A 67-year-old woman with known bronchiectasis presents with 2 days of worsening dyspnea and cough productive of 2 tablespoons of green sputum streaked with blood. She reports struggling to walk 1 city block. She has no fever or systemic symptoms. At baseline, she is able to walk 2 blocks and averages a teaspoon of yellow sputum production per day. A chest radiograph shows diffuse tram-track opacities, consistent with her prior imaging.
Could this patient have an acute exacerbation of bronchiectasis?
Bronchiectasis is an inflammatory disease of the airways defined by persistent respiratory symptoms (e.g., cough, sputum production, recurrent infections) and permanent dilatation of bronchi on chest computed tomography (CT).1 Tram track opacities on chest radiograph indicate airway thickening consistent with chronic bronchial infection. Abnormal bronchial anatomy, which may be idiopathic or caused by a number of underlying etiologies, disrupts mucociliary clearance. This can lead to the development of chronic airway infections, commonly caused by Haemophilus influenzae, Pseudomonas aeruginosa, Moraxella catarrhalis, or Staphylococcus aureus.1 Bronchiectasis is the third most common airway disease and its incidence is rising, likely because of increasing awareness and access to CT.2 Among patients living with bronchiectasis, 61% to 75% have at least 1 exacerbation annually, of which 25% lead to hospitalization.3,4 Recognition of exacerbations is important, as these events are independently associated with mortality.5
An acute exacerbation is defined by worsening respiratory (e.g., cough, sputum production, hemoptysis, dyspnea) or constitutional symptoms and can be triggered by several factors, including bacterial or viral infection, host inflammation (e.g., neutrophilic inflammation), or environmental effects (e.g., air pollutants).6
When should a sputum culture be obtained during an exacerbation?
Every reasonable effort should be made to obtain a sputum culture in a patient with a bronchiectasis exacerbation, ideally immediately before or shortly after treatment initiation to maximize its yield. Reviewing prior culture results and testing new sputum cultures during exacerbations is key to management.
A positive culture obtained while the patient is asymptomatic may suggest bacterial colonization and not require treatment; however, it can direct antibiotic selection in the presence of an acute exacerbation. Infection by P. aeruginosa is linked to more severe disease and higher mortality, and often requires more prolonged antibiotic therapy than other common causative organisms.1,5 Sputum cultures may help guide second-line treatment options for patients who do not respond to an initial course of antibiotic treatment.
How are exacerbations of bronchiectasis managed?
The mainstay of treatment for exacerbations is antibiotics; ideally, therapy would target known organisms from prior sputum cultures. In the absence of an identified causative organism, empirical treatment may consist of a broad-spectrum antibiotic with coverage for common respiratory isolates such as H. influenzae or M. catarrhalis (e.g., amoxicillin–clavulanate, cefuroxime, levofloxacin, moxifloxacin). An additional benefit of using amoxicillin–clavulanate is that patients with bronchiectasis often have anaerobic pathogens causing their exacerbation,7 and these may not grow in sputum culture. Choice of antibiotic can be further altered once sputum cultures are obtained, particularly if a resistant organism is detected on sputum culture (e.g., methicillin-resistant S. aureus or P. aeruginosa).
Treatment of an exacerbation of bronchiectasis differs from treatment of community-acquired pneumonia (CAP) in 2 major ways: antibiotic duration and choice. As patients with bronchiectasis have chronic inflammation and anatomic distortion of their bronchi, they typically require a longer antibiotic course than patients with CAP. The optimal treatment length is not known, but current guidelines recommend 14 days of antibiotics for exacerbations of bronchiectasis.1,8 The microbiology of the disease is distinct from CAP, necessitating different antibiotic choices. Atypical respiratory pathogens (Chlamydophila pneumonia, Mycoplasma pneumonia, and Legionella) are commonly empirically covered in the treatment of CAP; however, these are infrequently implicated in exacerbations of bronchiectasis.3 Use of macrolides (azithromycin or clarithromycin) for the latter requires caution, as bronchiectasis often coexists with nontuberculous mycobacteria (NTM). Treatment for NTM infections is important in its chronic management and often necessitates a prolonged multi-drug regimen that includes a macrolide. Prior exposure to macrolide monotherapy may lead to drug resistance and subsequent treatment failure.9
Which patients require hospital admission for an exacerbation of bronchiectasis?
Hospital admission is indicated in patients with an exacerbation who require supplemental oxygen or have hemoptysis of 10 mL or more over 24 hours. Potential complications include respiratory failure and severe hemoptysis. Patients without these indications can usually be managed as outpatients, but some may require hospitalization if they do not respond to oral antibiotics or if susceptibilities of the causative organism indicate the need for intravenous antibiotics.7
When should patients be referred for expert opinion?
Ideally, all patients with a new diagnosis of bronchiectasis should be referred to a respirologist to evaluate for secondary causes and to initiate chronic management. A respirologist can assist patients by teaching airway clearance techniques (e.g., huff cough, positive expiratory pressure devices) and evaluate and treat coexisting NTM. Referral is particularly important for patients younger than 50 years; those with severe, progressive, or idiopathic disease; those whose sputum culture grows P. aeruginosa; those with frequent exacerbations (3 or more per year, which may necessitate chronic macrolide therapy); or those with complications such as massive hemoptysis (generally defined as expectorating 150 mL of blood in 24 hours).1,8 Specialty clinics can also provide advanced therapies, including inhaled antibiotics and immunomodulators (Table 1).1,8
Table 1:
Suggested empiric antibiotic options for treatment of bronchiectasis exacerbation
| Medication | Usual dosing* | Duration, d | Additional considerations |
|---|---|---|---|
| Amoxicillin–clavulanate | 875 mg amoxicillin, 125 mg clavulanate twice daily by mouth | 14 | First-line treatment |
| Cefuroxime | 500 mg twice daily by mouth | 14 | First-line treatment |
| Moxifloxacin | 400 mg once daily by mouth | 14 | Consider if patient is allergic to penicillin; use with caution, given potential adverse events (e.g., tendon rupture, hypoglycemia, QT prolongation) |
| Levofloxacin | 750 mg once daily by mouth | 14 | Consider if patient is allergic to penicillin; use with caution, given potential adverse events (e.g., tendon rupture, hypoglycemia, QT prolongation) |
| Ciprofloxacin | 750 mg twice daily by mouth | 14 | Consider if patient’s prior sputum culture showed growth of Pseudomonas aeruginosa |
| Cephalexin | 500 mg 4 times daily by mouth | 14 | Consider if patient’s prior sputum culture showed growth of MSSA |
| Doxycycline | 100 mg twice daily by mouth | 14 | Consider if patient’s prior sputum culture showed growth of MRSA |
| Sulfamethoxazole–trimethoprim | 1–2 double-strength (800 mg sulfamethoxale, 160 mg trimethoprim) tablets twice daily by mouth | 14 | Consider if patient’s prior sputum culture showed growth of MRSA |
Note: MRSA = methicillin-resistant Staphylococcus aureus, MSSA = methicillin-sensitive Staphylococcus aureus.
Dosing recommendation provided in idealized conditions; additional modifications may be necessary, depending on patient circumstance.
Case revisited
The patient was diagnosed with an acute exacerbation of bronchiectasis. She did not have a prior sputum result available and was prescribed a 14-day course of amoxicillin–clavulanate. She was given a requisition for a sputum culture at an outpatient laboratory. Her sputum culture ultimately showed growth of H. influenzae with susceptibility to amoxicillin–clavulanate. She had a prompt response to antibiotic treatment, with resolution of her hemoptysis, and returned to her previous baseline. She was referred to a respirologist for outpatient evaluation of secondary causes of bronchiectasis and for initiation of airway clearance techniques.
Decisions is a series that focuses on practical evidence-based approaches to common presentations in primary care. The articles address key decisions that a clinician may encounter during initial assessment. The information presented can usually be covered in a typical primary care appointment. Articles should be no longer than 650 words, may include one box, figure or table and should begin with a very brief description (75 words or less) of the clinical situation. The decisions addressed should be presented in the form of questions. A box providing helpful resources for the patient or physician is encouraged.
Footnotes
Competing interests: Christina Thornton reports funding from the Canadian Institutes of Health Research, Alberta Innovates, Cystic Fibrosis Canada, the Cystic Fibrosis Foundation, the Weston Foundation, the Canadian Federation for Innovation, Insmed, Trudell Medical, Trudell Healthcare Solutions, and Baxter, as well as travel support from the Cystic Fibrosis Foundation. No other competing interests were declared.
This article has been peer reviewed.
Decisions articles include a brief, common clinical scenario that is either real or fictional, as a starting point to discuss an evidence-based approach to a common presentation in primary care. The following article presents a fictional clinical scenario.
Contributors: Both authors contributed to the conception and design of the work. Omri Arbiv drafted the manuscript. Both authors revised it critically for important intellectual content, gave final approval of the version to be published, and agreed to be accountable for all aspects of the work.
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