Risk assessment and prevention of disease progression: new concepts in bronchiectasis management

Bronchiectasis management is traditionally guided by exacerbation frequency. Previous guidelines have recommended treatment escalation only in patients experiencing three or more exacerbations per year. In contrast, the 2025 European Respiratory Society (ERS) guideline introduces a paradigm shift by advocating individualised risk assessment to identify patients at high risk of future complications, instead of relying solely on prior exacerbation. High-risk features include severe daily symptoms, underlying aetiologies or comorbidities, such as chronic obstructive pulmonary disease, rheumatoid arthritis, primary ciliary dyskinesia, and chronic infection with Pseudomonas aeruginosa or enteric Gram-negative pathogens. The 2025 ERS guideline also recommends long-term macrolides as first-line treatment for a broad patient population, irrespective of P. aeruginosa status, which is relevant in settings where inhaled antibiotics are unavailable. In this study, we present a clinical case, describe the appropriate management strategy, and discuss key practical considerations, including exclusion of nontuberculous mycobacterial infection before initiation, monitoring for adverse effects, and criteria for macrolide withdrawal. The availability of more effective therapies further underscores the importance of initiating treatment and avoiding delays until the disease becomes established or severe. In summary, the central tenet of the 2025 ERS guideline, revolving around identifying high-risk patients and initiating treatment early, is a proactive approach to preventing disease progression rather than managing its consequences.