Treatment Assessment for Smoker with Bronchitis and Green Sputum
The Z-pack (azithromycin) prescribed for this case is likely inappropriate, as antibiotics are not recommended for acute uncomplicated bronchitis regardless of sputum color, and the patient should instead receive symptomatic treatment with bronchodilators and smoking cessation counseling. 1
Critical First Step: Rule Out Pneumonia
Before proceeding with any treatment plan, you must determine if this is pneumonia versus bronchitis. For healthy adults, pneumonia is unlikely if ALL of the following are absent: 1
- Heart rate >100 beats/min
- Respiratory rate >24 breaths/min
- Oral temperature >38°C (100.4°F)
- Abnormal chest examination findings (rales, egophony, or tactile fremitus)
If pneumonia IS suspected based on these criteria, then antibiotics are appropriate. 1 If pneumonia is ruled out, proceed with the algorithm below.
The Green Sputum Pitfall
Colored sputum is the most common reason clinicians inappropriately prescribe antibiotics for viral bronchitis, but it has no diagnostic value for bacterial infection. 1 The characteristics of cough, including sputum color, have been shown to lack both diagnostic sensitivity and specificity. 2
Why Azithromycin is Wrong Here
More than 90% of acute bronchitis cases are viral, making antibiotics ineffective regardless of which one you choose. 1 The American College of Physicians and CDC explicitly recommend against routine antibiotic treatment for acute bronchitis in the absence of pneumonia. 1
Patients with acute bronchitis treated with macrolides (including azithromycin) had significantly more adverse events than those receiving placebo, with no improvement in cough resolution. 1 Acute bronchitis leads to more inappropriate antibiotic prescribing than any other respiratory infection in adults, with over 70% of visits resulting in unnecessary prescriptions. 1
Appropriate Treatment Algorithm
1. Smoking Cessation (Most Important)
Cigarette smoking is commonly associated with cough that meets the definition of chronic bronchitis, and smoking cessation is almost always effective. 2 The majority of patients will have cough resolution within 4 weeks of cessation, though in some cases it may take longer. 2
2. Bronchodilator Therapy
Randomized controlled trials have demonstrated consistent benefit of albuterol versus placebo for uncomplicated acute bronchitis in reducing the duration and severity of cough, with approximately 50% fewer patients reporting cough after 7 days. 2
- In stable patients with chronic bronchitis, therapy with short-acting β-agonists should be used to control bronchospasm and relieve dyspnea; in some patients, it may also reduce chronic cough. 2
- Therapy with ipratropium bromide should be offered to improve cough in stable patients with chronic bronchitis. 2
3. Tessalon Perles (Benzonatate) - Appropriate
The Tessalon Perles prescription is reasonable for symptomatic cough relief. Preparations containing dextromethorphan or codeine probably have a modest effect on severity and duration of cough in patients with acute bronchitis. 2
4. Realistic Expectations
Provide realistic expectations for the duration of the patient's cough, which will typically last 10 to 14 days after the office visit. 2 Refer to the illness as a "chest cold" rather than bronchitis, as use of the term "chest cold" is associated with less frequent belief that antibiotic therapy is necessary. 2
When Antibiotics ARE Indicated
Antibiotics should only be considered if the patient has:
- Confirmed pneumonia (based on clinical criteria above) 1
- Acute exacerbation of COPD with increased sputum purulence, increased sputum volume, and increased dyspnea (Anthonisen criteria) 3
- Chronic bronchiectasis with ≥3 exacerbations per year, particularly with Pseudomonas aeruginosa infection 1
If the patient has severe COPD with frequent exacerbations, then antibiotics may be warranted. When sputum becomes purulent in COPD exacerbations, patients are treated on empirical grounds with a 7-14 day course of antibiotics. 2 The most common organisms are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. 2
Common Pitfalls to Avoid
- Don't prescribe antibiotics based on sputum color alone - this is viral bronchitis until proven otherwise 1
- Don't assume two weeks of symptoms means bacterial infection - viral bronchitis cough typically lasts 10-14 days 2
- Don't forget to assess for COPD - if the patient is a chronic smoker with productive cough, they may have undiagnosed COPD requiring different management 2
- Don't use β-agonists routinely in all patients - they are most beneficial in patients with wheezing or clinical evidence of bronchial hyperresponsiveness 2