What is the recommended treatment for bacterial bronchitis?

Treatment of Bacterial Bronchitis

Antibiotics should NOT be routinely prescribed for acute bronchitis, as it is viral in 89-95% of cases and antibiotics provide minimal benefit (reducing cough by only half a day) while exposing patients to adverse effects and promoting resistance. 1, 2

Distinguishing Acute Bronchitis from Conditions Requiring Antibiotics

Acute Bronchitis (No Antibiotics Needed)

• Most cases are viral and resolve without antibiotics regardless of purulent sputum, which occurs in 89-95% of viral cases 1, 2
• Cough typically lasts 10-14 days after the visit, even without treatment 1, 2
• Purulent or colored sputum does NOT indicate bacterial infection and is NOT an indication for antibiotics 1, 2

When to Consider Antibiotics

Rule out pneumonia first by checking for:

• Tachycardia (heart rate >100 beats/min) 2
• Tachypnea (respiratory rate >24 breaths/min) 2
• Fever (oral temperature >38°C) 2
• Abnormal chest examination findings (rales, egophony, tactile fremitus) 2

Bacterial superinfection is suggested by:

• Fever >38°C persisting beyond 3 days 1, 2
• This threshold is critical—do not prescribe antibiotics before 3 days of fever 2

Chronic Bronchitis Exacerbations (Different Disease Entity)

Simple Chronic Bronchitis (FEV1 >80%)

• Immediate antibiotics NOT recommended, even with fever 1
• Only prescribe if fever >38°C persists beyond 3 days 1

Obstructive Chronic Bronchitis (FEV1 35-80%)

Prescribe antibiotics immediately if at least 2 of 3 Anthonisen criteria present: 1

• Increased dyspnea
• Increased sputum volume
• Increased sputum purulence

Severe Obstructive Chronic Bronchitis with Respiratory Insufficiency (FEV1 <35% or hypoxemia)

• Immediate antibiotics recommended 1

Antibiotic Selection for Chronic Bronchitis Exacerbations

First-Line Antibiotics (for infrequent exacerbations ≤3/year, FEV1 ≥35%)

• Amoxicillin remains the reference compound 1
• First-generation cephalosporins as alternative 1
• Macrolides, pristinamycin, or doxycycline for beta-lactam allergy 1
• Avoid cotrimoxazole due to inconsistent pneumococcal activity and poor benefit/risk ratio 1

Second-Line Antibiotics (for frequent exacerbations ≥4/year, FEV1 <35%, or first-line failure)

• Amoxicillin-clavulanate (reference antibiotic) 1
• Second-generation cephalosporins: cefuroxime-axetil 1
• Third-generation cephalosporins: cefpodoxime-proxetil, cefotiam-hexetil 1
• Respiratory fluoroquinolones: levofloxacin, moxifloxacin 1, 3

Duration: 7-10 days standard 1

Target Pathogens

Antibiotics should cover: 1

• Streptococcus pneumoniae
• Haemophilus influenzae
• Moraxella catarrhalis (Branhamella catarrhalis)

Exception: Pertussis (Whooping Cough)

For confirmed or suspected pertussis, prescribe a macrolide antibiotic immediately: 1, 2

• Erythromycin or azithromycin 2
• Isolate patient for 5 days from treatment start 2
• Early treatment (within first few weeks) diminishes coughing paroxysms and prevents spread 2

Symptomatic Treatment for Acute Bronchitis

• β2-agonist bronchodilators should NOT be routinely used, except in select patients with wheezing 2
• Codeine or dextromethorphan may provide modest benefit for bothersome dry cough 2
• Do NOT prescribe: expectorants, mucolytics, antihistamines, inhaled corticosteroids, or NSAIDs at anti-inflammatory doses 2

Critical Patient Communication

To reduce inappropriate antibiotic expectations: 1, 2

• Refer to the condition as a "chest cold" rather than "bronchitis" 1, 2
• Explain that cough typically lasts 10-14 days regardless of treatment 1, 2
• Discuss risks of unnecessary antibiotics: side effects, resistance, rare anaphylaxis 1
• Emphasize that patient satisfaction depends on communication quality, not antibiotic prescription 1, 2

Common Pitfalls to Avoid

• Do not prescribe antibiotics based on: 1, 2
  • Purulent or colored sputum alone
  • Duration of cough
  • Patient expectation or demand
  • Presence of fever <3 days duration
• Do not confuse acute bronchitis with: 2
  • Pneumonia (requires chest examination and vital signs assessment)
  • Chronic bronchitis exacerbations (different diagnostic criteria and treatment approach)
  • Asthma or COPD exacerbations