Modification and duration of intravenous therapy for P. aeruginosa bronchiectasis exacerbations in adults

Review the results of culture and susceptibility testing, and the response to initial therapy for adults with a P. aeruginosa bronchiectasis exacerbation.

If P. aeruginosa is not identified by culture and intravenous therapy is still required, switch to an appropriate narrower-spectrum antibiotic regimen. 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, 2023Visser, 2018.

If the patient has significantly improved, consider switching to oral therapy (see Guidance for intravenous to oral switch for guidance on when to switch to oral therapy). For regimens, see oral antibiotic therapy.

For severe infections, some experts continue intravenous therapy for the full course. In stable patients, if there is no suitable oral therapy, consider ambulatory antimicrobial therapy.

If the patient is clinically improving, additional therapy with an aminoglycoside is not necessary once susceptibility results are known. Aminoglycosides are not recommended as ongoing monotherapy if appropriate alternative drugs are available, because clinical outcomes may be inferior in comparison to an antipseudomonal beta lactam.

If the patient is not improving, modify treatment based on the results of sputum culture and susceptibility tests when available¹Chang, 2023. Consider adding an aminoglycoside if the patient is not improving on monotherapy – see Additional intravenous therapy for P. aeruginosa bronchiectasis exacerbations in adults. Ensure other aspects of bronchiectasis management are optimised, such as airway clearance, physical activity and, if appropriate, bronchodilator therapy (see Management of bronchiectasis).

Data to guide the optimal duration of therapy are limitedWurzel, 2011; expert consensus is to treat exacerbations of bronchiectasis caused by P. aeruginosa for 14 days (intravenous + oral)Chang, 2023Hill, 2019Polverino, 2017. If clinical response is rapid and the current exacerbation is not caused by a new acquisition of P. aeruginosa, it is reasonable to shorten the duration of therapy to 10 days (intravenous + oral)Hill, 2019Polverino, 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.