Acute bronchitis

• Cough lasting for more than five days (+/- sputum)

• Almost all episodes due to viruses• Mycoplasma, Chlamydia, Bordetella

responsible for a minority.• Symptomatic treatment

Indications for antibiotic treatment in COPD

exacerbations

• Anthonisen type 1 patients• Type 2 patients with purulent sputum • Severe exacerbations necessitating

mechanical ventilation

Group Features of patients / exacerbations

Possible pathogens

1st choice antibiotics

A Mild and simple exacerbation (No respiratory failure or severe obstruction,no comorbidity,3 exacerbations in previous year,No antibiotic use during the preceding 3 months)

H. influenzaeS. pneumoniaeM. catarrhalisC. pneumoniae*

Viruses

Amoxicillin **

Beta-lactam + beta-lactamase inhibitor2nd generation cephalosporins Macrolides(azithromycin, chlarithromycin, roxithromycin)

* Although detected at exacerbations, it is not clear whether Chlamydia is a true infective agent and whether it needs to be covered by antimicrobial treatment.** Amoxicillin should be given to patients in whom sputum culture reveals penicillin- sensitive S.pneumoniae or non-beta-lactamase producing bacteria.

Risk factors for treatment failure / early recurrence in

COPD exacerbations

• Presence of comorbidity (especially cardiac disease)

• Severe COPD (FEV1<50%)• > 3 exacerbations during the

preceding year• Antibiotic use in the last 3 months

Risk factors for P. aeruginosa in exacerbations of COPD and

bronchiectasis

• Hospitalization during the last month• Antibiotic use during the preceding

month or for four times during the preceding year

• Exacerbations leading to respiratory failure

• Isolation of P. aeruginosa from respiratory samples in the previous exacerbation or in the stable period

Group Features of patients / exacerbations

Possible pathogens

1st choice oral antibiotics

Other choices Parenteral treatment options

B Moderate-to-severe, uncomplicated exacerbation(presence of risk factors for treatment failure; no risk factors for P.aeruginosa)

Group A bacteriaBeta-lactamase producing bacteriaEnteric Gram (-) bacteria(K. pneumoniae, E. coli etc)

Beta-lactam + beta-lactamase inhibitor or2. and 3. generation non-pseudomonalcephalosporins

Respiratory fluoroquinolone(levofloxacin, moxifloxacin)*, #

Beta-lactam + beta-lactamase inhibitors2. ad 3. generation cephalosporinsRespiratory FQ’s

* First choice in patients who have been treated with a beta-lactam during the preceding three months or who are allergic to penicillin. Because of their effectiveness against potential pathogens, high concentrations in lung tissue and respiratory secretions and efficacy for eradication, these FQ’s can be used as first choices; however it must be remembered that frequent use may be associated with increases in resistance rates.# Gemifloxacin

Group Features of patients / exacerbations

Possible pathogens

1st choice oral antibiotics*

Parenteral treatment options*

C Severe exacerbation with risk for P. aeruginosa

Group B bacteriaP. aeruginosaESBL(+) EGNB

Fluoroquinolone active against P. aeruginosa (ciprofloxacin)

Fluoroquinolone active against P. aeruginosa (ciprofloxacin)Beta-lactam antibioticsactive against P. aeruginosa

* Sputum culture and susceptibility tests are recommended in these patients. Empiric treatment can thsu be modified according to the results of these tests and a narrower- spectrum antibiotic can be chosen.

Oral treatment Parenteral treatment

Patients without any risk factors for Pseudomonas

Beta-lactam + beta-lactamase inhibitors

MoxifloxacinLevofloxacin

Beta-lactam + beta-lactamase inhibitor3. generation non-pseudomonal cephalosporinMoxifloxacinLevofloxacin

Patients with risk factors for Pseudomonas*

Ciprofloxacin # Ciprofloxacin3. or 4. generation anti-pseudomonal cephalosporinCarbapenemPiperacillin-tazobactamAnti-pseudomonal beta-lactam + FQ or aminoglycoside

Recommendations for antibiotics in exacerbations of bronchiectasis

* Sputum culture and susceptibility tests are recommended in these patients.# An antibiotic active against Gram + bacteria must be added in cases with IgG deficiency