Staphylococcus aureus in bronchiectasis: epidemiology, clinical impact, and challenges in management

Bronchiectasis is a chronic respiratory disease characterized by permanent bronchial dilation, productive cough, and recurrent exacerbations. Staphylococcus aureus (including methicillin-resistant strains, MRSA) is increasingly recognized as a relevant pathogen in bronchiectasis, though its role remains less well defined than that of Pseudomonas aeruginosa or Haemophilus influenzae . This narrative review examines the epidemiological, pathophysiological, clinical, and therapeutic implications of S. aureus infection in adults with bronchiectasis, drawing comparisons from other disease models. Epidemiological data reveal a lower prevalence of S. aureus in bronchiectasis compared to other pathogens, with significant regional variation. Its clinical impact is debated, with some studies associating chronic S. aureus infection with more severe disease, while others consider it a marker of severity rather than a direct driver of progression. Unlike P. aeruginosa , current guidelines do not recommend specific eradication or long-term suppressive strategies for S. aureus . British guidelines suggest MRSA eradication may be considered in cases of clinical deterioration, though no standardized protocol exists. Exacerbations are managed with a 14-day course of targeted antibiotics. Preventive strategies, including decolonization and vaccine development, are under investigation or adapted from other clinical contexts. While no vaccine is currently available, monoclonal antibodies targeting S. aureus toxins have shown promise in early trials. Further research is needed to clarify the pathogen's role in disease progression and the efficacy of targeted therapies. This review also outlines clinical practice points and research priorities to support evidence-based management.