TABLE 1.

Antibiotic selection guide (related to Statement‐9).

	Mild‐to‐moderate exacerbations	Moderate‐to‐severe exacerbations
	(Oral therapy)	(Intravenous therapy)
Initial empiric therapy a	Children: amoxycillin‐clavulanate Adults/adolescents: amoxycillin‐clavulanate or doxycycline b	All ages: amoxycillin‐clavulanate, cefotaxime or ceftriaxone (amoxycillin, amoxycillin‐clavulanate or cefuroxime in New Zealand)
	All ages: ciprofloxacin if P. aeruginosa in recent cultures	All ages: piperacillin‐tazobactam or ceftazidime ± tobramycin c if severe or P. aeruginosa in recent cultures
Specific pathogens
H. influenzae d
β‐lactamase −ve	Amoxycillin	Ampicillin (amoxycillin in New Zealand)
β‐lactamase +ve	Amoxycillin‐clavulanate or doxycycline b	Amoxycillin‐clavulanate, cefotaxime or ceftriaxone (amoxycillin‐clavulanate or cefuroxime in New Zealand)
S. pneumoniae	Amoxycillin	Benzylpenicillin G, ampicillin (amoxycillin in New Zealand)
M. catarrhalis	Amoxycillin‐clavulanate	Amoxycillin‐clavulanate, cefotaxime or ceftriaxone (amoxycillin‐clavulanate or cefuroxime in New Zealand)
S. aureus MRSA	Di‐/flucloxacillin seek specialist advice e	Flucloxacillin seek specialist advice e
P. aeruginosa	Ciprofloxacin (max 14‐days)	Piperacillin‐tazobactam or ceftazidime ± tobramycin c
Aspergillus or NTM	Seek specialist advice	Seek specialist advice

Abbreviations: MRSA, methicillin‐resistant S. aureus; NTM, non‐tuberculous mycobacteria species.

^a In addition to clinical severity, initial empiric therapy is also guided by previous lower airway culture results (sputum, bronchoscopy washings or bronchoalveolar lavage), local antibiotic susceptibility patterns, patient tolerance and hypersensitivity to antibiotics and prior responses to antibiotic treatments. In children too young to expectorate sputum, and in older patients when no previous lower airway culture results are available, prescribed empiric antibiotic therapy should be active against Haemophilus influenzae, Streptococcus pneumoniae and Moraxella catarrhalis. ¹⁶

^b Doxycycline is used only in adults and adolescents.

^c Although treating serious Pseudomonas aeruginosa infections in adults with combined beta‐lactam and aminoglycoside antibiotic therapy provides no additional clinical benefit than when using a single beta‐lactam agent, ²¹ the role of single beta‐lactam antibiotics compared with combination antibiotic therapy for P. aeruginosa associated exacerbations in bronchiectasis remains unproven. ²² Thus, in the absence of evidence, the current standard of care of combination parenteral antibiotic therapy for moderate to‐severe exacerbations in children/adolescents should continue, as it should in adults when multi‐resistant P. aeruginosa strains are suspected. Otherwise, in elderly patients and those with significant medical co‐morbidities, beta‐lactam monotherapy is recommended. Whenever systemic aminoglycoside antibiotics are prescribed, careful monitoring for toxicity and measurement of serum drug levels are required. Seek specialist advice when treating multi‐resistant organisms, including P. aeruginosa.

^d Routine beta‐lactam susceptibility testing for H. influenzae is unreliable and no longer performed by many microbiology laboratories for respiratory isolates. Amoxycillin/ampicillin remains standard therapy for beta‐lactamase negative strains, while amoxycillin‐clavulanate, cefotaxime/ceftriaxone or cefuroxime (New Zealand) are appropriate for beta‐lactamase positive strains. Seek specialist advice if further susceptibility testing is required.

^e Specialist advice should be sought for treating MRSA strains in accordance with local susceptibility patterns and infection control policies.