Antibiotic management of COPD exacerbations that are not improving

Lack of response to initial antibiotic therapy for a COPD exacerbation rarely requires switching to broader-spectrum therapy. For patients with mild COPD, symptoms of an exacerbation can last for 7 to 10 days. In patients with moderate to severe COPD, symptoms can persist for weeks.

Ensure the patient is receiving appropriate inhaled bronchodilator therapy and (if required) oral corticosteroid therapy – see Treatment of a COPD exacerbation in the Respiratory guidelines.

Evaluate patients who are deteriorating or not improving for common viral and noninfective causes of COPD exacerbations. Consider other diagnoses such as community-acquired pneumonia, hospital-acquired pneumonia, coronavirus disease 2019 (COVID-19), influenza and heart failure.

Sputum culture is not routinely recommended for exacerbations of COPDDabscheck, 2022Global Initiative for Chronic Obstructive Lung Disease (GOLD), 2025. If sputum culture and susceptibility testing was performed and the pathogen is resistant to initial antibiotic therapy, use the narrowest spectrum antibiotic to which the pathogen is susceptible. Modification of therapy is not required if symptoms are improving.

For patients with severe COPD who have a COPD exacerbation that does not respond to initial antibiotic therapy after 48 to 72 hours, if bacterial infection remains the likely cause, consider:

For patients with a COPD exacerbation that does not respond to initial antibiotic therapy after 48 to 72 hours, if bacterial infection remains the likely cause and P. aeruginosa is identified in sputum (current isolation, or known colonisation within the past 3 months), consider:

For patients with a COPD exacerbation that does not respond to ciprofloxacin therapy, or the P. aeruginosa isolates are reported as ciprofloxacin-resistant, seek expert advice.