Which patients with acute bronchitis should be treated with antibiotics?

From the Guidelines

Antibiotics should only be considered for patients with acute bronchitis who have underlying chronic lung disease, such as COPD, and show signs of a bacterial infection, including increased sputum purulence, dyspnea, or sputum volume. This recommendation is based on the most recent and highest quality study from the American College of Physicians, which suggests that antibiotics may be beneficial for patients with COPD exacerbations who have clinical signs of a bacterial infection 1. The study recommends limiting antibiotic treatment duration to 5 days for these patients. It is essential to note that acute uncomplicated bronchitis is typically a self-limited infection caused by a virus, and antibiotics are not recommended unless there is a high pretest probability of a bacterial cause 1.

Patient Selection for Antibiotic Treatment

When selecting patients for antibiotic treatment, clinicians should consider the following factors:

• Presence of underlying chronic lung disease, such as COPD
• Clinical signs of a bacterial infection, including increased sputum purulence, dyspnea, or sputum volume
• Normal chest radiograph to rule out pneumonia

Antibiotic Treatment Options

For patients with COPD exacerbations who require antibiotic treatment, the choice of antibiotic should be based on effective treatment of the most commonly reported bacterial pathogens, including Haemophilus influenzae, Streptococcus pneumoniae, and Moraxella catarrhalis 1. Treatment options may include an aminopenicillin with clavulanic acid, a macrolide, or a tetracycline.

Rationale for Limited Antibiotic Use

The rationale for limiting antibiotic use in most cases of acute bronchitis is that overuse contributes to antibiotic resistance while providing minimal benefit for conditions that are predominantly viral in nature and self-limiting 1. Clinical assessment should focus on distinguishing acute bronchitis from pneumonia through evaluation of vital signs, oxygen saturation, and chest examination, with chest imaging when pneumonia is suspected.

From the FDA Drug Label

Azithromycin Tablets, USP are indicated for the treatment of patients with mild to moderate infections (pneumonia: see WARNINGS) caused by susceptible strains of the designated microorganisms in the specific conditions listed below Adults Acute bacterial exacerbations of chronic obstructive pulmonary disease due to Haemophilus influenzae, Moraxella catarrhalis or Streptococcus pneumoniae

The patients with acute bronchitis who should be treated with antibiotics are those with acute bacterial exacerbations of chronic obstructive pulmonary disease due to:

• Haemophilus influenzae
• Moraxella catarrhalis
• Streptococcus pneumoniae 2 2

From the Research

Patient Selection for Antibiotic Treatment

• Patients with acute bronchitis who should be treated with antibiotics include:
  • Immune-compromised hosts 3
  • Patients with chronic respiratory or cardiac diseases 3
  • Elderly patients with co-morbidities 3
  • Frail, elderly people with multimorbidity, although this is not directly supported by trial evidence 4, 5

Clinical Presentation

• Patients with severe airway obstruction, especially in the presence of purulent sputum, may benefit from antibiotic therapy 6
• Patients with moderate and severe episodes of chronic obstructive pulmonary disease (COPD) exacerbations should be treated with antibiotics 3

Antibiotic Choice

• Extended-spectrum oral cephalosporins, newer macrolides, and doxycycline have demonstrated efficacy in clinical trials 6
• Amoxicillin-clavulanate and fluoroquinolones should generally be reserved for patients with more severe disease 6
• First-choice drugs for COPD exacerbations include amoxicillin/beta-lactamase inhibitor, macrolides, and fluoroquinolones 3