Bronchitis Empiric Therapy

Empiric therapeutic regimens for bronchitis are outlined below, including those for acute bronchitis, chronic bronchitis, and acute bacterial exacerbation of chronic bronchitis. ^{[1, 2, 3, 4, 5, 6, 7, 8, 9]}

See Bronchitis and Chronic Obstructive Pulmonary Disease for full discussions of these topics.

Acute bronchitis

Patients typically present with a cough that lasts more than 5 days and may be associated with sputum production. Cough usually resolves within 3 weeks but may linger for up to 8 weeks.

• Acute bronchitis is typically caused by viruses.  

• There is limited evidence to support the use of antibiotics for treating acute bronchitis in otherwise healthy adults. Antibiotic administration does not significantly alter presence of productive cough or activity limitations at follow-up doctor visits; however, there is a trend toward increased adverse effects with their use. ^[6]

• There may be a limited role for antibiotic treatment of acute bronchitis in elderly patients with multiple comorbidities, although this typically is viral so the threshold should be low.

• Symptomatic treatment includes the use of cough suppressants (dextromethorphan or codeine), mucolytics, and bronchodilators (albuterol), where appropriate.

• Patients without underlying heart or lung disease who present with a persistent cough lasting more than 14 days should be evaluated for pertussis.

Chronic bronchitis

Chronic bronchitis is typically defined as cough and sputum production on most days of the month for at least 3 months of the year for 2 consecutive years. Chronic bronchitis results from excessive airway mucus due to increased production (ie, inflammation, oxidative stress, infection) and decreased clearance (ie, poor ciliary function, airway occlusion, respiratory muscle weakness). It is a phenomenon with variable presentations that is most common in individuals with inhalation exposures, such as smoking, and often coincides with chronic obstructive pulmonary disease (COPD).

• Empiric antibiotic therapy is not recommended.

• Although chronic macrolide therapy, known for its anti-inflammatory properties, reduces COPD exacerbations, it does not show any additional benefit in patients with baseline chronic bronchitis.

• Reduce mucus production.

  • Smoking cessation and avoidance of environmental irritants will decrease goblet cell stimulation and hyperplasia.

  • Anticholinergics decrease mucus secretion via their action on the muscarinic receptors; however, use with caution as they may dehydrate airways making secretions more difficult to expectorate.

  • Inhaled glucocorticoids reduce inflammation and thus mucus production.

  • PDE-4 inhibitors (eg, roflumilast) may decrease COPD exacerbations in patients with concomitant chronic bronchitis by decreasing mucus secretions; however, evidence is limited.

• Facilitate mucus elimination.

  • Physical maneuvers such as chest physical therapy or flutter valve may help to augment shear stressors to aid mucus breakdown and clearance (minimal evidence available).

  • Methylxanthines and short-acting beta agonists increase airway lumen diameter, intensify ciliary beat frequency, and promote mucus hydration via activation of the cystic fibrosis transmembrane regulator.

  • Inhale hypertonic saline directly rehydrate airways and promotes cough (minimal evidence to show benefit).

  • Expectorants (eg, guaifenesin) vagally medicate increase in airway secretions improving mucus clearance in the short term (no long-term benefit found).

Acute bacterial exacerbation of chronic bronchitis (ABECB)

Bacterial pathogens are identified in less than half of all ABECB cases. The Anthonisen Criteria is typically used to qualify severity of acute exacerbations. Three clinical factors are considered: dyspnea, sputum volume, and sputum purulence. Antibiotic treatment is recommended for moderate (2 of 3 symptoms) or severe (all 3 symptoms) exacerbations. Change in sputum color has also been recognized to be a strong predictor of presence of potentially pathologic microorganisms in ABECB. Green and yellow sputum are more likely than white sputum to be culture positive.

Mild ABECB:

• No antibiotics recommended

• Outpatient symptomatic therapy and monitor for worsening symptoms

Moderate ABECB and/or any one of the following: age < 65 years, FEV1 >50% predicted, no cardiac disease, or < 3 exacerbations per year:

• Azithromycin 500 mg PO on first day then 250 mg PO daily for next 4 days or

• Clarithromycin 250-500 mg PO BID for 7-14 days or

• Doxycycline 100 mg PO BID for 7 days or

• Trimethoprim-sulfamethoxazole (160 mg/800 mg) 1 DS tablet PO BID for 10-14 days or

• Cefuroxime 250-500 mg PO q12h for 10 days or

• Cefdinir 300 mg PO BID for 5-10 days or

• Cefpodoxime 200 mg PO q12h for 10 days

• If recent antibiotic exposure within 3 months, use alternative class.

Severe ABECB and/or anyone of the following: age ≥65 years, FEV1 ≤ 50% predicted, cardiac disease, or ≥3 exacerbations per year ^[10] :

• Consider hospitalization.

• Amoxicillin-clavulanate (875 mg/125 mg) 1 tablet PO BID for 7-10 days or

• Levofloxacin  750mg PO daily for at least 7 days or

• Gemifloxacin 320mg PO daily for 5 days or

• Moxifloxacin 400 mg PO daily for 5 days

• If at risk for Pseudomonas infection consider sputum culture and treatment with levofloxacin 750 mg PO daily for 14 days. ^[11]

• If recent antibiotic exposure within 3 months, use alternative class.