Antibiotic Treatment for Acute Bronchitis

Introduction to Antibiotic Use

The American Thoracic Society recommends that antibiotics should NOT be prescribed for acute bronchitis in otherwise healthy adults, as the benefit has not been confirmed in clinical trials versus placebo 3, 4
The European Respiratory Society suggests considering antibiotics only if fever (>38°C) persists for more than 3 days 1, 2
In patients with underlying obstructive chronic bronchitis (FEV1 between 35% and 80%), antibiotics are indicated when at least two of the three Anthonisen criteria are present (increased sputum volume, increased sputum purulence, increased dyspnea) 1, 2
The Infectious Diseases Society of America recommends that in patients with chronic respiratory insufficiency (FEV1 <35%), immediate antibiotic therapy is recommended during exacerbations 1, 2

The American College of Chest Physicians recommends Amoxicillin as the first-line treatment for acute bronchitis of suspected bacterial origin 1, 2
First-generation cephalosporins are an alternative option for first-line treatment 1, 2
For patients with penicillin allergy, macrolides (such as azithromycin), pristinamycin, or doxycycline can be considered as first-line treatment 1, 2

The European Respiratory Society suggests considering second-line antibiotics in cases of failure of first-line antibiotics 1, 2
Second-line options include Amoxicillin-clavulanate (reference second-line therapy) 1, 2
Second-generation (cefuroxime-axetil) or third-generation (cefpodoxime-proxetil, cefotiam-hexetil) oral cephalosporins are also second-line options 1, 2
Fluoroquinolones active against pneumococci (levofloxacin, moxifloxacin) can be used as second-line treatment 1, 2

Antibiotic therapy should be active against Streptococcus pneumoniae 1, 2
Antibiotic therapy should be active against Haemophilus influenzae 1, 2
Antibiotic therapy should be active against Moraxella catarrhalis (formerly Branhamella catarrhalis) 1, 2

Purulent sputum or change in sputum color (green or yellow) does not necessarily indicate bacterial infection 6
Fever persistence beyond 3 days suggests bacterial infection (bronchial superinfection or pneumonia) 1, 5
Associated ENT symptoms (rhinorrhea, upper airway obstruction) suggest viral rather than bacterial etiology 1, 5
Distinguish acute bronchitis from pneumonia, which requires different management 6

Prescribing antibiotics for acute bronchitis in healthy adults without clear indications 3, 6
Assuming purulent sputum indicates bacterial infection 6
Failing to distinguish between acute bronchitis and pneumonia 6
Using fluoroquinolones inactive against pneumococci (ofloxacin, ciprofloxacin) or cefixime as these are not recommended due to inadequate coverage 1, 2
Using cotrimoxazole, which has inconsistent activity against pneumococci and a poor benefit/risk ratio 1, 2