What is the treatment plan for a 15-month-old with acute bronchitis lasting 2 weeks, presenting with a wet cough?

Treatment Plan for 15-Month-Old with Acute Bronchitis and 2-Week Wet Cough

For this 15-month-old with a wet cough lasting 2 weeks, initiate a 2-week course of antibiotics targeting common respiratory bacteria (amoxicillin-clavulanate preferred), as the child has reached the threshold where protracted bacterial bronchitis (PBB) becomes the likely diagnosis. 1

Clinical Context and Timing

At 2 weeks duration, this child is at a critical juncture:

• Chronic cough is defined as >4 weeks, but the CHEST guidelines specifically recommend antibiotic treatment for wet cough in children without specific cough pointers, and 2 weeks represents the point where bacterial bronchitis becomes established 1
• The wet character of the cough strongly suggests bacterial involvement with Streptococcus pneumoniae, Haemophilus influenzae, or Moraxella catarrhalis 1
• Early intervention may prevent progression to bronchiectasis, which has been associated with persistent wet cough 1

Essential Assessment Before Treatment

Evaluate for "cough pointers" that would require different management:

• Coughing with feeding (suggests aspiration or swallowing dysfunction) 1
• Digital clubbing (suggests chronic suppurative lung disease or bronchiectasis) 1
• Respiratory distress (retractions, grunting, nasal flaring, respiratory rate >70/min) 2
• Poor feeding or signs of dehydration 2
• Fever ≥38°C (100.4°F) 2

If any cough pointers are present, immediate further investigation is required rather than empiric antibiotics. 1

Antibiotic Regimen

Prescribe amoxicillin-clavulanate for 2 weeks:

• This is the most commonly used and evidence-based antibiotic for PBB 1
• Targets the three most common respiratory bacteria causing wet cough in children 1
• Dose according to local guidelines and the child's weight
• Alternative agents include clarithromycin or erythromycin if amoxicillin-clavulanate is contraindicated 1

What NOT to Do

Avoid the following interventions that lack efficacy:

• Do NOT prescribe over-the-counter cough suppressants (including dextromethorphan) in children under 2 years due to lack of efficacy and risk of serious adverse events 2, 3
• Do NOT use asthma medications (bronchodilators or inhaled corticosteroids) unless there is clear evidence of asthma with recurrent wheeze and dyspnea responsive to beta-2 agonists 1
• Do NOT use hypertonic saline for post-bronchiolitis cough, as it has no proven efficacy 1
• Do NOT dismiss this as "just a viral cold" requiring only watchful waiting—the 2-week duration with wet cough warrants active treatment 1

Supportive Care Measures

Provide concurrent supportive management:

• Maintain hydration through continued breastfeeding or formula feeding 2
• Saline nasal drops for congestion relief 2
• Elevate head of bed for comfort 2
• Eliminate environmental irritants, especially tobacco smoke exposure 2, 4

Follow-Up and Escalation

Reassess after completing the 2-week antibiotic course:

• If cough resolves, the diagnosis is protracted bacterial bronchitis (PBB) 1
• If wet cough persists after 2 weeks of appropriate antibiotics, prescribe an additional 2 weeks of antibiotics 1
• If cough persists after 4 weeks total of antibiotics, refer for flexible bronchoscopy with quantitative cultures and consider chest CT imaging 1, 4

Seek immediate medical attention if any of the following develop:

• Respiratory distress (retractions, grunting, respiratory rate >70/min) 2
• Oxygen saturation <92% 2
• High fever ≥39°C (102.2°F) 4, 5
• Inability to feed or signs of dehydration 2
• Paroxysmal cough with post-tussive vomiting or inspiratory "whoop" (concerning for pertussis) 2, 4
• Apneic episodes 2

Important Clinical Pitfalls

Common errors to avoid:

• Do not wait until 4 weeks to initiate antibiotics in a child with persistent wet cough without cough pointers—the 2-week mark is appropriate for treatment initiation 1
• Do not assume all coughs are viral and self-limiting—wet cough specifically suggests bacterial involvement requiring antibiotics 1
• Do not use antibiotics for acute cough <2 weeks duration unless there are signs of specific bacterial infection like pneumonia 5, 6, 7
• Consider pertussis evaluation if the child is incompletely vaccinated or if cough pattern changes to paroxysmal episodes 2

Parent Education

Counsel parents that:

• This wet cough likely represents protracted bacterial bronchitis requiring antibiotics 1
• Complete the full 2-week antibiotic course even if symptoms improve earlier 1
• The cough should improve within 2 weeks of starting antibiotics 1
• Return immediately if warning signs develop (listed above) 2
• Persistent wet cough is never normal in children and requires active management 4