Antibiotic prescribing for acute bronchitis and cough

This note shows when and how to prescribe antibiotic for acute bronchitis. And which antibiotic should be prescribed.

Assessment

Presents as cough with or without sputum, breathlessness, wheeze or general malaise. No chest signs other than wheeze and crackles. Crackles, if present, should clear with coughing; if they persist, review diagnosis. First line management is self-care and safety-netting. Antibiotics offer little benefit if the patient has no co-morbidities and may cause side effects. More than 90% of acute bronchitis has no identifiable bacterial cause. A 7-day delayed antibiotic strategy may be used where this approach is felt to be safe.

Table (1). Methods help you for prescribing antibiotics
Consider immediate antibiotics for the following conditions...
Is systemically very unwell
If > 80 years of age and one of	Hospitalized in past year Taking oral steroids Insulin-dependent diabetic Congestive heart failure Serious neurological disorder/stroke
If > 65 years with two of the above
Consider using C-reactive protein (CRP) results to guide antibiotic prescribing as follows
If CRP less than 20 mg/L do not routinely offer antibiotics. Consider a delayed antibiotic prescription if CRP 20-100 mg/L. If CRP greater than 100 mg/L, offer antibiotic therapy.

Antibiotic prescribing

General treatment

Advise the patient on self-care strategies such as rest, adequate fluid intake, and the use of paracetamol 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day for symptomatic relief. Advise the patient to stop smoking. Over-the-counter cough medicines are not recommended, but some people may find simple remedies such as hot water, honey, and lemon soothing.

Antibiotics prescribing recommendations

American guidelines recommend against use of antibiotics for uncomplicated acute bronchitis in adults or children...

American College of Physicians/Centers for Disease Control and Prevention (ACP/CDC) do not recommend routine antibiotic treatment for uncomplicated acute bronchitis, unless pneumonia suspected. If pertussis suspected, diagnostic testing should be performed and antimicrobial therapy started. Antimicrobial therapy for suspected pertussis in adults recommended primarily to decrease shedding of pathogen and spread of disease. Antibiotic treatment does not appear to hasten resolution of symptoms.
National Institute for Health and Care Excellence (NICE) guidelines: No antibiotic strategy or delayed antibiotic prescribing strategy recommended for adults and children > 3 months old with acute cough/acute bronchitis. Advise patients that expected length of illness is about 3 weeks.
Canadian Association of Emergency Physicians recommends avoiding use of antibiotics in adults with bronchitis/asthma. Patient satisfaction with care for acute bronchitis depends most on physician-patient communication and not on antibiotic treatment.

Antibiotics therapy

Amoxicillin/Clavulanate can be prescribed as oral suspension for neonates and infants 3 months and younger by dose 30 mg/kg/day PO in divided doses every 12 hours. Amoxicillin/Clavulanate oral tablet may be used for infants older than 3 months, children, and adolescents by dose 45 mg/kg/day orally divided every 12 hours (Max: 875 mg/dose) or 40 mg/kg/day orally divided every 8 hours (Max: 500 mg/dose). Dose in adults 875 mg orally every 12 hours or 500 mg orally every 8 hours. Other agents may be (see table 2)...

Table (2). Antibiotic dosage
ANTIBIOTIC	DOSE
Doxycycline	Children 8 years and older and Adolescents weighing 45 kg or more: 100 mg orally every 12 hours on day 1, then 100 mg orally once daily, or for severe infections, every 12 hours. Children 8 years and older and Adolescents weighing less than 45 kg: 2.2 mg/kg/dose orally every 12 hours on day 1, then 2.2 mg/kg/dose orally once daily, or for severe infections, every 12 hours. Adults: 100 mg orally every 12 hours on day 1, then 100 mg orally once daily, or for severe infections, every 12 hours.
Erythromycin	Neonates 7 days and younger: 10 mg/kg/dose orally every 12 hours recommended by AAP. Neonates older than 7 days: 10 mg/kg/dose orally every 8 hours recommended by AAP. Infants, Children, and Adolescents: 30 to 50 mg/kg/day (Max: 1 to 2 g/day) orally in 3 to 4 divided doses; 40 mg/kg/day orally in 4 divided doses is recommended by the IDSA for CAP due to presumed/confirmed atypical pathogens as an alternative therapy to azithromycin. Adults: 250 to 500 mg orally every 6 hours.
Azithromycin	Neonates and Infants 1 to 5 months: 10 mg/kg/day PO for 5 days. Monitor for infantile hypertrophic pyloric stenosis (IHPS) in patients younger than 1 month of age. Adults: 500 mg PO once daily for 3 days, or 500 mg orally once daily for 1 day followed by 250 mg orally once daily for 4 days.
Clarithromycin	Infants, Children, and Adolescents: 15 mg/kg/day PO (Max: 1 g/day) in 2 divided doses for 7 days. Adults: 250 to 500 mg orally every 12 hours for 7 to 14 days.

References

Wenzel RP, Fowler AA 3rd. Clinical practice. Acute bronchitis. N Engl J Med. 2006;355(20):2125-2130.
Kinkade S, Long NA. Acute Bronchitis. Am Fam Physician. 2016;94(7):560-565.
Harris AM, Hicks LA, Qaseem A; High Value Care Task Force of the American College of Physicians and for the Centers for Disease Control and Prevention. Appropriate Antibiotic Use for Acute Respiratory Tract Infection in Adults: Advice for High-Value Care From the American College of Physicians and the Centers for Disease Control and Prevention. Ann Intern Med. 2016;164(6):425-434.