Modification and duration of intravenous therapy for bronchiectasis exacerbations in children with P. aeruginosa colonisation

Review the results of culture and susceptibility testing, and the response to initial therapy for children 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.

If the child 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 children, if there is no suitable oral therapy, consider ambulatory antimicrobial therapy.

If the child 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.

Note: Additional therapy with an aminoglycoside is not necessary once susceptibility results are known and if the child is clinically improving.

If the child is not improving, modify treatment based on culture and susceptibility results from respiratory tract samples1Chang, 2021. Consider adding an aminoglycoside if the child is not improving on monotherapy – see Additional intravenous therapy for P. aeruginosa bronchiectasis exacerbations in children. 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 for 14 days (intravenous + oral)Chang, 2023Chang, 2021. If clinical response is rapid (eg cough resolved by day 7) 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 all children with bronchiectasis to a paediatric specialist. Children with frequent exacerbations should have regular specialist and physiotherapist review. Management decisions should be discussed with the treating specialist and guided by the child’s individualised bronchiectasis management plan.

1 Gram stain of poor-quality respiratory 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