MONTREAL — Exacerbations of chronic obstructive pulmonary disease may need more aggressive therapy when they co-occur with pneumonia, according to Dr. Charles Chan, professor of medicine at the University of Toronto and head of respirology at University Health Network and Mount Sinai Hospital in Toronto.
Chronic obstructive pulmonary disease (COPD) can predispose patients to pneumonia, but differentiating between the two conditions can be difficult, he said at an international conference on community-acquired pneumonia (CAP).
“COPD exacerbations alone are generally recognized, but COPD exacerbations with pneumonia may be underappreciated” and therefore undertreated, Dr. Chan said in an interview at the meeting, which was sponsored by the International Society of Chemotherapy.
Guidelines for treating mild COPD exacerbations recommend treatment with macrolides, but only in the presence of purulent sputum (Can. Respir. J. 2004;11[suppl. B]:3B-59B), he said, adding, “Primary care physicians tend to overprescribe antibiotics for COPD exacerbations.”
In contrast, guidelines for CAP (Clin. Infect. Dis. 2007;44:S27–72) in older patients with comorbidities such as COPD recommend treatment with fluoroquinolones. But recognizing CAP with COPD exacerbation can be rather tricky.
“You can see the differences on x-ray, but sometimes even this can be subtle, and certainly if you don't do an x-ray—which is not an uncommon practice at the primary care level—it is hard to tell the difference,” he said in the interview. “Without the x-ray, you may just label someone as having a COPD exacerbation when in actual fact they may already have pneumonia.”
This is not a problem in the older, more vulnerable COPD population, whose exacerbations should be treated with fluoroquinolones—the same antibiotics recommended for CAP, he noted. “For this group, fluoroquinolones are always a safe choice. But we should not be using these drugs for the milder, simpler COPD patients. Those are the ones who can still use macrolides, and we are trying to sway them away from the fluoroquinolones.”
Most COPD exacerbations show hyperinflated lungs (left); concurrent pneumonia shows subtle air space and nodular infiltrates (right). Photos courtesy Dr. Charles Chan
