Modification and duration of empirical therapy for bronchiectasis exacerbations in children

If children with an exacerbation of bronchiectasis are improving on empirical antibiotic therapy, adjustment of antibiotic therapy based on the results of sputum culture and susceptibility testing is not requiredChang, 2021, unless P. aeruginosa is identified on the first occasion (see Approach to antibiotic therapy for bronchiectasis exacerbations in children with newly isolated Pseudomonas aeruginosa).

If the child 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:

Assess adherence to antibiotic therapy and 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 child is not improving with initial antibiotic therapy, reassess the diagnosis and modify treatment based on the results of sputum culture and susceptibility testing when available1Chang, 2021. Consider intravenous therapy for children with an exacerbation of bronchiectasis who do not improve on oral therapy.

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)Chang, 2023.

Refer all children with bronchiectasis to a paediatric specialist. Children with frequent exacerbations and those who do not respond to empirical therapy 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 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