrexial. If patient afebrile but has signs of severe sepsis, then consider blood cultures before starting intravenous antibiotics. (not in NICE)

Evidence of infection
Sputum purulence may be used to guide treatment. Click to learn more.
Patients reporting a change in sputum colour from uncoloured to yellow-green over the past 72 hours should receive antibiotics.
Uncomplicated* patients who report no changes in sputum colour over the past 72 hours may be managed without antibiotics.
(*None of pneumonia/ immunocompromised/ on critical care/ non-invasive ventilation/ heart failure/ neoplasm/ recent hospitalisation).
Risk of antibiotic resistance
P. aeruginosa is a less common infecting pathogen but is resistant to many antibiotics. Click to learn more.
Risk factors for colonisation or infection with P. aeruginosa include:
  • Bronchiectasis
  • Pseudomonas isolated from sputum or bronchial lavage previously
  • Systemic steroid treatment
Severity assessment
The severity of the infection may be assessed using the Systemic Inflammatory Response Syndrome (SIRS) criteria. Click to learn more.
SIRS present if 2 or more of the following are met:
Temperature > 38.3⁰C or < 36.0⁰C
Heart rate > 90 beats per minute
Respiratory rate > 20 breaths per minute
White blood cell count >12 or <4 x 10⁹/L
Choosing an antibiotic 
Please consult your local antibiotics guidelines for the preferred choice of agents. Here is an example protocol from University Hospital Southampton, <check external link>for you to look at, but it is not intended to replace your local guidelines.
Follow up 
The clinical diagnosis and continuing need for antibiotics should be reviewed regularly and the decision clearly documented. Click to learn more.
Consider escalation of therapy:
• There is any new emerging evidence of severe sepsis
• There is no improvement in pyrexia after at least 24 hours of antibiotics

Remember that:
• CRP may not begin to fall until 24-48 hours of antibiotic therapy
• White blood cell count can rise when oral steroids are started
Duration guide
There is considerable variation between different sources so check your local guidelines. This is an example protocol: 
Hospitalised, uncomplicated patients: 5 days (if on azithromycin 3 days)
Hospitalised, complicated patients: 5-7 days (longer courses may be required for recurrent infections)