Dr Nguyen Thi To Nhu 

Lecturer, Vinh Long University;  

Clinical Doctor, Internal Medicine Department,  

University Medical Shing Mark Hospital, Vietnam 

While the aetiology of acute exacerbations of chronic obstructive pulmonary disease (AECOPD) is multifactorial, bacterial infection accounts for half of these exacerbations.^1,2 Both the 2018 National Institute for Health and Care Excellence (NICE) and 2025 Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines recommend considering antibiotics as treatment for AECOPD in the presence of bacterial infection.^2,3   

In this interview, Dr Nguyen Thi To Nhu from the University Medical Shing Mark Hospital in Vietnam shared her insights on the practical aspects and experiences with using antibiotics for the treatment of AECOPD. 

Q1: In your clinical practice, what are the recommended first-line antibiotic options for treating mild, moderate, and severe AECOPD cases caused by bacterial infections? When do you consider prescribing quinolones and what guides your decision?   

Based on the findings from local studies and aligned with the GOLD (2018 and 2023) and NICE guidelines, the Vietnam Ministry of Health has developed antibiotic regimens for mild, moderate and severe cases of AECOPD exacerbations caused by infections.^4,5 

According to the local guidelines, outpatient treatment for patients with mild-to-moderate chronic obstructive pulmonary disease (COPD) exacerbations typically involves empirical or oral antibiotics.^4,5 Commonly prescribed antibiotics include azithromycin, clarithromycin, amoxicillin-clavulanate, and second- or third-generation cephalosporins.^4,5 If a Pseudomonas infection is suspected, quinolones such as ciprofloxacin or levofloxacin should be considered.^4,5 For inpatient treatment, the initial treatment includes third-generation cephalosporins or fluoroquinolones, with subsequent adjustments based on the antibiogram results.^4,5 

Prescription of quinolone antibiotics is guided by the patient’s risk of P. aeruginosa infection, indicated by various factors such as green sputum, a history of Pseudomonas infection within the last year, a forced expiratory volume in 1 second (FEV1) of <30%, presence of bronchiectasis, or broad-spectrum antibiotic use within the past three months.^4,5 

Q2: In elderly patients with multiple comorbidities and AECOPD, how do you balance the benefits of antibiotics against the risks of adverse drug reactions (ADRs)? 

Elderly patients with AECOPD and various comorbidities are at an increased risk of ADRs and interactions from antibiotic treatments owing to age-related immune system decline.^6,7 Therefore, physicians must carefully weigh the therapeutic benefits of antibiotics against the risk of ADRs and drug–drug interactions (DDIs) when treating elderly patients. Considerations for treating the elderly population include: 

1. Use antibiotics with caution 

• Prescribe antibiotics only when necessary.⁸  
• Select a narrow spectrum of activity tailored to the suspected or confirmed infection type, taking into consideration of local resistance patterns to reduce the risk of ADRs and development of antibiotic resistance.
• Tailor antibiotic dosages to the patient’s age, renal, hepatic function and any concomitant comorbidities to minimise ADRs.
• Treatment duration will be dependent on the severity of exacerbation, typically ranging from 5 to 7 days for outpatients and 7 to 10 days for inpatients.
• Avoid extending antibiotic use beyond stability to reduce the risk of ADRs and antibiotic resistance.
• Assess the effectiveness of the antibiotic therapy with bacteriological tests at 48 to 72 hours and again at 7 to 10 days.
• Administer oral administration whenever possible; if injections are necessary, switch to oral administration as soon as the patient’s condition allows.² 

2. Consistently monitor for ADRs 

• Monitor for side effects during the treatment course using clinical and paraclinical data to enable timely intervention. Potential side effects include drug allergies, anaphylactic shock, liver and kidney failure, thrombocytopenia, digestive disorders and candidiasis.  

3. Select appropriate drugs to limit DDIs

• Review the patient’s medication list and identify any potential interactions.  
• Consider exploring alternative medications or dosage adjustments to minimise risk if adverse interactions are unavoidable.  

4. Explain and encourage patient involvement 

• Inform patients of the importance of treatment adherence and course completion.
• Advise patients to report any adverse effects promptly. 

Q3: The 2018 NICE and recent 2025 GOLD guidelines recommend limiting antibiotic treatment for AECOPD to 5 days. Based on your experience, are shorter antibiotic courses as effective as longer ones (e.g., 7 days) in AECOPD treatment? 

The 5-day treatment recommended by the NICE 2018 and GOLD 2025 guidelines was designed to limit the development of antibiotic resistance and minimise DDIs (particularly in elderly patients with polypharmacy).^2,3 While these recommendations are valuable, they are primarily based on international studies in which study populations and treatment conditions differ from those commonly encountered in Vietnam. Certain antibiotics with longer half-lives or post-antibiotic effects (e.g., intravenous azithromycin) are not locally available. Moreover, the healthcare settings in those studies were not under the same level of strain as many facilities in Vietnam, which may have contributed to the more favourable outcomes reported. 

In my experience, a shorter antibiotic course might only be suitable for outpatients with moderate AECOPD who do not require hospitalisation, or for hospitalised patients with stable vital signs receiving brand-name antibiotics available in Vietnam. Longer antibiotic courses are typically considered for those who are immunocompromised and experience frequent exacerbations. For patients who show a poor response by day 5 of treatment, we would consider extending treatment to 7 days. Further research is necessary to accurately assess the effectiveness of short-term antibiotic courses for local patients with AECOPD. 

Q4: What are the current local bacterial resistance patterns in Vietnam? How do these patterns influence your choice of antibiotics for managing AECOPD? 

In Vietnam, various studies across local hospitals have investigated local bacterial resistance patterns in AECOPD patients. While there are limited data on the prevalence of drug-resistant bacteria in outpatient clinics, some results demonstrated that the main pathogenic bacteria in outpatients with AECOPD are related to community-acquired bacteria, which include H. influenzae, S. pneumoniae and M. catarrhalis.⁹ 

Studies conducted in local hospitals on hospitalised patients with severe AECOPD have consistently identified Gram-negative bacteria such as K. pneumoniae, P. aeruginosa and A. baumannii as the primary causative agents.^10-13 Approximately 25% of cases reported were Gram-positive bacteria, including S. pneumoniae and S. aureus.^10-13 Strains of mono- and multi-drug–resistant bacteria such as Klebsiella spp, Pseudomonas spp and A. baumannii were recorded as well.^10-13 For hospitalised patients with severe AECOPD, the 2018 Vietnam Ministry of Health guideline recommends⁴: 

• Moxifloxacin, levofloxacin, ceftriaxone or cefotaxime for those who are not at risk of P. aeruginosa infection⁴  
• Ciprofloxacin, ceftazidime, cefepime, piperacillin-tazobactam, imipenem or meropenem for individuals with risk of P. aeruginosa infection⁴  
• Combination treatment with antibiotics from the aminoglycoside groups (e.g., amikacin and tobramycin) for patients who are at risk for multi-resistant P. aeruginosa infection⁴ 

In my clinical practice, antibiotic-resistant bacteria are often observed in hospitalised patients with severe AECOPD; therefore, close monitoring is essential for patients who experienced ≥3 exacerbations per year, have used antibiotics in the past 3 months, have severe structural lung disease or FEV1 of <50%, suffer from immunodeficiency-related comorbidities, and those at risk of infection with Gram-negative bacteria. Antibiotic selection should be guided by results from the sputum Gram staining, culture and antibiotic susceptibility testing. When choosing a treatment regimen, it is necessary to prioritise initial broad-spectrum antibiotics that are effective against Gram-negative bacteria. It is also crucial to select antibiotics with good lung penetration and the most appropriate administration route, ensuring sufficient treatment duration. The antibiotic regimen should also be adaptable, allowing for changes based on the paraclinical test results.  

References

1. Dao DT, et al. BMC Infect Dis 2024;24:622.
2. National Institute for Health and Care Excellence. Chronic obstructive pulmonary disease (acute exacerbation): antimicrobial prescribing. Accessed 13 June 2025. 
3. Global Initiative for Chronic Obstructive Lung Disease. GLOBAL STRATEGY FOR PREVENTION, DIAGNOSIS AND MANAGEMENT OF COPD: 2025 Report. Accessed 13 June 2025. 
4. Ministry of Health of Vietnam. Guidelines for the diagnosis and treatment of chronic obstructive pulmonary disease (Updated 2018). [Original guideline in Vietnamese]
5. Ministry of Health of Vietnam. Guidelines for the diagnosis and treatment of chronic obstructive pulmonary disease (Updated 2023). [Original guideline in Vietnamese]
6. Matera MG, et al. Drugs Aging 2023;40:605-619.
7. Soraci L, at al. Drugs Aging 2023;40:499-526.
8. Worldwide Antimicrobial Resistance National/International Network Group (WARNING) Collaborators. World J Emerg Surg 2023;18:50.
9. Hoàng T, et al. Vietnam Medical Journal 2023;232-236. [Original article in Vietnamese: https://tapchiyhocvietnam.vn/index.php/vmj/article/view/7855] 
10. Ngo TÁL, et al. Can Tho Journal of Medicine and Pharmacy 2021;43; 81-88. [Original article in Vietnamese: https://tapchi.ctump.edu.vn/index.php/ctump/article/view/1084]
11. Lê TD. Ho Chi Minh City Medical Journal 2016;2; 259-262. [Original article in Vietnamese]
12. Thành NV, et al. Vietnam Medical Journal 2021;168-171. [Original article in Vietnamese]
13. Tuyên DD, et al. Journal of 108 – Clinical Medicine and Pharmacy 2024;19;1-9. [Original article in Vietnamese: https://tcydls108.benhvien108.vn/index.php/YDLS/article/view/2169]