Choice of Antibiotics in the Emergency Room for COPD Patients Who Are Getting Intubated

Abstract

Patients with acute exacerbation of chronic obstructive pulmonary disease requiring emergency intubation have a high risk of bacterial infection, resistant organisms, treatment failure, and mortality. Appropriate empirical antibiotic selection must provide timely coverage while avoiding unnecessary broad-spectrum therapy. Objective: To determine the pattern and guideline concordance of empirical antibiotic selection in intubated COPD patients and assess its association with microbiological and clinical outcomes. Methods: This prospective observational cohort study included 80 consecutive patients aged ≥40 years with established COPD who required emergency endotracheal intubation at a tertiary-care hospital in Pakistan from July to December 2024. Demographic, clinical, radiological, microbiological, and treatment-related data were recorded. Empirical antibiotic treatment was classified as guideline-concordant or non-concordant according to clinical features, recognised resistance-risk factors, and local antibiograms. The primary outcome was the frequency of guideline-concordant treatment. Secondary outcomes included culture positivity, antibiotic modification, 72-hour clinical response, extubation by day 7, duration of ventilation, ICU stay, and in-hospital mortality. Results: The mean age was 66.4 ± 9.7 years, and 61 (76.3%) patients were male. Piperacillin–tazobactam plus azithromycin was the most frequently prescribed regimen in 27 (33.8%) patients. Initial treatment was guideline-concordant in 58 (72.5%) patients. Respiratory cultures were positive in 38 of 70 sampled patients (54.3%), with Pseudomonas aeruginosa being the most frequent isolate. Multidrug-resistant organisms were identified in 14 (36.8%) culture-positive patients. Guideline-concordant treatment was associated with a higher 72-hour clinical response (74.1% vs 40.9%; p=0.005), greater extubation by day 7 (65.5% vs 36.4%; p=0.019), shorter mechanical ventilation and ICU stay, and lower in-hospital mortality (13.8% vs 40.9%; p=0.008). Non-concordant treatment remained associated with treatment failure after adjustment (adjusted OR 3.72; 95% CI: 1.22–11.34). Conclusion: Guideline-concordant empirical antibiotic selection was associated with improved early clinical outcomes and lower mortality among intubated COPD patients. Risk-based antibiotic selection, early respiratory sampling, and reassessment within 48–72 hours may improve treatment while limiting unnecessary broad-spectrum antibiotic exposure.