Complex bronchiectasis referral pathway (Guidelines)

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

Review

Consultant led at MDT
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Other Health Care Professional review

• Physiotherapy
• Pharmacy
• Community Nurses
• Hospice

Right patient

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

Right Treatment

Airway clearance optimised with physiotherapy
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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
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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
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Removal of line at 14 days

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
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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

• Refer to NHSH Antibiotics for Bronchiectasis

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