Bronchiectasis Resource Pack
Non-CF Bronchiectasis in adults
Section 7: Treatment Strategies – Pharmacological Management in Primary and Secondary Care
Bronchiectasis Resource Pack V1.1 Date approved (MCN): 4th April 2018 Section 7: Treatment Strategies – Date approved (ADTC): 19th Nov 2019 Pharmacological Management in Primary and Last Updated: November 2019 Secondary Care Review: November 2021
TREATMENT STRATEGIES – PHARMACOLOGICAL MANAGEMENT
Inhaled Bronchodilators
Used for symptom control if evidence of airflow obstruction [+/- reversibility] Ensure effective use of inhaler device Increase Bronchodilators during exacerbations. 4 – 8 puffs Salbutamol PRN +/- Aerochamber face mask (for very breathless patients an MDI and spacer allows high doses to be taken safely). Add or increase dose of anti-cholinergic using patient’s usual inhaler device. Nebulisers are rarely needed but if the patient is very unwell give Salbutamol 2.5mgs via nebuliser, and consider adding nebulised ipratropium, however, caution is advised with regards to glaucoma.
Inhaled Corticosteroids
Can reduce sputum volume but no clear benefit in maintenance of FEV1 or reduction in exacerbation frequency Use if airways reversibility and / variability consistent with asthma in association with bronchiectasis Use if clinical benefit when trialled for 6 months in bronchiectasis with adverse features [800mcg ICS daily] Use in COPD patients who meet the criteria
Mucolytics (secondary care)
reduce inflammatory mediators, reduce micro-organism load, and improve QOL scores in non-CF bronchiectasis and have comparable effects • Consider trial of acetylcysteine NACSYS effervescent tablet 600mg OD – stop if no benefit at 6 months • If above not helpful, consider trials of nebulised hypertonic saline 6% in hospital setting if sputum production/ retention a reported or observed problem
Vitamin D
The epidemiological data shows a significant association between bronchiectasis and infection risk, but there is no interventional study demonstrating the effects of vitamin D supplementation in patients with bronchiectasis
There is NO proven benefit for recombinant human DNase, carbocysteine, inhaled mannitol
Oral corticosteroids [except ABPA, airways exacerbation]
Leukotriene receptor antagonist [except asthma]
Page 2 of 6
Long term oxygen therapy
There are no specific recommendations concerning LTOT in bronchiectasis in the latest BTS Guidelines.
Thus, it is suggested that the LTOT recommendations for COPD are followed for bronchiectasis.
https://www.brit-thoracic.org.uk/quality-improvement/guidelines/emergency-oxygen/
Antibiotics for acute exacerbations
Exacerbation of Bronchiectasis is defined as new or increased
Cough, wheeze, dyspnoea +/- systemic upset in any combination + sputum purulence + sputum volume/ change in viscosity +/- haemoptysis
Antibiotics are mainstay of treatment at time of an acute exacerbation At the time of an exacerbation, obtain a sputum sample Be guided by past sputum cultures If the patient has NEVER had Pseudomonas (PsAs) in their sputum and there are no recent sputum cultures to go on then antibiotics need to cover a) Strep Pneumoniaes and b) Haem Influenzae and for 14 days . Amoxicillin 1G tds . Clarithromycin 500mg bd . Doxycyline 100mg bd
If there are 2 pathogens, use one antibiotic to cover these, but if not possible due to resistance use combination antibiotics If known PsA . Ciproflaxacin 750mg bd for 14 days Or
. Ciprofloxacin 500mg bd for 14 days if eGFR < 30 [consider monitoring renal function, and discuss dose advise with pharmacy]
Recent warnings have highlighted a greater risk of serious side effects with fluoroquinolone antibiotics than was previously realised. This includes tendinitis and tendon rupture, myalgia and muscle weakness, arthralgia and joint swelling, gait disturbance, peripheral neuropathy or sensory disturbance. Patients should be advised of these and advised to stop treatment and seek medical advice if they experience new or significantly worsening symptoms associated with these side-effects. Page 3 of 6
If PsA and / severe disease likely to need iv antibiotics 14 days PsA 3rd generation penicillin and aminoglycoside combination e.g. tazocin/ceftazidime/meropenem and neb colomycin /iv gentamicin MRSA – Always discuss with microbiology. Attempt eradication.
BTS guidelines 2018 recommend 14 days of antibiotics treatment as standard, and where possible this should be guided by sputum microbiology – see below.
When prescribing antibiotics it is good practice
to give advise about possible side effects eg diarrhoea with clarithromycin advise patient to seek medical attention if their symptoms are worsening and / or they are less well Some patients may respond to antibiotic treatment despite resistance in vitro testing, antibiotics should only be changed if patients are not improving, preferably guided by antibiotic sensitivity results
Page 4 of 6
Table 3: Antibiotic Guidelines (peer reviewed by Antimicrobial Management Team)
Refer to Fife Primary Care Antibiotic Guidelines for advice on Antibiotic (http://www.fifeadtc.scot.nhs.uk/)
Doses are for adults with normal renal function unless otherwise stated, seek pharmacy advice for dose adjustments Before prescribing antibiotics check the BNF for any potential drug interactions. Organism Oral Community Hospital Treatment Options Length of Treatment Options [use community treatment options treatment if admission purely due to non- clinical reasons] Streptococcus Amoxicillin Benzylpenicillin 1.2g IV qds & 14 days pneumoniae 1G tds Clarithromycin 500mg bd (po) or Clarithromycin 500mg bd
Haemophilus Amoxicillin 14 days influenzae, 1G tds Benzylpenicillin 1.2g IV qds & -lactamase or Clarithromycin 500mg bd (po) In BTS negative Clarithromycin 500mg bd guidelines or Doxycycline 100mg bd Haemophilus Co-amoxiclav Benzylpenicillin 1.2g IV qds & 14 days influenzae, 625mg TDS # Clarithromycin 500mg bd (po) -lactamase or positive Clarithromycin 500mg bd or Doxycycline 100mg bd
Moraxella Co-amoxiclav Benzylpenicillin 1.2g IV qds & 14 days catarrhalis 625mg TDS # Clarithromycin 500mg bd (po) or Clarithromycin 500mg bd or Doxycycline 100mg bd Staphylococcus Flucloxacillin Flucloxacillin 1g IV qds 14 days aureus (MSSA) 1G QDS or Clarithromycin [co-amoxiclav 1.2 g IV tds may be 500mg BD suitable for H@H] Coliforms e.g. Ciprofloxacin Intravenous Temocillin 2G bd 14 days Klebsiella, 500mg bd (only covers gram negatives) Enterobacter or [If eGFR <35 then discuss with co-trimoxazole 960mg bd microbiology] [not if eGFR < 35]
Pseudomonas Oral Ciprofloxacin Monotherapy IV 14 days aeruginosa 750mg bd* (po) Ceftazidime 2G tds* [Avoid if history of seizures or prolonged QT] Combination therapy: The above can be combined with IV gentamicin* (refer to respiratory pharmacist) or colistin1-2 MU* bd (under 60 kg, 50 000-75 000 units/kg daily separated into 3 divided doses) OR oral ciprofloxacin 500mg BD See link below for gentamicin dosing
* Ceftriaxone 2G od* (IV) or 1g bd if administering as iv bolus (outpatient) or H@H, requires microbiologist authorisation # If severe illness, add amoxicillin 500mg tds, [plus co-amoxiclav, equates to 1g amoxicillin tds]
Note: caution with aminoglycosides in pregnancy, renal failure, elderly or on multiple other drugs.
Page 5 of 6
Useful links
1. Guide to Gentamicin dosing – click here to access the Gentamicin calculator
2. Microguide Viewer: http://microguide.horizonsp.co.uk/viewer/fife/adult
Eradication of Pseudomonas – secondary care
Pseudomonas
is an independent predictor of mortality is associated with more extensive lung disease is associated with worse PFT BTS guidelines recommend eradication although there is no direct evidence to support eradication, this is based on recommendations in CF BTS PsA eradication, algorithm follow STEP 1, if failed to eradicate, then chose one option for STEP 2
Page 6 of 6