Many COPD exacerbations are not caused by bacterial infection, so antibiotics are unlikely to be beneficial. However, they may be appropriate if the following are considered:14

·       symptom severity, especially sputum colour changes, increased volume and viscosity

·       whether hospital treatment may otherwise be needed

·       previous exacerbations history

·       previous sputum cultures and susceptibility results

·       the increasing risk of antibiotic resistance with repeated antibiotics.

Some people at risk of COPD exacerbations may be prescribed antibiotics to keep at home as part of their exacerbation action plan.9

First choice antibiotic therapy is with amoxicillin, doxycycline or clarithromycin for 5 days. If there is no improvement within 2-3 days, then one of the alternative first choice antibiotics from a different class should be tried. For higher risk patients, co-amoxiclav, co-trimoxazole or levofloxacin may be used.14

A severely unwell patient may need an intravenous antibiotic, with the first choice being from amoxicillin, co-amoxiclav, clarithromycin, co-trimoxazole, or piperacillin with tazobactam.14

In addition to the NICE guidance, be aware that the Global Initiative for Chronic Obstructive Lung Disease (GOLD) regularly updates its guideline on the diagnosis, management and prevention of COPD.22

The Primary Care Respiratory Society has also published a consensus-based article on a simple treatment pathway based on prominent COPD characteristics. The document reviews the similarities and differences between the NICE and GOLD guidelines, but also offers its own algorithm for managing COPD, depending on whether breathlessness is predominant or whether exacerbations are the key feature, or if the COPD patient also has asthma.23