What are the treatment guidelines for bronchitis in patients aged 65 years and older, covering both acute and chronic forms and accounting for common comorbidities?

Treatment Guidelines for Bronchitis in the Elderly

Acute Bronchitis: Antibiotics Are NOT Indicated

Antibiotics should NOT be prescribed for acute bronchitis in elderly patients, as they provide minimal benefit (reducing cough by only half a day) while causing significant adverse effects and contributing to antibiotic resistance. 1

Key Diagnostic Considerations

Before diagnosing acute bronchitis, exclude pneumonia by checking for these findings 2, 1:

• Heart rate >100 beats/min
• Respiratory rate >24 breaths/min
• Oral temperature >38°C
• Focal consolidation, egophony, or fremitus on chest examination

If any of these are present, obtain chest radiography to rule out pneumonia, as elderly patients often present atypically with lower prevalence of respiratory symptoms 2.

Appropriate Management of Acute Bronchitis

Symptomatic treatment only 1:

• Inform patients cough typically lasts 10-14 days, may persist up to 3 weeks 1
• Codeine or dextromethorphan for bothersome dry cough, especially if disturbing sleep 1
• β2-agonist bronchodilators (albuterol) only in select patients with accompanying wheezing 1
• Elimination of environmental irritants and humidified air 1

Critical Exception: Pertussis

For confirmed or suspected pertussis (whooping cough), prescribe a macrolide antibiotic (azithromycin or erythromycin) immediately and isolate the patient for 5 days from treatment start 1.

When to Reassess

Reevaluate if 1:

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

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Acute Exacerbation of Chronic Bronchitis (AECB): Selective Antibiotic Use

For elderly patients with chronic bronchitis experiencing an acute exacerbation, antibiotics ARE indicated when specific criteria are met. 2, 3

Criteria for Antibiotic Treatment in AECB

Prescribe antibiotics when the patient has at least 2 of 3 Anthonisen criteria 2, 3:

1. Increased dyspnea
2. Increased sputum volume
3. Increased sputum purulence

AND at least one high-risk factor 3:

• Age ≥65 years
• FEV₁ <50% predicted
• ≥4 exacerbations in past 12 months
• Comorbidities (cardiac failure, diabetes mellitus, renal insufficiency, chronic neurologic disease) 2, 3

Antibiotic Selection for AECB in Elderly

For moderate-severity exacerbations 1, 3:

• Doxycycline 100 mg twice daily for 7-10 days (first-line)
• Azithromycin 500 mg daily for 5 days
• Clarithromycin extended-release 1000 mg once daily for 5-7 days 1

For severe exacerbations (FEV₁ <35%, frequent exacerbations, multiple comorbidities) 1, 3:

• Amoxicillin-clavulanate 625 mg three times daily for 14 days
• Respiratory fluoroquinolone (levofloxacin 750 mg daily for 5 days)

Critical Pitfalls to Avoid

• Do NOT use simple amoxicillin alone, as 25% of H. influenzae and 50-70% of M. catarrhalis produce β-lactamase 1
• Do NOT prescribe antibiotics for stable chronic bronchitis as prophylaxis 2
• Do NOT rely on sputum color alone—purulent sputum occurs in 89-95% of viral cases 1

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Chronic Bronchitis: Maintenance Management

Bronchodilator Therapy

Ipratropium bromide is first-line therapy to improve cough in stable chronic bronchitis 2, 4:

• Reduces cough frequency and severity more reliably than β-agonists 2
• Decreases sputum volume 2

Short-acting β-agonists (albuterol) should be used to control bronchospasm and relieve dyspnea; may reduce chronic cough in some patients 2.

For severe airflow obstruction (FEV₁ <50%) or frequent exacerbations, combine long-acting β-agonist with inhaled corticosteroid 2.

Corticosteroid Use

During acute exacerbations, systemic corticosteroids are beneficial 2:

• Use for 2 weeks only (equivalent efficacy to 8 weeks with fewer side effects) 2

Do NOT use 2:

• Long-term oral corticosteroids in stable patients (no benefit, significant side effects)
• Theophylline during acute exacerbations (grade D recommendation)

Most Effective Intervention: Smoking Cessation

Smoking cessation is mandatory and the single most effective intervention 2, 4:

• 90% of patients experience cough resolution after quitting 2
• Benefits occur within first month and are sustained long-term 2

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Special Considerations for Elderly Patients

High-Risk Comorbidities Requiring Lower Threshold for Antibiotics

Consider antibiotics more readily in elderly patients with 2, 1, 5:

• Cardiac failure
• Insulin-dependent diabetes mellitus
• Chronic renal insufficiency
• Chronic neurologic disease
• Immunosuppression
• Malignancy

Age-Related Diagnostic Challenges

Elderly patients with pneumonia present with lower prevalence of respiratory symptoms, requiring high index of suspicion 2. When in doubt, obtain chest radiography rather than treating empirically as bronchitis 2.

Monitoring During Treatment

For AECB treated with antibiotics, reassess at 2-3 days to evaluate treatment response 1. If no improvement, consider sputum culture and adjust therapy based on sensitivity results 1.