Recommendations

1.1 Managing an acute exacerbation of bronchiectasis (non-cystic fibrosis)

1.1.1 Be aware that an acute exacerbation of bronchiectasis is a sustained worsening of symptoms from a person's stable state.

Treatment

1.1.2 Obtain a sputum sample from people with an acute exacerbation of bronchiectasis and send for culture and susceptibility testing.

1.1.3 Offer an antibiotic to people with an acute exacerbation of bronchiectasis. When choosing an antibiotic (see the recommendations on choice of antibiotic), take account of:

  • the severity of symptoms

  • previous exacerbation and hospital admission history, and the risk of developing complications

  • previous sputum culture and susceptibility results.

1.1.4 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).

1.1.5 With an antibiotic, give advice about:

  • possible adverse effects of antibiotics, particularly diarrhoea

  • seeking medical help if symptoms worsen rapidly or significantly at any time, or the person becomes systemically very unwell.

To find out why the committee made the recommendations on treatment of an acute exacerbation, see the rationales.

Reassessment

1.1.6 Reassess people with an acute exacerbation of bronchiectasis if their symptoms worsen rapidly or significantly at any time, taking account of:

  • other possible diagnoses, such as pneumonia

  • 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.

To find out why the committee made the recommendation on reassessment, see the rationales.

Referral and seeking specialist advice

1.1.7 Refer people with an acute exacerbation of bronchiectasis to hospital if they have any symptoms or signs suggesting a more serious illness or condition (for example, cardiorespiratory failure or sepsis).

1.1.8 Seek specialist advice for people with an acute exacerbation of bronchiectasis if they:

  • have symptoms that are not improving with repeated courses of antibiotic treatment or

  • have bacteria that are resistant to oral antibiotics or

  • cannot take oral medicines (to explore locally available options for giving intravenous antibiotics at home or in the community, rather than in hospital, where this is appropriate).

To find out why the committee made the recommendations on referral and seeking specialist advice, see the rationales.

1.2 Choice of antibiotic for treating an acute exacerbation of bronchiectasis

1.2.1 When prescribing antibiotic treatment for an acute exacerbation of bronchiectasis:

  • follow table 1 for adults aged 18 years and over

  • follow table 2 for children and young people under 18 years.

1.2.2 Give oral antibiotics first line if the person can take oral medicines, and the severity of their condition does not require intravenous antibiotics.

1.2.3 Review intravenous antibiotics by 48 hours and consider stepping down to oral antibiotics where possible.

Table 1 Antibiotics for adults aged 18 years and over

Antibiotic 1,2

Dosage and course length

First-choice oral antibiotics for empirical treatment in the absence of current susceptibility data (guided by most recent sputum culture and susceptibilities where possible)

Amoxicillin3

500 mg three times a day for 7 to 14 days4

Doxycycline

200 mg on first day, then 100 mg once a day for a 7- to 14‑day course4

Clarithromycin

500 mg twice a day for 7 to 14 days4

Alternative choice oral antibiotics (if person at higher risk of treatment failure 5 ) for empirical treatment in the absence of current susceptibility data (guided by most recent sputum culture and susceptibilities where possible)

Co-amoxiclav

500/125 mg three times a day for 7 to 14 days4

Levofloxacin6

500 mg once or twice a day for 7 to 14 days4

First-choice intravenous antibiotics (if unable to take oral antibiotics or severely unwell) for empirical treatment in the absence of current susceptibility data (guided by most recent sputum culture and susceptibilities where possible) 7

Co-amoxiclav

1.2 g three times a day

Piperacillin with tazobactam

4.5 g three times a day, increased if necessary to 4.5 g four times a day

Levofloxacin6

500 mg once or twice a day

When current susceptibility data available, choose antibiotics accordingly

Consult local microbiologist as needed

1 See the British national formulary (BNF) for appropriate use and dosing in specific populations, for example, hepatic impairment, renal impairment, pregnancy and breastfeeding, and administering intravenous antibiotics.

2 When a person is receiving antibiotic prophylaxis, treatment should be with an antibiotic from a different class.

3 Amoxicillin is the preferred choice for women who are pregnant.

4 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.

5 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.

6 The European Medicines Agency's Pharmacovigilance Risk Assessment Committee has recommended restricting the use of fluoroquinolone antibiotics following a review of disabling and potentially long-lasting side effects mainly involving muscles, tendons, bones and the nervous system. This includes a recommendation not to use them for mild or moderately severe infections unless other antibiotics cannot be used (press release October 2018).

7 Review intravenous antibiotics by 48 hours and consider stepping down to oral antibiotics where possible for a total antibiotic course of 7 to 14 days.

Table 2 Antibiotics for children and young people under 18 years

Antibiotic 1,2

Dosage and course length 3

First-choice oral antibiotics for empirical treatment in the absence of current susceptibility data (guided by most recent sputum culture and susceptibilities where possible)

Amoxicillin4

1 to 11 months, 125 mg three times a day for 7 to 14 days5

1 to 4 years, 250 mg three times a day for 7 to 14 days5

5 to 17 years, 500 mg three times a day for 7 to 14 days5

Clarithromycin

1 month to 11 years:

Under 8 kg, 7.5 mg/kg twice a day for 7 to 14 days5

8 to 11 kg, 62.5 mg twice a day for 7 to 14 days5

12 to 19 kg, 125 mg twice a day for 7 to 14 days5

20 to 29 kg, 187.5 mg twice a day for 7 to 14 days5

30 to 40 kg, 250 mg twice a day for 7 to 14 days5

or

12 to 17 years, 250 mg to 500 mg twice a day for 7 to 14 days5

Doxycycline

12 to 17 years, 200 mg on first day, then 100 mg once a day for a 7- to 14‑day course in total5

Alternative choice oral antibiotics (if person at higher risk of treatment failure 6 ) for empirical treatment in the absence of current susceptibility data (guided by most recent sputum culture and susceptibilities where possible)

Co-amoxiclav

1 to 11 months, 0.25 ml/kg of 125/31 suspension three times a day for 7 to 14 days5

1 to 5 years, 5 ml of 125/31 suspension three times a day or 0.25 ml/kg of 125/31 suspension three times a day for 7 to 14 days5

6 to 11 years, 5 ml of 250/62 suspension three times a day or 0.15 ml/kg of 250/62 suspension three times a day for 7 to 14 days5

12 to 17 years, 250/125 mg three times a day or 500/125 mg three times a day for 7 to 14 days5

Ciprofloxacin (on specialist advice)7

1 to 17 years, 20 mg/kg twice daily (maximum 750 mg per dose) for 7 to 14 days5

First-choice intravenous antibiotics (if unable to take oral antibiotics or severely unwell) for empirical treatment in the absence of current susceptibility data (guided by most recent sputum culture and susceptibilities where possible) 8

Co-amoxiclav

1 to 2 months, 30 mg/kg twice a day

3 months to 17 years, 30 mg/kg three times a day (maximum 1.2 g three times a day)

Piperacillin with tazobactam

1 month to 11 years, 90 mg/kg three or four times a day (maximum per dose 4.5 g four times a day)

12 to 17 years, 4.5 g three times a day, increased if necessary to 4.5 g four times a day

Ciprofloxacin (on specialist advice)7

1 to 17 years, 10 mg/kg three times a day (maximum 400 mg per dose)

When current susceptibility data available, choose antibiotics accordingly

Consult local microbiologist as needed

1 See BNF for children for appropriate use and dosing in specific populations, for example, hepatic impairment and renal impairment, and administering intravenous antibiotics.

2 When a person is receiving antibiotic prophylaxis, treatment should be with an antibiotic from a different class.

3 The age bands apply to children of average size and, in practice, the prescriber will use the age bands in conjunction with other factors such as the severity of the condition and the child's size in relation to the average size of children of the same age.

4 Amoxicillin is the preferred choice in young women who are pregnant.

5 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.

6 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.

7 The European Medicines Agency's Pharmacovigilance Risk Assessment Committee has recommended restricting the use of fluoroquinolone antibiotics following a review of disabling and potentially long-lasting side effects mainly involving muscles, tendons, bones and the nervous system. This includes a recommendation not to use them for mild or moderately severe infections unless other antibiotics cannot be used (press release October 2018).

8 Review intravenous antibiotics by 48 hours and consider stepping down to oral antibiotics where possible for a total antibiotic course of 7 to 14 days.

To find out why the committee made the recommendations on choice and duration of antibiotics for managing an acute exacerbation, see the rationales.

1.3 Preventing acute exacerbations of bronchiectasis (non-cystic fibrosis)

1.3.1 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.

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

1.3.3 Only start a trial of antibiotic prophylaxis (with oral or inhaled antibiotics) in people with repeated acute exacerbations on the advice of a specialist. To ensure shared decision-making, discuss the following with the person:

  • the potential benefits of antibiotics for reducing exacerbations (taking into account the uncertain evidence of benefit for inhaled antibiotics)

  • the risks of antimicrobial resistance with long-term antibiotics, which may mean fewer effective antibiotics for future exacerbations

  • the possible adverse effects of long-term antibiotics, such as:

    • diarrhoea, cardiac events, hearing loss or tinnitus with macrolide antibiotics

    • bronchospasm with inhaled antibiotics

  • the possible interactions of macrolide antibiotics with other medicines

  • the need to regularly review prophylaxis.

To find out why the committee made the recommendations on preventing acute exacerbations of bronchiectasis, see the rationales.

  • Public Health England
  • National Institute for Health and Care Excellence (NICE)