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A girl aged 13 years with a background of bronchiectasis presents with an increasing wet cough and temperature. You diagnose an acute bronchiectasis exacerbation and want to prescribe antibiotics to treat this. However, it is unclear which antibiotics are most likely to be effective without any previous sputum results and there is a vague history of a possible penicillin allergy.
Structured clinical question
In children with an exacerbation of bronchiectasis (population) does treatment with amoxicillin (intervention) compared with alternative antibiotics (comparison) lead to exacerbation resolution (outcome)?
In March 2019, Medline, Embase and Cochrane databases were searched using the Ovid interface. The following search terms were used: Bronchiectasis AND antibiotic OR penicillins OR beta lactams AND exacerbation AND treatment. This identified 117 articles. Articles not written in English, case and brief reports, review articles and those where the diagnosis was not bronchiectasis were excluded. Nine trials were then felt to have direct relevance to the clinical question but five of these only included adults, a further two looked at long-term antibiotic treatment in children. A summary of the main findings is presented in table 1.
A bronchiectasis exacerbation is defined by the British Thoracic Society (BTS) guidelines as an acute deterioration in the nature of the cough with increased sputum volume, purulence and viscosity. There may be breathlessness, wheeze and systemic symptoms.1 It is felt important to treat exacerbations due to concerns they may contribute to overall lung function decline which is related to overall prognosis.2 In the absence of culture results broad-spectrum antibiotics are used, with amoxicillin as first-line antibiotic for bronchiectasis exacerbations.1 The National Institute for Health and Care Excellence (NICE) guidelines also suggest amoxicillin, clarithromycin and doxycycline as first-line antibiotics for treatment of an acute exacerbation, with co-amoxiclav suggested as an alternative and ciprofloxacin only on specialist …
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