What is the recommended management for infected bronchiectasis?

Management of Infected Bronchiectasis

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

Acute Exacerbation Management

Immediate Actions

• Collect sputum for culture and sensitivity testing before starting antibiotics, particularly in hospitalized patients, but start empirical therapy immediately without waiting for results 3
• Treat all acute exacerbations with 14 days of antibiotics as the standard duration, regardless of causative organism 1, 2, 3
• Modify antibiotic selection once pathogen is isolated if there is no clinical improvement, guided by sensitivity results 3

Antibiotic Selection Based on Pathogen

For patients WITHOUT Pseudomonas aeruginosa risk factors: 3

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

For patients WITH Pseudomonas aeruginosa: 3

• Oral therapy: Ciprofloxacin 500 mg twice daily (750 mg twice daily in severe infections) for 14 days 3, 4
• 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 3

For E. coli infections: Select antibiotics according to susceptibility patterns, commonly fluoroquinolones, amoxicillin-clavulanate, or trimethoprim-sulfamethoxazole 5

Duration Modifications

• Extend treatment beyond 14 days only if the patient has not returned to baseline by day 14; re-evaluate clinically and obtain new sputum culture at this point 3, 5
• Shorter courses (<14 days) may be considered only for mild exacerbations with rapid return to baseline, though evidence is lacking 1, 3
• Longer courses may be appropriate for severe exacerbations or inadequate response to treatment 1, 3

Route of Administration

• Oral antibiotics are first-line for most exacerbations 3, 5
• Switch to intravenous antibiotics for: severe exacerbations, treatment failures after oral therapy, or acute deterioration 3, 5

Long-Term Prophylactic Antibiotic Therapy

Indications for Long-Term Antibiotics

Initiate long-term antibiotics only for patients with ≥3 exacerbations per year after optimizing airway clearance techniques and treating underlying causes 1, 2

This threshold may be reduced for: 1

• Patients with history of severe exacerbations
• Relevant comorbidities such as primary/secondary immunodeficiency
• Patients in whom exacerbations significantly impact quality of life
• Those with more severe bronchiectasis

Treatment Algorithm Based on Pathogen

For chronic Pseudomonas aeruginosa infection: 1, 2

1. First-line: Inhaled antibiotics (colistin, gentamicin, or liposomal ciprofloxacin) 1, 2
2. Second-line: Oral macrolides (azithromycin or erythromycin) if inhaled antibiotics are contraindicated, not tolerated, or not feasible 1
3. Consider adding or switching to macrolides if high exacerbation frequency persists despite inhaled antibiotics 1

For non-Pseudomonas infections: 1, 2

1. First-line: Oral macrolides (azithromycin or erythromycin) 1, 2, 6
2. Second-line: Oral antibiotics (choice based on antibiotic susceptibility and patient tolerance) if macrolides are contraindicated, not tolerated, or ineffective 1
3. Third-line: Inhaled antibiotics if oral antibiotic prophylaxis is contraindicated, not tolerated, or ineffective 1

Eradication Treatment

• For new isolation of Pseudomonas aeruginosa, offer eradication antibiotic treatment with ciprofloxacin 500-750 mg twice daily for 2 weeks 1, 3
• Do NOT offer eradication treatment for pathogens other than Pseudomonas aeruginosa 1
• For new growth of MRSA with clinical deterioration, offer eradication treatment with oral doxycycline 100 mg twice daily for 14 days 3

Monitoring and Safety Considerations

Regular Monitoring

• Review patients on long-term antibiotics every 6 months for efficacy, toxicity, and continuing need 2
• Monitor sputum culture and sensitivity regularly, recognizing that in vitro resistance may not affect clinical efficacy 2
• Before starting long-term macrolides, exclude active NTM infection because macrolide monotherapy can increase the risk of macrolide resistance in NTM 1

Inhaled Antibiotic Safety

• Inhaled antibiotics carry a 10-32% risk of bronchospasm 1
• Perform a supervised test dose with pre- and post-spirometry 1
• Administer a short-acting bronchodilator prior to inhalation to prevent bronchospasm 1

Drug Toxicity Monitoring

• Monitor for drug toxicity, most notably with macrolides and inhaled aminoglycosides 1
• Characterize sputum pathogens (bacteria, mycobacteria, fungi) before and after implementation of long-term antibiotics to direct choices, monitor resistance patterns, and identify treatment-emergent organisms 1

Critical Pitfalls to Avoid

• Do NOT use inhaled corticosteroids for bronchiectasis treatment unless the patient has comorbid asthma or COPD 1, 2, 3
• Do NOT use statins for bronchiectasis treatment 1, 3
• Re-evaluate patients who fail to respond by day 14: obtain repeat sputum culture, reassess for non-infectious causes, and consider antibiotic change with broader coverage 3

Patient Self-Management

Provide patients with a self-management plan that includes prompt treatment of exacerbations, antibiotics to keep at home, and clear instructions on when to initiate treatment 3