Best Practice Advocacy Centre New Zealand

## Respiratory COPD -acute exacerbations Management Antibiotic treatment is usually only necessary for patients with moderate to severe signs and symptoms of infection. Approximately half of COPD exacerbations are triggered by viruses rather than bacteria. Antibiotic treatment is more likely to be helpful in patients with clinical signs of chest infection (e.g. purulent sputum and increased shortness of breath and/or increased volume of sputum) and those with more severe airflow obstruction at baseline. Common pathogens Respiratory viruses, Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis Antibiotic treatment Acute exacerbation of COPD with moderate to severe signs of infection First choice Amoxicillin Adult: 500 mg, three times daily, for five days \* \* Longer courses may not provide additional clinical benefit ## Alternatives Doxycycline Adult: 200 mg, on day one (loading dose), followed by 100 mg, once daily, on days two to five \* \* See note above re. macrolides Trimethoprim + sulfamethoxazole † (for adults and children aged > 6 weeks allergic to macrolides) Child: 24mg/kg/dose, twice daily, for 14 days Adult: 960 mg (two tablets), twice daily, for 14 days \* Ciprofloxacin eye drops 0.3% (five drops administered into the ear, twice daily for nine days) are funded for the second-line treatment of CSOM (unapproved indication). These drops do not contain an anti-inflammatory component that is usually recommended to treat CSOM and so may be less effective than combination drops. ## Dexamethasone + framycetin + gramicidin (Sofradex) Child and adult: 2 -3 drops, three to four times daily, for five to seven days In practice, Sofradex is often used first-line (unless there is suspicion of Pseudomonas or a framycetin/gramicidin-resistant organism) as it is a thin fluid, generally well-tolerated and currently partly funded ## Flumethasone + clioquinol (Locorten Vioform) Child > 2 years and adult: 2 -3 drops, twice daily, for five to seven days This ear drop is most appropriate for fungal/yeast infections in addition to aural microsuction. ## Triamcinolone + neomycin + gramicidin + nystatin (Kenacomb) Child and adult: 2 -3 drops, two to four times daily, for five to seven days Kenacomb is an alternative to Locorten-Vioform, although these drops can be difficult to instil (thick yellow liquid) and their appearance can confound whether an infection is settling or not. N.B. Avoid using drops for longer than seven days as there is increasing risk of ototoxicity, and a secondary infection, e.g. fungal, can develop \* Frequency of administration can be reduced after two to three days Alternatives Framycetin eye/ear drops (Soframycin) Adult and child: 2 drops every 1 -2 hours reducing to 2 -3 drops, three times daily, until 48 hours after symptoms have cleared. ## Fusidic acid eye gel 1% Adult and child: 1 drop, twice daily until 48 hours after symptoms have cleared.