Modification and duration of therapy for S. pneumoniae (pneumococcal) bronchiectasis exacerbations in adults

Review the results of culture and susceptibility testing, and the response to initial therapy for S. pneumoniae bronchiectasis exacerbations in adults. Seek expert advice if methicillin-resistant Staphylococcus aureus (MRSA), nontuberculous mycobacteria, Aspergillus species or other less common drug-resistant organisms (eg Achromobacter species, Stenotrophomonas maltophilia) are isolated in sputum samples taken for cultureChang, 2023 Visser, 2018.

If adults with an exacerbation of bronchiectasis are improving, adjustment of antibiotic therapy based on the results of sputum culture and susceptibility testing is not requiredChang, 2023 Hill, 2019 Visser, 2018.

If the patient was treated with intravenous antibiotic therapy and is clinically improving, consider switching to oral therapy (see Guidance for intravenous to oral switch for guidance on when to switch to oral therapy):

For patients without penicillin hypersensitivity, use amoxicillin.
For patients with nonsevere (immediate or delayed) penicillin hypersensitivity, or severe immediate¹ penicillin hypersensitivity who tolerated ceftriaxone, use cefuroxime.
For patients with severe immediate¹ penicillin hypersensitivity in whom ceftriaxone was not used nor tolerated, or for patients with severe delayed² penicillin hypersensitivity, use doxycycline or moxifloxacin.

Ensure other aspects of bronchiectasis management are optimised, such as airway clearance, physical activity and, if appropriate, bronchodilator therapy (see Management of bronchiectasis).

Note: Optimise airway clearance, physical activity and, if appropriate, bronchodilator therapy during exacerbations of bronchiectasis.

If the patient is not improving with initial antibiotic therapy, modify treatment based on the results of sputum culture and susceptibility testing³ Hill, 2019. Consider intravenous therapy for those who do not improve on oral therapy.

Data to guide the optimal duration of therapy are limitedWurzel, 2011; expert consensus is to treat exacerbations of bronchiectasis for 14 days (intravenous + oral). If clinical response is rapid in an adult with an S. pneumoniae bronchiectasis exacerbation, it is reasonable to shorten the duration of therapy to 10 days (intravenous + oral)Hill, 2019 Polverino, 2017.

Refer adults who do not respond to antibiotic therapy and those who have 3 or more bronchiectasis exacerbations per year to a respiratory physicianChang, 2023. Management decisions should be discussed with the treating respiratory specialist and guided by an individualised bronchiectasis management plan.

¹ Severe immediate hypersensitivity reactions include anaphylaxis, compromised airway, airway angioedema, hypotension and collapse.Return

² Severe delayed hypersensitivity reactions include cutaneous adverse drug reactions (eg drug rash with eosinophilia and systemic symptoms [DRESS], Stevens–Johnson syndrome/toxic epidermal necrolysis [SJS/TEN], severe blistering or desquamative rash), and significant internal organ involvement (eg acute interstitial nephritis).Return

³ Gram stain of poor-quality sputum samples can give misleading results. Use a good-quality sample (presence of polymorphs but few or no squamous epithelial cells on microscopy), collected before starting antibiotics, to adjust antibiotic therapy – the pathogen should be predominant in the Gram stain as well as the culture.Return