What is the recommended management for acute bronchitis, including indications for antibiotics, and how should chronic or recurrent bronchitis be treated?

Management of Bronchitis

Acute Bronchitis: Antibiotics Are NOT Recommended

Antibiotics should NOT be prescribed for acute bronchitis in otherwise healthy adults, as they provide minimal benefit (reducing cough by only half a day) while causing significant adverse effects and contributing to antibiotic resistance. 1, 2

Why Antibiotics Don't Work

• Respiratory viruses cause 89-95% of acute bronchitis cases, making antibiotics completely ineffective regardless of which one you choose 1, 3
• Purulent (green or yellow) sputum occurs in 89-95% of viral cases and does NOT indicate bacterial infection—this is a critical pitfall to avoid 1, 2
• Cough duration alone does not indicate bacterial infection; viral bronchitis cough typically lasts 10-14 days, sometimes up to 3 weeks 1

Essential Diagnostic Steps Before Diagnosing Acute Bronchitis

Rule out pneumonia first by checking for these specific findings 1:

• Heart rate >100 beats/min
• Respiratory rate >24 breaths/min
• Oral temperature >38°C
• Focal consolidation findings on lung examination (rales, egophony, tactile fremitus)

If any of these are present, obtain chest radiography—you're dealing with pneumonia, not simple bronchitis 1

Rule out asthma/COPD, especially in patients with recurrent episodes—approximately one-third of patients diagnosed with "recurrent acute bronchitis" actually have undiagnosed asthma 1

Appropriate Management for Acute Bronchitis

Patient education is paramount 1:

• Inform patients that cough typically lasts 10-14 days after the visit, even without antibiotics, and may persist up to 3 weeks 1
• Refer to the condition as a "chest cold" rather than bronchitis to reduce antibiotic expectations 1
• Explain that patient satisfaction depends more on physician-patient communication than whether an antibiotic is prescribed 1

Symptomatic treatment options 1:

• Codeine or dextromethorphan may provide modest relief for bothersome dry cough, especially when sleep is disturbed 1
• β2-agonist bronchodilators should NOT be routinely used, but may be considered only in select patients with accompanying wheezing 1
• Low-cost measures: elimination of environmental cough triggers and vaporized air treatments 1

What NOT to prescribe 1:

• Expectorants or mucolytics
• Antihistamines
• Inhaled corticosteroids
• Systemic corticosteroids
• NSAIDs at anti-inflammatory doses

The ONE Exception: Pertussis (Whooping Cough)

For confirmed or suspected pertussis, prescribe a macrolide antibiotic (erythromycin or azithromycin) immediately 1, 2:

• Isolate the patient for 5 days from the start of treatment 1
• Early treatment within the first few weeks diminishes coughing paroxysms and prevents disease spread 1

When to Reassess

Instruct patients to return if 1:

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

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Acute Exacerbations of Chronic Bronchitis (AECB): A Different Story

For patients with underlying chronic bronchitis or COPD, antibiotics ARE indicated when specific criteria are met. This is fundamentally different from acute bronchitis in otherwise healthy adults.

Indications for Antibiotics in AECB

Use the Anthonisen criteria 2, 4, 5:

Prescribe antibiotics when the patient has at least 2 of these 3 cardinal symptoms:

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

AND at least one risk factor 5:

• Age ≥65 years
• FEV1 <50% of predicted value
• ≥4 exacerbations in the past 12 months
• Presence of comorbidities (cardiac failure, insulin-dependent diabetes, serious neurological disorders)

Special populations requiring immediate antibiotics 2:

• Patients with chronic respiratory insufficiency (FEV1 <35%) should receive immediate antibiotic therapy during exacerbations 2
• Patients with severe COPD exacerbations requiring hospitalization 4

First-Line Antibiotic Options for AECB

Amoxicillin is the first-line treatment for moderate-severity exacerbations 2, 4:

• Dosing: 500 mg three times daily for 7 days 1
• Targets the three most common pathogens: Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis 2, 4

Alternative first-line options 2:

• First-generation cephalosporins
• For penicillin allergy: macrolides (azithromycin), doxycycline, or pristinamycin 2

Second-Line Antibiotic Options for AECB

Reserve these for severe exacerbations or treatment failure 1, 2:

• Amoxicillin-clavulanate 625 mg three times daily for 7-14 days (preferred for severe exacerbations) 1, 2
• Respiratory fluoroquinolones (levofloxacin, moxifloxacin) for 5-7 days 2, 6
• Second-generation cephalosporins (cefuroxime-axetil) or third-generation cephalosporins (cefpodoxime-proxetil) 2

Critical resistance considerations 1:

• Up to 25% of H. influenzae and 50-70% of M. catarrhalis produce β-lactamase, making simple aminopenicillins ineffective 1
• Avoid aminopenicillins alone, older-generation macrolides, first-generation cephalosporins, and cotrimoxazole due to increasing resistance 1

Duration of Antibiotic Therapy

Standard duration is 7 days for uncomplicated bacterial infections 4:

• May extend to 14 days for patients with documented bacterial pathogens or severe disease 1
• Short-course therapy (5 days) with respiratory fluoroquinolones may suffice for mild cases 1, 6

Monitoring Treatment Response

Fever should resolve within 2-3 days after starting antibiotics 4:

• If no improvement, perform careful microbiological reevaluation 4
• Consider changing to an antibiotic with coverage against Pseudomonas aeruginosa or resistant S. pneumoniae 4

Supportive Care for AECB

All patients should receive 5:

• Removal of environmental irritants
• Bronchodilators (short-acting β-agonists improve pulmonary function and breathlessness) 1
• Ipratropium bromide (reduces cough frequency and sputum volume) 1
• Oxygen therapy if needed
• Hydration
• Consider systemic corticosteroids for severe exacerbations 5

Smoking cessation is the most effective intervention—90% of patients experience resolution of chronic cough after quitting 1

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Common Pitfalls to Avoid

1. Do NOT prescribe antibiotics based on sputum color alone—purulent sputum is present in 89-95% of viral cases 1, 2
2. Do NOT assume all "bronchitis" is the same—acute bronchitis in healthy adults requires NO antibiotics, while AECB in COPD patients often does 1, 2
3. Do NOT use fluoroquinolones inactive against pneumococci (ofloxacin, ciprofloxacin) or cefixime—inadequate coverage 2
4. Do NOT miss undiagnosed asthma—one-third of "recurrent bronchitis" cases are actually asthma 1
5. Do NOT forget to rule out pneumonia first by checking vital signs and lung examination 1