What is the treatment for bronchiectasis exacerbation?

Treatment for Bronchiectasis Exacerbation

Bronchiectasis exacerbations should be treated with 14 days of antibiotics, with the specific antibiotic selection based on previous sputum culture results and local resistance patterns. 1

Initial Management

Antibiotic Selection

• Obtain sputum sample for culture and sensitivity before starting antibiotics when possible 1
• Start empiric antibiotics while awaiting culture results 1
• Select antibiotics based on:
  • Previous sputum culture results
  • Severity of exacerbation
  • Risk of Pseudomonas aeruginosa infection 1, 2

Common Pathogens and First-Line Antibiotics

1. Streptococcus pneumoniae: Amoxicillin 500mg three times daily for 14 days 1
2. Haemophilus influenzae (beta-lactamase negative): Amoxicillin 500mg three times daily for 14 days 1
3. Haemophilus influenzae (beta-lactamase positive): Amoxicillin-clavulanate 625mg three times daily for 14 days 1
4. Moraxella catarrhalis: Amoxicillin-clavulanate 625mg three times daily for 14 days 1
5. Pseudomonas aeruginosa: Oral ciprofloxacin 500-750mg twice daily for 14 days 1, 3
6. MRSA: Doxycycline 100mg twice daily for 14 days 1

Route of Administration

• Oral antibiotics: For mild to moderate exacerbations
• Intravenous antibiotics: Consider for:
  • Severe symptoms
  • Treatment failures
  • P. aeruginosa infections resistant to oral therapy 2
  • Switch from IV to oral by day 3 if clinically stable 1

Duration of Treatment

• Standard duration is 14 days 1
• While shorter courses might be appropriate in some mild cases, evidence for shorter courses is lacking 1

Additional Supportive Measures

Airway Clearance

• Perform airway clearance techniques once or twice daily 2
• Techniques include:
  • Active cycle of breathing
  • Autogenic drainage
  • Postural drainage
  • Device-assisted methods 2
• Ensure adequate hydration to thin secretions 2

Bronchodilators

• Consider short-acting bronchodilators to improve symptoms and facilitate airway clearance 2
• Not recommended as preventive approach for LRTI 1

Mucoactive Agents

• Consider for patients with difficulty expectorating sputum 2
• Do not use recombinant human DNase (dornase alfa) in non-CF bronchiectasis 2

Special Considerations

Pseudomonas aeruginosa

• First isolation requires eradication therapy:
  • First line: Ciprofloxacin 500-750mg twice daily for 2 weeks 1
  • Second line: IV anti-pseudomonal beta-lactam ± IV aminoglycoside for 2 weeks, followed by 3 months of nebulized colistin, gentamicin, or tobramycin 1

MRSA

• New isolation requires eradication therapy 1

Non-Responding Patients

• Re-evaluate for non-infectious causes of failure (inadequate medical treatment, pulmonary embolism, cardiac failure) 1
• Perform careful microbiological reassessment 1
• Change antibiotic to one with good coverage against P. aeruginosa, resistant S. pneumoniae, and non-fermenters 1
• Adjust treatment according to new microbiological results 1

Prevention of Future Exacerbations

For patients with ≥3 exacerbations per year, consider:

• Long-term macrolides (azithromycin, erythromycin) 1, 2, 4
• Inhaled antibiotics for patients with chronic P. aeruginosa infection 1, 2

Common Pitfalls to Avoid

• Failing to obtain sputum cultures before starting antibiotics
• Inadequate duration of antibiotic therapy (less than 14 days)
• Not considering P. aeruginosa in antibiotic selection
• Overlooking airway clearance techniques as part of treatment
• Using inhaled corticosteroids without specific indications (ABPA, asthma, COPD) 1, 2
• Using recombinant human DNase which can be harmful in non-CF bronchiectasis 2

The evidence strongly supports a 14-day course of antibiotics for bronchiectasis exacerbations, with the specific antibiotic choice guided by previous sputum culture results and local resistance patterns. Combining antibiotic therapy with airway clearance techniques is essential for optimal management.