What antibiotics are used to treat bronchiectasis?

Antibiotic Treatment for Bronchiectasis

For acute exacerbations, treat with 14 days of oral antibiotics selected based on prior sputum microbiology, and for patients with ≥3 exacerbations annually, initiate long-term prophylactic antibiotics—either inhaled antibiotics for Pseudomonas aeruginosa infection or oral macrolides for non-Pseudomonas cases. 1, 2

Acute Exacerbation Management

Initial Steps

• Collect sputum for culture and sensitivity before starting antibiotics, particularly in hospitalized patients, then begin empirical therapy immediately 2
• Treat exacerbations presenting with acute deterioration—increased cough, sputum volume/purulence, breathlessness, or systemic symptoms 1
• Use 14-day antibiotic courses for all acute exacerbations based on expert consensus and clinical outcome data 1, 2

Antibiotic Selection for Non-Pseudomonas Infections

For patients without Pseudomonas aeruginosa risk factors: 2

• Streptococcus pneumoniae: Amoxicillin 500 mg-1 g three times daily for 14 days 2
• Haemophilus influenzae (beta-lactamase negative): Amoxicillin 500 mg three times daily for 14 days 2
• Haemophilus influenzae (beta-lactamase positive): Amoxicillin-clavulanate 625 mg three times daily for 14 days 2
• Moraxella catarrhalis: Amoxicillin-clavulanate 625 mg three times daily for 14 days 2
• Staphylococcus aureus (MSSA): Flucloxacillin 500 mg four times daily for 14 days 2

Antibiotic Selection for Pseudomonas aeruginosa Infections

For oral therapy: 2

• Ciprofloxacin 500 mg twice daily (or 750 mg twice daily for severe infections) for 14 days 2

For severe cases requiring IV therapy: 2

• Ceftazidime 2 g three times daily 2
• Piperacillin-tazobactam 4.5 g three times daily 2, 3
• Aztreonam 2 g three times daily 2
• Meropenem 2 g three times daily 2

New Pseudomonas Isolation

• Offer eradication treatment with ciprofloxacin 500-750 mg twice daily for 2 weeks when P. aeruginosa is newly isolated 1, 2
• The European Respiratory Society supports eradication attempts for new Pseudomonas isolations, though evidence quality is very low 1

Long-Term Prophylactic Antibiotic Therapy

Indications

Initiate long-term antibiotics only for patients with ≥3 exacerbations per year after optimizing airway clearance and treating underlying causes. 1

For Chronic Pseudomonas aeruginosa Infection

First-line approach: 1, 2

• Inhaled colistin (preferred first-line inhaled antibiotic) 1
• Inhaled gentamicin (alternative option) 1

If inhaled antibiotics are contraindicated, not tolerated, or ineffective: 1

• Oral macrolides: Azithromycin 250 mg three times weekly (can increase based on response and tolerability) or erythromycin 1

For inadequate response despite inhaled antibiotics: 1

• Add macrolides to or substitute for inhaled antibiotics 1

For Non-Pseudomonas Infections

First-line approach: 1, 4

• Oral macrolides: Azithromycin (250 mg three times weekly as pragmatic starting dose) or erythromycin 1

If macrolides are contraindicated, not tolerated, or ineffective: 1

• Oral antibiotics selected based on antibiotic susceptibility and patient tolerance 1
• Inhaled antibiotics may be considered if oral prophylaxis fails 1

Monitoring Requirements

• Review patients on long-term antibiotics every 6 months for efficacy, toxicity, and continuing need 1
• Monitor sputum culture and sensitivity regularly, recognizing that in vitro resistance may not affect clinical efficacy 1
• Remain on the same prophylactic oral antibiotic rather than monthly rotation; change only if efficacy is lost, guided by sensitivity results 1

Critical Pitfalls to Avoid

• Do not use inhaled corticosteroids for bronchiectasis treatment unless the patient has comorbid asthma or COPD 1, 2
• Do not offer statins for bronchiectasis treatment 1, 2
• Do not use recombinant human DNase in non-CF bronchiectasis—this is a strong recommendation with moderate quality evidence 1
• Re-evaluate treatment failures by day 14: obtain repeat sputum culture, reassess for non-infectious causes, and consider broader antibiotic coverage 2
• For patients with ≥5 exacerbations per year despite other treatments, consider cyclical IV antibiotics 1

Special Considerations

New MRSA Isolation

• Offer eradication treatment with oral doxycycline 100 mg twice daily for 14 days if clinical deterioration occurs 2

Patient Self-Management

• Provide self-management plans including prompt exacerbation treatment, antibiotics to keep at home, and clear instructions on when to initiate treatment 2