Synopsis
Recognise an infective deterioration, grade the need for admission and intravenous treatment, select antibiotics from prior microbiology, and use eradication or long-term suppression with antimicrobial-safety safeguards.
- An exacerbation is a sustained worsening from the person's baseline in cough, sputum amount or character, purulence, breathlessness, fatigue or haemoptysis that prompts a treatment change.
- Before antibiotics, obtain a good sputum sample if possible and retrieve previous stable and attack cultures; previous organisms and susceptibilities are often more informative than a delayed new result.
- NICE advises a seven-to-fourteen-day oral course for most adults, chosen from severity, resistance risk, allergy, renal function and microbiology; BTS generally uses fourteen days for Pseudomonas.
- Review response and culture results, narrowing or changing treatment when indicated; intravenous antibiotics are considered for severe illness, resistant pathogens or failure of suitable oral therapy.
- A first or regrown Pseudomonas isolation with clinical deterioration should trigger specialist discussion of eradication, not automatic acceptance as permanent chronic infection.
- Before long-term macrolide treatment, optimise airway clearance, document attack frequency, obtain mycobacterial cultures, assess ECG QTc, liver function, hearing and medicine interactions.
- Frequent exacerbators with chronic Pseudomonas may benefit from a specialist-selected inhaled antibiotic; device choice, bronchospasm testing, susceptibility and commissioning vary locally.
- Long-term antimicrobial treatment is a monitored trial with a defined outcome and stop review; it creates resistance and adverse effects even when the attack count improves.
Key red flags
Marked tachypnoea, low oxygen saturation, hypotension, confusion, inability to maintain intake, respiratory acidosis or rapidly worsening function indicates hospital-level assessment and possible intravenous treatment.
Focal pleuritic pain, lobar consolidation, disproportionate hypoxaemia, unilateral leg swelling, sudden chest pain or major bleeding should open a broader acute pathway instead of being absorbed into the exacerbation label.
Investigation priorities
Identify a treatable organism and compare it with the patient's established airway microbiology.
Management branches
A clear symptom deterioration without physiological instability or another indication for admission.
- Collect sputum, review earlier organisms, allergies, renal function, pregnancy status and recent antibiotic exposure, then select a NICE-listed oral option or organism-directed alternative using local resistance advice.
- Agree a course within the NICE seven-to-fourteen-day range; use a full fourteen-day course for Pseudomonas under BTS practice and individualise duration when illness severity or response justifies it.
- Increase the frequency or adapt the method of airway clearance with physiotherapy advice, maintain hydration and give explicit review triggers for breathlessness, bleeding, fever, confusion or failure to improve.
- Act on the culture and clinical response, documenting why treatment was continued, narrowed, changed or escalated rather than issuing sequential empirical courses.
Key medicines
Amoxicillin for a susceptible uncomplicated exacerbationNICE lists 500 mg orally three times daily for 7 to 14 days; use previous culture, severity and local guidance to decide whether this narrow-spectrum option is appropriate.Check immediate and severe delayed penicillin allergy, renal function and recent organisms. It does not cover Pseudomonas and should not be continued blindly when culture, deterioration or previous resistance indicates another choice.
Azithromycin for specialist long-term suppressionBTS-supported regimens include 500 mg orally three times weekly or 250 mg daily; a lower 250 mg three-times-weekly start may reduce adverse effects, with response-led specialist adjustment.Exclude NTM pulmonary disease first. Check ECG QTc, LFT, hearing and balance history, interactions and antimicrobial-resistance implications; repeat safety testing under the BTS schedule and reassess ongoing need.