What is the best treatment for infective exacerbation of bronchiectasis?

Treatment of Infective Exacerbation of Bronchiectasis

Treat acute exacerbations with 14 days of oral antibiotics, selecting the agent based on prior sputum microbiology and risk factors for Pseudomonas aeruginosa infection. 1

Immediate Management Steps

Obtain Sputum Culture Before Starting Antibiotics

• Collect sputum (spontaneous or induced) for culture and sensitivity testing prior to commencing antibiotics, particularly in patients requiring hospitalization 1
• Start empirical antibiotics immediately while awaiting microbiology results 1
• Modify antibiotic selection once pathogen is isolated if there is no clinical improvement, guided by sensitivity results 1

Stratify Patients by Pseudomonas Risk

For patients WITHOUT Pseudomonas aeruginosa risk factors:

• Streptococcus pneumoniae: Amoxicillin 500 mg-1 g three times daily for 14 days (first-line); alternatives include doxycycline 100 mg twice daily or ciprofloxacin 500-750 mg twice daily 1

• Haemophilus influenzae (beta-lactamase negative): Amoxicillin 500 mg three times daily for 14 days; doxycycline 100 mg twice daily as alternative 1

• Haemophilus influenzae (beta-lactamase positive): Amoxicillin-clavulanate 625 mg three times daily for 14 days (first-line); alternatives include doxycycline 100 mg twice daily, ciprofloxacin 500-750 mg twice daily, or IV ceftriaxone 2 g once daily 1

• Moraxella catarrhalis: Amoxicillin-clavulanate 625 mg three times daily for 14 days (first-line); alternatives include clarithromycin 500 mg twice daily, doxycycline 100 mg twice daily, or ciprofloxacin 500-750 mg twice daily 1

• Staphylococcus aureus (MSSA): Flucloxacillin 500 mg four times daily for 14 days (first-line); alternatives include clarithromycin 500 mg twice daily, doxycycline 100 mg twice daily, or amoxicillin-clavulanate 625 mg three times daily 1

For patients WITH Pseudomonas aeruginosa:

• Oral therapy: Ciprofloxacin 500 mg twice daily (750 mg twice daily in more severe infections) for 14 days 1, 2

• IV therapy for severe cases: Ceftazidime 2 g three times daily, piperacillin-tazobactam 4.5 g three times daily, aztreonam 2 g three times daily, or meropenem 2 g three times daily for 14 days 1

• Combination therapy: Consider adding an aminoglycoside to IV beta-lactam therapy for severe Pseudomonas infections 1

Duration of Treatment

The British Thoracic Society and European Respiratory Society both recommend 14 days of antibiotic therapy for acute exacerbations 1. This duration is based on expert consensus and studies demonstrating good clinical outcomes, though the evidence base is limited 1.

Exceptions where duration may be modified:

• Shorter courses may be appropriate for mild exacerbations, mild disease severity, or pathogens more sensitive to antibiotics (such as S. pneumoniae) 1
• Longer courses may be needed for severe exacerbations, inadequate response to treatment, or specific microbiological findings 1

Special Considerations

New Isolation of Pseudomonas aeruginosa

If P. aeruginosa is newly isolated (first isolation or regrowth with intermittently positive cultures), offer eradication antibiotic treatment 1:

• First-line: Ciprofloxacin 500-750 mg 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 Eradication

For new growth of MRSA with clinical deterioration, offer eradication treatment 1:

• Oral: Doxycycline 100 mg twice daily for 14 days (first-line); rifampicin 450-600 mg once daily (based on weight), linezolid 600 mg twice daily, or trimethoprim 200 mg twice daily as alternatives 1
• IV: Vancomycin 1 g twice daily (monitor levels) or teicoplanin 400 mg once daily for 14 days 1

Common Pitfalls to Avoid

• Do not use inhaled corticosteroids for bronchiectasis exacerbations unless the patient has comorbid asthma or COPD 1
• Avoid statins for bronchiectasis treatment 1
• Re-evaluate patients who fail to respond by day 14: obtain repeat sputum culture, reassess for non-infectious causes (pulmonary embolism, cardiac failure), and consider antibiotic change with broader coverage 1
• Monitor for antibiotic resistance: Some P. aeruginosa isolates develop resistance rapidly during treatment; periodic culture and sensitivity testing during therapy is essential 3

Patient Self-Management

Provide patients with a self-management plan that includes 1:

• Prompt treatment of exacerbations
• Antibiotics to keep at home for suitable patients
• Clear instructions on when to initiate treatment