This protocol is for patients with bronchiectasis who remain at high risk of exacerbations after a 12-month trial of first-line long-term macrolide therapy has not achieved a meaningful reduction in exacerbation frequency — or where macrolides are contraindicated or not tolerated.
High exacerbation risk, defined as a history of two or more exacerbations in the prior year, or at least one severe exacerbation, or one exacerbation combined with severe daily symptoms — and without chronic Pseudomonas aeruginosa infection.
Long-term macrolide therapy was the recommended first-line approach for this exacerbation risk profile. The treatment goal over 12 months was a reduction in exacerbation frequency. This protocol applies when that goal has not been reached, or when macrolides could not be used.
The structured next step centres on long-term antibiotic therapy. The specific agent category, delivery route, and patient-selection criteria are detailed in the full protocol.
We recommend to offer long-term macrolides to patients at high risk of exacerbations despite standard care.
Patients at high risk of exacerbations include patients with a history of ≥2 exacerbations in the prior year OR ≥1 severe exacerbation OR 1 exacerbation plus severe daily symptoms.
For patients without P. aeruginosa infection, macrolides are a clear first-line option.
Long-term non-macrolide oral antibiotics may have a role in specific situations where patients are at high risk of frequent exacerbations and other options such as long-term macrolides are contraindicated or have proven ineffective.
DOI: 10.1183/13993003.01126-2025
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