The role of long-term oral or inhaled antibiotic therapy for bronchiectasis in adults

Before considering long-term oral or inhaled antibiotic therapy for bronchiectasis in adults, refer to a respiratory physician for exclusion of nontuberculous mycobacterial infections and assessment of the benefits and potential harms of antibiotic therapy (eg adverse effects, development of bacterial resistance)Chang, 2023Hill, 2019.

Long-term oral or inhaled antibiotic therapy for bronchiectasis should be considered in adults who have 3 or more exacerbations per year despite optimisation of other aspects of bronchiectasis management (eg treating the cause, airway clearance, physical activity and, if appropriate, bronchodilator therapy – see Management of bronchiectasis)Chang, 2023Hill, 2019Polverino, 2017.

Note: Before considering long-term oral or inhaled antibiotic therapy for bronchiectasis, refer to a respiratory physician.

Long-term macrolide therapy (azithromycin or erythromycin) in adults with 3 or more bronchiectasis exacerbations per year has been shown to reduce the frequency of exacerbations, and has shown a small improvement in health-related quality of lifeChalmers, 2019Chang, 2023. These benefits were sustained in adults with and without Pseudomonas aeruginosa colonisationChalmers, 2019Chang, 2023. If a long-term macrolide is used, it is essential to monitor for adverse effects and tolerability (eg gastrointestinal upset, hearing impairment, prolonged QT interval). Review the benefit of therapy after 6 months and after each exacerbation of bronchiectasisChang, 2023.

Avoid the use of long-term non-macrolide oral antibiotics (eg quinolones) in bronchiectasis to minimise the development of antibiotic resistance (eg to ciprofloxacin, which is the only oral drug available to treat P. aeruginosa).

Data to support long-term inhaled antibiotic therapy (eg colistin, tobramycin) for adults with 3 or more bronchiectasis exacerbations per year are limitedChang, 2023Hill, 2019Polverino, 2017. Inhaled antibiotics may reduce the frequency of exacerbations in adults colonised with P. aeruginosa who have frequent exacerbationsHaworth, 2021. However, no consistent improvements were seen in health-related quality of life, hospitalisations or mortality, and the risk of developing antibiotic resistance was increasedLaska, 2019Tejada, 2021. If long-term inhaled antibiotic therapy is used, the benefit and tolerability of therapy should be reviewed after 6 months and after each exacerbation of bronchiectasis.