Questionnaire/history:

Acute deterioration of normal symptoms (usually over several days)?

Worsening cough?

Increased sputum volume, viscosity or purulence?

Increased breathlessness?

Also may have new symptoms, eg fever, haemoptysis, pleurisy?

Past medical history?

Current medication?

Known drug allergies?

Management:

Sputum sample for MC+S prior to initiating antibiotics

Offer an antibiotic to all patients with an acute exacerbation

Consider severity, previous exacerbation/admission history, risk of complications and previous sputum culture results.

1st line (adults) - Course length depends on the severity, previous history, etc:

Amoxicillin 500mg TDS 7-14 days

Doxycycline 200mg D1, then 100mg OD for 7-14 day course

Clarithromycin 500mg BD 7-14 days

If high risk of treatment failure (eg repeated courses, resistant bacteria, risk of complications):

Co-amoxiclav 500/125 TDS 7-14 days

Levofloxacin 500mg once or twice daily 7-14 days - especially if previously confirmed

Pseudomonas

1st line (children):

Amoxicillin, clarithromycin or doxycycline 7-14 days (dosage)

If prophylactic antibiotics, suspend these during the acute exacerbation and prescribe an acute antibiotic from a different class

When sputum results are available review the choice of antibiotic BUT only change if the bacteria are resistant AND the infection is not improving

Reassess people if symptoms worsen rapidly or significantly:

Consider differential diagnosis, eg pneumonia, sepsis, antibiotic resistance

Seek advice if failure to improve despite repeated courses of antibiotics, if an infection resistant to oral antibiotics or if the patient cannot take oral antibiotics

Prophylactic Antibiotics?

Not routinely recommended but new BTS guidance 2020 recommends consideration of a atrial of prophylactic macrolides (eg azithromycin 500 mg 3 x per week) for people with ≥3 exacerbations per year under specialist supervision

Prophylactic antibiotics can reduce exacerbation rates for those with high exacerbation rates ≥ 3x per year, however before commencing careful assessment of potential benefits/risks is needed incl. ECG to check QTc 

Resource(s):

British Thoracic Guidelines (BTS): BTS Guideline for Bronchiectasis in Adults

NICE guideline [NG117]: Bronchiectasis (non-cystic fibrosis), acute exacerbation: antimicrobial prescribing

NICE CKS: Bronchiectasis