Principles of antibiotic therapy for bronchiectasis exacerbations in adults
This topic focuses on antibiotic management of adults with exacerbations of bronchiectasis.
- For causes, clinical features, diagnosis and general management of bronchiectasis, see Bronchiectasis in the Respiratory guidelines.
- For management of airway infection in cystic fibrosis, see Airway infection and antibiotic therapy in cystic fibrosis in the Respiratory guidelines.
An exacerbation of bronchiectasis in adults is an acute deterioration of symptoms from the patient’s baseline for 48 hours or longer that warrants a change of managementHill, 2017. Adults with bronchiectasis may have airways colonised with bacteria such as Haemophilus influenzae, Streptococcus pneumoniae, Moraxella catarrhalis, Pseudomonas aeruginosa and Staphylococcus aureusHill, 2019Polverino, 2017. Exacerbations of bronchiectasis may be caused by colonising organisms and/or infection with a new organism, including common respiratory viruses (eg coronaviruses, rhinoviruses, influenza A or B). Do not use antibiotic therapy to treat colonising organisms in adults with bronchiectasis who are clinically stable.
Consider antibiotic therapy if 3 or more of the clinical features listed in Clinical features of an exacerbation of bronchiectasis in adults that may benefit from antibiotic therapy are present for at least 48 hours. The clinical features of exacerbations of bronchiectasis can be similar to pneumonia – consider diagnostic imaging (see Diagnostic imaging for CAP in adults or Diagnosis of HAP).
Consider antibiotic therapy for adults with an exacerbation of bronchiectasis if 3 or more of the following clinical features are present for at least 48 hours:
- increased cough
- increased sputum volume or change in sputum viscosity
- increased sputum purulence
- increased breathlessness or reduced exercise tolerance
- fatigue or malaise
- haemoptysis.
Before starting antibiotic therapy for adults with an exacerbation of bronchiectasis, collect a sputum sample for culture and susceptibility testing. Consider performing nose and throat or nasopharyngeal swabs1 for nucleic acid amplification testing (NAAT) (eg polymerase chain reaction [PCR]) for influenza and other respiratory viruses if clinically indicatedGao, 2015Hill, 2019.
While awaiting the results of current investigations, review the results of sputum culture and susceptibility testing from the past 12 months and, if available, direct initial antibiotic therapy accordinglyChang, 2023Visser, 2018. Regimens are included in this topic for:
- Haemophilus influenzae bronchiectasis exacerbations in adults
- Moraxella catarrhalis bronchiectasis exacerbations in adults
- Streptococcus pneumoniae (pneumococcal) bronchiectasis exacerbations in adults
- Pseudomonas aeruginosa bronchiectasis exacerbations in adults.
If results from culture and susceptibility testing are not available, use empirical antibiotic therapy for bronchiectasis exacerbations.
Seek expert advice if methicillin-resistant S. 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, 2023Visser, 2018.
This topic also briefly discusses the benefits and harms of long-term antibiotic therapy for patients who have 3 or more exacerbations per year.