Long-term antibiotics in the management of non-CF bronchiectasis—do they improve outcome?

Abstract

In addition to bacteria and inflammatory cells, the sputum of patients with bronchiectasis contains mediators that damage the airway epithelium and promote inflammatory change. The deleterious effects of these mediators, such as neutrophil elastase, reduce host defences and consequently perpetuate the propensity to recurrent infection. This 'vicious cycle' of infection and inflammation in bronchiectasis suggests that long-term antibiotic therapy might be beneficial in these patients by reducing microbial load and, in doing so, inhibit inflammation in the lung allowing tissue repair to occur. Short courses of antibiotics achieve clinical improvements and also have been shown to reduce the levels of harmful mediators in the sputum. This article will cite the studies reported for long-term antibiotic treatment in bronchiectasis and overall there seems to be benefits for patients with chronic sputum purulence. The evidence that supports the postulated pathological mechanisms will also be discussed. Important issues in clinical practice such as the usefulness of antibiotic sensitivities, the evolution of resistance patterns, and drug delivery will also be discussed.

Mucociliary Clearance in Bronchiectasis

“…[1][2][3] Defective mucociliary clearance can be due to abnormalities in the ciliary or mucus components or a combination of both. 7 Mucus of high elasticity and low viscosity is ideal for mucociliary clearance.…”

“…[1][2][3] Clinically, most patients present with a long-standing history of either persistent or intermittent sputum production, which could be viscous, mucoid, or mucopurulent. 1,3,4 Hemoptysis does occur and may range from minor to life-threatening. Other constitutional symptoms include fever, loss of appetite, and shortness of breath.…”

“…Other constitutional symptoms include fever, loss of appetite, and shortness of breath. 3,4 Approximately 50% of patients have pleuritic chest pain due to either peripheral bronchiectasis or distal pneumonitis. 4 Although many patients may not have an associated disease that initially leads to the development of bronchiectasis, there are many conditions that have been recognized to cause bronchiectasis, however, which may be very difficult to identify.…”

“…6 The common feature among all the conditions that lead to bronchiectasis is that they either alter the pulmonary defense mechanisms or have associated inflammation, which results in progressive lung damage. 1,3 The individual becomes susceptible to lung infection due to damage to the mucociliary transport consequent to ciliary damage. The mucociliary system is regarded as the means of filtration and purification not only at the nasal but also at the tracheobronchial level.…”

Bronchiectasis: A Correct Diagnosis Needed for Proper Management

“…During infective exacerbations, antibiotics are effective in reducing sputum volume and purulence leading to clinical improvement [6]. The choice of antibiotics may be difficult because some patients may not have organism isolated in their sputum during exacerbations.…”