Acute Exacerbation of Chronic Obstructive Pulmonary Disease (AECOPD): An acute worsening of respiratory symptoms that is sustained (48 hours or more) and results in additional therapy.
Last revised August 2023
Respiratory viral infections
Respiratory bacterial infections
Last revised August 2023
Although viral and bacterial infections may cause AECOPD, it is important to rule out non-infectious precipitants including pulmonary embolism, pneumothorax, heart failure or pleural effusion.
Viral causes
If radiographic and clinical evidence of pneumonia, choose antibiotic based on CAP section of Handbook.
Last revised August 2023
Last revised August 2023
OR
Last revised August 2023
The recommended duration of antibiotic therapy in most patients is 5 days (except azithromycin)
Last revised August 2023
Last reviewed August 2023
1. Agustí A, Celli BR, Criner GJ, et al. Global Initiative for Chronic Obstructive Lung Disease 2023 Report: GOLD Executive Summary. Eur Respir J. 2023;61(4):2300239.
2. Dalhousie Academic Detailing Service. Antibiotics: Why and Why Not. 2012. Available from: https://cdn.dal.ca/content/dam/dalhousie/pdf/faculty/medicine/departments/core-units/cpd/academic-detailing/antibiotics_2012.pdf
3. Ospina MB, et al. for the COPD PRIHS-2 Group. Development of a patient-centred, evidence-based and consensus-based discharge care bundle for patients with acute exacerbation of chronic obstructive pulmonary disease. BMJ Open Resp Res 2018;5:e000265. doi:10.1136/bmjresp-2017-000265.
Last revised August 2023
Community-acquired pneumonia (CAP): acute infection acquired outside of hospital or within 48 hours of admission
Last revised March 2020
Last updated March 2020
CRB-65: Patient Criteria | Points |
---|---|
Confusion (either based on specific mental test OR new disorientation to person, place or time) | 1 |
Respiratory rate 30 breaths or more per minute | 1 |
Hypotension (systolic less than 90 mm Hg OR diastolic less than 60 mm Hg) | 1 |
Age 65 years old or greater | 1 |
⇩
CRB-65 Score | 30 Day Mortality | Management Setting |
---|---|---|
0 points AND O2 sat greater than 92% (on room air) | 2.4 % (low risk) | Usually outpatient treatment |
1-2 points | 13.3 % (moderate risk) | Consider admission to inpatient ward |
3-4 points | 34.3 % (high risk) | Often requires an ICU admission |
Last reviewed March 2020
Last reviewed March 2020
*May require renal dose adjustments. Please see Nova Scotia Health Firstline app Note: amoxicillin/clavulanate unnecessarily broad for most community acquired pneumonia in previously healthy individuals. |
Last reviewed June 2023
Usual duration is 5 days, exceptions include:
Last reviewed March 2020
Last reviewed March 2020
1. Jain S, Self WH, Wunderink RG, Fakhran S, Balk R, Bramley AM, et al. Community-Acquired Pneumonia Requiring Hospitalization among U.S. Adults. N Engl J Med. 2015; 373;5: pp 415-427.
2. Metlay JP, Waterer GW, Long AC, Anzueto A, Brozek J, Crothers K, et al. Diagnosis and Treatment of Adults with Community-acquired Pneumonia. Am J Respir Crit Care Med. 2019; Vol 200 (Iss 7): pp 809-821.
3. National Institute for Health and Care Excellence. Pneumonia (community-acquired): antimicrobial prescribing. NICE Guideline. 2019. www.nice.org.uk/guidance/ng138. Accessed September 18, 2019
4. Antibiotics Why and Why Not 2018 Dalhousie CPD Academic Detailing Service, November 2018. http://www.medicine.dal.ca/departments/core-units/cpd/programs/academic-detailing-service.html. Accessed August 12, 2019
5. Management of Community Acquired Pneumonia in Adults. SHS + UHN Antimicrobial Stewardship Program, 2018. https://www.antimicrobialstewardship.com/community-acquired-pneumonia. Accessed August 19, 2019.
Last reviewed March 2020
Hospital-acquired pneumonia (HAP): pneumonia not present at the time of hospital admission and occurring ≥ 48 hours after admission
Last reviewed March 2024
Last reviewed March 2024
Last reviewed March 2024
Last reviewed March 2024
Last reviewed March 2024
Risk Factors | Regimen |
---|---|
|
Ceftriaxone 1 g IV q24h OR Amoxicillin-clavulanate* 875 mg PO BID OR Levofloxacin* 750 mg PO/IV q24h |
Any ONE of the following:
|
Piperacillin-tazobactam* 4.5g IV q6h† OR Meropenem* 500 mg IV q6h Preferred if: colonized/infected with piperacillin-tazobactam resistant microorganism OR IgE mediated penicillin allergy |
If MRSA suspected:
|
ADD: Vancomycin* IV (See NSHA Antimicrobial Handbook or Spectrum App) |
*May require renal dose adjustments, see NSHA Spectrum app or dosing table
†Critical care may have a prolonged infusion protocol
Last reviewed March 2024
1. Kalil AC, Metersky ML, Klompas M, Musced-ere J, Sweeney DA, Palmer LB, et al. Management of Adults With Hospital-Acquired and Ventilator-Associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clin Infect Dis. 2016; 63: pp e61-e111.
2. National Institute for Health and Care Excellence. Pneumonia (hosptial-acquired): antimicrobial prescribing. NICE Guideline. 2019. www.nice.org.uk/guidance/ng138. Accessed March 13, 2020.
3. Management of Hospital-Acquired Pneumonia in Adults. SHS + UHN Antimicrobial Stewardship Program, 2018. https://www.antimicrobialstewardship.com/community-acquired-pneumonia. Accessed March 13, 2020.
4. Treatment Guidelines. Sunnybrook Health Sciences Centre. https://sunnybrook.ca/content/?page=antimicrobial-stewardship-treatment-guidelines. Accessed April 5, 2020.
Last reviewed March 2024
Ventilator-associated pneumonia (VAP): pneumonia occurring 48 hours or more after mechanical ventilation
Last reviewed April 2020
Last reviewed April 2020
Last reviewed April 2020
Last reviewed April 2020
Last reviewed April 2020
Considerations | Regimen |
---|---|
First Line |
Piperacillin-tazobactam* 4.5g IV q6h† OR Meropenem* 500 mg IV q6h Preferred if: colonized/infected with piperacillin-tazobactam resistant microorganism OR IgE-mediated penicillin allergy |
If MRSA suspected:
|
Add Vancomycin* IV (See NSHA Antimicrobial Handbook or Spectrum App)
|
Last reviewed January 2024
1. Kalil AC, Metersky ML, Klompas M, Musced-ere J, Sweeney DA, Palmer LB, et al. Management of Adults With Hospital-Acquired and Ventilator-Associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clin Infect Dis. 2016; 63: pp e61-e111.
2. National Institute for Health and Care Excellence. Pneumonia (hosptial-acquired): antimicrobial prescribing. NICE Guideline. 2019. www.nice.org.uk/guidance/ng138. Accessed March 13, 2020.
3. Ventilator-Associated Pneumonia. SHS + UHN Antimicrobial Stewardship Program, 2020. https://www.antimicrobialstewardship.com/community-acquired-pneumonia. Accessed March 13, 2020.
Last reviewed April 2020
Last reviewed December 2023
Last reviewed December 2023
Severe or complicated: characterized by signs of lower respiratory tract disease, CNS abnormalities, complications of low blood pressure, myocarditis or rhabdomyolysis, or invasive secondary bacterial infection
Progressive: characterized by signs or symptoms suggesting more than mild illness, including chest pain, poor oxygenation (e.g., tachypnea, hypoxia, laboured breathing), cardiopulmonary insufficiency (e.g., low blood pressure), CNS impairment (e.g., confusion, altered mental status), severe dehydration, or exacerbations of chronic conditions (e.g., asthma, COPD).
Table A. Risk factors for complications of influenza illness in adults3 |
---|
‡The risk of influenza-related hospitalization increases with length of gestation (i.e., it is higher in the third trimester than in the second) |
Last reviewed December 2023
Oseltamivir (Tamiflu®) 75 mg PO BID x 5 days
Table B: Adult dosing of oseltamivir | |||||||
---|---|---|---|---|---|---|---|
Greater than 60 mL/min |
CrCl |
PD |
IHD |
CRRT |
|||
31-60 mL/min | 10-30 mL/min | Less than 10 mL/min | |||||
Oseltamivir (PO/NG/OG) |
75 mg BID | 30 mg BID | 30 mg daily | 75 mg x 1 dose | 30 mg x 1 dose | 75 mg x 1 and after each hemodyalysis | 75 mg daily |
Last reviewed December 2023
Last reviewed December 2023
Last reviewed December 2023
1. Government of Canada. Flu (influenza) for Health Professionals. Accessed online 09/2023. https://www.canada.ca/en/public-health/services/diseases/flu-influenza/health-professionals.html
2. Communicable disease Prevention and Control -Respiratory Watch Report. Accessed online 9/2023. https://novascotia.ca/dhw/cdpc/respiratory-watch.asp
3. Aoki FY, et al. Use of antiviral drugs for seasonal influenza: Foundation document for practitioners—Update 2019. Journal of the Association of Medical Microbiology and Infectious Disease Canada. 2019;4(2):60–82.
4. Aoki FY, et al. 2021–2022 AMMI Canada guidance on the use of antiviral drugs for influenza in the COVID-19 pandemic setting in Canada. Official Journal of the Association of Medical Microbiology and Infectious Disease Canada. 2022;7(1):1-7.
5. SHS-UHN Antimicrobial Stewardship Program: https://www.antimicrobialstewardship.com/influenza-treatment. Accessed online 09/2023.
6. Ontario Agency for Health Protection and Promotion (Public Health Ontario). At a glance: antiviral medications for seasonal influenza: public health considerations. Toronto, ON: King's Printer for Ontario; 2022.
7. Harrison R, et al. AMMI Canada 2023 update on influenza: Management and emerging issues. Journal of the Association of Medical Microbiology and Infectious Disease Canada. 2023;8(3):176-86.
Last reviewed December 2023
Viral infection with SARS-CoV-2
Last reviewed Dec 2023
Last reviewed Dec 2023
Last reviewed Dec 2023
Asymptomatic COVID-19 |
---|
No COVID-directed therapy indicated; monitor for symptoms and changes in clinical status |
Non-Severe COVID-19 | |
Consider inhaled budesonide
|
+/- anti-SARS-CoV-2 antiviral
OR
|
Moderate to Severe COVID-19 | ||
---|---|---|
Oral/IV corticosteroid
|
+/- anti-SARS-CoV-2 antiviral
|
+/- additional anti-inflammatory therapy
OR
|
*May require renal dose adjustments. Please see NS Health Firstline app
Last reviewed Dec 2023
Last reviewed Dec 2023
1. Centers for Disease Control and Prevention. Clinical considerations for care of children and adults with confirmed COVID-19. Updated August 4, 2023. https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-guidance-management-patients.html
2. World Health Organization. COVID-19 Clinical Care Pathway. Updated November 10, 2022. COVID-19 Clinical Care Pathway (who.int).
3. Langford BJ, So M, Raybardhan S, et al. Bacterial co-infection and secondary infection in patients with COVID-19: a living rapid review and meta-analysis. Clin Microbiol Infect. 2020 Dec;26(12):1622-1629.
Last reviewed Dec 2023
Most patients with COVID-19 have mild respiratory disease and recover with supportive care alone. Investigational antivirals and immunomodulatory treatments may be considered as part of approved clinical trials and will be assessed by an Infectious Diseases physician prior to initiation in Nova Scotia Health (NSH).
Antibiotics for bacterial pneumonia are often unnecessary in patients with COVID-19. The rates of bacterial pneumonia co-infections and secondary infections are low.
Last revised November 2020
Empiric Bacterial Pneumonia Treatment in Patients With COVID-192
COVID-19 Severity | Antibiotic Treatment |
---|---|
Mild
|
No antibiotic therapy |
Moderate/Severe
|
No antibiotic therapy unless strong clinical suspicion for bacterial infection such as
A gradually worsening respiratory failure in the first week is more likely to be from progression of COVID-19 than from a new superimposed secondary bacterial pneumonia. |
Critical
|
Antibiotic treatment for community-acquired pneumonia (CAP), hospital-acquired pneumonia (HAP), or ventilator-associated pneumonia (VAP) as indicated (link to Spectrum) |
Other sources of infection (e.g. UTI, cellulitis, sepsis, etc) should be assessed as usual in COVID-19 patients and treated if indicated. There is no evidence that prolonged or more aggressive antimicrobial courses are warranted in COVID-19 patients.
Antibiotics are not benign and may result in adverse events including:
Last revised November 2020
1. Langford BJ, So M, Raybardhan S, Leung V, Westwood D, MacFadden DR, Soucy J-PR, Daneman N, Bacterial co-infection and secondary infection in patients with COVID-19:a living rapid review and meta-analysis Clinical Microbiology and Infection, https://doi.org/10.1016/j.cmi.2020.07.016
2. Ontario Clinical Practice Guidelines for Antimicrobial and Immunomodulatory Therapy. Available from: https://www.antimicrobialstewardship.com/covid-19
3. Clinical Management of COVID-19: interim guidance: World Health Organization; 2020 Available from: https://www.who.int/publications-detail/clinical-management-of-covid-19
4. Clinical Management of Patients with Moderate to Severe COVID-19 - Interim Guidance (April 2, 2020) Available from: https://www.ammi.ca/Content/Clinical%20Care%20COVID%2D19%20Guidance%20FINAL%20April2%20ENGLISH%281%29%2Epdf
5. Rawson TM, Moore LSP, Zhu N, Ranganathan N, Skolimowska K, Gilchrist M, et al. Bacterial and fungal co-infection in individuals with coronavirus: A rapid review to support COVID-19 antimicrobial prescribing. Clin Infect Dis. 2020.
6. Wang L, He W, Yu X, Hu D, Bao M, Liu H, et al. Coronavirus disease 2019 in elderly patients: Characteristics and prognostic factors based on 4-week follow-up. J Infect. 2020;80(6):639-45.
7. Wu CP, Adhi F, Highland K. Recognition and management of respiratory coinfection and secondary bacterial pneumonia in patients with COVID-19 [published online ahead of print, 2020 May 11]. Cleve Clin J Med. 2020;ccc015.
Last reviewed November 2020