What is the treatment approach for acute bronchitis vs pneumonia?

Treatment Approach for Acute Bronchitis vs Pneumonia

Antibiotics should not be prescribed for acute bronchitis in healthy adults, while pneumonia requires prompt antibiotic therapy tailored to likely pathogens and severity. 1

Diagnosis and Differentiation

Signs Suggestive of Acute Bronchitis:

• Cough (often persisting 10-14 days), sometimes preceded by upper respiratory tract infection 1
• Inconstant or slightly raised fever 1
• Retrosternal burning sensation 1
• Normal auscultation or diffuse bronchial rales 1
• Typically viral etiology (rarely bacterial pathogens like Mycoplasma pneumoniae, Chlamydia pneumoniae, or Bordetella pertussis) 1

Signs Suggestive of Pneumonia:

• Fever >37.8°C, tachycardia >100 bpm, tachypnea >25/min 1
• Chest pain and overall impression of severity 1
• Focal signs on auscultation (crepitations, rales) 1
• Radiographic confirmation is definitive 1

Treatment for Acute Bronchitis

Primary Management:

• Antibiotics should not be prescribed for acute bronchitis in healthy adults 1, 2
  • No evidence that antibiotic therapy prevents superinfection or improves outcomes 1, 2
  • Antibiotics provide only minimal benefit (reducing cough by about half a day) while risking adverse effects 2

Symptomatic Treatment:

• Short-acting β-agonists (albuterol) for bronchospasm 3
• Consider adding ipratropium bromide for severe bronchospasm 3
• Ensure adequate hydration to help mobilize secretions 3
• Patient education about the natural course of disease (cough typically lasting 2-3 weeks) 2

Common Pitfalls:

• Prescribing NSAIDs at anti-inflammatory doses or systemic corticosteroids is not justified for uncomplicated acute bronchitis 1
• Theophylline should not be used due to risk of side effects and lack of benefit 3

Treatment for Pneumonia

Community-Acquired Pneumonia Without Risk Factors:

• For adults <40 years with no underlying disease:
  • Oral macrolides (first-line for suspected atypical pathogens) 1
• For adults ≥40 years and/or with underlying disease:
  • Oral amoxicillin 3 g/day (for suspected pneumococcal origin) 1

Community-Acquired Pneumonia With Risk Factors or Requiring Hospitalization:

• For non-severe hospitalized patients:
  • β-lactam + macrolide OR respiratory fluoroquinolone 1
• For severe hospitalized patients:
  • β-lactam + macrolide OR β-lactam + fluoroquinolone 1

Duration of Treatment:

• Standard duration is 7-10 days for most pathogens 1
• Intracellular pathogens (e.g., Legionella) require at least 14 days of treatment 1

Monitoring Response:

• Response should be assessed within 48-72 hours of initiating treatment 3
• Monitor temperature, respiratory parameters, and hemodynamic status 1
• Complete response, including radiographic resolution, requires longer time periods 1

Special Considerations

Elderly Patients:

• Higher risk of pneumococcal infection with decreased susceptibility to penicillin 1
• Consider broader coverage for those >65 years 1

Influenza Testing:

• When influenza is circulating in the community, test with rapid influenza molecular assay 1
• Antiviral treatment within 48 hours of symptom onset can reduce antibiotic use and improve outcomes 1

Non-Responding Patients:

• For pneumonia not responding to initial therapy, full reinvestigation and adjustment of antibiotic regimen is recommended 1
• For slowly resolving pneumonia, reinvestigation should be guided by clinical needs and individual risk factors 1

Algorithm for Management

1. Determine if pneumonia is present (clinical assessment + chest radiography when available) 1
2. If pneumonia is confirmed:
   • Assess severity and risk factors 1
   • Initiate appropriate antibiotic therapy based on likely pathogens 1
   • Monitor response within 48-72 hours 1
3. If acute bronchitis is diagnosed:
   • Provide symptomatic treatment only 1, 2
   • Educate patient about expected duration of cough 2
   • Consider bronchodilators for bronchospasm 3

This approach prioritizes appropriate antibiotic stewardship while ensuring effective treatment of bacterial pneumonia, which carries significant morbidity and mortality risks if undertreated.