Day 7 was a post call day – we had 6 new patients. COPD exacerbations dominated our service.
We discussed 2 major issues
- When to give antibiotics and which antibiotic to give
- When to evaluate for pulmonary thromboembolism
For the first issue I recommend – Antibiotic Therapy in Elderly Patients with Acute Exacerbation of Chronic Bronchitis
Several potential triggers for AECB have been identified, including bacterial, viral and atypical pathogens, environmental conditions (e.g., air pollution and tobacco smoke), lack of compliance with COPD therapies, and worsening congestive heat failure or pulmonary embolism.[7,18,19] However, infections are likely to cause more than 80% of AECBs. Respiratory viruses are associated with 30% of cases, atypical bacterial (mostly Chlamydophila pneumoniae) infections are implicated in less than 10%, and bacterial pathogens in approximately 40–50% of exacerbations.[20]
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This article reviews various antibiotic regimens. As I read the article, most hospitalized patients should receive a respiratory quinolone, and 5 days of moxifloxacin is a good choice.
So this gave me a new strategy – 5 days of moxifloxacin rather than 10 days as I previously prescribed.
The article also supports the 3 point scoring system for antibiotics in acute exacerbations:
- Increased dyspnea
- Increased sputum production
- Change in sputum color to purulent
The antibiotic strategy is very clear for 3 points, and clear for 2 points.
Prevalence of Pulmonary Embolism in Acute Exacerbations of COPD
This article recently caught my eye. Our chief of medicine, an excellent pulmonologist, came by during rounds. We asked him about the necessity of obtaining a chest CT to look for PTE. He stated what the team has assumed. He thinks about PTE when the patient does not have an obvious diagnosis. I recall this previous post: Why COPD patients present dyspneic
I hope these references and the discussion are helpful
{ 3 comments… read them below or add one }
I submit that many COPD patients could be labeled as "not having an obvious trigger" when they get more wheezy, sob, increased cough, etc. We like to provide labels, but we often don't have great objective evidence to back it up..
this is a tough issue. there are certainly PEs not being diagnosed because they aren't being looked for, but do we really want to change the standard of care in COPD exacerbations to include a much lower threshold for a CT?
An important issue to consider with the use of respiratory fluoroquinolones is that there should be documentation of the QTc. I've witnessed an excessive prescription of these agents and residents don't even think about its potential arrhythmogenic potential.
In these times of increased liability, we should have all corners covered, as patient safety is the priority. I would advocate to have a checklist for using moxifloxacin or levofloxacin and this includes a baseline QTc documentation.
Another important issue with fluoroquinolones is the risk of C. Diff infections, especially in elderly patients, as fluoroquinolones are a major provider of these often dreadfull infections, much more now than the traditionally incriminated antibiotics.