What are the treatment options for pneumonia vs bronchitis?

Treatment of Pneumonia vs Bronchitis

Pneumonia requires immediate antibiotic therapy, while acute bronchitis in healthy adults typically does not benefit from antibiotics and should not be routinely treated with them.

Key Diagnostic Distinction

The fundamental difference lies in parenchymal involvement:

• Pneumonia presents with fever, cough, respiratory distress, and abnormal pulmonary auscultation indicating parenchymal involvement—bacterial origin must be considered 1
• Acute bronchitis in healthy adults is predominantly viral (90% of lower respiratory tract infections), with cough but normal pulmonary auscultation 1

Bronchitis Treatment Approach

Acute Bronchitis in Healthy Adults

Antibiotics should NOT be prescribed as routine treatment 1:

• No benefit on clinical course or prevention of complications has been demonstrated in placebo-controlled trials 1
• Purulent sputum during acute bronchitis does NOT indicate bacterial superinfection in healthy adults 1
• Consider antibiotics only if fever >38°C persists beyond 7 days, suggesting bacterial superinfection 1

Chronic Bronchitis Exacerbations

Treatment depends on severity classification 1:

Simple chronic bronchitis (FEV1 >80%):

• Immediate antibiotics NOT recommended, even with fever 1
• Prescribe antibiotics only if fever >38°C persists >3 days 1

Chronic obstructive bronchitis (FEV1 35-80%):

• Immediate antibiotics recommended if ≥2 of 3 Anthonisen criteria present: increased dyspnea, increased sputum volume, increased sputum purulence 1

Severe COPD with respiratory insufficiency (FEV1 <35%, hypoxemia at rest):

• Immediate antibiotic therapy recommended 1

First-line antibiotics for bronchitis:

• Amoxicillin (reference compound) 1
• Alternative: First-generation cephalosporins, macrolides, pristinamycin, or doxycycline (especially for β-lactam allergy) 1

Second-line antibiotics (for frequent exacerbations ≥4/year or FEV1 <35%):

• Amoxicillin-clavulanate (reference) 1
• Alternatives: Cefuroxime-axetil, cefpodoxime-proxetil, levofloxacin, or moxifloxacin 1

Pneumonia Treatment Approach

Community-Acquired Pneumonia (Outpatient, Non-Severe)

Antibiotic therapy should be initiated immediately 1, 2:

For adults ≥40 years or with underlying disease:

• Amoxicillin 3 g/day orally (reference treatment for suspected pneumococcal pneumonia) 1, 2

For adults <40 years without underlying disease:

• Macrolide (azithromycin preferred) for suspected atypical pathogens 1, 2

Alternative options:

• Telithromycin 1
• Respiratory fluoroquinolone (levofloxacin or moxifloxacin) for patients with comorbidities or recent antibiotic use 2

Duration: 7 days for uncomplicated cases 1

Hospitalized Non-ICU Pneumonia

Immediate parenteral or oral antibiotics required 1, 2, 3:

Preferred regimens:

• β-lactam (ceftriaxone 1-2g IV daily or cefotaxime 1-2g IV q8h) PLUS macrolide (azithromycin 500mg IV daily) 2, 3
• Alternative: Respiratory fluoroquinolone monotherapy (levofloxacin 750mg IV daily or moxifloxacin 400mg IV daily) 1, 2, 3

Timing: Antibiotics must be administered within 4 hours of presentation in the Emergency Department 3

Switch to oral therapy when patient is hemodynamically stable, clinically improving, afebrile for 24 hours, and able to take oral medications 1, 3

Duration: Minimum 5 days, patient must be afebrile 48-72 hours with no more than one sign of clinical instability 1, 2

Severe Pneumonia (ICU)

Immediate parenteral combination therapy required 1, 2:

Without Pseudomonas risk factors:

• Non-antipseudomonal cephalosporin III (ceftriaxone or cefotaxime) PLUS macrolide 1, 2
• Alternative: Moxifloxacin or levofloxacin ± non-antipseudomonal cephalosporin III 1, 2

With Pseudomonas risk factors:

• Antipseudomonal cephalosporin OR acylureidopenicillin/β-lactamase inhibitor OR carbapenem (meropenem preferred) PLUS ciprofloxacin OR macrolide plus aminoglycoside 1, 2

Duration: 10 days for microbiologically undefined pneumonia; extend to 14-21 days for Legionella, Staphylococcus, or Gram-negative enteric bacilli 1

Critical Pitfalls to Avoid

For bronchitis:

• Do not prescribe antibiotics for viral acute bronchitis in healthy adults—this promotes resistance without clinical benefit 1
• Cotrimoxazole is a poor choice due to inconsistent pneumococcal activity 1

For pneumonia:

• Ciprofloxacin alone is inadequate for pneumococcal coverage—only levofloxacin (750mg) and moxifloxacin have sufficient activity 3
• Azithromycin monotherapy should not be used for hospitalized moderate-risk patients due to increasing pneumococcal resistance 3
• Do not delay antibiotics beyond 8 hours in hospitalized pneumonia—this increases 30-day mortality by 20-30% 3

Non-Response to Treatment

For pneumonia not improving within 48-72 hours 1, 4:

• Reassess for resistant pathogens (MDR bacteria, tuberculosis, fungi), septic complications (empyema), or non-infectious mimics (pulmonary embolism, malignancy, ARDS, vasculitis) 4
• Obtain repeat chest radiograph, CRP, white cell count, and additional microbiological specimens 1
• Consider bronchoscopy for alternative pathogen identification 1, 4
• For non-severe pneumonia on amoxicillin monotherapy: add or substitute macrolide 1
• For severe pneumonia not responding to combination therapy: consider adding rifampicin 1