Long-term macrolide therapy offers an evidence-based treatment to reduce frequent exacerbations in stable adult patients with bronchiectasis. There is limited evidence that they also attenuate the decline in lung function and improve health-related quality of life. The benefits and risks of long-term macrolides need to be clearly explored for individual patients. Further work is needed to understand the optimal drug, dose and regimen, the mechanisms behind these benefits, appropriate patient selection, sustainability of efficacy, potential long-term risk on the lung microbiome, and their placement with or without inhaled antibiotic treatment. We reviewed the current evidence on long term macrolides in adults with bronchiectasis.