Is Augmentin (amoxicillin-clavulanate) an appropriate treatment for a patient with bronchitis, considering the potential for bacterial infection and underlying respiratory conditions such as asthma or chronic obstructive pulmonary disease (COPD)?

Augmentin for Bronchitis

Augmentin (amoxicillin-clavulanate) should NOT be prescribed for acute uncomplicated bronchitis in otherwise healthy adults, as it provides no clinical benefit—reducing cough by only half a day while significantly increasing adverse effects. 1

Critical Distinction: Acute Bronchitis vs. Chronic Bronchitis Exacerbations

The answer depends entirely on whether you're treating acute bronchitis (a viral illness) or acute exacerbations of chronic bronchitis/COPD (which may be bacterial).

For Acute Bronchitis (Immunocompetent Adults)

Do NOT prescribe Augmentin or any antibiotic. 1, 2

• Respiratory viruses cause 89-95% of acute bronchitis cases, making antibiotics completely ineffective regardless of which one you choose. 2
• A randomized controlled trial specifically comparing amoxicillin-clavulanate to placebo showed no significant difference in days with cough: amoxicillin-clavulanate resulted in 11 days of cough versus 11 days with placebo. 1
• Antibiotics only reduce cough duration by approximately 0.5 days (12 hours) while significantly increasing adverse events (RR 1.20; 95% CI 1.05-1.36). 1, 2

Common pitfalls to avoid:

• Do NOT assume bacterial infection based on purulent or discolored sputum—this occurs in 89-95% of viral cases and does not indicate bacterial infection. 1, 2
• Do NOT prescribe antibiotics based on cough duration alone—viral bronchitis cough typically lasts 10-14 days, sometimes up to 3 weeks. 2
• Do NOT prescribe antibiotics to meet patient expectations—patient satisfaction depends more on physician-patient communication than whether an antibiotic is prescribed. 2

What TO do instead:

• Inform patients that cough typically lasts 10-14 days after the visit, even without antibiotics, and may persist up to 3 weeks. 2
• Consider antitussives (codeine or dextromethorphan) for bothersome dry cough, especially when sleep is disturbed. 1, 2
• Consider β2-agonist bronchodilators only in select patients with accompanying wheezing. 1, 2

When to reassess:

• If fever persists beyond 3 days—this strongly suggests bacterial superinfection or pneumonia rather than simple viral bronchitis. 1, 2
• If cough persists beyond 3 weeks—consider other diagnoses such as asthma, COPD, pertussis, or gastroesophageal reflux. 2

For Acute Exacerbations of Chronic Bronchitis/COPD

Augmentin MAY be appropriate in specific high-risk situations. 2, 3

Indications for antibiotics (including Augmentin):

• Patients with chronic respiratory insufficiency (dyspnea at rest and/or FEV1 <35% with hypoxemia PaO2 <60 mmHg). 2
• Patients meeting at least 2 of 3 Anthonisen criteria: increased dyspnea, increased sputum volume, or increased sputum purulence. 2
• High-risk patients (age >65 years with moderate-to-severe COPD, cardiac failure, insulin-dependent diabetes, or serious neurological disorders). 2

Augmentin dosing for chronic bronchitis exacerbations:

• Standard dose: 875/125 mg twice daily for 7 days. 3
• High-dose formulation: 2,000/125 mg (Augmentin XR) twice daily for 5 days—shown to be as effective as the 7-day standard course with high bacteriological efficacy (76.7% success rate). 3
• Augmentin provides coverage for β-lactamase-producing H. influenzae and M. catarrhalis, which account for up to 25% and 50-70% of cases respectively. 2, 4

Alternative antibiotics to consider:

• First-line for infrequent exacerbations: amoxicillin, first-generation cephalosporins, macrolides, or doxycycline. 2
• Second-line for frequent exacerbations or FEV1 <35%: respiratory fluoroquinolones (levofloxacin, moxifloxacin) or second/third-generation cephalosporins. 2

Before Diagnosing Bronchitis: Rule Out Pneumonia

Always check vital signs and perform chest examination before diagnosing bronchitis. 1, 2

Pneumonia is likely (NOT bronchitis) if any of the following are present:

• Heart rate >100 beats/min. 2
• Respiratory rate >24 breaths/min. 2
• Oral temperature >38°C. 2
• Abnormal chest examination findings (rales, egophony, tactile fremitus, or focal consolidation). 1, 2

If any of these are present, obtain chest radiography and treat as pneumonia, not bronchitis. 2

Special Consideration: Asthma and COPD Mimics

Approximately one-third of patients diagnosed with "recurrent acute bronchitis" actually have undiagnosed asthma or COPD exacerbations. 2

• Differential diagnoses such as exacerbations of chronic airways diseases (COPD, asthma, bronchiectasis) may require other therapeutic management (such as oral corticosteroids) rather than antibiotics. 1
• If the patient has known asthma or COPD, you are NOT treating simple acute bronchitis—different management applies. 1, 2

Exception: Pertussis

For confirmed or suspected pertussis (whooping cough), prescribe a macrolide antibiotic (erythromycin or azithromycin), NOT Augmentin. 1, 2

• Patients with pertussis should be isolated for 5 days from the start of treatment. 2
• Early treatment within the first few weeks diminishes coughing paroxysms and prevents disease spread. 2