What is the treatment for bronchitis with fever?

Treatment of Bronchitis with Fever

Antibiotics are generally not indicated for acute uncomplicated bronchitis, even with fever, unless pneumonia is suspected or the patient has specific risk factors. 1

Diagnosis and Assessment

• Distinguish between acute bronchitis (typically viral) and pneumonia:

  • Check for tachycardia (heart rate >100 beats/min), tachypnea (respiratory rate >24 breaths/min), fever >38°C, and abnormal chest examination findings (rales, egophony, tactile fremitus) 1
  • If all these signs are absent in an immunocompetent adult <70 years, pneumonia is unlikely
  • Colored sputum (green or yellow) does not indicate bacterial infection; it's due to inflammatory cells 1

• Consider pertussis if cough persists >2 weeks with paroxysmal cough, whooping, or post-tussive emesis 2

Treatment Approach

First-line Treatment (Symptomatic Management)

For uncomplicated bronchitis with fever:

1. Antipyretics for fever management:

   • Acetaminophen or NSAIDs like ibuprofen

2. Symptomatic relief options: 1, 3

   • Cough suppressants (dextromethorphan, codeine)
   • Expectorants (guaifenesin)
   • First-generation antihistamines (diphenhydramine)
   • Decongestants (phenylephrine)
   • β-agonists (albuterol) - Note: Only beneficial in patients with underlying asthma or COPD 1

3. Adequate hydration and rest

When to Consider Antibiotics

Antibiotics should only be considered in specific circumstances:

1. Suspected pneumonia based on clinical criteria 1
2. Pertussis to reduce transmission 4
3. High-risk patients (>65 years, immunocompromised) 4
4. Exacerbation of chronic bronchitis meeting Anthonisen criteria (at least 2 of: increased dyspnea, increased sputum volume, increased sputum purulence) 3

If antibiotics are indicated for exacerbation of chronic bronchitis:

• First-line: Amoxicillin (3g/day) for 7-10 days 1, 3
• Alternatives for penicillin allergy: Macrolides or doxycycline 3
• For treatment failures: Amoxicillin-clavulanate, second/third-generation cephalosporins, or respiratory fluoroquinolones 3

Special Considerations for Chronic Bronchitis

For patients with established chronic bronchitis: 1

• Short-acting β-agonists should be used to control bronchospasm and may reduce chronic cough
• Ipratropium bromide improves cough
• Theophylline may be considered for chronic cough management (with careful monitoring)

Patient Education

• Emphasize that bronchitis is typically viral and self-limiting 3, 4
• Cough typically lasts 2-3 weeks regardless of treatment 3, 2
• Explain that antibiotics provide minimal benefit (reducing cough by only about half a day) and carry risks including allergic reactions, nausea, vomiting, and C. difficile infection 2
• Advise to return if symptoms persist beyond 3 weeks or if fever lasts >3-4 days 3

Common Pitfalls to Avoid

1. Overuse of antibiotics for viral bronchitis - more than 70% of acute bronchitis visits result in antibiotic prescriptions despite limited evidence of benefit 1

2. Misinterpreting colored sputum as indicating bacterial infection 1

3. Prolonged use of topical decongestants (>3 days) which can lead to rhinitis medicamentosa 3

4. Using β-agonists in patients without asthma or COPD, as they show no benefit in these populations 1

5. Missing pneumonia - always assess for signs of pneumonia requiring different management 1

Remember that acute bronchitis is self-limiting in most cases, and symptomatic treatment focusing on fever control and cough management is the mainstay of therapy.