What is the best treatment approach for a patient experiencing a bronchiectasis exacerbation?

Treatment of Bronchiectasis Exacerbation

Treat acute bronchiectasis exacerbations with 14 days of oral antibiotics selected based on prior sputum microbiology, and obtain sputum culture before starting empirical therapy immediately. 1, 2

Immediate Management Steps

• Collect sputum for culture and sensitivity testing before starting antibiotics, particularly in hospitalized patients, but do not delay empirical treatment while awaiting results 1, 2
• Start empirical antibiotics immediately based on previous sputum microbiology and risk factors for Pseudomonas aeruginosa 1, 2
• Modify antibiotic selection once pathogen is isolated if there is no clinical improvement by day 14, guided by sensitivity results 1, 2

Antibiotic Selection by Organism

For Non-Pseudomonas Pathogens:

• Streptococcus pneumoniae: Amoxicillin 500 mg-1 g three times daily for 14 days (first-line); doxycycline 100 mg twice daily for 14 days (second-line) 1, 2
• Haemophilus influenzae (beta-lactamase negative): Amoxicillin 500 mg three times daily for 14 days 1, 2
• Haemophilus influenzae (beta-lactamase positive): Amoxicillin-clavulanate 625 mg three times daily for 14 days 1, 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

For Pseudomonas aeruginosa:

• Oral therapy: Ciprofloxacin 500 mg twice daily (or 750 mg twice daily for 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 2

Duration of Treatment

The standard duration is 14 days for all acute exacerbations regardless of causative organism. 1, 2 This recommendation is based on expert consensus and clinical outcome studies, though shorter courses may be appropriate for mild exacerbations or longer courses for severe exacerbations with inadequate response. 1, 2

Special Considerations for New Pathogen Isolation

First Isolation of Pseudomonas aeruginosa:

• Offer eradication treatment with ciprofloxacin 500-750 mg twice daily for 2 weeks (first-line) 1, 2
• Second-line eradication: IV anti-pseudomonal beta-lactam ± IV aminoglycoside for 2 weeks, followed by 3 months of nebulized colistin, gentamicin, or tobramycin 1
• Discuss risks and benefits of eradication versus clinical observation in stable patients, considering likelihood of sustained eradication and risk of chronic infection 1

First Isolation of MRSA:

• Offer eradication treatment with oral doxycycline 100 mg twice daily for 14 days (first-line) for patients with clinical deterioration 1, 2

Critical Pitfalls to Avoid

• Do NOT use inhaled corticosteroids for bronchiectasis exacerbations unless the patient has comorbid asthma or COPD 1, 2, 3
• Do NOT use statins for bronchiectasis treatment 1, 2, 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 2, 3

Patient Self-Management

• Provide patients with a self-management plan that includes prompt treatment of exacerbations and antibiotics to keep at home for rapid initiation 1, 2
• Suitable patients should have antibiotics at home to start immediately when exacerbation symptoms develop 1

Long-Term Prevention (For Frequent Exacerbators)

Consider long-term prophylactic antibiotics only for patients with ≥3 exacerbations per year after optimizing airway clearance techniques and treating underlying causes. 1, 4, 3

• For chronic Pseudomonas aeruginosa infection: Use inhaled colistin 1 MU twice daily as first-line 1, 4, 3
• For non-Pseudomonas infections: Use oral azithromycin 250 mg three times weekly as first-line (pragmatic starting dose that can be increased based on response) 1, 4, 3
• Review patients on long-term antibiotics every 6 months for efficacy, toxicity, and continuing need 1, 4, 3