What are the treatment differences between whooping cough, bronchitis, and croup in pediatric patients?

Treatment Differences Between Whooping Cough, Bronchitis, and Croup

The treatment approaches for whooping cough (pertussis), acute bronchitis, and croup differ fundamentally: whooping cough requires macrolide antibiotics for public health containment; acute bronchitis should not receive antibiotics; and croup is managed with corticosteroids (though croup-specific evidence was not provided in the available guidelines).

Whooping Cough (Pertussis)

Antibiotic Treatment is Mandatory

• Children and adults with confirmed or probable whooping cough must receive a macrolide antibiotic and be isolated for 5 days from the start of treatment 1
• Early treatment within the first few weeks diminishes coughing paroxysms and prevents disease spread, though patients are unlikely to respond to treatment beyond this period 1
• Erythromycin or trimethoprim/sulfamethoxazole should be used when a macrolide cannot be given 1

Shorter Antibiotic Courses Are Equally Effective

• Short-term antibiotics (azithromycin for 3-5 days, or clarithromycin or erythromycin for 7 days) are as effective as long-term erythromycin (10-14 days) in eradicating Bordetella pertussis from the nasopharynx, but have fewer side effects 2
• Antibiotics effectively eliminate B. pertussis but do not alter the subsequent clinical course of the illness 2

Public Health Rationale

• Antibiotic treatment is recommended primarily to decrease shedding of the pathogen and spread of disease, not to hasten symptom resolution if initiated 7-10 days after illness onset 1
• Diagnostic testing should always accompany antibiotic treatment due to public health implications 1

Symptomatic Treatment Has Limited Evidence

• No interventions (including corticosteroids, beta2-agonists, pertussis immunoglobulin, or antihistamines) have shown statistically significant benefit in reducing paroxysmal cough severity 3

Acute Bronchitis

Antibiotics Are Not Indicated

• For patients with acute bronchitis, routine treatment with antibiotics is not justified and should not be offered 1
• Acute bronchitis is primarily a viral illness, making antibiotic treatment ineffective 1
• Meta-analyses show no impact of antibiotic treatment on cough duration, illness duration, activity limitation, or work loss 1

Patient Education is Essential

• The decision not to use antibiotics should be addressed individually with explanations, as many patients expect antibiotics based on previous experiences 1
• Office time must be allocated to explain potential harm of unnecessary antibiotics to the individual and community 1

Bronchodilators Have Limited Role

• Beta2-agonist bronchodilators should not be routinely used to alleviate cough in most patients with acute bronchitis 1
• In select adult patients with wheezing accompanying the cough, beta2-agonist bronchodilators may be useful 1

Symptomatic Management

• Antipyretics and analgesics can be used to keep the patient comfortable and help with coughing 1

Protracted Bacterial Bronchitis (Chronic Wet Cough)

When Bronchitis Becomes Chronic

• Young children with mild symptoms of lower respiratory tract infection need not be treated with antibiotics initially 1
• For children with chronic wet cough (>4 weeks) without specific cough pointers, a 2-week course of antibiotics targeting Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis is recommended 1

Antibiotic Selection

• Amoxicillin-clavulanate is first choice for children under 5 years because it is effective against the majority of pathogens causing community-acquired pneumonia, is well tolerated, and inexpensive 1
• Alternatives include clarithromycin, erythromycin, or azithromycin 1

Treatment Duration and Escalation

• If wet cough persists after 2 weeks of appropriate antibiotics, an additional 2 weeks of antibiotics should be prescribed 1
• If cough persists after 4 weeks total of antibiotics, further investigations (flexible bronchoscopy with quantitative cultures and/or chest CT) should be undertaken 1

Critical Distinctions in Management Approach

Diagnostic Clues

• Whooping cough: Paroxysmal cough with post-tussive vomiting or inspiratory "whoop," though adults with previous immunity may not display classic features 1, 4
• Acute bronchitis: Acute cough (<4 weeks) without specific features suggesting bacterial infection 1
• Protracted bacterial bronchitis: Chronic wet cough (>4 weeks) with loose, self-propagating sound in young children who cannot expectorate 1, 4

Age-Specific Considerations

• In children under 2 years, over-the-counter cough and cold medications should not be used due to lack of proven efficacy and potential for serious toxicity 5
• Macrolide antibiotics may be used as first-line empirical treatment in children aged 5 and above for community-acquired pneumonia due to higher prevalence of Mycoplasma pneumoniae 1

Common Pitfalls to Avoid

• Do not prescribe antibiotics for acute bronchitis based on patient expectation alone—this contributes to antimicrobial resistance 1
• Do not delay antibiotic treatment for suspected pertussis during documented outbreaks, as early treatment prevents disease spread 1
• Do not wait until 4 weeks to initiate antibiotics in children with persistent wet cough without cough pointers—the 2-week mark is appropriate for treatment initiation 6
• Chest physiotherapy is not beneficial and should not be performed in children with pneumonia 1