How should I manage an acute bronchiectasis exacerbation, including empiric antibiotic choice (amoxicillin‑clavulanate if no recent Pseudomonas isolation, IV cefepime or piperacillin‑tazobactam or oral ciprofloxacin if Pseudomonas risk), bronchodilator therapy, airway‑clearing measures, short‑course oral prednisone if severe inflammation, follow‑up sputum cultures if no improvement, second‑line antibiotics, and long‑term macrolide prophylaxis for patients with frequent exacerbations?

Management of Acute Bronchiectasis Exacerbation

Treat all acute bronchiectasis exacerbations with 14 days of antibiotics, selecting empiric therapy based on prior sputum microbiology and Pseudomonas aeruginosa risk factors, while immediately collecting sputum for culture before starting treatment. 1, 2

Immediate Diagnostic Steps

• Obtain sputum for culture and sensitivity testing prior to starting antibiotics, particularly in hospitalized patients, to guide subsequent therapy if initial treatment fails 1, 2
• Start empirical antibiotics immediately while awaiting microbiology results—do not delay treatment 2
• Modify antibiotic selection once pathogen is isolated if there is no clinical improvement, guided by sensitivity results 1, 2

Empiric Antibiotic Selection

For Patients WITHOUT Pseudomonas Risk Factors

• First-line: Amoxicillin-clavulanate 625 mg three times daily for 14 days covers the most common pathogens (H. influenzae, M. catarrhalis, S. pneumoniae) 1, 2
• Alternative oral options for penicillin allergy:
  • Doxycycline 100 mg twice daily for 14 days 2
  • Azithromycin 500 mg once daily for 14 days 2

For Patients WITH Pseudomonas aeruginosa Risk or Prior Isolation

• Oral therapy (mild-moderate exacerbations): Ciprofloxacin 500-750 mg twice daily for 14 days 1, 2
• IV therapy (severe exacerbations or treatment failure):
  • Ceftazidime 2 g three times daily for 14 days 2
  • Piperacillin-tazobactam 4.5 g three times daily for 14 days 2
  • Meropenem 2 g three times daily for 14 days 2
  • Aztreonam 2 g three times daily for 14 days (safest option for severe β-lactam allergy) 2

Adjunctive Therapies During Exacerbations

Airway Clearance

• Increase frequency of airway clearance techniques during acute exacerbations beyond baseline regimen 1
• Consider short-acting β2-agonists prior to airway clearance to facilitate expectoration 1

Bronchodilators

• Use bronchodilators as needed for symptomatic relief, particularly in patients with concurrent airflow obstruction 2

Corticosteroids

• Do NOT routinely use inhaled or systemic corticosteroids for bronchiectasis exacerbations unless the patient has comorbid asthma or COPD 2, 3
• Short-course oral prednisone may be considered only in severe exacerbations with documented significant airway inflammation, though this is not standard practice 2

Treatment Duration

• Standard duration: 14 days for all exacerbations based on expert consensus and clinical outcome data 1, 2
• Shorter courses may be appropriate for mild exacerbations with rapid return to baseline, though evidence is lacking 1
• Longer courses may be needed for severe exacerbations or inadequate response at day 14 1, 2

Management of Treatment Failure

Re-evaluation at Day 14 if No Clinical Improvement

• Obtain repeat sputum culture and sensitivity testing 2
• Reassess for non-infectious causes of deterioration:
  • Pulmonary embolism
  • Heart failure
  • Inadequate bronchodilator therapy
  • Pneumothorax 2
• Change antibiotics to broader coverage based on culture results 1, 2

Special Situations: New Pathogen Isolation

First Isolation of Pseudomonas aeruginosa

• Offer eradication therapy: Ciprofloxacin 500-750 mg twice daily for 2 weeks (first-line) 1
• Second-line eradication: IV anti-pseudomonal β-lactam ± IV aminoglycoside for 2 weeks, followed by 3 months of nebulized colistin, gentamicin, or tobramycin 1
• Eradication should be attempted promptly after confirming P. aeruginosa presence 1

First Isolation of MRSA with Clinical Deterioration

• Offer eradication treatment: Doxycycline 100 mg twice daily for 14 days (first-line) 2
• Alternative: Appropriate anti-MRSA therapy based on local resistance patterns 1

Patient Self-Management Plan

• Provide patients with antibiotics to keep at home for prompt self-initiation of treatment when exacerbation symptoms develop 1, 2
• Educate patients on exacerbation symptoms: acute deterioration with worsening cough, increased sputum volume or purulence, increased breathlessness, or systemic upset 1

Long-Term Prevention for Frequent Exacerbators

• For patients with ≥3 exacerbations per year, consider long-term prophylactic antibiotics after optimizing airway clearance 3
• Chronic Pseudomonas infection: Inhaled colistin as first-line prophylaxis 3
• Non-Pseudomonas infections: Oral macrolides (azithromycin) as first-line prophylaxis 3, 4

Common Pitfalls to Avoid

• Do not use statins for bronchiectasis treatment—they provide no benefit 2
• Avoid inhaled corticosteroids unless comorbid asthma or COPD is present 2, 3
• Do not delay antibiotic treatment while waiting for sputum culture results 2
• Recognize that in vitro antibiotic resistance may not correlate with clinical failure—continue effective antibiotics even if resistance is reported 3