Differentiating Treatment: Bronchitis vs Pneumonia
Diagnostic Differentiation Before Treatment
The critical first step is clinical differentiation, as bronchitis does not require antibiotics while pneumonia mandates immediate antimicrobial therapy. 1, 2
Clinical Features Suggesting Pneumonia (Not Bronchitis):
- Fever >37.8°C, tachycardia >100 bpm, tachypnea >25/min 2
- Focal chest signs on auscultation (crepitations, rales) rather than normal or diffuse bronchial sounds 2, 3
- Chest pain and overall severe clinical impression 2
- Radiographic confirmation showing parenchymal infiltrates (definitive for pneumonia) 2, 3
Clinical Features Suggesting Bronchitis (Not Pneumonia):
- Cough persisting 10-14 days, often with retrosternal burning 2, 3
- Normal or only slightly elevated fever 2
- Normal auscultation or diffuse bronchial rales 2, 3
- Normal chest radiograph 3
Treatment Algorithm for Acute Bronchitis
Antibiotics should NOT be prescribed for acute uncomplicated bronchitis in healthy adults. 1, 2, 3
Symptomatic Management:
- Short-acting β-agonists (albuterol) for bronchospasm relief 2, 3
- Adequate hydration to mobilize secretions 2, 3
- Dextromethorphan or codeine for bothersome dry cough 3
- NSAIDs or systemic corticosteroids are NOT justified 2
Exception - Exacerbation of Chronic Bronchitis/COPD:
For patients with chronic lung disease requiring hospital admission with bacterial exacerbation, antibiotics ARE indicated 4:
Preferred oral regimens:
Alternative regimens:
- Clarithromycin 500 mg twice daily (better H. influenzae coverage than azithromycin) 4
- Levofloxacin 500 mg once daily or moxifloxacin 400 mg once daily 4
Duration: 5-7 days 1
Treatment Algorithm for Community-Acquired Pneumonia
Immediate antibiotic therapy is required for all confirmed pneumonia cases. 3
Outpatient Pneumonia (Healthy Adults Without Comorbidities):
First-line treatment:
- Amoxicillin 1 g three times daily (total 3 g/day) for 7 days 1, 3, 5
- This targets suspected pneumococcal pneumonia, particularly in adults >40 years 1
Alternative for suspected atypical pathogens (adults <40 years, no underlying disease):
- Azithromycin 500 mg once daily for 3-5 days 1, 6, 7
- Clarithromycin 500 mg twice daily 4
- Levofloxacin 500 mg once daily 4
- Moxifloxacin 400 mg once daily 4
Hospitalized Patients (Non-Severe Pneumonia):
Preferred oral regimens:
If IV therapy needed:
- Co-amoxiclav 1.2 g three times daily IV 4
- Cefuroxime 1.5 g three times daily IV 4
- Cefotaxime 1 g three times daily IV 4
Alternative:
Hospitalized Patients (Severe Pneumonia/ICU):
Combination therapy required:
- β-lactam (co-amoxiclav 1.2 g three times daily IV OR cefuroxime 1.5 g three times daily IV OR cefotaxime 1 g three times daily IV) 4
- PLUS macrolide (clarithromycin 500 mg twice daily IV OR erythromycin 500 mg four times daily IV) 4
Alternative:
Duration of Therapy
Pneumonia:
- Minimum 5 days, with extension guided by clinical stability 3
- Standard duration: 7-10 days for most pathogens 4, 2
- Some guidelines suggest up to 14 days for community-acquired pneumonia 1
- Treatment should not exceed 8 days in a responding patient 4
Bronchitis with Bacterial Superinfection:
- 5-7 days 1
IV to Oral Switch
Switch to oral therapy when clinical stability is achieved (typically 48-72 hours) 4:
- Resolution of fever
- Hemodynamic stability
- Improved respiratory parameters
- Ability to take oral medications
Most patients do not need to remain hospitalized after switching to oral therapy. 4
Response Assessment
Assess clinical response within 48-72 hours of initiating treatment. 2, 3
Signs of Treatment Failure:
- No improvement or worsening within 48-72 hours 2
- Persistent fever, tachycardia, or respiratory distress 4
If Non-Response Occurs:
- Obtain repeat chest radiograph, CRP, white cell count 3
- Collect additional microbiological specimens 3
- Consider antimicrobial resistance or unusually virulent organisms 3
- Do NOT change treatment within first 72 hours unless clinical deterioration 1
Critical Pitfalls to Avoid
- Never prescribe antibiotics for viral acute bronchitis in healthy adults - this is the most common error 2, 3
- Do not use ciprofloxacin alone for pneumonia - inadequate pneumococcal coverage 3
- Avoid azithromycin monotherapy for hospitalized moderate-risk pneumonia - increasing pneumococcal resistance 3
- Do not use macrolide monotherapy where pneumococcal macrolide resistance exceeds 25% 3
- Previously well adults with acute bronchitis complicating influenza do NOT routinely require antibiotics in the absence of pneumonia 4