What is the appropriate treatment plan for a patient diagnosed with bronchitis, considering potential bacterial causes and the patient's possible history of smoking or exposure to pollutants?

Treatment of Bronchitis

Distinguish Between Acute and Chronic Bronchitis First

For acute bronchitis in otherwise healthy adults, do NOT prescribe antibiotics—they provide no meaningful clinical benefit (reducing cough by only half a day) while exposing patients to adverse effects and contributing to antibiotic resistance. 1, 2, 3

Acute Bronchitis Management

Rule out pneumonia before diagnosing acute bronchitis by checking for heart rate >100 bpm, respiratory rate >24 breaths/min, oral temperature >38°C, or focal consolidation on lung examination—if any are present, obtain chest radiography rather than treating as simple bronchitis. 2, 4

When Antibiotics Are NOT Indicated

• Purulent or green sputum does NOT indicate bacterial infection—it occurs in 89-95% of viral bronchitis cases and is not an indication for antibiotics. 2, 3
• Cough duration alone does NOT warrant antibiotics—viral bronchitis cough typically lasts 10-14 days, sometimes up to 3 weeks. 1, 2, 4
• Fever alone does NOT require immediate antibiotics unless it persists beyond 3 days, which suggests bacterial superinfection or pneumonia and warrants reassessment. 2

The ONE Exception: Pertussis

For confirmed or suspected pertussis (whooping cough), prescribe a macrolide antibiotic immediately (erythromycin or azithromycin) and isolate the patient for 5 days from treatment start—early treatment within the first few weeks diminishes coughing paroxysms and prevents disease spread. 1, 2

Symptomatic Treatment Options

• β2-agonist bronchodilators should NOT be routinely used for cough in most patients with acute bronchitis. 1
• In select patients with wheezing accompanying cough, β2-agonist bronchodilators may be useful. 1, 5
• Antitussive agents (codeine or dextromethorphan) can be offered for short-term symptomatic relief of bothersome dry cough, especially when sleep is disturbed. 1, 2
• Do NOT prescribe mucokinetic agents, expectorants, antihistamines, inhaled corticosteroids, oral corticosteroids, or NSAIDs at anti-inflammatory doses—there is no consistent evidence for beneficial effects. 1, 2

Patient Education Strategy

Inform patients that cough typically lasts 10-14 days after the visit and the condition is self-limiting, resolving within 3 weeks—patient satisfaction depends more on physician-patient communication than whether an antibiotic is prescribed. 2, 3, 4

Refer to the condition as a "chest cold" rather than bronchitis to reduce patient expectation for antibiotics. 2

Instruct patients to return if:

• Fever persists >3 days (suggests bacterial superinfection or pneumonia) 2
• Cough persists >3 weeks (consider other diagnoses: asthma, COPD, pertussis, GERD) 2
• Symptoms worsen rather than gradually improve 2

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Chronic Bronchitis Management

Adults with chronic cough and sputum expectoration occurring on most days for at least 3 months and for at least 2 consecutive years should be diagnosed with chronic bronchitis when other respiratory or cardiac causes are ruled out. 1

Most Effective Intervention

Avoidance of respiratory irritants (tobacco smoke, passive smoke, workplace hazards) is the most effective means to improve or eliminate chronic bronchitis cough—90% of patients will have resolution of their cough after smoking cessation. 1

Stable Chronic Bronchitis

• There is NO role for long-term prophylactic antibiotics in stable patients with chronic bronchitis. 1
• Short-acting β-agonists should be used to control bronchospasm and relieve dyspnea; in some patients, it may also reduce chronic cough. 1
• Ipratropium bromide should be offered to improve cough. 1
• Theophylline should be considered to control chronic cough, with careful monitoring for complications. 1

Acute Exacerbations of Chronic Bronchitis

Patients with sudden deterioration of symptoms (increased cough, sputum production, sputum purulence, and/or shortness of breath) should be considered to have an acute exacerbation as long as other conditions are ruled out. 1

Antibiotics ARE recommended for acute exacerbations of chronic bronchitis—patients with severe exacerbations and those with more severe airflow obstruction at baseline are most likely to benefit. 1

Antibiotic Selection for High-Risk Patients

High-risk patients include those aged >65 years with moderate-to-severe COPD, cardiac failure, insulin-dependent diabetes, or serious neurological disorders. 2

First-line antibiotics for infrequent exacerbations:

• Amoxicillin 500 mg three times daily for 5-8 days 2
• Doxycycline 100 mg twice daily for 7-10 days 2
• Azithromycin (no dose adjustment needed for renal impairment) 6, 7

Second-line antibiotics for frequent exacerbations or FEV1 <35%:

• Amoxicillin/clavulanate 625 mg three times daily for 14 days 2
• Clarithromycin extended-release 1000 mg once daily for 5-7 days (achieves 90-97% clinical cure rates) 2, 7
• Respiratory fluoroquinolones (levofloxacin)—avoid as first-line in elderly patients unless specifically indicated due to risk of serious adverse effects 6

Critical Pitfalls to Avoid

• Up to 25% of H. influenzae and 50-70% of M. catarrhalis produce β-lactamase, making simple aminopenicillins ineffective—use amoxicillin/clavulanate instead. 2
• Avoid aminoglycosides in patients with renal impairment due to nephrotoxicity risk. 6
• Obtain sputum cultures when possible before starting empirical antibiotics, then adjust therapy based on sensitivity results if no clinical improvement occurs. 2

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Chemical Bronchitis (Exposure to Pollutants)

The single most critical intervention is immediate cessation of exposure to the chemical irritant—this is the cornerstone of therapy, with 90% of patients experiencing resolution of cough after removing the exposure. 8

Pharmacologic Management

• Short-acting β-agonists or anticholinergic bronchodilators should be administered if bronchospasm is present to control bronchospasm and reduce cough. 8
• Antibiotics are NOT indicated unless there is evidence of secondary bacterial infection (fever >38°C persisting >3 days or purulent sputum with systemic symptoms). 8
• Inhaled corticosteroids may be considered for severe airflow obstruction or persistent symptoms, with a short course of systemic corticosteroids potentially effective for significant acute inflammation. 8

Monitoring

Monitor for improvement in cough frequency and severity after starting therapy—reassessment is necessary if symptoms persist or worsen, watching for development of secondary bacterial infection. 8