What is the recommended treatment, dose, and frequency for a patient with acute or chronic bronchitis, considering symptoms and potential underlying conditions such as chronic obstructive pulmonary disease (COPD)?

Bronchitis Treatment: Dose and Frequency

Acute Bronchitis (Viral)

Antibiotics should NOT be prescribed for acute bronchitis, as they reduce cough duration by only 0.5 days while exposing patients to adverse effects and contributing to antibiotic resistance. 1, 2, 3

Symptomatic Management

• Patient education is the cornerstone: Inform patients that cough typically lasts 10-14 days after the visit, with complete resolution within 3 weeks 1, 2
• Antitussives (for bothersome dry cough, especially disturbing sleep):
  • Codeine or dextromethorphan provide modest symptom relief 1, 4
  • Dosing: Standard over-the-counter formulations as directed
• Bronchodilators: β2-agonist bronchodilators should NOT be routinely used, except in select patients with accompanying wheezing 1
• Avoid: Expectorants, mucolytics, antihistamines, inhaled corticosteroids, oral corticosteroids, and NSAIDs at anti-inflammatory doses have no proven benefit 1

Critical Exception: Pertussis

• If pertussis is confirmed or suspected, prescribe a macrolide antibiotic immediately 1:
  • Erythromycin or azithromycin (standard dosing per drug label)
  • Isolate patient for 5 days from treatment start 1
  • Early treatment (within first few weeks) diminishes coughing paroxysms and prevents disease spread 1

When to Reassess

• Fever persisting >3 days: Suggests bacterial superinfection or pneumonia—consider antibiotics 1
• Cough persisting >3 weeks: Consider alternative diagnoses (asthma, COPD, pertussis, GERD) 1
• Vital sign abnormalities (heart rate >100, respiratory rate >24, temperature >38°C) or focal lung findings: Rule out pneumonia 1

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Chronic Bronchitis (Stable)

For stable chronic bronchitis, ipratropium bromide is the first-line therapy to improve cough, with a Grade A recommendation. 5, 6, 4

First-Line Bronchodilator Therapy

• Ipratropium bromide: 36 μg (2 inhalations) four times daily 6, 4
  • Reduces cough frequency, cough severity, and sputum volume 5, 6
• Short-acting β-agonists: Use to control bronchospasm and relieve dyspnea; may also reduce chronic cough in some patients 5
  • Standard metered-dose inhaler dosing: 2 inhalations every 4-6 hours as needed

Alternative Therapy

• Theophylline: Consider for chronic cough control, but requires careful monitoring for complications (narrow therapeutic window, drug interactions, especially in elderly) 5
  • Dosing: Individualized based on serum levels (therapeutic range 5-15 mcg/mL)

Advanced Therapy (Severe Disease)

• For FEV1 <50% or frequent exacerbations: Add inhaled corticosteroid (ICS) with long-acting β-agonist (LABA) 5, 6
  • Example: Fluticasone/salmeterol 250/50 mcg, 1 inhalation twice daily 7
• Long-acting bronchodilators (LABA/LAMA combinations) for persistent breathlessness 6

What NOT to Use

• Mucokinetic agents and expectorants: No proven benefit for chronic cough 5
• Oral corticosteroids: Not recommended for stable chronic bronchitis due to lack of benefit and significant side effects 5
• Long-term prophylactic antibiotics: Not recommended due to resistance concerns 6, 4

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Acute Exacerbation of Chronic Bronchitis (AECB)

During acute exacerbations, administer short-acting β-agonists or anticholinergic bronchodilators; if no prompt response, add the other agent at maximal dose. 5

Bronchodilator Therapy

• Short-acting β-agonists OR anticholinergic bronchodilators (ipratropium) 5
  • If inadequate response, add the second agent at maximal dose 5
• Avoid theophylline during acute exacerbations (Grade D recommendation) 5

Systemic Corticosteroids

• Recommended for acute exacerbations: 10-15 day course 4
  • IV therapy for hospitalized patients; oral therapy for ambulatory patients 4
  • A 2-week course is equivalent to 8 weeks, with fewer side effects 5

Antibiotic Therapy (High-Risk Patients Only)

Reserve antibiotics for patients with ≥1 key symptom (increased dyspnea, sputum volume, or sputum purulence) AND ≥1 risk factor. 1, 8

Risk Factors for Antibiotic Use:

• Age ≥65 years 1, 8
• FEV1 <50% predicted 1, 8
• ≥4 exacerbations in 12 months 8
• Comorbidities (cardiac failure, insulin-dependent diabetes, immunosuppression) 1, 8

Antibiotic Regimens (Moderate Severity):

• Doxycycline: 100 mg twice daily for 7-10 days 1
• Clarithromycin extended-release: 1000 mg once daily for 5-7 days 1
• Clarithromycin immediate-release: 500 mg twice daily for 7-14 days 1

Antibiotic Regimens (Severe Exacerbations):

• Amoxicillin/clavulanate: 625 mg three times daily for 14 days 1
• Respiratory fluoroquinolone (e.g., levofloxacin, moxifloxacin) 8

Critical Pitfall:

• Up to 25% of H. influenzae and 50-70% of M. catarrhalis produce β-lactamase, making simple aminopenicillins (amoxicillin alone) ineffective 1
• Purulent sputum occurs in 89-95% of viral cases and does NOT indicate bacterial infection 1, 2

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Key Communication Strategy

Refer to acute bronchitis as a "chest cold" rather than "bronchitis" to reduce patient expectations for antibiotics. 1, 2 Patient satisfaction depends more on physician-patient communication than whether an antibiotic is prescribed 1.