Bronchiectasis
Standard Treatment Guidelines and Essential Medicines List for South Africa, Hospital Level, Adults 2019 Edition
J47
GENERAL MEASURES
- Advice on early self-referral for suspected acute infections.
- Physiotherapy: Regular chest clearance exercises (20 minutes morning and night) are the mainstay of therapy and must be emphasised and demonstrated to the patients, including cough and chest drainage techniques, and must be emphasised repetitively.
MEDICINE TREATMENT
Antimicrobial therapy
- Antibiotic therapy in patients with bronchiectasis should only be used when there is either systemic evidence of sepsis such as pyrexia, or there is a history of increasing sputum purulence or volume.
- Antibiotic choices should be guided by sputum microscopy, culture and sensitivity. The number and duration of physiotherapy sessions should be increased.
- Treatment may need to be prolonged for two weeks, depending on the extent of the bronchiectasis and the organisms suspected.
In patients otherwise stable and before culture results:
- Amoxicillin/clavulanic acid, oral, 875/125 mg 12 hourly for 10 days, or longer, depending on the response.
LoE:IIIxxi
Severe penicillin allergy: (Z88.0)
- Azithromycin, oral, 500 mg daily for 10 days
LoE:IVb
More severely ill patients may require hospitalisation and initiation of parenteral antibiotic therapy.
Sputum microscopy, culture and sensitivity determination are indicated in all cases.
- Ceftriaxone 2 g, IV, daily, until patient apyrexial for 24 hours.
LoE:IIIxxii
Follow with:
- Amoxicillin/clavulanic acid, oral, 875/125 mg 12 hourly.
LoE:IIIxxiii
If Pseudomonas infection is confirmed on culture, change to: (B96.5)
- Ciprofloxacin, oral, 750 mg 12 hourly for 7 days.
If penicillin allergic and unable to tolerate oral therapy: (Z88.0)
- Management of these patients should be discussed with a specialist for possible referral and alternative parenteral therapy:
- Moxifloxacin, IV, 400 mg daily infused over 60 minutes.
If penicillin allergic and unable to tolerate oral therapy: (Z88.0)
Management of these patients should be discussed with a specialist for possible referral and alternative parenteral therapy:
- Moxifloxacin, IV, 400 mg daily infused over 60 minutes.
LoE:IIIxxiv
Switch to oral treatment once able to take orally:
- Moxifloxacin, oral, 400 mg daily to complete a total of 7 days of treatment with moxifloxacin i.e. total duration of 7 days for IV and oral combined.
Subsequent antibiotic therapy should be based on results of sputum investigations. A sputum smear for Acid Fast Bacilli (AFB), followed by culture if positive, is recommended in patients with a poor response to antibiotics as patients with bronchiectasis are at increased risk for infection with non-tuberculous Mycobacteria which will not be detected by Xpert® MTB/RIF PCR assay. If tuberculosis is a consideration, also send a sputum for TB-NAAT testing.
Inhaled bronchodilators
- Bronchodilators may be used, as for COPD, if airflow obstruction is present.
- There is no indication for inhaled corticosteroids in the management of bronchiectasis.
- Any asthmatic component (i.e. reversible obstruction) should be treated in the usual way, as for asthma (See: Asthma, acute, and Asthma, chronic persistent).
- See Appendix VI: Devices for Respiratory Conditions for guidance on inhaler, spacer and nebuliser device techniques.
Prophylaxis (Z25.1)
- Annual influenza vaccine. See Adult vaccination.
For frequent severe exacerbations, consult a specialist.
REFERRAL
- For exclusion of a possible foreign body.
- For assessment for surgical removal of a bronchiectatic segment.
- Major haemoptysis.
Standard Treatment Guidelines and Essential Medicines List for South Africa, Adult Hospital Level, 2020-2024_Version 1.1_16 September 2024
Chapter 16: Respiratory Disorders _16.3 Bronchiectasis