Introduction

Bronchiectasis is damage to and destruction of central conducting airways, resulting in abnormal widening of one or more branches of the bronchial tree, leading to frequent infective exacerbations.  It is particularly common in patients with cystic fibrosis and in the late stages of chronic obstructive airways disease.

Bronchiectasis is a powerful predisposing factor for infection, and infection can be both life-threatening in itself and accelerate the clinical course of bronchiectasis.

Pathogenesis of bronchiectasis

Aetiology of bronchiectasis

Diagnosis of bronchiectasis

Clinical

Signs and symptoms include:

• Productive cough
• Shortness of breath and wheezing in advanced cases.

Microbiology

• Sputum culture is often positive, but can be misleading since it is impossible to distinguish those species merely colonising the bronchi from the pathogens implicated in the infective episode.
• Bronchial washings are useful.

Management of bronchiectasis

Objectives of antibiotic therapy

Antibiotic management of bronchiectasis requires broad-spectrum treatment to cover the wide range of possible pathogens.  Short courses should be used for each infective exacerbation and the dose may have to be high to achieve effective concentrations in the sputum, since sputum production is prolific. 

If the exacerbation is severe, intravenous antibiotics are recommended.

Empirical therapy

Treatment should be continued until the sputum volume and purulence return to normal.

A suitable first-line treatment is:

• High-dose amoxicillin.

Alternative regimens include:

• An injectable cephalosporin such as cefuroxime
• In penicillin-allergic patients, a macrolide such as clarithromycin.

Once the causative organism and its antibiotic sensitivities are known, treatment should be adapted accordingly.