What is the treatment for bronchitis?

Treatment of Bronchitis

Antibiotics should not be routinely prescribed for acute bronchitis as it is typically a self-limiting viral infection, but they are indicated for exacerbations of chronic bronchitis with specific symptoms and risk factors. 1, 2

Acute Bronchitis Treatment

Definition and Diagnosis

• Acute bronchitis is an acute respiratory infection with normal chest radiograph
• Characterized by cough with or without phlegm lasting up to 3 weeks
• Primarily caused by respiratory viruses (>90% of cases)
• Less than 10% of cases have bacterial etiology 1

First-Line Management

1. Symptomatic relief:

   • Cough suppressants (dextromethorphan or codeine) for short-term symptomatic relief of bothersome dry cough, especially at night 1
   • Avoid expectorants, mucolytics, antihistamines, and bronchodilators as they lack evidence of benefit 1

2. Antibiotic therapy:

   • NOT recommended for routine treatment of uncomplicated acute bronchitis 1, 2
   • Despite being commonly prescribed, antibiotics only decrease cough duration by approximately 0.5 days while exposing patients to side effects 2, 3

3. Patient education:

   • Explain the expected duration of cough (2-3 weeks)
   • Describe acute bronchitis as a "chest cold" to reduce antibiotic expectations 2

Chronic Bronchitis Treatment

Exacerbation Management

For exacerbations of chronic bronchitis, treatment depends on severity and risk factors:

1. Simple chronic bronchitis exacerbation:

   • Immediate antibiotic therapy is not recommended, even with fever 1
   • Reassess after 2-3 days; antibiotics only if fever >38°C persists for more than 3 days 1

2. Chronic obstructive bronchitis exacerbation:

   • Immediate antibiotic therapy recommended if at least two of three Anthonisen criteria present (increased dyspnea, increased sputum volume, increased sputum purulence) 1
   • Antibiotics indicated if patient has at least one key symptom (increased dyspnea, sputum production, sputum purulence) AND one risk factor (age ≥65 years, FEV1 <50% predicted, ≥4 exacerbations/year, or comorbidities) 4

3. Chronic obstructive bronchitis with respiratory insufficiency:

   • Immediate antibiotic therapy recommended 1

Antibiotic Selection

• First-line antibiotics for infrequent exacerbations:

  • Amoxicillin (reference compound)
  • First-generation cephalosporins
  • Macrolides, pristinamycin, or doxycycline (if allergic to beta-lactams) 1

• Second-line antibiotics for frequent exacerbations or FEV1 <35%:

  • Amoxicillin-clavulanate (reference compound)
  • Second/third generation oral cephalosporins
  • Respiratory fluoroquinolones (levofloxacin, moxifloxacin) 1

Additional Treatments

• Bronchodilators: Short-acting beta-agonists for relief of bronchospasm 5
• Corticosteroids: Short course of systemic corticosteroids for acute exacerbations 5
• Long-term management: For patients with COPD and chronic bronchitis, consider:
  • Long-acting muscarinic antagonists (LAMAs) as first-line treatment 5
  • LABA/LAMA combinations for inadequate response to monotherapy 5

Prevention and Lifestyle Modifications

1. Smoking cessation:

   • Most effective intervention for chronic bronchitis
   • 90% of patients have resolution of cough after smoking cessation 1

2. Avoidance of respiratory irritants:

   • Workplace hazards
   • Passive smoke exposure
   • Environmental pollutants 1, 5

3. Vaccinations:

   • Annual influenza vaccination
   • Pneumococcal vaccinations 5

Common Pitfalls to Avoid

1. Overuse of antibiotics:

   • Prescribing antibiotics for uncomplicated acute bronchitis without appropriate indications
   • Using fluoroquinolones as first-line therapy in simple cases

2. Inadequate symptom management:

   • Failing to provide adequate cough suppression for bothersome symptoms
   • Using expectorants and mucolytics despite lack of evidence

3. Neglecting underlying conditions:

   • Failing to recognize exacerbations of asthma, COPD, or heart failure that may mimic bronchitis
   • Not addressing smoking cessation as a primary intervention

Remember that acute bronchitis is typically self-limiting, and treatment should focus on symptom relief while avoiding unnecessary antibiotics. For chronic bronchitis exacerbations, antibiotic therapy should be targeted to patients with specific symptoms and risk factors.