tional antimicrobials (eg, Pseudomonas, Steno-trophomonas). Quinolones have been extensively
studied in COPD exacerbations and represent a
relatively effective therapeutic approach in mild to
moderate exacerbations, though a variety of antibiotic options exist.109,110 Importantly, if a patient with a
COPD exacerbation has radiographic evidence of
pneumonia, he or she should be treated using an
antibacterial regimen appropriate for their particular
risk strata. Patients with evidence of severe infection, such as shock, should receive broad-spectrum
empiric coverage including an agent directed towards coverage of methicillin-resistant
Staphylococcus aureus and gram-negative rods. Regardless of
initial antibiotic therapy provided, sputum cultures
should be obtained (if able) and antibiotic therapy
should be adjusted depending on the results.
Therapy should be continued for 5 to 10 days unless clinical circumstances or culture data suggest
otherwise (Table 4). 1
Systemic Corticosteroids
Systemic corticosteroids are the mainstay of
treatment for COPD exacerbations. Pathologically,
COPD primarily involves a process of chronic air-
way and parenchymal inflammation punctuated
by acute episodes of exacerbation. Irritants (eg,
tobacco smoke, infections) induce activation of
inflammatory cells with subsequent release of
cytokines. The result of this inflammatory activ-
ity is mucus gland hyperplasia and hypersecre-
tion with eventual progression to tissue distortion
and destruction. Therefore, corticosteroid therapy
seems to logically follow as a means to address
these inflammatory changes. Relative corticoste-
roid efficacy, optimal route of administration, and
appropriate duration of therapy remain areas of
uncertainty. Much work has been done to elucidate
answers to these questions. In exacerbations of
COPD, corticosteroid therapy is associated with
significant improvement in FEV1 when compared
with placebo.111–113 Further, corticosteroid therapy
remains superior to placebo in preventing treat-
ment failure and relapse. 13,114 A recent systematic
review of 11 studies (n = 1081) confirmed these
findings and demonstrated that systemic cortico-
steroids significantly reduced the risk of treatment
failure (odds ratio [OR] 0.48, 95% CI, 0.34–0.68)
and relapse (HR 0.78, 95% CI 0.63–0.97) within
30 days.115 In addition, treatment with systemic
corticosteroids during a COPD exacerbation im-
proved recovery of FEV1 at 72 hours in comparison
to placebo and decreased length of hospital stay
(– 1.22 days, 95% CI – 2.26 to –0.18). Interestingly,
systemic corticosteroids did increase the likelihood
of adverse events (particularly hyperglycemia), but
did not affect mortality.
Based on the results of small studies, previous
guidelines recommended the use of oral corticosteroids for 10 to 14 days to treat COPD exacerbations.116,117 Recently, Leuppi et al evaluated the
effects of 40 mg of oral prednisone for 5 days versus 14 days in a placebo-controlled, double-blind
fashion in patients with a COPD exacerbation.118
Therapy for 5 days was noninferior compared to
14 days in terms of mortality, recovery of lung
function, and re-exacerbation rates. Additionally,
a meta-analysis of 12 studies demonstrated that
when compared with initial steroid doses greater
than 80 mg of prednisone equivalents, a dose of
Table 4. Indications for Antibiotic Therapy
Increased sputum purulence AND either:
Increased sputum volume OR
Need for mechanical ventilation
