The following aspects of therapy should be assessed and optimised prior to initiation of long term azithromycin as per available local and national (BTS, NICE) guidelines:
- Review by respiratory physiotherapist
- Trial of oral mucolytic therapy (and nebulised saline 7% in bronchiectasis if tolerated / not contra-indicated
Steroid therapy (oral and inhaled) reviewed (optimise steroid therapy if asthmatic - consider monitoring FeNO; minimise steroid therapy if not asthmatic):
- Review spirometry / reversibility / consider formal steroid trial; FeNO; sputum eosinophiliato identify asthmatic component / eosinophilic bronchitis.
- Ensure meets guidelines for use of ICS in COPD (if COPD); consider change from more potent to less potent ICS (refer to NHSGGC COPD inhaler device guide). Consider trial of withdrawal of steroid therapy if no asthma and does not meet COPD criteria for ICS.
Prior to initiation the following antimicrobial colonisation must be excluded or treated:
Exclusion of allergic bronchopulmonary aspergillosis (aspergillus specific IgE and IgG, skin prick testing)
Exclusion of pathogenic colonising / exacerbating organism (eg haemophilus, streptococcus, moraxella)
- 2 weeks appropriate oral or IV therapy to eradicate if present
- Consider longer course of oral antibiotics (up to 8 weeks) if no clinical response. This advice is based on local experience.
- Not all colonising organisms are pathogenic and need eradicated – discuss with microbiologist if unsure
Exclusion of pseudomonal colonisation.
- Adequate attempts at eradicating airways colonisation by pseudomonas if present with oralor IV antibiotic therapy / maintenance inhaled antibiotics (see BTS guidelines on the management of non-cystic fibrosis bronchiectasis for details).
Exclusion of MSSA and MRSA colonisation.
- Eradication with 2 weeks appropriate oral or IV antibiotics if present
Exclusion of non tuberculosis mycobacteria (NTM) colonisation.
- At least 3 sputum samples in last year excluding NTM colonisation.
- At least 3 sputum samples in last year for bacteriology associated with exacerbations.
- Successful treatment of NTM airways infection if present.
Immuno-deficiency excluded or treated (Immunoglobulins and functional antibodies). HIV excluded.
Smoking cessation (if appropriate).
Pulmonary rehabilitation (if appropriate).