People with COPD experience flare-ups an average of 1.3 times per year, according to a report published in the journal American Family Physician. The exacerbations contribute significantly to the high mortality rate among people with the disease. The symptoms of exacerbations can include shortness of breath, chest tightness, and excess mucus (sputum) that may be yellow or green in color. Exacerbations can be caused by poor air quality, continued cigarette use, or an infection (bacterial or viral). They often lead to worsening lung function. In the case of infection, the right course of treatment depends on whether the underlying cause is viral or bacterial. If the infection is viral, antibiotics will be of no use, says David Hill, MD, a pulmonologist in Waterbury, Connecticut, who treats people with COPD. “What’s more,” says Dr. Hill, who is a board member of the American Lung Association, “if the antibiotics are unwarranted, using them increases the risk of side effects and of creating resistance to the antibiotic drugs chosen for both the patient and the population in general.” RELATED: What Are Antibiotics? Hill says that if doctors have a high suspicion of a bacterial infection, or if they are able to determine that an exacerbation is bacterial by testing the sputum a person coughs up, “then a short course of antibiotics is a reasonable approach because COPD exacerbations accelerate decline in lung function, can lead to hospitalizations and death, and are the primary cost driver for COPD. When used appropriately, antibiotics help patients get better quicker and reduce deaths.”
Testing for Bacterial Infections
There are newer tests that can help doctors determine if an infection is viral or bacterial. One of these is a blood test known as procalcitonin. Many types of cells in the body produce the substance procalcitonin in response to a bacterial infection. While this test can help distinguish whether an infection is bacterial, it will not determine the type of bacteria. Tests on sputum can help identify specific types of bacteria and determine what antibiotic should be prescribed. Another test, called polymerase chain reaction, looks at the genetics in sputum collected with a swab of the nose or throat to detect whether an infection is viral. According to 2017 guidelines published by a task force of COPD experts, “use of antibiotics in ambulatory patients with exacerbations of COPD reduces the treatment failure rate and increases the time to the next exacerbation.” However, the guidelines add, “not all exacerbations require treatment with antibiotics.” They also cited some adverse effects from antibiotic treatment, including mild gastrointestinal side effects such as diarrhea. A study published in the New England Journal of Medicine found that people with COPD benefited from treatment with the antibiotic azithromycin (Zithromax, Zmax). However, a small percentage of subjects experienced some hearing loss. Jeffery Kaner, MD, a pulmonologist at Weill Cornell Medicine and NewYork-Presbyterian Hospital in New York City, who was not involved in the study, says that the risk of hearing loss can make it complicated for physicians to prescribe azithromycin to older people with COPD, who may already have some hearing loss as a normal part of aging. “People who didn’t have normal hearing were excluded from the study,” says Dr. Kaner. “That’s a significant exclusion in comparison to the real world situation where a lot of older people have hearing loss.”
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 exacerbationsSeverity of exacerbationsIndications 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.”
