Bronquiectasia

Principais recomendações do NICE sobre tratamento

Please be aware that some of the following indications for medications may not be licensed by the manufacturer (i.e., the use of the medication is ‘off-label’). Refer to the full NICE guideline and your local drug formulary for further information when prescribing.

Please note that this summary only covers antimicrobial prescribing recommendations for acute exacerbations of bronchiectasis (non-cystic fibrosis).

Antibiotic treatment for acute exacerbation of bronchiectasis

Obtain a sputum sample from people with an acute exacerbation of bronchiectasis (i.e., a sustained worsening of symptoms from their stable state) and send it for culture and susceptibility testing.

Offer an empirical antibiotic, guided by previous sputum culture and susceptibility results (where available), when current susceptibility data is unavailable.

When current susceptibility data is available, choose antibiotics accordingly, consulting with a local microbiologist as needed.

• If an empirical antibiotic has already been started, review the choice of antibiotic and only change treatment if the bacteria are resistant to the current antibiotic and symptoms are not already improving. Use a narrow-spectrum antibiotic wherever possible.

When choosing an antibiotic, in addition to considering any sputum culture and susceptibility results, consider the severity of symptoms, any previous exacerbation or hospital admission history, and the risk of developing complications.

• If the person is taking antibiotic prophylaxis for their bronchiectasis, choose an antibiotic treatment from a different class to treat the exacerbation.

Give oral antibiotics if the person can take oral medicines and they are not severely unwell.

• If an intravenous antibiotic is needed, review this by 48 hours and step down to oral antibiotics where possible for a total antibiotic course of 7 to 14 days.

Prescribe the shortest course of antibiotics that is likely to be effective. This is to reduce the risk of antimicrobial resistance and adverse effects. When choosing how long to prescribe antibiotics for, consider:

• Severity of exacerbation symptoms and severity of underlying bronchiectasis

• Exacerbation history

• Previous culture and susceptibility results

• Response to treatment.

Advise people taking antibiotics to seek medical help if their symptoms worsen rapidly or significantly at any time, or they become systemically very unwell. Reassess them if this occurs, taking account of:

• Other possible diagnoses (e.g., pneumonia), and any symptoms or signs suggesting a more serious illness or condition (e.g., cardiorespiratory failure or sepsis)

• Previous antibiotic use, which may have led to resistant bacteria.

Refer people to hospital if they have any symptoms or signs suggesting a more serious illness or condition (e.g., cardiorespiratory failure or sepsis).

Seek specialist advice if symptoms are not improving with repeated courses of antibiotics, or the person has bacteria that are resistant to oral antibiotics, or if they cannot take oral medicines.

Choice of empirical antibiotic

Prescribe a 7 to 14 day course of oral amoxicillin or clarithromycin (first-choice oral antibiotics) for people who are not at higher risk of treatment failure.

• People at higher risk of treatment failure include those who have had repeated antibiotic courses, resistant or atypical bacteria (e.g., pseudomonas aeruginosa) on previous sputum culture, and those at higher risk of developing complications.

• Oral doxycycline is another first-choice oral antibiotic but it is only suitable for those aged 12 years and over.

• Amoxicillin is the preferred choice in pregnancy.

Prescribe a 7 to 14 day course of oral co-amoxiclav (amoxicillin/clavulanate), an alternative choice oral antibiotic, for people who are at higher risk of treatment failure.

If oral co-amoxiclav cannot be used for a person at higher risk of treatment failure, other alternative choice oral antibiotics that can be used with specialist advice are levofloxacin (for adults) or ciprofloxacin (for children and young people under 18 years), prescribed as a 7 to 14 day course.

• Fluoroquinolone antibiotics (e.g., levofloxacin, ciprofloxacin) must only be prescribed when other commonly recommended antibiotics are inappropriate. Consider safety concerns with fluoroquinolones (e.g., risk of disabling and potentially long-lasting or irreversible adverse effects) on an individual patient basis. See MHRA advice for more information on restrictions and precautions for using fluoroquinolones.

Prescribe intravenous co-amoxiclav or piperacillin with tazobactam (first-choice intravenous antibiotics) for people who are severely unwell or unable to take oral antibiotics.

• If intravenous co-amoxiclav or piperacillin with tazobactam cannot be used, other intravenous antibiotics that can be used with specialist advice are levofloxacin (for adults) or ciprofloxacin (for children and young people under 18 years).

Preventing acute exacerbations

Advise people to seek medical help if symptoms of an acute exacerbation develop.

Seek specialist advice about preventative options for people with repeated acute exacerbations.

Do not routinely offer antibiotic prophylaxis to prevent acute exacerbations.

• Only start a trial of antibiotic prophylaxis on the advice of a specialist. Prophylaxis requires regular review.

• Advise the person about the risks of antimicrobial resistance (which may mean fewer effective antibiotics for future exacerbations), and the possible adverse effects of long-term antibiotics (e.g., cardiac events or hearing loss/tinnitus with macrolide antibiotics, and bronchospasm with inhaled antibiotics).

© NICE (2018) All rights reserved. Subject to Notice of rights NICE guidance is prepared for the National Health Service in England https://www.nice.org.uk/terms-and-conditions#notice-of-rights . All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication.