Complex bronchiectasis referral pathway (Guidelines)

TAM (Treatments and Medicines) NHS Highland
NHS Highland

Audience

  • North Highland only
  • Primary and Secondary Care
  • Adults only

Referral criteria for Primary Care

Criteria

  1. Those with 3 or more microbiologically proven exacerbations with Pseudomonas aeruginosa or Methicillin Resistant Staphylococcus Aureus, which may necessitate IV or nebulised therapy
  2. Bronchiectasis secondary to immunodeficiency or Primary Ciliary Dyskinesia
  3. Those on nebulised antibiotics
  4. Those with intractable symptoms despite optimal primary care management
  5. Structural Bronchiectasis on CT

NOT for those with COPD and super imposed bronchiectasis / bronchiectasis phenotype unless meets one of the above

NOT for diagnosis of bronchiectasis

Triage

  • REFER patients to respiratory via SCI gateway 

Assessed each month at Bronchiectasis MDT with microbiology

The remainder of this pathway is for use in SPECIALIST AREAS ONLY but can be referred to by primary care to understand the pathway for your patients. 

Review in the Specialist service

Consultant-led at MDT
⇓

Nurse-led/ PA follow-up

Registrar / Consultant
  • Met patient already and plan in place
  • Annual reviews
  • Monitoring of nebulised antibiotic discontinuation
    1st month: Sputum culture
    3 month: phone call to ensure stable
  • New to service patients
  • Provide review for PA/Nurse where concern arises in clinic
  • Commencement of macrolide antibiotic therapy

Other Health Care Professional review

  • Physiotherapy
  • Pharmacy
  • Community Nurses
  • Hospice

Bronchiectasis IV antibiotics at home: Specialist use

Consider eradication therapy in conjunction with specialist advice and ONLY if deemed to be in patient's best interest

Right patient

When are IVs indicated?

Can this be delivered as an outpatient?

  1. Pseudomonas aeruginosa
  1. FIRST GROWTH where it is deemed to be in patient's best interest ciprofloxacin* contraindicated or failed at high dose (750mg twice daily for 14 days)
  2. COLONISED AND EXACERBATED
  1. Suitable for discharge
  2. Suitable home destination
  3. Suitable IV access: Midline sited early in admission

*Ciprofloxacin is the only oral option available. Patients MUST be counselled on fluoroquinolone risks

Right Treatment

Airway clearance optimised with physiotherapy
⇓
DECISION with PATIENT

  • Right Time
  • Right Regime
  • Right Place: District Nurses, self-administration, community hospital

As per OPAT referral and assessment

And follow up arranged in clinic
⇓
IV antibiotics

  • 1st line: Ceftazidime: 2g 8 hourly
  • 2nd line: Piperacillin/tazobactam: 4.5g every 6 hours or 18g via infusion device/24 hours
  • AND consider nebulised tobramycin 160mg twice daily, for 3 months
  • OR second-line colomycin

Order supply from pharmacy for home (NB infusion devices require special order)

Right plan

Review at 1 week
⇓
Removal of line at 14 days

Caution: Beware Clostridium difficile risk in this patient group

Discontinuation of nebulised antibiotics: Specialist use

Criteria to stop

  1. Patients on nebulised antibiotics (tobramycin or colomycin) OR inhaled antibiotics for 3 months after first growth
  2. Colonised patients
    • Who have not growth Pseudomonas aeruginosa for 12 months
  3. Treatment burden/frailty now outweighs benefit
  4. FEV1 less than 30%

Protocol

Airway clearance revisited with physiotherapy
⇓
SPUTUM MC+S & AAFB at month 1

And review by primary care/community team

If exacerbating:

Refer to Antibiotic guidance for Bronchiectasis and consider IVs at home.

If NOT exacerbating:

  • Sputum at month 3
    • If 3 months of no growth: consider discharge from service
    • If ambiguity, further sputum at month 6
  • Offer review (consider NearMe/telephone)

Outcomes

Regrowth of Pseudomonas

  • Refer to NHSH Antibiotics for Bronchiectasis
  • If 3 or more exacerbations or colonised: suggest nebulised tobramycin

NO regrowth of Pseudomonas

  • Discharge back to referring clinician

Growth of another organism

Macrolide antibiotic use in bronchiectasis: Specialist use

Assessment & Prescription

  • Baseline ECG with normal QTc (<440ms for men and <460ms for women)
  • No contraindications to therapy
  • Baseline liver function tests and full blood count
  • Medication review to exclude interactions of any drugs that may cause prolonged QTc or other interaction (eg, Digoxin)
  • 3 sputum cultures negative for AFB
  • Patient advised about risk of hearing loss /tinnitus

Prescribe Azithromycin 250mg once daily
Arrange repeat LFT check in 2 weeks

Exclusion Criteria:

  • LFTs more than 2 times upper limit of normal
  • Atypical mycobacterial infection
  • Allergy to Azithromycin

3 month review

  • Assess response to, and tolerability of, treatment
  • Review liver function tests, then for 6 monthly monitoring
  • If no symptomatic improvement, but a reduction in exacerbation frequency, discuss with the patient whether they wish to continue for a total of 12 months then consider stopping.
  • If treatment continues beyond 12 months, a break may be considered during the summer months.

6 monthly assessment thereafter

STOP if side effects or intolerability

Non-tuberculous mycobacteria (NTM) testing: Specialist use

When to test for NTM in Complex Bronchiectasis

  1. Prior to commencement of Macrolide
    • This would suggest 3 exacerbations per year as per BTS Bronchiectasis guidance
  2. Deteriorating patient 
    • Rapid decline in lung function
    • Unexpected increased frequency or severity of exacerbations
    • Frequent hospital admissions
    • Early relapse on treatment

What to test

  • 3 sputum samples on different days, with clear instruction to test for AFB (Acid Fast Bacillus), having stopped any NTM-active antibiotics (macrolides, co-trimoxazole, aminoglycosides, linezolid, fluoroquinolones, tetracyclines) for 2 weeks.

Considering a positive NTM sample

  • Extent of disease
    • Clinical
    • Radiological
  • Progression of disease
    • Radiological
    • Clinical
  • Significance and persistence of organism
  • Treatment going ahead

What to consider for investigations:

  • Consider high-resolution CT and CT directed bronchoscopy with lavage for mycobacterial culture.

Treatment going ahead

  • Chest physiotherapy
  • Consideration of whether inhaled corticosteroid is necessary
  • Consideration of concomitant organism, and it’s effect on clinical situation
    • Bystander versus active infection
  • As current drug therapies are associated with significant tolerance and toxicity issues, the decision to commence treatment should consider the NTM species, severity of disease, risks of progression, co-morbidities and patient choice.

Abbreviations

  • BTS: British Thoracic Society
  • CT: Computed tomography
  • NTM: Non-tuberculous mycobacteria
  • PA: Physician's Assistant

Editorial Information

Last reviewed: 27/06/2024

Next review date: 30/06/2027

Author(s): Respiratory Medicine.

Version: 2

Approved By: TAM Subgroup of the ADTC

Reviewer name(s): Dr G Christie, Consultant Respiratory Physician, L Blaikie, Cystic Fibrosis Clinical Nurse Specialist, L Allan, Physician Associate in Respiratory Medicine.

Document Id: TAM642

References
  • British Thoracic Society, 2019. Guideline for Bronchiectasis in Adults. Thorax, [online] Available at: https://www.brit-thoracic.org.uk/qualityimprovement/guidelines/bronchiectasis-in-adults/ [Accessed 19 March 2025].
  • Kumar K et al. Non-tuberculous mycobacterial pulmonary disease (NTM-PD): Epidemiology, diagnosis and multidisciplinary management. Clin Med (Lond). 2024 Jan;24(1):100017. doi: 10.1016/j.clinme.2024.100017. Epub 2024 Jan 17.