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• Consider antibiotic therapy for patients with recent increase in symptoms, change in sputum color or amount and/or worsening cough FIRST-LINE ANTIBIOTICS
Levaquin (levofloxacin) 500 mg po daily x 5-7 days Levaquin (levofloxacin) 750 mg po daily x 5-7 days Ceftin (cefuroxime
XL(clarithromycin-ER) 1000 mg po once daily x 5-7 days
2. Start or increase short-acting inhaled beta2-agonist and inhaled anticholinergic agent:

• The need for this high frequency of every 1-2 hours of short acting bronchodilators should be considered high risk of progression to severe exacerbation if no improvement achieved within hours • Don’t hesitate to add steroid therapy and antibiotics per physician judgment • Use of spacers with MDI is strongly encouraged.
• Remind patients NOT to discontinue other medications. The above regimens should be added to existing therapy.
Ipratropium bromide
Mild to Moderate Exacerbation If 3 to 4 puffs q4h not effective, then 3 to 4 puffs q1-2h, if tolerated, until clinical 3. If patient is unable to use an MDI, start or increase nebulizer treatment to maximum doses.
• Ipratropium inhalation solution 0.5 mg 4. The addition of a combination long acting beta2-agonist with inhaled steroid is an individual decision but may be associated with increased pneumonia. Inhaled anticholinergics should be considered in moderate to severe disease. It is often effective, but if the patient fails or side effects like urinary reten- tion or blurred vision develop then it should be discontinued. 5. Is patient on maximal dose of 40 to 60 mg per day of prednisone equivalent dose? • If yes, patient should be referred on an emergent basis for specialist consultation or consider admission 6. Indications for systemic corticosteroid therapy include: • Patients who recently stopped taking steroids for recent acute exacerbation (physician judgment) • Patients who are experiencing a 5% decrease in O2 saturation from baseline • PEF <30% of predicted or significant decrease from baseline • Patients not responding to initial bronchodilator therapy • Recommended dose of 0.6 to 1mg/kg/day orally • Once the patient is stable, taper dose over a 2 week period monitoring for relapse of the exacerbation. Goal is to wean the patient, and if not possible, then treat with the smallest effective dose.
8. If patient is on theophylline, measure plasma theophylline concentration and adjust doses to obtain • No evidence to support introduction of theophylline in acute COPD exacerbation. Consider initiating low dose theophylline when patient is stable.
9. If no improvement within 24 to 48 hours consider an alternate diagnosis or resistant disease, as well as a pulmonary consultation and/or hospitalization.
10. Taper treatment to maintenance regimen with careful follow-up: • As patient’s level of function improves, reduce the intensity of bronchodilator therapy down to the usual level of treatment over the course of a few days.
• Office visit two weeks post exacerbation as indicated.
11. Patients who are stabilized after aggressive drug therapy but continues to have hypoxemia may require home oxygen therapy on a temporary basis. Need to have an oxygen therapy assessment and appropri- 12. Review patient’s maintenance medications.
13. Consider referral for pulmonary rehab and smoking cessation.
14. Check pneumococcal and influenza vaccination status.
15. Consider care management referral for psychosocial assessment and/or telephonic monitoring.



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Submission- albendazole in neurocysticercosis (choon ean)

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