What antibiotic is needed for bronchitis?

Antibiotics for Bronchitis: Evidence-Based Recommendations

Antibiotics should NOT be prescribed for acute bronchitis in otherwise healthy adults, as the benefit has not been confirmed in clinical trials versus placebo. 1, 2

Diagnosis and Clinical Assessment

• Acute bronchitis is among the most common adult outpatient diagnoses, accounting for approximately 100 million ambulatory care visits annually in the United States 1
• More than 90% of otherwise healthy patients presenting with an acute cough have a syndrome caused by a virus 1
• The presence of purulent sputum or a change in its color (green or yellow) does not signify bacterial infection; purulence is due to inflammatory cells or sloughed mucosal epithelial cells 1, 2
• Acute bronchitis must be distinguished from pneumonia, which requires different management 1, 2
• Pneumonia is unlikely in the absence of all of the following clinical criteria: tachycardia (heart rate >100 beats/min), tachypnea (respiratory rate >24 breaths/min), fever (oral temperature >38°C), and abnormal findings on chest examination 1

Antibiotic Recommendations

• The American College of Physicians and CDC advise against antibiotic therapy for acute bronchitis unless pneumonia is suspected 1
• The American College of Chest Physicians recommends against routine treatment with antibiotics for acute bronchitis 1
• The World Health Organization's evidence review concluded that antibiotics should not be recommended for acute bronchitis in otherwise healthy people 1
• Systematic reviews have found limited evidence to support antibiotic use for acute bronchitis and a trend toward increased adverse events in patients treated with antibiotics 1

Special Circumstances Where Antibiotics May Be Considered

• The one uncommon circumstance for which evidence supports antibiotic treatment is suspicion of pertussis 1
• For confirmed or probable pertussis, a macrolide antibiotic (erythromycin) is recommended, and the patient should be isolated for 5 days from the start of treatment 1
• In patients with underlying chronic obstructive pulmonary disease (COPD) with exacerbation, antibiotics may be indicated when at least two of the three Anthonisen criteria are present (increased sputum volume, increased sputum purulence, increased dyspnea) 3, 2

Symptomatic Management

• Patients may benefit from symptomatic relief with cough suppressants (dextromethorphan or codeine), expectorants (guaifenesin), first-generation antihistamines (diphenhydramine), decongestants (phenylephrine), and β-agonists (albuterol), although data to support specific therapies are limited 1
• β-Agonists have not been shown to benefit patients without asthma or chronic obstructive lung disease 1
• In select adult patients with acute bronchitis and wheezing accompanying the cough, treatment with β2-agonist bronchodilators may be useful 1

Common Pitfalls to Avoid

• Prescribing antibiotics for acute bronchitis in healthy adults without clear indications - more than 70% of visits for acute bronchitis result in antibiotic prescriptions despite evidence against their use 1, 2
• Assuming purulent sputum indicates bacterial infection - color of sputum is not a reliable indicator of bacterial infection 1, 2
• Failing to distinguish between acute bronchitis and pneumonia - pneumonia requires different management 1, 2
• Not addressing patient expectations - because many patients with acute bronchitis expect to receive an antibiotic based on previous experiences, time should be set aside to explain the decision not to use these agents 1

Patient Education

• Explain that acute bronchitis is primarily a viral illness and routine treatment with antibiotics is not justified 1
• Inform patients about the potential harm of using unnecessary antibiotics to the individual and to the community at large 1
• Advise patients that symptoms typically last about three weeks 4
• Discuss symptomatic relief options and their potential minor adverse effects, including nausea, vomiting, headache, and drowsiness 1