What is the most appropriate empiric antibiotic class for acute exacerbations of bronchiectasis?

The most appropriate empiric antibiotic class for treating acute exacerbations of bronchiectasis is fluoroquinolones. This class of antibiotics is often chosen because they have excellent gram-negative coverage, which is particularly important in bronchiectasis since the most common pathogens involved in exacerbations are typically gram-negative bacteria such as Pseudomonas aeruginosa.

Fluoroquinolones, like ciprofloxacin or levofloxacin, not only cover these pathogens effectively but also exhibit excellent tissue penetration, which can be beneficial in addressing infections in the pulmonary system. Additionally, they can be administered orally, providing a convenient option for outpatient treatment.

While macrolides are used as a long-term maintenance therapy in some patients with bronchiectasis due to their anti-inflammatory properties and ability to inhibit certain bacteria, they are not the first choice for acute exacerbations. Cephalosporins and aminoglycosides can also be effective but are generally not first-line agents for this specific indication, with cephalosporins often being more useful for broader hospital settings and aminoglycosides typically reserved for more severe or resistant infections, particularly in a hospital setting.