Synopsis
Recognise an infective deterioration, grade the need for admission and intravenous treatment, select antibiotics from prior microbiology, and use eradication or long-term suppression with antimicrobial-safety safeguards.
- An exacerbation is a sustained worsening from the person's baseline in cough, sputum amount or character, purulence, breathlessness, fatigue or haemoptysis that prompts a treatment change.
- Before antibiotics, obtain a good sputum sample if possible and retrieve previous stable and attack cultures; previous organisms and susceptibilities are often more informative than a delayed new result.
- NICE advises a seven-to-fourteen-day oral course for most adults, chosen from severity, resistance risk, allergy, renal function and microbiology; BTS generally uses fourteen days for Pseudomonas.
Key red flags
Marked tachypnoea, low oxygen saturation, hypotension, confusion, inability to maintain intake, respiratory acidosis or rapidly worsening function indicates hospital-level assessment and possible intravenous treatment.
Investigation priorities
Identify a treatable organism and compare it with the patient's established airway microbiology.
Management branches
A clear symptom deterioration without physiological instability or another indication for admission.
- Collect sputum, review earlier organisms, allergies, renal function, pregnancy status and recent antibiotic exposure, then select a NICE-listed oral option or organism-directed alternative using local resistance advice.
- Agree a course within the NICE seven-to-fourteen-day range; use a full fourteen-day course for Pseudomonas under BTS practice and individualise duration when illness severity or response justifies it.
Key medicines
Amoxicillin for a susceptible uncomplicated exacerbationNICE lists 500 mg orally three times daily for 7 to 14 days; use previous culture, severity and local guidance to decide whether this narrow-spectrum option is appropriate.
Azithromycin for specialist long-term suppressionBTS-supported regimens include 500 mg orally three times weekly or 250 mg daily; a lower 250 mg three-times-weekly start may reduce adverse effects, with response-led specialist adjustment.