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How do I know my patient has an infective exacerbation of bronchiectasis?
- Diagnose an infective exacerbation of bronchiectasis requiring antibiotic therapy when there is:
- Acute deterioration (usually over several days), with worsening cough (with increased sputum volume, viscosity, or purulence; with or without increasing wheeze, breathlessness, or haemoptysis) and/or systemic upset.
- The presence of mucopurulent or purulent sputum alone, or the isolation of a pathogen alone, without a deterioration in symptoms is not necessarily an indication for antibiotic treatment, particularly in adults.
Basis for recommendation
Diagnostic criteria for infective exacerbations of bronchiectasis are based on expert opinion from the British Thoracic Society [British Thoracic Society, 2010].
When should I admit someone with an acute exacerbation?
- Arrange hospital admission for adults who:
- Are unable to cope at home.
- Are cyanosed or confused.
- Have a respiratory rate more than 25 breaths per minute.
- Have signs of cardiorespiratory failure (such as marked breathlessness, rapid respiration, laboured breathing, cyanosis, worsening peripheral oedema, or oxygen saturation < 93% on room air).
- Have a temperature of 38°C or more.
- Are unable to take oral therapy.
- Have failed to respond adequately to oral therapy.
- Have pleuritic pain severe enough to inhibit coughing and the clearing of secretions.
- Arrange hospital admission for children who:
- Are cyanosed.
- Have increased respiratory rate and work of breathing.
- Have signs of cardiorespiratory failure (such as marked breathlessness, rapid respiration, laboured breathing, cyanosis, worsening peripheral oedema, or oxygen saturation < 93% on room air).
- Have a temperature of 38°C or more.
- Are unable to take oral therapy.
- Fail to respond adequately to oral therapy.
Basis for recommendation
Admission criteria for people with an infective exacerbation of bronchiectasis are based on expert opinion from the British Thoracic Society [British Thoracic Society, 2010] and (in the case of pleuritic complications) a CKS expert reviewer.
How do I manage an infective exacerbation of bronchiectasis in primary care?
- Send sputum for culture and sensitivity testing before starting antibiotics (even if the person is taking long-term antibiotics).
- Collect expectorated sputum after deep coughing. A pharyngeal swab after coughing may be of value in very young children.
- Ensure prompt transport of specimens to the laboratory, as Haemophilus influenzae and Streptococcus pneumoniae may only be viable if the specimen is processed within 3 hours.
- Promptly prescribe an antibiotic for 10–14 days.
- Prescribe a short-acting inhaled beta2-agonist (such as salbutamol) if necessary for wheeze or breathlessness in the acute phase.
- Avoid using inhaled or oral corticosteroids, unless required for the treatment of coexisting asthma or chronic obstructive pulmonary disease.
- Ensure that a suitable airway clearance technique (that has been taught by a respiratory physiotherapist) is used during the exacerbation.
- Arrange an urgent appointment with a physiotherapist if the person has not already been taught this or if they cannot manage this alone.
- Review the response to empirical treatment when sputum culture and sensitivity results are available.
- If the person is responding well, continue with the prescribed antibiotic. Do not change the treatment based on the culture results.
- If the person has not responded well to treatment, prescribe a different antibiotic. The choice of antibiotic should be guided by the results of sputum culture and sensitivity testing.
- If the person deteriorates at any stage after starting treatment, re-assess to see if hospital admission is indicated.
Basis for recommendation
Sputum culture
- Experts recommend that samples should be collected even in people taking long-term antibiotics, as the antibiotic doses used are low and have little effect on actual pathogens isolated [McLean, 2008].
Antibiotics
- Recommendations on the use of antibiotics are based on the expert opinion of the British Thoracic Society [British Thoracic Society, 2010] and the opinions of CKS expert reviewers, who also recommend some flexibility in the duration of antibiotic treatment. Not all people may require the full 14 days. Clinical judgement is advised due to the weakness of the evidence base.
- The recommendation to not switch antibiotic on the basis of culture results unless there also is a lack of clinical response is based on expert opinion. This is because some people may respond to antibiotic treatment despite resistance to that drug in vitro [Murray and Hill, 2009; British Thoracic Society, 2010].
Inhaled short-acting beta2-agonist
- CKS expert reviewers advise that while a short-acting beta2-agonist may be prescribed for acute symptoms, longer-term use should prompt secondary care referral for review.
Corticosteroids
- CKS expert reviewers advised that inhaled or oral corticosteroids have no routine role for the treatment of isolated bronchiectasis; but they may be of value for the treatment of coexisting conditions such as asthma.
Physiotherapy
- It is not possible, from the limited available evidence, to assess the effectiveness of physiotherapy for people with bronchiectasis.
- It is widely believed by experts that airway clearance techniques are an important component of managing bronchiectasis [British Thoracic Society, 2010].
Which antibiotic should I prescribe for an infective exacerbation of bronchiectasis?
- Previous microbiology cultures, when available, should guide antibiotic choice.
- When previous microbiology cultures are not available:
- Prescribe according to local protocols where available, or
- Prescribe amoxicillin 500 mg three times a day (for 10–14 days). Clarithromycin 500 mg twice a day, erythromycin 500 mg four times a day, or doxycycline (adults only) 200 mg stat and then 100 mg once a day (all for 10–14 days) are alternatives for people allergic to penicillin.
- For further information on dosing regimens for empirical antibiotic treatment, see Prescriptions.
Table 1. Recommended antibiotics (with doses for adults) for acute exacerbations of bronchiectasis if sputum results from a previous sputum sample are available.
Organism | First-line antibiotic | Second-line antibiotic | Duration |
|---|
Streptococcus pneumoniae | Amoxicillin 500 mg TDS | Clarithromycin 500 mg BD | 10–14 days |
Haemophilus influenzae (beta-lactamase negative) | Amoxicillin 500 mg TDS or Amoxicillin 1 g TDS or Amoxicillin 3 g BD | Clarithromycin 500 mg BD or Doxycycline 200 mg stat, then 100 mg OD* | 10–14 days |
Haemophilus influenzae (beta-lactamase positive) | Co-amoxiclav 625 mg TDS | Clarithromycin 500 mg BD or Doxycycline 200 mg stat, then 100 mg OD* | 10–14 days |
Moraxella catarrhalis | Co-amoxiclav 625 mg TDS | Doxycycline 200 mg stat, then 100 mg OD* | 10–14 days |
Staphylococcus aureus (MSSA) | Flucloxacillin 500 mg QDS | Clarithromycin 500 mg BD | 10–14 days |
Staphylococcus aureus (MRSA) | Rifampicin‡ PLUS trimethoprim 200 mg BD | Rifampicin PLUS doxycycline 100 mg BD‡§ | 10–14 days |
Coliforms (such as Klebsiella or enterobacter) | Ciprofloxacin 500 mg BD | Intravenous antibiotics | 10–14 days |
Pseudomonas aeruginosa | Ciprofloxacin 500 mg BD† or Ciprofloxacin 750 mg BD | Intravenous antibiotics | 10–14 days |
* Doxycycline is not recommended as a second-line choice for Haemophilus influenzae infection in children. † Ciprofloxacin is recommended as a second-line choice for Moraxella catarrhalis or Pseudomonas aeruginosa infection in children (benefits thought to outweigh theoretical risk of arthropathy). See the BNF (British National Formulary) for dosage in children. ‡ For adults weighing < 50 kg, give rifampicin 450 mg OD. For adults weighing > 50 kg, give rifampicin 600 mg OD. § Rifampicin plus doxycycline is not recommended as a second-line choice for children with MRSA. Seek specialist advice if first-line treatment is contraindicated. For children's doses, see the BNF (British National Formulary). |
|
Basis for recommendation
Recommendations on the use of antibiotics are largely based on the expert opinion of the British Thoracic Society [British Thoracic Society, 2010].
Choice of antibiotic
- Recommended antibiotics reflect the likely pathogens. The commonest bacteria isolated during infective exacerbations of bronchiectasis include Haemophilus influenzae, Pseudomonas aeruginosa, Moraxella catarrhalis, Streptococcus pneumoniae, Staphylococcus aureus (the presence of which raises the suspicion of cystic fibrosis), and mycobacterium. Sometimes no organism is found [O'Donnell, 2008].
- Amoxicillin is a reasonable first-line empirical choice in the absence of previous sputum results as it has good activity against H. influenzae and S. pneumoniae [Murray and Hill, 2009; British Thoracic Society, 2010]. In addition, it is usually well tolerated and is inexpensive.
- Clarithromycin and erythromycin are recommended as alternatives for people with penicillin allergy [Murray and Hill, 2009; British Thoracic Society, 2010]. They are active against H. influenzae, S. pneumoniae, S. aureus (meticillin sensitive) and M. catarrhalis. However, resistance to H. influenzae is increasing [Bryskier and Butzler, 2003].
- Doxycycline is an alternative empirical antibiotic for people with penicillin allergy [HPA, Personal Communication, 2010]. It is active against H. influenzae, S. pneumoniae, S. aureus and M. catarrhalis. It is available as a convenient, once-daily regimen (after an initial loading dose), is well tolerated by most people, and is relatively inexpensive.
Duration of antibiotic treatment
- The duration of treatment is based on the expert opinion of the British Thoracic Society [British Thoracic Society, 2010] and the opinions of CKS expert reviewers, who also recommend some flexibility in the duration of antibiotic treatment. Not all people may require the full 14 days. Clinical judgement is advised due to the weakness of the evidence base.
Prescriptions
For information on contraindications, cautions, drug interactions, and adverse effects, see the electronic Medicines Compendium (eMC) (http://emc.medicines.org.uk), or the British National Formulary (BNF) (www.bnf.org).
1st line (if no sputum results): amoxicillin
Age from 1 year to 4 years 11 months
Amoxicillin s/f suspension: 250mg three times a day for 14 days
Amoxicillin 250mg/5ml oral suspension sugar free
Take one 5ml spoonful three times a day for 14 days.
Supply 200 ml.
Amoxicillin s/f suspension: 250mg three times a day for 10 days
Amoxicillin 250mg/5ml oral suspension sugar free
Take one 5ml spoonful three times a day for 10 days.
Supply 200 ml.
Age from 5 years to 11 years 11 months
Amoxicillin s/f suspension: 500mg three times a day for 14 days
Amoxicillin 250mg/5ml oral suspension sugar free
Take two 5ml spoonfuls three times a day for 14 days.
Supply 400 ml.
Amoxicillin s/f suspension: 500mg three times a day for 10 days
Amoxicillin 250mg/5ml oral suspension sugar free
Take two 5ml spoonfuls three times a day for 10 days.
Supply 300 ml.
Age from 12 years onwards
Amoxicillin capsules: 500mg three times a day for 14 days
Amoxicillin 500mg capsules
Take one capsule three times a day for 14 days.
Supply 42 capsules.
Amoxicillin capsules: 500mg three times a day for 10 days
Amoxicillin 500mg capsules
Take one capsule three times a day for 10 days.
Supply 30 capsules.
Penicillin allergy (if no sputum results): clarithromycin
Age from 1 year to 3 years
Clarithromycin suspension for 14 days: child weighs 7.9kg or less
Clarithromycin 125mg/5ml oral suspension
*WEIGHT REQUIRED* Give 7.5mg per kg bodyweight TWICE a day for 14 days.
Supply 70 ml.
Clarithromycin suspension for 10 days: child weighs 7.9kg or less
Clarithromycin 125mg/5ml oral suspension
*WEIGHT REQUIRED* Take 7.5mg per kg bodyweight TWICE a day for 10 days.
Supply 70 ml.
Age from 1 year to 5 years
Clarithromycin suspension for 14 days: child weighs 8kg to 11.9 kg
Clarithromycin 125mg/5ml oral suspension
Take 2.5ml twice a day for 14 days.
Supply 70 ml.
Clarithromycin suspension for 10 days: child weighs 8kg to 11.9 kg
Clarithromycin 125mg/5ml oral suspension
Take 2.5ml twice a day for 10 days.
Supply 70 ml.
Age from 1 year to 7 years
Clarithromycin suspension for 14 days: child weighs 12kg to 19.9kg
Clarithromycin 125mg/5ml oral suspension
Take one 5ml spoonful twice a day for 14 days.
Supply 140 ml.
Clarithromycin suspension for 10 days: child weighs 12kg to 19.9kg
Clarithromycin 125mg/5ml oral suspension
Take one 5ml spoonful twice a day for 10 days.
Supply 140 ml.
Age from 3 to 10 years
Clarithromycin suspension for 14 days: child weighs 20kg to 29.9kg
Clarithromycin 125mg/5ml oral suspension
Take 7.5ml twice a day for 14 days.
Supply 210 ml.
Clarithromycin suspension for 10 days: child weighs 20kg to 29.9kg
Clarithromycin 125mg/5ml oral suspension
Take 7.5ml twice a day for 10 days.
Supply 140 ml.
Age from 7 years to 11 years 11 months
Clarithromycin suspension for 14 days: child weighs 30kg or more
Clarithromycin 250mg/5ml oral suspension
Take one 5ml spoonful twice a day for 14 days.
Supply 140 ml.
Clarithromycin suspension for 10 days: child weighs 30kg or more
Clarithromycin 250mg/5ml oral suspension
Take one 5ml spoonful twice a day for 10 days.
Supply 140 ml.
Age from 12 years onwards
Clarithromycin tablets: 500mg twice a day for 14 days
Clarithromycin 500mg tablets
Take one tablet twice a day for 14 days.
Supply 28 tablets.
Clarithromycin tablets: 500mg twice a day for 10 days
Clarithromycin 500mg tablets
Take one tablet twice a day for 10 days.
Supply 20 tablets.
Penicillin allergy (if no sputum results): erythromycin
Age from 1 month to 1 year 11 months
Erythromycin s/f suspension: 125mg four times a day for 14 days
Erythromycin ethyl succinate 125mg/5ml oral suspension sugar free
Take one 5ml spoonful four times a day for 14 days.
Supply 300 ml.
Erythromycin s/f suspension: 125mg four times a day for 10 days
Erythromycin ethyl succinate 125mg/5ml oral suspension sugar free
Take one 5ml spoonful four times a day for 10 days.
Supply 200 ml.
Age from 2 years to 7 years 11 months
Erythromycin s/f suspension: 250mg four times a day for 14 days
Erythromycin ethyl succinate 250mg/5ml oral suspension sugar free
Take one 5ml spoonful four times a day for 14 days.
Supply 300 ml.
Erythromycin s/f suspension: 250mg four times a day for 10 days
Erythromycin ethyl succinate 250mg/5ml oral suspension sugar free
Take one 5ml spoonful four times a day for 10 days.
Supply 200 ml.
Age from 8 years to 11 years 11 months
Erythromycin s/f suspension: 500mg four times a day for 14 days
Erythromycin ethyl succinate 500mg/5ml oral suspension sugar free
Take one 5ml spoonful four times a day for 14 days.
Supply 300 ml.
Erythromycin s/f suspension: 500mg four times a day for 10 days
Erythromycin ethyl succinate 500mg/5ml oral suspension sugar free
Take one 5ml spoonful four times a day for 10 days.
Supply 200 ml.
Age from 12 years onwards
Erythromycin e/c tablets: 500mg four times a day
Erythromycin 250mg gastro-resistant tablets
Take two tablets four times a day for 14 days.
Supply 112 tablets.
Erythromycin e/c tablets: 500mg four times a day for 10 days
Erythromycin 250mg gastro-resistant tablets
Take two tablets four times a day for 10 days.
Supply 80 tablets.
Penicillin allergy (if no sputum results): doxycycline
Age from 12 years onwards
Doxycycline capsules: 100mg once a day for 14 days
Doxycycline 100mg capsules
Take TWO capsules now and then take one capsule once a day for the next 13 days.
Supply 15 capsules.
Doxycycline capsules: 100mg once a day for 10 days
Doxycycline 100mg capsules
Take TWO capsules now and then take one capsule once a day for the next 9 days.
Supply 11 capsules.
Short-acting beta2-agonists (pMDI)
Age from 1 year to 1 year 11 months
Multi-therapy: Airomir 100mcg MDI + Infant AeroChamber Plus + mask
Airomir 100mcg CFC-free MDI: 1-2 puffs up to 4 times a day
Airomir 100micrograms/actuation inhaler
Inhale one to two puffs up to four times a day using the spacer, when required to relieve breathlessness.
Supply 1 200 dose inhaler.
AeroChamber Plus + infant face mask
AeroChamber Plus with infant mask
Use to aid inhalation.
Supply 1 spacer.
Age from 1 year to 4 years 11 months
Multi-therapy: Ventolin 100mcg MDI + Volumatic + mask
Ventolin 100mcg CFC-free MDI: 1-2 puffs up to 4 times a day
Ventolin Evohaler 100micrograms/actuation
Inhale one to two puffs up to four times a day using the spacer, when required to relieve breathlessness.
Supply 1 200 dose inhaler.
Volumatic with paediatric mask
Use to aid inhalation.
Supply 1 spacer.
Age from 2 years to 4 years 11 months
Multi-therapy: Airomir 100mcg MDI + Child AeroChamber Plus + mask
Airomir 100mcg CFC-free MDI: 1-2 puffs up to 4 times a day
Airomir 100micrograms/actuation inhaler
Inhale one to two puffs up to four times a day using the spacer, when required to relieve breathlessness.
Supply 1 200 dose inhaler.
AeroChamber Plus + child face mask
AeroChamber Plus with child mask
Use to aid inhalation.
Supply 1 spacer.
Age from 5 years onwards
Salbutamol 100mcg CFC-free MDI: 1-2 puffs upto 4 times a day
Salbutamol 100micrograms/actuation inhaler CFC free
Inhale one to two puffs up to four times a day, when required to relieve breathlessness.
Supply 1 200 dose inhaler.
Airomir 100mcg CFC-free MDI: 1-2 puffs up to 4 times a day
Airomir 100micrograms/actuation inhaler
Inhale one to two puffs up to four times a day, when required to relieve breathlessness.
Supply 1 200 dose inhaler.
Ventolin 100mcg CFC-free MDI: 1-2 puffs up to 4 times a day
Ventolin Evohaler 100micrograms/actuation
Inhale one to two puffs up to four times a day, when required to relieve breathlessness.
Supply 1 200 dose inhaler.