Current and emerging stratification and therapeutic targeting of the microbiome in bronchiectasis
| Current methods | Emerging/future methods |
|---|---|
| Stratification based on clinical phenotypes, e.g. frequent exacerbators | Microbiome as an integrated biomarker and treatable trait |
| Stratification based on disease severity (BSI, FACED) | Ecological metrics (α-/β-diversity), graph-theoretic measures (degree, betweenness centrality and modularity) |
| Broad antimicrobial therapy based on microbial culture results | Evaluations of pathogens and associated commensal–pathobiont interaction networks to inform antimicrobial therapies |
| Use of azithromycin, doxycycline, fluoroquinolones (pathogen-centric) for pathogen eradication | Targeted antimicrobial eradication programmes, bacteriophage therapy, antibody–drug conjugates, narrow-spectrum microbiome-targeting |
| Broad anti-inflammatory therapy, e.g. inhaled corticosteroids | Precision therapeutics, e.g. anti-IL5 and DPP1 inhibitors |
| Focus on the lung as an independent biome | Holistic integration and appreciation of multi-site “axes”, e.g. gut–lung and oral–lung |
| One size fits all treatments based on the “vicious vortex” model | Multimodal precision interventions integrating ongoing assessments of the microbiome into the vicious vortex |
| Stratification of patients into microbiome types defined in relation to other patients’ microbiomes | Personalised individual prognostic/diagnostic microbiome results |
BSI: bronchiectasis severity index; DDP1: dipeptidyl peptidase 1; FACED: forced expiratory volume in 1 s, age, chronic Pseudomonas aeruginosa colonisation, radiological extension and dyspnoea; IL: interleukin.