What is the treatment for recurrent infective bronchiectasis?

Treatment for Recurrent Infective Bronchiectasis

For patients with recurrent infective bronchiectasis (≥3 exacerbations per year), long-term antibiotic therapy is the cornerstone of treatment, with the specific regimen determined by the presence or absence of Pseudomonas aeruginosa infection. 1

Stepwise Management Algorithm

Step 1: Optimize Airway Clearance and Baseline Management

• All patients must be taught airway clearance techniques by a trained respiratory physiotherapist, performing sessions for 10-30 minutes once or twice daily 1, 2
• Offer active cycle of breathing techniques or oscillating positive expiratory pressure 1
• Consider gravity-assisted positioning where not contraindicated to enhance effectiveness 1
• Obtain sputum cultures before initiating any antibiotic therapy to guide treatment selection 2
• Ensure annual influenza and pneumococcal vaccinations 1

Step 2: Treat Acute Exacerbations Appropriately

• Use 14 days of antibiotics for all exacerbations, not shorter courses 1, 2
• Select antibiotics based on previous sputum culture results 2:
  • Streptococcus pneumoniae: Amoxicillin 500mg three times daily 2
  • Haemophilus influenzae (beta-lactamase negative): Amoxicillin 500mg three times daily 2
  • Pseudomonas aeruginosa: Ciprofloxacin 500-750mg twice daily 2
• Consider intravenous antibiotics for severely unwell patients, resistant organisms, or failed oral therapy 2

Step 3: Initiate Long-Term Antibiotics for ≥3 Exacerbations/Year

The choice depends critically on whether Pseudomonas aeruginosa is present:

For Patients WITH Chronic Pseudomonas aeruginosa:

1. First-line: Inhaled colistin 1
2. Second-line: Inhaled gentamicin as alternative to colistin 1
3. Alternative: Azithromycin or erythromycin if patient cannot tolerate inhaled antibiotics 1
4. Consider adding macrolide to inhaled antibiotic for patients with very high exacerbation frequency 1

Critical safety measures before starting inhaled antibiotics:

• Perform suitable challenge test when stable 1
• Avoid if creatinine clearance <30 mL/min (for aminoglycosides) 1
• Use caution with significant hearing loss requiring hearing aids or balance issues 1
• Avoid concomitant nephrotoxic medications 1

For Patients WITHOUT Pseudomonas aeruginosa:

1. First-line: Long-term macrolides (azithromycin 250mg three times weekly or erythromycin) 1, 2
2. Alternative: Long-term oral or inhaled targeted antibiotic based on specific pathogen 1

Critical safety measures before starting macrolides:

• Ensure at least one negative respiratory non-tuberculous mycobacteria (NTM) culture to exclude active NTM infection 1
• Use caution with significant hearing loss or balance issues 1
• Counsel patients about potential major side effects 1

Step 4: Escalate for Persistent Frequent Exacerbations

• If still ≥3 exacerbations/year despite Step 3: Consider combining long-term macrolide with long-term inhaled antibiotic 1
• If ≥5 exacerbations/year despite Step 4: Consider cyclical intravenous antibiotics every 2-3 months 1

Additional Therapeutic Considerations

Mucoactive Treatments

• Consider long-term mucoactive treatment for patients with difficulty expectorating sputum, poor quality of life, or failure of standard airway clearance 2
• Consider humidification with sterile water or normal saline 2
• Do NOT routinely use recombinant human DNase (dornase alfa) in non-CF bronchiectasis 1, 2

Bronchodilators

• Use bronchodilators in patients with significant breathlessness, particularly those with airflow obstruction or bronchial hyperreactivity 1
• Discontinue if no symptom reduction achieved 1

Anti-inflammatory Therapy

• Do NOT routinely offer inhaled corticosteroids unless comorbid asthma or COPD is present 2
• Do NOT offer long-term oral corticosteroids without specific indications (ABPA, chronic asthma, COPD, inflammatory bowel disease) 2

Pulmonary Rehabilitation

• Patients with impaired exercise capacity should participate in pulmonary rehabilitation programs 1, 2

Critical Monitoring Requirements

• Review patients on long-term antibiotics every 6 months assessing efficacy, toxicity, and continuing need 1
• Monitor sputum culture and sensitivity regularly, though in vitro resistance may not affect clinical efficacy 1
• For long-term prophylactic oral antibiotics, remain on the same antibiotic rather than monthly rotation; change only if lack of efficacy, guided by sensitivity results 1

Common Pitfalls to Avoid

• Do not use antibiotic courses shorter than 14 days for exacerbations—this increases treatment failure risk 1, 2
• Do not start macrolides without excluding NTM infection—this can lead to macrolide resistance in undiagnosed NTM disease 1
• Do not extrapolate CF bronchiectasis treatments to non-CF bronchiectasis—treatment responses differ significantly 2
• Thresholds for long-term treatment may be lower if patient is symptomatic between exacerbations, exacerbations respond poorly to treatment, or patient is immunosuppressed 1

Advanced Interventions for Refractory Disease

Surgical Considerations

• Consider lung resection only for localized disease whose symptoms are not controlled by optimized medical treatment 1
• Requires multidisciplinary assessment including bronchiectasis physician, thoracic surgeon, and experienced anaesthetist 1

Transplant Referral

• Consider transplant referral for patients ≤65 years if FEV₁ <30% with significant clinical instability or rapid progressive respiratory deterioration despite optimal medical management 1, 2
• Consider earlier referral with massive hemoptysis, severe secondary pulmonary hypertension, ICU admissions, or respiratory failure requiring non-invasive ventilation 1, 2