OBJECTIVES: To determine recurrent (infective) exacerbations (AECOPD) and health care utilization among patients with moderate to very severe COPD. METHODS: Data for this study was obtained from the PHARMO Record Linkage System (RLS), which includes drug dispensing records from pharmacies, hospitalization records and detailed information from general practitioners. Patients with moderate to very severe COPD (GOLD II-III-IV) and a moderate or severe AECOPD between 2000 and 2010  were included in the study. Moderate and severe AECOPD were defined by drug use and hospitalizations respectively. Date of first AECOPD after first GOLD classification-test was defined as cohort entry. Study patients were followed from cohort entry to end of registration in PHARMO RLS, death, or end of study period, whichever occurred first. During follow-up, all recurrent AECOPDs were counted and characterized by type of AECOPD and healthcare utilization. RESULTS: Of 886 patients included in the study, 56% was male and mean (±SD) age was 66 (±11) years. The proportion of patients with GOLD II, III and IV was 52%, 34% and 14% respectively. At cohort entry, 747 patients (84%) had a moderate AECOPD and 139 (16%) had a severe AECOPD. The overall exacerbation recurrence rate per person year (PY) was 0.9. When stratifying by GOLD stage at cohort entry, this rate increased from 0.6 for patients with GOLD II to 1.1 for GOLD III patients and 1.3 for GOLD IV patients. The rate of severe exacerbations was 0.1 for patients with GOLD II and III and 0.2 for patients with GOLD IV. Mean hospital stay for severe exacerbations was 12 (±11) days and 75% were infectious. Moderate exacerbations were mostly treated with tetracyclines (46%), followed by penicillins (34%). CONCLUSIONS: This study provides a comprehensive overview of recurrent AECOPD among patients with moderate to very severe COPD, but also emphasizes the need for more research in infective AECOPD.