Modification and duration of empirical therapy for bronchiectasis exacerbations in adults

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

If the patient is clinically improving on intravenous therapy, consider switching to oral therapy (see Guidance for intravenous to oral switch for guidance on when to switch to oral therapy). For oral regimens, see:

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, reassess the diagnosis and modify treatment based on the results of sputum culture and susceptibility testing1Chang, 2023Hill, 2019. 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. Consider intravenous therapy for adults with an exacerbation of bronchiectasis who do not improve on oral therapy.

Data to guide the optimal duration of therapy are limited; expert consensus is to treat exacerbations of bronchiectasis for 14 days (intravenous + oral)Chang, 2023Hill, 2019Polverino, 2017Wurzel, 2011. 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.

1 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