× NICE uses cookies to make the site better.  Learn more
A-Z
Topics
Latest


Bronchiectasis (non-cystic fibrosis) – antimicrobial prescribing

About

What is covered

This interactive flowchart covers antimicrobial prescribing for managing and preventing an acute exacerbation of bronchiectasis (non-cystic fibrosis). It aims to optimise antibiotic use and reduce antibiotic resistance.

Updates

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Short Text

Everything NICE has said on antimicrobial prescribing for managing and preventing an acute exacerbation of bronchiectasis (non-cystic fibrosis) in an interactive flowchart

What is covered

This interactive flowchart covers antimicrobial prescribing for managing and preventing an acute exacerbation of bronchiectasis (non-cystic fibrosis). It aims to optimise antibiotic use and reduce antibiotic resistance.

Quality standards

Quality statements

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

NICE has produced resources to help implement its guidance on:

Information for the public

NICE has written information for the public on each of the following topics.

Pathway information

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Supporting information

An acute exacerbation of bronchiectasis is characterised by an acute deterioration of normal symptoms and signs usually over several days. It presents with worsening local symptoms (such as cough, increased sputum volume, change of sputum viscosity, or increased sputum purulence) with or without increased wheeze, breathlessness or haemoptysis. Fever or pleurisy may also be present (British Thoracic Society's 2010 guideline on non-cystic fibrosis bronchiectasis).
Bronchiectasis is defined as persistent or recurrent bronchial sepsis related to irreversibly damaged and dilated bronchi (British Thoracic Society's 2010 guideline on non-cystic fibrosis bronchiectasis).

Antibiotics for adults aged 18 years and over

Antibiotic1,2
Dosage and course length
First-choice oral antibiotics for empirical treatment in the absence of current susceptibility data (guided by most recent sputum culture and susceptibilities where possible)
Amoxicillin3
500 mg three times a day for 7 to 14 days4
Doxycycline
200 mg on first day, then 100 mg once a day for a 7- to 14-day course4
Clarithromycin
500 mg twice a day for 7 to 14 days4
Alternative choice oral antibiotics (if person at higher risk of treatment failure5) for empirical treatment in the absence of current susceptibility data (guided by most recent sputum culture and susceptibilities where possible)
Co-amoxiclav
500/125 mg three times a day for 7 to 14 days4
Levofloxacin6
500 mg once or twice a day for 7 to 14 days4
First-choice intravenous antibiotics (if unable to take oral antibiotics or severely unwell) for empirical treatment in the absence of current susceptibility data (guided by most recent sputum culture and susceptibilities where possible)7
Co-amoxiclav
1.2 g three times a day
Piperacillin with tazobactam
4.5 g three times a day, increased if necessary to 4.5 g four times a day
Levofloxacin6
500 mg once or twice a day
When current susceptibility data available, choose antibiotics accordingly
Consult local microbiologist as needed
1 See the British national formulary BNF for appropriate use and dosing in specific populations, for example hepatic impairment, renal impairment, pregnancy and breastfeeding, and administering intravenous antibiotics.
2 When a person is receiving antibiotic prophylaxis, treatment should be with an antibiotic from a different class.
3 Amoxicillin is the preferred choice for women who are pregnant.
4 Course length based on an assessment of the severity of bronchiectasis, exacerbation history, severity of exacerbation symptoms, previous culture and susceptibility results and response to treatment.
5 People who may be at higher risk of treatment failure include people who have had repeated courses of antibiotics, a previous sputum culture with resistant or atypical bacteria, or a higher risk of developing complications.
6 The European Medicines Agency's Pharmacovigilance Risk Assessment Committee has recommended restricting the use of fluoroquinolone antibiotics following a review of disabling and potentially long-lasting side effects mainly involving muscles, tendons, bones and the nervous system. This includes a recommendation not to use them for mild or moderately severe infections unless other antibiotics cannot be used (press release October 2018).
7 Review intravenous antibiotics by 48 hours and consider stepping down to oral antibiotics where possible for a total antibiotic course of 7 to 14 days.

Antibiotics for children and young people under 18 years

Antibiotic1,2
Dosage and course length3
First-choice oral antibiotics for empirical treatment in the absence of current susceptibility data (guided by most recent sputum culture and susceptibilities where possible)
Amoxicillin4
1 to 11 months, 125 mg three times a day for 7 to 14 days5
1 to 4 years, 250 mg three times a day for 7 to 14 days5
5 to 17 years, 500 mg three times a day for 7 to 14 days5
Clarithromycin
1 month to 11 years:
Under 8 kg, 7.5 mg/kg twice a day for 7 to 14 days5
8 to 11 kg, 62.5 mg twice a day for 7 to 14 days5
12 to 19 kg, 125 mg twice a day for 7 to 14 days5
20 to 29 kg, 187.5 mg twice a day for 7 to 14 days5
30 to 40 kg, 250 mg twice a day for 7 to 14 days5
or
12 to 17 years, 250 mg to 500 mg twice a day for 7 to 14 days5
Doxycycline
12 to 17 years, 200 mg on first day, then 100 mg once a day for a 7- to 14-day course in total5
Alternative choice oral antibiotics (if person at higher risk of treatment failure6) for empirical treatment in the absence of current susceptibility data (guided by most recent sputum culture and susceptibilities where possible)
Co-amoxiclav
1 to 11 months, 0.25 ml/kg of 125/31 suspension three times a day for 7 to 14 days5
1 to 5 years, 5 ml of 125/31 suspension three times a day or 0.25 ml/kg of 125/31 suspension three times a day for 7 to 14 days5
6 to 11 years, 5 ml of 250/62 suspension three times a day or 0.15 ml/kg of 250/62 suspension three times a day for 7 to 14 days5
12 to 17 years, 250/125 mg three times a day or 500/125 mg three times a day for 7 to 14 days5
Ciprofloxacin (on specialist advice)7
1 to 17 years, 20 mg/kg twice daily (maximum 750 mg per dose) for 7 to 14 days5
First-choice intravenous antibiotics (if unable to take oral antibiotics or severely unwell) for empirical treatment in the absence of current susceptibility data (guided by most recent sputum culture and susceptibilities where possible)8
Co-amoxiclav
1 to 2 months, 30 mg/kg twice a day
3 months to 17 years, 30 mg/kg three times a day (maximum 1.2 g three times a day)
Piperacillin with tazobactam
1 month to 11 years, 90 mg/kg three or four times a day (maximum per dose 4.5 g four times a day)
12 to 17 years, 4.5 g three times a day, increased if necessary to 4.5 g four times a day
Ciprofloxacin (on specialist advice)7
1 to 17 years, 10 mg/kg three times a day (maximum 400 mg per dose)
When current susceptibility data available, choose antibiotics accordingly
Consult local microbiologist as needed
1 See BNF for children for appropriate use and dosing in specific populations, for example hepatic impairment and renal impairment, and administering intravenous antibiotics.
2 When a person is receiving antibiotic prophylaxis, treatment should be with an antibiotic from a different class.
3 The age bands apply to children of average size and, in practice, the prescriber will use the age bands in conjunction with other factors such as the severity of the condition and the child's size in relation to the average size of children of the same age.
4 Amoxicillin is the preferred choice in young women who are pregnant.
5 Course length based on an assessment of the severity of bronchiectasis, exacerbation history, severity of exacerbation symptoms, previous culture and susceptibility results and response to treatment.
6 People who may be at higher risk of treatment failure include people who have had repeated courses of antibiotics, a previous sputum culture with resistant or atypical bacteria, or a higher risk of developing complications.
7 The European Medicines Agency's Pharmacovigilance Risk Assessment Committee has recommended restricting the use of fluoroquinolone antibiotics following a review of disabling and potentially long-lasting side effects mainly involving muscles, tendons, bones and the nervous system. This includes a recommendation not to use them for mild or moderately severe infections unless other antibiotics cannot be used (press release October 2018).
8 Review intravenous antibiotics by 48 hours and consider stepping down to oral antibiotics where possible for a total antibiotic course of 7 to 14 days.

Rationale: prevention

The committee discussed the evidence for prophylactic antibiotics. Overall, antibiotics reduced exacerbation rates, hospitalisations and the number of people with an exacerbation. However, there was a significant increase in antibiotic resistance and adverse effects.
Most of the studies were in populations who had experienced multiple exacerbations in the previous year, and the committee thought the findings could not be generalised to everyone with bronchiectasis.
Based on evidence and experience, the committee agreed that people should not routinely be offered antibiotic prophylaxis to prevent acute exacerbations, because of the balance of risks and benefits in the overall population.
For people with repeated exacerbations, where the benefits of prophylaxis may outweigh the risks, specialist advice should be sought on various management options, which may include a trial of antibiotic prophylaxis (with oral or inhaled antibiotics).
The committee noted it was difficult to give a precise definition of 'repeated exacerbations' and clinical judgement would be needed to define this on an individualised patient basis.
The committee agreed that a trial of antibiotic prophylaxis should only be started in people with repeated acute exacerbations on the advice of a specialist, because it is important to consider antibiotic prophylaxis alongside other management options. Shared decision-making is important for taking into account the risks and benefits of prophylaxis on an individualised patient basis. This includes discussing the potential benefits of antibiotics for reducing exacerbations, but also the harms of long-term antibiotics. There is an increased risk of resistance with long-term antibiotics, which impacts at both a population and an individual level, and people should be advised that this can mean fewer antibiotics may work for their exacerbations in the future. People should also be advised about possible adverse effects. With macrolides, diarrhoea is common but there are also less common cardiac events, hearing loss and tinnitus, and the potential to interact with other medicines. Bronchospasm is a possible adverse effect with inhaled antibiotics and a challenge test is needed. The committee discussed that people being considered for antibiotic prophylaxis would also need to return for regular review.
The committee discussed that most evidence for prophylactic antibiotics was for oral macrolide antibiotics in adults, where they reduced exacerbation rates and the number of people with an exacerbation. However, they also increased antibiotic resistance and adverse effects. The limited evidence in children and young people found prophylactic oral macrolide antibiotics did not significantly reduce exacerbations but increased antimicrobial resistance.
The evidence for nebulised or inhaled antibiotics was particularly limited, and not all products studied are available in the UK. As a class, prophylaxis with nebulised or inhaled antibiotics did not significantly reduce exacerbations in adults. In 1 trial of nebulised colistimethate sodium in people with chronic Pseudomonas aeruginosa infection, exacerbations were significantly reduced in an adherent population, but not in the intention-to-treat population, which was the primary end point. In another trial of nebulised tobramycin, a non-significant increase in exacerbations, and adverse events such as dyspnoea, chest pain and wheeze were seen.
The committee were unable to make specific recommendations on the choice of antibiotic for prophylaxis, because this will be an individualised decision based on the clinical needs of the person, their preferences and advice from a specialist.

Rationale: when to refer to hospital or seek specialist advice

Based on experience, the committee agreed that, for safety netting, people with an acute exacerbation of bronchiectasis should be referred to hospital if they have any symptoms or signs suggesting a more serious illness or condition (for example cardiorespiratory failure or suspected sepsis).
The committee discussed that some people who are severely ill or have resistant bacteria (particularly Pseudomonas aeruginosa) may need intravenous antibiotics, particularly if their symptoms are not responding to several courses of oral antibiotics for the same episode, or if several sputum samples show resistance to oral antibiotics. The committee discussed that specialist advice should be sought for people needing intravenous antibiotics, to discuss local options for giving intravenous antibiotics at home or in the community, rather than in hospital, if this is appropriate for the person.

Rationale: when to reassess

Based on experience, the committee agreed that, for safety netting, reassessment was needed if symptoms of the acute exacerbation worsen rapidly or significantly at any time.

Rationale: antibiotic treatment and advice

The committee agreed, based on their experience, that people with an acute exacerbation of bronchiectasis presenting with worsening local symptoms (such as cough, increased sputum volume, change of sputum viscosity or increased sputum purulence) with or without increased wheeze, breathlessness, haemoptysis, fever or pleurisy, should receive an antibiotic. Choice should take account of the severity of their symptoms, their previous exacerbation and hospital admission history, their risk of developing complications, and previous sputum culture and susceptibility results.
The committee discussed the limited evidence base for antibiotics for treating an acute exacerbation of bronchiectasis. No evidence was found comparing antibiotics with placebo from systematic reviews or randomised controlled trials from the search, which went back to 2006. However, the committee were aware of older, heterogeneous, head-to-head studies comparing different antibiotic regimens (which may not reflect current practice).
Based on experience, the committee agreed that although in the first instance, antibiotic treatment for an acute exacerbation may be empirical, a new sputum sample should be sent for culture to confirm susceptibility of the bacteria. The committee discussed that for empirical treatment, antibiotics should be chosen initially based on the most recent sputum culture and susceptibility results. People with bronchiectasis are likely to have previous sputum samples, and because pathogenic bacteria are reasonably static in this population, antibiotics that worked previously are a good starting point to treat new exacerbations. However, pathogenic bacteria can change and a new sputum sample should be sent for culture when people present with a new exacerbation of bronchiectasis, and this new susceptibility data used to review antibiotic choice. The committee discussed the importance of all prescribers having access to microbiology results, with hospital managers ensuring that primary care teams have easy access to microbiology results.
Based on experience, the committee agreed that when results of sputum cultures are available, if they suggest the bacteria are not susceptible, the person should be contacted to assess symptoms. However, the antibiotic should only be changed according to susceptibility results if symptoms are not already improving. In line with good antimicrobial stewardship, narrow-spectrum antibiotics should be used wherever possible.
The committee agreed that when an antibiotic is given, people should be advised about possible adverse effects and also be given safety netting advice.

Rationale: choice of antibiotic

Very limited evidence was identified to guide the choice of antibiotic for treating an acute exacerbation of bronchiectasis.
Based on experience, common pathogens in acute exacerbations, the susceptibility of these to various classes of antibiotics, the risks of resistance and good antimicrobial stewardship, the committee agreed the following antibiotic choices for empirical treatment in the absence of current susceptibility data. Choice should be guided by the most recent sputum culture and susceptibilities where possible. Several oral and intravenous antibiotics were recommended to enable antibiotics to be selected based on the severity of illness and previous antibiotic use.
First-choice oral antibiotics for empirical treatment are:
  • amoxicillin (a penicillin), which has good activity against common pathogens, such as Streptococcus pneumoniae and Haemophilus influenzae
  • clarithromycin (a macrolide)
  • doxycycline (a tetracycline; adults and young people over 12 years only).
Alternative choice oral antibiotics for empirical treatment for people who are at higher risk of treatment failure (which may include people who have had repeated courses of antibiotics, a previous sputum culture with resistant or atypical bacteria, or people at higher risk of developing complications) are:
  • co-amoxiclav, a broad-spectrum antibiotic which combines a penicillin with a beta-lactamase inhibitor, making it active against beta-lactamase-producing bacteria that are resistant to amoxicillin alone or
  • a fluoroquinolone: levofloxacin in adults or ciprofloxacin in children (only on specialist advice because fluoroquinolones are generally not recommended in children or young people who are growing), which have good activity against atypical bacteria, particularly Pseudomonas aeruginosa.
The committee was aware of the European Medicines Agency's Pharmacovigilance Risk Assessment Committee recommendation to restrict the use of fluoroquinolone antibiotics following a review of disabling and potentially long-lasting side effects mainly involving muscles, tendons and bones and the nervous system (press release October 2018). This includes a recommendation to not use them for mild or moderately severe infections unless other antibiotics cannot be used. The committee discussed that fluoroquinolones are appropriate as an alternative option for people who may be at a higher risk of treatment failure. However, the committee was keen to point out that fluoroquinolone safety concerns should be taken into account on an individual patient basis.
First-choice intravenous antibiotics for empirical treatment in people who are unable to take oral antibiotics or are severely unwell are:
  • co-amoxiclav (a penicillin with a beta-lactamase inhibitor)
  • piperacillin with tazobactam (an antipseudomonal penicillin with a beta-lactamase inhibitor)
  • levofloxacin (in adults) or ciprofloxacin (in children [on specialist advice only]), which are fluoroquinolones.
When current susceptibility data are available, antibiotics should be chosen and modified accordingly, consulting local microbiologists as needed.
The committee discussed evidence from a randomised controlled trial, which showed that adding nebulised tobramycin to oral ciprofloxacin did not improve the resolution of exacerbation symptoms, and increased wheeze.

Antibiotic course length

Very limited evidence was identified to guide the duration of antibiotics for treating an acute exacerbation of bronchiectasis. The 1 randomised controlled trial identified, which compared a nebulised antibiotic plus an oral antibiotic with an oral antibiotic alone, used a 14‑day course, which is current practice.
Based on experience, the committee agreed that the shortest course that is likely to be effective should be prescribed to reduce the risk of antimicrobial resistance and minimise the risk of adverse effects.
The committee agreed that a course of 7 to 14 days was required to treat an acute exacerbation, based on an assessment of the person's severity of bronchiectasis, their exacerbation history, the severity of their exacerbation symptoms, previous culture and susceptibility results, and response to treatment.
Oral antibiotics should be used first line where possible, in line with the NICE guideline on antimicrobial stewardship.
The committee agreed that the use of intravenous antibiotics should be reviewed by 48 hours (taking into account the person's response to treatment and susceptibility results from sputum culture) and switched to oral treatment where possible. This aligns with the NICE guideline on antimicrobial stewardship and Public Health England's Start smart – then focus.

Glossary

Paths in this pathway

Pathway created: December 2018 Last updated: December 2018

© NICE 2019. All rights reserved. Subject to Notice of rights.

Recently viewed