TSANZ: no need for therapeutic nihilism in CSLD/bronchiectasis


By Mardi Chapman

6 Feb 2024

Recognition that bronchiectasis in children is potentially reversible if diagnosed early and treated optimally, underpins many of the recommendations in the 2023 TSANZ position statement on chronic suppurative lung disease and bronchiectasis in children, adolescents and adults in Australia and New Zealand.

For example the statement, published in Respirology last year [link here] and summarised recently in The MJA [link here], strengthens recommendations for the management of newly detected Pseudomonas aeruginosa in respiratory secretions.

It now states that eradication therapy should be offered, rather than considered as was the recommendation in the earlier 2015 TSANZ guidelines.

The 2023 Statement also recommends antibiotics – oral, inhaled or IV depending on symptoms – be continued for at least 14 days, rather than the ten days stated in the 2015 guidelines.

The suggested pathway for treatment when P. aeruginosa is newly detected also includes repeat lower airway specimen for culture and sensitivity testing where possible

“The goal of long term antibiotics (> 2 months) is to reduce bacterial load and/or airway inflammation when eradication is not possible,” the MJA summary said.

The position statement recommended against long-term (>3-months) inhaled antibiotics (e.g., aminoglycosides, colistin) for patients with clinically stable bronchiectasis.

Similarly, inhaled and oral corticosteroids should not be prescribed routinely unless there is an established diagnosis of co-existing asthma and/or eosinophilic airway inflammation.

“Inhaled bronchodilators should not be prescribed routinely and instead used only on an individual basis (e.g., before using inhaled mucoactive agents or inhaled antibiotics or before undertaking airway clearance techniques),” the Position Statement said.

It also advised that recombinant human deoxyribonuclease is contraindicated in chronic suppurative lung disease (CSLD)/bronchiectasis.

The Position Statement encourages the identification and management of treatable traits and comorbidities including nutritional deficiencies, gastro-oesophageal reflux disease/aspiration, asthma, COPD in adults and allergic broncho-pulmonary aspergillosis.

The TSANZ authors, led by Professor Anne Chang from the Queensland Children’s Hospital, also acknowledged the high prevalence of CSLD/bronchiectasis in Australian First Nations, Māori and Pacific Islanders which warranted “a high index of suspicion with early diagnostic investigation, and institution of best-practice treatment”.

“Providing healthcare for Australian First Nations, Māori and Pacific Islanders and under-serviced communities in rural-remote regions requires flexible and adaptive arrangements,” the Statement also said.

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