What is the recommended treatment approach for acute exacerbations of non-cystic fibrosis bronchiectasis, including treatment duration and dosage?

Treatment Approach for Acute Exacerbations of Non-Cystic Fibrosis Bronchiectasis

Acute exacerbations of non-cystic fibrosis bronchiectasis should be treated with 14 days of antibiotics, with antibiotic selection guided by prior sputum cultures and patient-specific factors. 1

Antibiotic Duration and General Approach

• Treat acute exacerbations with a 14-day course of antibiotics, based on expert consensus and studies documenting good clinical outcomes with this duration 1
• Obtain sputum samples for culture and sensitivity testing prior to starting antibiotics whenever possible 1
• Start empiric antibiotics while awaiting culture results, then adjust based on sensitivity results if there is no clinical improvement 1

Antibiotic Selection by Pathogen

Streptococcus pneumoniae

• First-line: Amoxicillin 500 mg three times daily for 14 days 1
• Alternative options:
  • Amoxicillin 1g three times daily for 14 days 1
  • Amoxicillin 3g twice daily for 14 days 1
• Second-line: Doxycycline 100 mg twice daily for 14 days 1

Haemophilus influenzae

• Beta-lactamase negative:
  • Amoxicillin 500 mg three times daily for 14 days 1
• Beta-lactamase positive:
  • Amoxicillin-clavulanate 625 mg three times daily for 14 days 1
• Second-line for both: Doxycycline 100 mg twice daily for 14 days 1

Pseudomonas aeruginosa

• First-line: Ciprofloxacin 500-750 mg twice daily for 14 days 1
• For severe exacerbations: Intravenous anti-pseudomonal beta-lactam (with or without an aminoglycoside) for 14 days 1

Route of Administration

• Oral antibiotics: First-line for mild to moderate exacerbations 1, 2
• Intravenous antibiotics: Consider for:
  • Severe exacerbations (e.g., when the patient is hypoxic) 1
  • Patients who fail to respond to oral antibiotics 1
  • Patients with resistant organisms based on culture results 1

Special Considerations

• For patients with new isolation of P. aeruginosa, consider eradication antibiotic treatment (first-line: ciprofloxacin 500-750 mg twice daily for 2 weeks; second-line: IV anti-pseudomonal beta-lactam with or without aminoglycoside for 2 weeks, followed by 3 months of nebulized colistin, gentamicin, or tobramycin) 1
• In mild exacerbations, exacerbations in mild patients, or those with pathogens more sensitive to antibiotics (e.g., S. pneumoniae), shorter courses might be appropriate, though evidence supporting shorter treatment is lacking 1
• For patients who don't recover after 14 days of antibiotic therapy, re-evaluate clinical condition and obtain new microbiological samples 1

Monitoring During Treatment

• Assess clinical response including symptoms of cough, sputum volume, purulence, and systemic symptoms 1
• For patients on IV aminoglycosides, monitor renal function and drug levels 3
• Consider repeat sputum culture if inadequate clinical response 1

Prevention of Future Exacerbations

• For patients with ≥3 exacerbations per year, consider long-term antibiotic therapy 1, 2
• For patients with chronic P. aeruginosa infection, consider inhaled colistin (1 MU twice daily) as first-line prophylaxis 1, 3
• Inhaled gentamicin can be considered as a second-line alternative to colistin 1, 3

Common Pitfalls to Avoid

• Do not use shorter antibiotic courses without clear evidence of clinical improvement 1
• Do not use recombinant human DNase (rhDNase) in non-CF bronchiectasis as it may be harmful 2
• Avoid inhaled aminoglycosides if creatinine clearance is <30 mL/min 3
• Do not routinely offer inhaled corticosteroids unless there is comorbid asthma or COPD 2