What are the symptoms and treatment options for bacterial bronchitis?

Symptoms and Treatment of Bacterial Bronchitis

Key Clinical Symptoms

Bacterial bronchitis presents with a persistent wet or productive cough, often accompanied by increased sputum volume, purulent (green or yellow) sputum, and worsening dyspnea—particularly in patients with underlying chronic obstructive lung disease. 1

Primary Symptom Triad (Anthonisen Criteria)

The presence of at least two of the following three criteria suggests bacterial origin in chronic bronchitis exacerbations: 1

• Increased sputum volume 1
• Increased sputum purulence (change to green or yellow color) 1
• Increased dyspnea (worsening shortness of breath) 1

Additional Clinical Features

• Fever may be present but does not reliably distinguish bacterial from viral infection 1
• Persistent fever >38°C for more than 3 days strongly suggests bacterial infection (bronchial superinfection or pneumonia) 1
• Productive cough lasting >4 weeks in children suggests protracted bacterial bronchitis 2
• Associated upper respiratory symptoms (rhinorrhea, nasal obstruction) suggest viral rather than bacterial etiology 1

Important Clinical Pitfall

Purulent sputum or green/yellow sputum color alone does NOT reliably indicate bacterial infection—this is a common misconception that leads to antibiotic overuse. 3, 4

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Treatment Approach: Algorithmic Decision-Making

Step 1: Determine Disease Severity and Baseline Lung Function

Treatment decisions depend critically on the patient's baseline respiratory status: 1

Simple Chronic Bronchitis (FEV1 >80%, no dyspnea)

• Do NOT prescribe immediate antibiotics, even if fever is present 1
• Reassess at 2-3 days 1
• Only prescribe antibiotics if fever >38°C persists beyond 3 days 1

Obstructive Chronic Bronchitis (FEV1 35-80%, exertional dyspnea)

• Prescribe antibiotics ONLY if at least 2 of 3 Anthonisen criteria are present 1, 4
• If criteria not met initially, reassess at 2-3 days 1
• Prescribe if fever >38°C persists beyond 3 days OR if 2+ Anthonisen criteria develop 1

Chronic Respiratory Insufficiency (FEV1 <35%, dyspnea at rest, hypoxemia)

• Immediate antibiotic therapy is recommended 1, 4
• Do not delay treatment in this high-risk population 1

Step 2: Select Appropriate Antibiotic Regimen

All antibiotics should target the three primary pathogens: Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. 1, 4

First-Line Antibiotics (for infrequent exacerbations, <3 per year, FEV1 >35%)

• Amoxicillin remains the reference first-line agent 1, 4
• First-generation cephalosporins are acceptable alternatives 1
• For penicillin allergy: Macrolides (azithromycin), pristinamycin, or doxycycline 1, 4
• Standard duration: 7-10 days 1

Avoid these agents due to resistance patterns: 1

• Aminopenicillins alone (without clavulanate) 1
• Macrolides as routine first-line (reserve for allergy) 1
• Cotrimoxazole (inconsistent pneumococcal activity, poor benefit/risk ratio) 1

Second-Line Antibiotics (for treatment failure or frequent exacerbations ≥3 per year)

• Amoxicillin-clavulanate (80 mg/kg/day in 3 doses, max 3 g/day) is the reference second-line therapy 1
• Cefpodoxime-proxetil (8 mg/kg/day in 2 doses) 1
• Second-generation cephalosporins (cefuroxime-axetil) 1
• Third-generation cephalosporins (cefotiam-hexetil) 1
• Fluoroquinolones with pneumococcal activity: Levofloxacin or moxifloxacin 1, 5

Do NOT use: 1

• Fluoroquinolones without adequate pneumococcal coverage (ciprofloxacin, ofloxacin) 1
• Cefixime (inadequate coverage) 1

Step 3: Special Considerations for Acute Bronchitis in Otherwise Healthy Adults

Antibiotics should NOT be prescribed for acute bronchitis in otherwise healthy adults—viruses cause >90% of cases and antibiotics provide no confirmed benefit. 4, 3

Exception: Consider antibiotics only if pertussis is suspected or patient is ≥65 years old with increased pneumonia risk. 3

Step 4: Protracted Bacterial Bronchitis in Children

For children with persistent wet cough >4 weeks: 2

• First-line: Amoxicillin-clavulanate for 2 weeks minimum 2
• Most common organisms: H. influenzae, S. pneumoniae, M. catarrhalis 6, 2
• >50% of patients resolve after 2 courses of antibiotics 6
• If no improvement after prolonged treatment, consider underlying disease (bronchiectasis, chronic suppurative lung disease) 7, 2
• Recurrent PBB (≥3 episodes/year) is a risk factor for bronchiectasis—close follow-up and consider chest CT 2

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Critical Clinical Pitfalls to Avoid

• Do not prescribe antibiotics for acute bronchitis in healthy adults without clear bacterial indicators 4, 3
• Do not assume purulent sputum equals bacterial infection—this leads to unnecessary antibiotic use 3, 4
• Do not fail to distinguish acute bronchitis from pneumonia—pneumonia requires different management and chest imaging 4
• Do not use cotrimoxazole due to poor pneumococcal coverage and adverse effect profile 1
• Do not overlook that PBB is often misdiagnosed as asthma in children—this leads to inappropriate steroid use 6, 8
• Do not ignore recurrent PBB in children—it may progress to bronchiectasis if untreated 6, 2