Obstructive lung disease guide

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A new position statement advises treating bronchiectasis with antibiotics for 14 days.

Extending the duration of antibiotic treatment from 10 to 14 days for exacerbations in bronchiectasis patients is just one of the changes in the latest Australian lung disease guidelines. 

The Thoracic Society of Australia and New Zealand has released a new position statement to update the previous 2015 guidelines, giving guidance on which investigations and antibiotics to use and when to refer to a specialist. 

“Bronchiectasis remains under recognised and undertreated,” the authors wrote in an MJA summary of the new position statement

“An Australian cohort study reported that over 60% of referred adults with bronchiectasis had symptoms dating from childhood and a worse prognosis than those with adult onset disease.” 

The authors said bronchiectasis had a “devastating impact on life expectancy” but was potentially reversible if diagnosed and treated early in children. 

“The possibility of mild bronchiectasis being reversible in children if identified early and treated optimally reinforces the importance of recognising the clinical features of bronchiectasis and using paediatric radiographic diagnostic criteria when interpreting chest CT scans,” they said in the MJA.  

Intensive treatment would reverse early bronchiectasis and optimise lung growth in children, preserve lung function, minimise exacerbations, optimise quality of life, prevent disease progression and improve survival, they said.

In adults, bronchiectasis is characterised by chronic cough, sputum production and recurrent exacerbations in adults, they said.  

In children and adolescents, bronchiectasis presents as a recurrent wet or productive cough for more than four weeks, with or without faltering growth, exertional dyspnoea, recurrent chest infections, digital clubbing, hyperinflation and chest wall deformity. 

Children should be referred to a specialist after more than three episodes of chronic (more than four weeks each) of wet or productive cough per year, a chronic wet or productive cough not responding to four weeks of antibiotics, more than two episodes of pneumonia, severe asthma with chronic wet or productive cough, or more than six weeks of lung parenchymal abnormalities on chest radiographs. 

The authors said the optimal duration of antibiotic treatment was unknown, but a double blind, randomised, controlled trial in children and adolescents with non severe exacerbations found that 14-day treatment of oral amoxycillin–clavulanate was superior to placebo at resolving symptoms.  

Therefore, the authors recommend antibiotics be continued for at least 14 days, rather than 10 days as stated in the 2015 guidelines. 

“Treat exacerbations with 14-day antibiotic courses based upon lower airway culture results, local antibiotic susceptibility patterns, clinical severity and patient tolerance,” they said in the position statement.  

“Patients with severe exacerbations and/or not responding to outpatient therapy are hospitalised for further treatments, including intravenous antibiotics and intensive airway clearance techniques.” 

The goal of long-term antibiotics for more than two months was to reduce bacterial load and airway inflammation when eradication was not possible.  

“The recommendation for using long-term oral macrolides has been simplified (considered in those with the frequent exacerbator phenotype [i.e., 3 exacerbations per year], which predicts mortality, hospitalisation, and reduced quality of life) and should be prescribed for at least a six month trial with regular review for clinical benefit,” said the authors. 

They said they had not changed their 2015 advice that inhaled antibiotics should not be prescribed routinely.  

The latest position statement lists the possible underlying causes of bronchiectasis and which baseline investigations to perform in paediatric and adult patients.  

“History should include: frequency and impact of exacerbations and hospitalisations, degree of effort limitation, exposure to tobacco smoke, vaping/e-cigarettes and other aero toxicants, immunisation and early childhood medical and social history, including housing,” they said. 

“Despite the growing evidence base for bronchiectasis, large knowledge gaps remain and no licensed therapies exist,” the authors said in the MJA.  

Indigenous Australians with bronchiectasis died more than 20 years earlier than non-Indigenous adults with the disease, the authors said. 

In Indigenous communities in remote northern regions of Australia, 1470 per 100,000 children aged under 14 years and 23% of adults have evidence of bronchiectasis after undergoing computed tomography scans. 

Children and adolescents with bronchiectasis unrelated to cystic fibrosis have substantially poorer lung function and receive less care than age-matched children/adolescents with cystic fibrosis. 

“Optimal care for people with bronchiectasis is crucial as poor treatment risks premature and accelerated pulmonary decline,” said the authors. 

MJA 2023, online 4 December 

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