Acute exacerbation of bronchiectasis (non-cystic fibrosis)

The information below is based on NICE NG117 Bronchiectasis (non-cystic fibrosis), acute exacerbation: antimicrobial prescribing (December 2018).

An acute exacerbation of bronchiectasis is a sustained worsening of normal symptoms and signs usually over several days.

Worsening local symptoms, with or without increased wheeze, breathlessness or haemoptysis, can include:

  • cough
  • increased sputum volume
  • change of sputum viscosity
  • increased sputum purulence

Fever or pleurisy may also be present.

Obtain a sputum sample from people with an acute exacerbation of bronchiectasis and send for culture and susceptibility testing. Do not delay treatment whilst awaiting culture result.

When results of sputum culture and susceptibility testing are available:

  • review the choice of antibiotic and
  • only change the antibiotic according to susceptibility results if bacteria are resistant and symptoms are not already improving (using a narrow-spectrum antibiotic wherever possible)

Start empirical antibiotics for people with an acute exacerbation of bronchiectasis (see sliders below)

Seek specialist advice if the patient:

  • has symptoms that are not improving with repeated courses of antibiotic treatment, or
  • has bacteria that are resistant to oral antibiotics, or
  • cannot take oral antibiotics (to explore options for giving intravenous antibiotics at home or in the community, rather than in hospital, where this is appropriate e.g. via outpatient or home parenteral antibiotic therapy service where available)

Refer to hospital if the patient:

  • has any symptoms or signs suggesting a more serious illness or condition (for example, cardiorespiratory failure or sepsis)

Specific information for patients with a lung condition during the Coronavirus (COVID-19) pandemic can be found here:

Patients with bronchiectasis are at increased risk of respiratory infections, and some are likely to be at an elevated risk of a poor outcome if infected with COVID-19.

It may be difficult to distinguish whether new symptoms are due to COVID-19 or due to an exacerbation or flare-up of bronchiectasis.

Advise patients to ensure they complete their airway clearance exercises regularly - this clears mucus from the lungs and reduces the risk of a flare-up (exacerbation).

Typically, exacerbations of COPD, bronchiectasis and asthma are not associated with a high fever.

Considerations when prescribing antibiotics:

When choosing an antibiotic, take account of:

  • the severity of symptoms
  • previous exacerbation and hospital admission history, drug interactions, and the risk of developing complications
  • previous sputum culture and susceptibility results

Take the opportunity to consider the ongoing management of the patient's condition e.g. compliance with current therapies.

Reassess at any time if symptoms worsen rapidly or significantly taking account of:

  • other possible diagnoses, such as pneumonia or a non-bacterial aetiology for worsening of symptoms
  • any symptoms or signs suggesting a more serious illness or condition, such as cardiorespiratory failure or sepsis
  • previous antibiotic use, which may have led to resistant bacteria

Adults aged 18 years and over

Course length based on an assessment of the severity of bronchiectasis, exacerbation history, severity of exacerbation symptoms, previous culture and susceptibility results, and response to treatment.

1st and 2nd line for empirical treatment
Amoxicillin

(including pregnancy)

  • 500mg to 1g three times a day for 10 to 14 days
Doxycycline
  • 200mg on first day, then 100mg once a day for a 10 to 14‑day course
  • Doxycycline is contraindicated in pregnancy, and the possibility of pregnancy should be considered in young women of childbearing age.
Clarithromycin
  • 500mg twice a day for 10 to 14 days
Alternative antibiotics for empirical treatment for people who are at higher risk of treatment failure

People who may be at higher risk of treatment failure include people who have had repeated courses of antibiotics, a previous sputum culture with resistant or atypical bacteria, or a higher risk of developing complications.

Co-amoxiclav
  • 500/125mg three times a day for 10 to 14 days

If co-amoxiclav is not suitable, seek specialist advice to discuss the use of fluoroquinolones.

See section 5.1.1 Penicillins, 5.1.3 Tetracyclines, and 5.1.5 Macrolides

Children and young people aged under 18 years

Course length based on an assessment of the severity of bronchiectasis, exacerbation history, severity of exacerbation symptoms, previous culture and susceptibility results, and response to treatment.

Amoxicillin is the preferred choice in young women who are pregnant

1st and 2nd line for empirical treatment
Amoxicillin
  • 1 month to 11 months: 125mg three times a day for 10 to 14 days
  • 1 to 4 years: 250mg three times a day for 10 to 14 days
  • 5 to 17 years: 500 mg three times a day for 10 to 14 days
Doxycycline
  • Children and young people 12 to 17 years of age:
    • 200mg on first day, then 100mg once a day for a 10 to 14‑day course
  • Doxycycline is contraindicated in pregnancy, and the possibility of pregnancy should be considered in young women of childbearing age.
Clarithromycin
  • Children and young people 12 to 17 years of age:
    • 250mg to 500mg twice daily for 10 to 14 days
  • Children 1 month to 11 years of age (doses given twice daily for 10 to 14 days):
    • Body-weight under 8 kg: 7.5mg/kg
    • Body-weight 8–11 kg: 62.5mg
    • Body-weight 12–19 kg: 125mg
    • Body-weight 20–29 kg: 187.5mg
    • Body-weight 30–40 kg: 250mg
Alternative antibiotics for empirical treatment for people who are at higher risk of treatment failure

People who may be at higher risk of treatment failure include people who have had repeated courses of antibiotics, a previous sputum culture with resistant or atypical bacteria, or a higher risk of developing complications.

Co-amoxiclav
  • Children 1 month to 17 years of age (doses given three times a day for 10 to 14 days):
    • 1 to 11 months: 0.25ml/kg (125/31mg/5ml suspension)
    • 1 to 5 years: 5ml or 0.25ml/kg (125/31mg/5ml suspension)
    • 6 to 11 years: 5ml or 0.15ml/kg (250/62mg/5ml suspension)
    • 12 to 17 years: 250/125mg or 500/125mg

If co-amoxiclav is not suitable, seek specialist advice to discuss the use of fluoroquinolones.

See section 5.1.1 Penicillins, 5.1.3 Tetracyclines, and 5.1.5 Macrolides

Preventing acute exacerbations

Do not routinely offer antibiotic prophylaxis to prevent acute exacerbations of bronchiectasis. Give advice about seeking medical help if symptoms of an acute exacerbation develop.

Seek specialist advice about options for preventing exacerbations in people with repeated acute exacerbations, which may include a trial of antibiotic prophylaxis.

  • Only start a trial of antibiotic prophylaxis (with oral or inhaled antibiotics) in people with repeated acute exacerbations on the advice of a specialist

Referral

Consider (re)referral to specialist clinic for review of physiotherapy/mucolytics and/or prophylactic antibiotics in the following indications:

  • Patients with chronic Pseudomonas aeruginosa, non-tuberculous mycobacteria (NTM) or methicillin-resistant Staphylococcus aureus colonisation (MRSA)
  • Deteriorating bronchiectasis with declining lung function
  • Recurrent exacerbations (>3 per year)
  • Patients receiving long term antibiotic therapy (oral, inhaled or nebulised)
Last updated: 31-07-2020

 

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