What is the treatment for an acute exacerbation of bronchiectasis?

From the Guidelines

Treatment of a bronchiectasis flare should involve antibiotics for 14 days, as suggested by the European Respiratory Society guidelines 1.

Key Considerations

• The choice of antibiotic should be guided by previous sputum cultures when available, and should cover common pathogens like Pseudomonas aeruginosa, Haemophilus influenzae, and Streptococcus pneumoniae.
• Airway clearance techniques, such as postural drainage, chest physiotherapy, and devices like oscillatory positive expiratory pressure devices, are essential and should be performed 2-3 times daily for 20-30 minutes.
• Bronchodilators like albuterol 2.5mg via nebulizer every 4-6 hours can help with associated bronchospasm.
• Adequate hydration is important to thin secretions, aiming for 2-3 liters of fluid daily unless contraindicated.

Antibiotic Regimens

• A common regimen includes ciprofloxacin 500-750mg orally twice daily for 14 days, as suggested by the British Thoracic Society guideline 1.
• If hospitalization is required, combination therapy with an anti-pseudomonal beta-lactam (piperacillin-tazobactam 4.5g IV every 6 hours) plus an aminoglycoside (tobramycin 5-7mg/kg IV daily) may be considered.

Special Considerations

• Eradication antibiotic treatment should be offered to patients with a new growth of P. aeruginosa, as suggested by the British Thoracic Society guideline 1.
• The potential risks and benefits of starting eradication antibiotic treatment versus clinical observation should be discussed with patients.

Quality of Life and Morbidity

• The goal of treatment is to control infection, improve mucus clearance, and reduce inflammation, addressing the pathophysiological cycle of infection, inflammation, and structural damage that characterizes bronchiectasis exacerbations.
• Treatment should be individualized to minimize morbidity and improve quality of life, taking into account the patient's specific clinical conditions and response to treatment.

From the FDA Drug Label

Adult Patients: Acute Bacterial Exacerbations of Chronic Obstructive Pulmonary Disease In a randomized, double-blind controlled clinical trial of acute exacerbation of chronic bronchitis (AECB), azithromycin (500 mg once daily for 3 days) was compared with clarithromycin (500 mg twice daily for 10 days).

The FDA drug label does not directly answer the question regarding the treatment of bronchiectasis flare. However, it does provide information on the treatment of acute bacterial exacerbations of chronic obstructive pulmonary disease (COPD) and acute exacerbations of chronic bronchitis (AECB) with azithromycin.

• Key points:
  • Azithromycin may be used to treat AECB.
  • The clinical cure rate for 3 days of azithromycin was 85% compared to 82% for 10 days of clarithromycin.
  • The most common side effects were diarrhea, nausea, and abdominal pain. However, bronchiectasis is not explicitly mentioned in the provided drug label, and therefore, no conclusion can be drawn regarding its treatment. 2

From the Research

Treatment of Bronchiectasis Flare

• The treatment of bronchiectasis flare typically involves a combination of pharmacological and non-pharmacological interventions 3.
• The goals of therapy for bronchiectasis are to reduce the symptom burden, improve quality of life, reduce exacerbations, and prevent disease progression 3.
• Antibacterial treatment is targeted towards likely organisms or tailored to the results of sputum culture, and may include oral or inhaled antibiotics 4, 5.
• Inhaled antibiotics may offer the advantage of increased local concentration of medication, while minimizing systemic adverse effects, although studies have been equivocal in this disorder 4, 5.
• Macrolides, such as azithromycin, have unique anti-inflammatory properties and may be useful in the treatment of bronchiectasis, particularly in children with non-severe exacerbations 6.
• A randomized controlled trial found that azithromycin is non-inferior to amoxicillin-clavulanate for resolving exacerbations in children with bronchiectasis, although exacerbations were significantly shorter in the amoxicillin-clavulanate group 6.

Pharmacological Treatment Options

• Bronchodilators may be used in the treatment of bronchiectasis, particularly in patients with airway obstruction, although their use is not universally recommended and there is limited evidence to support their effectiveness 7.
• Inhaled corticosteroids, mannitol, and hypertonic saline may also be used to reduce airway inflammation and improve mucociliary clearance, although further studies are needed to determine their effectiveness 4.
• Novel anti-inflammatory therapies are being developed for the management of bronchiectasis, although more research is needed to determine their safety and efficacy 3.

Non-Pharmacological Interventions

• Airway clearance techniques, such as physiotherapy and exercise, may be used to improve mucociliary clearance and reduce the risk of exacerbations 3.
• Patient education and self-management strategies, such as monitoring symptoms and adjusting treatment as needed, may also be important in the management of bronchiectasis 3.