Bronchiectasis- Acute Exacerbation

Publication: 01/03/2009  --
Last review: 29/10/2019  
Next review: 01/10/2022  
Clinical Guideline
CURRENT 
ID: 1550 
Approved By: Improving Antimicrobial Prescribing Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2019  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Acute Exacerbation in Bronchiectasis

Summary
Bronchiectasis- Acute Exacerbation

Criteria for use
Antibiotics are recommended for exacerbations with acute deterioration with worsening symptoms (cough, increased sputum production, increased sputum purulence, wheeze, breathlessness, haemoptysis) and/or systemic upset.

Investigations required

  • SpO2, CXR, FBC, U&Es, LFTs, CRP, review previous sputum culture

Treatment
Non-Antimicrobial Management

  • Effective clearance of respiratory secretions e.g. physiotherapy, postural drainage
  • Nutritional support
  • Identification and treatment of underlying cause
  • Annual influenza vaccination
  • Sodium Chloride 7% (Resp-Ease ®) nebulised solution 4ml twice daily

Antimicrobial treatment

Table 1. Empirical antimicrobial regimens

Situation

First line

Penicillin allergy

Low risk of P. aeruginosa (no previous positive sputum cultures, no recent hospitalisation)

PO Amoxicillin electronic Medicines Compendium information on Amoxicillin 500mg 8-hourly (increase to 1g in severe infections)

1st Line: PO Doxycycline electronic Medicines Compendium information on Doxycycline 100mg 12-hourly
2nd Line: PO Levofloxacin electronic Medicines Compendium information on Levofloxacin 500mg 24-hourly (second line) (check susceptibilities)

If Intravenous therapy required*:
IV Amoxicillin electronic Medicines Compendium information on Amoxicillin 1g 8-hourly

IV Levofloxacin electronic Medicines Compendium information on Levofloxacin 500mg 12-hourly

High risk of P. aeruginosa(previous positive sputum cultures, recent (last 3 months) hospitalisation)

Oral Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 750mg 12-hourly

If severe (i.e. anaphylaxis) penicillin and/or cephalosporin allergy:
IV Aztreonam electronic Medicines Compendium information on Aztreonam 2g 8-hourly (note: this must be discussed with microbiology first and a code issued)

If Intravenous therapy required*:

Under 65

IV Ceftazidime electronic Medicines Compendium information on Ceftazidime 2g 8-hourly
2nd line (at the direction of a consultant respiratory physician):
IV Meropenem electronic Medicines Compendium information on Meropenem 2g 8-hourly

Over 65

IV Piperacillin/tazobactam electronic Medicines Compendium information on Piperacillin/tazobactam 4.5g 8-hourly
2nd line (at the direction of a consultant respiratory physician):
IV Meropenem electronic Medicines Compendium information on Meropenem 2g 8-hourly

*Intravenous therapy is required in patients who clinically fail to improve after appropriate oral and/or aerosolised antibiotics.
1 Prior to commencing Levofloxacin electronic Medicines Compendium information on Levofloxacin, the possibility of tuberculosis should be considered, and, if appropriate, sputum sent for AAFBs.

Referral criteria for specialist input
Patients with bronchiectasis should be reviewed by a chest physician.

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Background

Criteria for use of guidelines:

  • Patients presenting with acute exacerbations in association with underlying bronchiectasis.

Evidence level: The recommendations in the guideline are supported by level [C] evidence

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Clinical Diagnosis

Definition of an exacerbation requiring antibiotic therapy
Antibiotics are recommended for exacerbations with acute deterioration with worsening symptoms (cough, increased sputum production, increased sputum purulence, wheeze, breathlessness, haemoptysis) and/or systemic upset.

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Severity Assessment
  • SpO2, CXR, FBC, U&Es, LFTs, CRP, review previous sputum culture
  • Inpatient treatment recommended if:

    1. unable to cope at home
    2. Development of cyanosis or confusion
    3. Breathlessness with a respiratory rate ≥ 25/minute
    4. Circulatory failure
    5. Respiratory failure
    6. Temperature  ≥ 38oC
    7. Unable to take oral antibiotics
    8. Intravenous therapy required in patients with clinical failure to appropriate oral antibiotics (if unsuitable for home IV service)

    Prophylaxis – aerosolised antibiotics

    Some patients with chronic Pseudomonas aeruginosa infection may benefit from long-term aerosolised antibiotic therapy. The first line option is Colomycin® (colistimethate sodium) nebuliser solution 2 million units twice daily. Tobramycin electronic Medicines Compendium information on Tobramycin nebuliser solution 160mg twice daily is the second line alternative (in this situation the Tobramycin electronic Medicines Compendium information on Tobramycin 80mg/2ml injection is administered via the nebulised route). The decision to use these should be taken clinically and depends on a number of factors (e.g. compliance, susceptibility, tolerability, etc.)

    Tobramycin electronic Medicines Compendium information on Tobramycin 300mg/5mL nebuliser solution is licensed only for patients with cystic fibrosis, but is approved for use in patients with non-Cystic Fibrosis Bronchiectasis under a shared care agreement with GPs as an Amber Drug Level 2 (for further information read this guideline). It can only be prescribed by the Leeds Teaching Hospitals Bronchiectasis Clinic after assessment of risks versus benefits and other clinical factors (e.g. renal function, serum levels).

    Azithromycin electronic Medicines Compendium information on Azithromycin as an anti-inflammatory is reserved for those with demonstrable chronic Pseudomonas aeruginosa infection e.g. growing mucoid strain. It can be used once non- tuberculosis mycobacterium infection is excluded.

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    Investigation

    Specimens

    • Sputum should be sent for culture prior to commencing antibiotic treatment.
    • blood cultures should be taken from patients with single temperature > 38.5oC or < 35oC or persistent temperature >38oC before antibiotic treatment

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    Treatment
    Non-Antimicrobial Treatment
    • Effective clearance of respiratory secretions e.g. physiotherapy, postural drainage
    • Nutritional support
    • Identification and treatment of underlying cause
    • Annual influenza vaccination
    • Sodium Chloride 7% nebs Resp-Ease ® 4ml twice daily

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    Empirical Antimicrobial Treatment

    Whenever possible, therapy should be guided by sputum culture results

    Prophylaxis – oral antibiotics

    There is insufficient evidence to make any specific recommendations regarding the use of long term oral antibiotic prophylaxis (e.g. cyclical antibiotics)
    Azithromycin electronic Medicines Compendium information on Azithromycin as an anti-inflammatory is reserved for those with demonstrable chronic Pseudomonas aeruginosa infection e.g. growing mucoid strain. It can be use once non- tuberculosis mycobacterium infection is excluded.

    Empirical therapy

    N.B. Intravenous therapy is required in patients who clinically fail to improve after appropriate oral antibiotics and/or exacerbation despite long-term aerosolised antibiotics

    Low risk of P. aeruginosa (no previous positive sputum cultures, no recent hospitalisation)
    Oral Amoxicillin electronic Medicines Compendium information on Amoxicillin 500mg 8-hourly (increase to 1g in severe infections)
    Intravenous therapy required: IV Amoxicillin electronic Medicines Compendium information on Amoxicillin 1g 8-hourly

    High risk of P. aeruginosa (previous positive sputum cultures, recent (last 3 months) hospitalization)

    Second line IV antibiotic (if Ceftazidime electronic Medicines Compendium information on Ceftazidime or Piperacillin/tazobactam electronic Medicines Compendium information on Piperacillin/tazobactam  have failed and at the direction of a consultant respiratory physician):

    In severe acute exacerbations of bronchiectasis, or where there is a poor clinical response or resistant strains:

    • Consider the addition of a second agent to beta-lactam (e.g. IV Tobramycin electronic Medicines Compendium information on Tobramycin 5mg/kg once daily or IV colistimethate sodium 1-2 million unit 8-hourly).

    Antimicrobial allergy

    If severe (i.e. anaphylaxis) penicillin and/or cephalosporin allergy, replace iv Ceftazidime electronic Medicines Compendium information on Ceftazidime with iv Aztreonam electronic Medicines Compendium information on Aztreonam 2g 8-hourly (note: this must be approved by microbiology and a code issued)

    1Prior to commencing Levofloxacin electronic Medicines Compendium information on Levofloxacin, the possibility of tuberculosis should be considered, and, if appropriate, sputum sent for AAFBs.

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    Directed Antimicrobial Treatment (when microbiology results are known)

    Meticillin-susceptible Staphylococcus aureus
    IV Flucloxacillin 1g 6-hourly. Switch to PO Flucloxacillin 1g 6-hourly when clinically appropriate

    Meticillin-resistant Staphylococcus aureus
    If oral therapy is appropriate: oral Doxycycline electronic Medicines Compendium information on Doxycycline 100mg 12-hourly.
    If IV therapy required: IV Teicoplanin electronic Medicines Compendium information on Teicoplanin 6mg/kg (see dosing guideline) or Oral Linezolid electronic Medicines Compendium information on Linezolid (see dosing guideline). Contact Microbiology for further advice if required.

    Haemophilus influenzae
    Oral: Amoxicillin electronic Medicines Compendium information on Amoxicillin 500mg 8-hourly or Doxycycline electronic Medicines Compendium information on Doxycycline 100mg 12-hourly or Clarithromycin 500mg 12-hourly (check susceptibilities)
    High-dose Amoxicillin electronic Medicines Compendium information on Amoxicillin 3g 12-hourly (use 500mg capsules) may be needed in patients with severe bronchiectasis chronically colonised with Haemophilus influenzae

    Intravenous: Amoxicillin electronic Medicines Compendium information on Amoxicillin 1g 8-hourly or Co-Amoxiclav electronic Medicines Compendium information on Co-amoxiclav (Amoxicillin-Clavulanate) 1.2g 8-hourly or Clarithromycin 500mg 12-hourly (check susceptibilities)*

    Pseudomonas aeruginosa
    Oral: Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 750mg 12-hourly
    Intravenous: Ceftazidime electronic Medicines Compendium information on Ceftazidime 2g 8-hourly*†

    *Replace with IV Piperacillin/tazobactam electronic Medicines Compendium information on Piperacillin/tazobactam † 4.5g 8-hourly if age >65

    Second line IV antibiotic (if Ceftazidime electronic Medicines Compendium information on Ceftazidime or Piperacillin/tazobactam electronic Medicines Compendium information on Piperacillin/tazobactam failed and at the direction of a consultant respiratory physician):

    In severe acute exacerbations of bronchiectasis, or where there is a poor clinical response or resistant strains:

    • Consider the addition of a second agent to beta-lactam (e.g. IV Tobramycin electronic Medicines Compendium information on Tobramycin 5mg/kg once daily or IV colomycin 1-2 million unit 8-hourly).

    †Please Discuss with Microbiology if resistance and/or allergy prevents the use of the listed options

    Information on Tobramycin Dosing and Administration

    • Dose: Intravenous Tobramycin electronic Medicines Compendium information on Tobramycin 5mg/kg once daily.
      • Dilute to 50-100mL (5% glucose or 0.9% sodium chloride) and infuse over 20-60 minutes and flush with Sodium Chloride 0.9%.
    • Dosing should be based on ideal body weight (IBW) not actual body weight (ABW) unless the ABW is less than the IBW (i.e. They are underweight)
    • Doses should be rounded to the closest number divisible by 40 for ease of administration of the drug
    • Reduce dose in renal impairment (see section below for dosing in renal impairment)
      • Creatinine Clearance (CrCl) not eGFR should be used to calculate the patient’s renal function

    Dose adjustment in renal impairment

    CrCl (ml/min)

    Dose

    >40

    5mg/kg

    10-40

    3mg/kg (max 300mg)

    < 10

    2mg/kg (max 200mg)

    • Renal function and electrolytes should be monitored daily
    • When renal function is unstable, serum levels should be performed daily and the dose adjusted as necessary based on the patients creatinine clearance
    • If renal function deteriorates whilst the patient is receiving Tobramycin electronic Medicines Compendium information on Tobramycin the trough level should be checked and the renal function monitored daily. A dose reduction may be required.

    Monitoring of Tobramycin electronic Medicines Compendium information on Tobramycin

    • Trough levels should be taken immediately prior to the next dose of Tobramycin electronic Medicines Compendium information on Tobramycin. Do not take the blood sample from the IV line used for Tobramycin electronic Medicines Compendium information on Tobramycin administration
      • Document on the microbiology request form the EXACT time and date the infusion was set up (see prescription chart) and the EXACT time and date the sample was taken in addition to the patient details
    • The first trough level should be taken prior to the 2nd dose and then at 3 day intervals during therapy
    • The Target trough level should be <1mg/mL
    • Obtain advice from microbiology if the trough level is ≥1mg/mL

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    Duration of Treatment

    Continue therapy for 14 days. Intravenous therapy should be switch to oral therapy as soon as clinically indicated. If treating P. aeruginosa, intravenous antibiotics should be extended to 14 days.

    Prophylaxis

    Aerosolised antibiotics
    Some patients with chronic P. aeruginosa infection may benefit from long-term aerosolised antibiotic therapy. The first line option is Colomycin® (colistimethate sodium) nebuliser solution 2 million units twice daily. Tobramycin electronic Medicines Compendium information on Tobramycin nebuliser solution 160mg twice daily is the second line alternative (in this situation the Tobramycin electronic Medicines Compendium information on Tobramycin 80mg/2ml injection is administered via the nebulised route). The decision to use these should be taken clinically and depends on a number of factors (e.g. compliance, susceptibility, tolerability, etc.)

    Tobramycin electronic Medicines Compendium information on Tobramycin 300mg/5mL nebuliser solution is licensed only for patients with cystic fibrosis, but is approved for use in patients with non-Cystic Fibrosis Bronchiectasis under a shared care agreement with GPs as an Amber Drug Level 2 (for further information read this guideline).It can only be prescribed by the Leeds Teaching Hospitals Bronchiectasis Clinic after assessment of risks versus benefits and other clinical factors (e.g. renal function, serum levels).

    Oral antibiotics
    There is insufficient evidence to make any specific recommendations regarding the use of long term oral antibiotic prophylaxis (e.g. cyclical antibiotics)

    Azithromycin electronic Medicines Compendium information on Azithromycin as an anti-inflammatory is reserved for those with demonstrable chronic Pseudomonas aeruginosa infection e.g. growing mucoid strain. It can be use once non- tuberculosis mycobacterium infection is excluded.

    Back to top

    Switch to oral agent(s)

    The following criteria may be considered when deciding to switch from intravenous to oral therapy:

    • Resolution of fever.
    • Pulse rate <100 beats/min
    • Resolution of tachypnoea
    • Clinically hydrated and taking oral fluids
    • Resolution of hypotension
    • Absence of hypoxia
    • Improving white cell count
    • Non-bacteraemic infection
    • No concerns over gastrointestinal absorption

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    Treatment Failure

    Consider the following explanations:

    • Incorrect diagnosis
    • Resistant organism (including Mycobacterium tuberculosis)
    • Antibiotic hypersensitivity reaction
    • Complication e.g. empyema, abscess
    • Immunosuppression (known or unexpected)

    Please note that these are guidelines. On some occasions you may be advised to manage patients differently, depending on clinical circumstances, microbiology results, etc.

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    Referral Criteria
    Patients with bronchiectasis should be reviewed by a chest physician.

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    Provenance

    Record: 1550
    Objective:
    • To provide evidence-based recommendations for appropriate diagnosis and investigation of acute exacerbations in bronchiectasis
    • To provide evidence-based recommendations for appropriate non-antimicrobial management of acute exacerbations in bronchiectasis
    • To provide evidence-based recommendations for appropriate empirical and directed antimicrobial therapy of acute exacerbations in bronchiectasis
    • To recommend appropriate dose, route of administration and duration of antimicrobial agents.
    • To advise in the event of antimicrobial allergy.
    • To set-out criteria for referral to specialists.
    Clinical condition:

    Acute exacerbation in bronchiectasis

    Target patient group: Adults with non-CF bronchiectasis
    Target professional group(s): Secondary Care Doctors
    Pharmacists
    Adapted from:

    Evidence base

    • Evans DJ, Bara AI, Greenstone M. Prolonged antibiotics for purulent bronchiectasis in children and adults (review). Cochrane Database Rev 2007; CD001392.
    • Rosen MJ. Chronic cough due to bronchiectasis. ACCP evidence-based clinical practice guidelines. Chest 2006; 129: S122-31.
    • Woodhead M, Blasi F, Ewig S, Huchon G, Leven M, Ortqvist A, Schaberg T, Torres A, van der Heijden G, Verheij TJM. ERS Task Force in collaboration with ESCMID. Guidelines for the management of adult lower respiratory tract infections. Eur Respir J 2005; 26: 1138-80.
    • BTS Guideline for non-CF Bronchiectasis 2010. 
    • Polverino E, Goeminne PC, McDonnell MJ, et al. European Respiratory Society guidelines for the management of adult bronchiectasis. Eur Respir J 2017; 50: 1700629. Available at: http://erj.ersjournals.com/content/erj/50/3/1700629.full.pdf

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    Approved By

    Improving Antimicrobial Prescribing Group

    Document history

    LHP version 2.0

    Related information

    Not supplied

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