Choice of antibiotic in infective exacerbation of bronchiectasis

• antibiotics in acute infection:
  • during exacerbations:
    • sputum should be sent for culture and sensitivity before starting empirical antibiotics (1)
    • the patient should be treated empirically (until results are known), generally with a 10-14-day course of antibacterial therapy
      
      

Bronchiectasis (acute exacerbation): antimicrobial prescribing

Key:

• 1 See the British national formulary (BNF) for appropriate use and dosing in specific populations, for example, hepatic impairment, renal impairment, pregnancy and breastfeeding, and administering intravenous antibiotics.
• 2 When a person is receiving antibiotic prophylaxis, treatment should be with an antibiotic from a different class.
• 3 Amoxicillin is the preferred choice for women who are pregnant.
• 4 Course length based on an assessment of the severity of bronchiectasis, exacerbation history, severity of exacerbation symptoms, previous culture and susceptibility results, and response to treatment.
• 5 People who may be at higher risk of treatment failure include people who have had repeated courses of antibiotics, a previous sputum culture with resistant or atypical bacteria, or a higher risk of developing complications.
• 6 The European Medicines Agency's Pharmacovigilance Risk Assessment Committee has recommended restricting the use of fluoroquinolone antibiotics following a review of disabling and potentially long-lasting side effects mainly involving muscles, tendons, bones and the nervous system. This includes a recommendation not to use them for mild or moderately severe infections unless other antibiotics cannot be used (press release October 2018).
• 7 Review intravenous antibiotics by 48 hours and consider stepping down to oral antibiotics where possible for a total antibiotic course of 7 to 14 days

Intermittent prophylactic antibiotics for bronchiectasis

• in adults who have frequent chest infections, long-term antibiotics given at 14-day on/off intervals slightly reduces the frequency of those infections and increases antibiotic resistance. Intermittent antibiotic regimens result in little to no difference in serious adverse events (5)

Notes:

• antibiotics for acute infection:
  • a sputum culture should be repeated if patient fails to respond to antibiotics (1)
  • combination regimens should be considered in
    • Pseudomonas aeruginosa infections resistant to one or more antipseudomonal antibiotics (including ciprofloxacin)
    • patients who require several subsequent antibiotic courses (to avoid drug resistance) (1)
  • two oral antibiotics or a single intravenous agent should be used to treat MRSA infections (1)
• prophylactic antibiotic treatment:
  • little evidence on whether long-term antibacterial therapy should be given between exacerbations (1,2)
    • long-term antibacterial therapy should be considered when the patient has
      • recurrent exacerbations sufficient to prevent participation in normal activities for 2 weeks or more out of every 2 months, in spite of optimal physiotherapy (2)
      • >=3 exacerbations per year requiring antibiotics (1)
    • the decision to treat needs to be considered carefully by a respiratory medicine specialist - this is due to the possibility of unwanted effects and because prolonged use of antibacterial agents may increase microbial resistance
    • the choice of the long term antibacterial treatment ehould be guided by sputum cultures and clinical evidence of an objective response (1). Oral antibacterials such as amoxicillin (which covers most streptococci and some Haemophilus species) or ciprofloxacin (which covers Pseudomonas aeruginosa) are often effective

Reference:

• Bott J et al. Guidelines for the physiotherapy management of the adult, medical, spontaneously breathing patient. Thorax. 2009;64 Suppl 1:i1-51
• Pasteur MC et al. British Thoracic Society guideline for non-CF bronchiectasis. Thorax. 2010;65 Suppl 1:i1-58
• NICE (December 2018).Bronchiectasis (acute exacerbation): antimicrobial prescribing
• Public Health England (June 2021). Managing common infections: guidance for primary care
• Spencer S, Donovan T, Chalmers JD, Mathioudakis AG, McDonnell MJ, Tsang A, Leadbetter P. Intermittent prophylactic antibiotics for bronchiectasis. Cochrane Database of Systematic Reviews 2022, Issue 1. Art. No.: CD013254. DOI: 10.1002/14651858.CD013254.pub2.