Management of Bronchitis with Asthma Exacerbation

Assessment and Diagnosis

The European Respiratory Society recommends confirming the presence of bacterial infection by assessing for increased sputum volume, purulence, and increased dyspnea (Anthonisen criteria) 1, 2
Obtaining sputum culture and sensitivity is crucial to identify potential pathogens, especially looking for Pseudomonas aeruginosa, as suggested by the British Thoracic Society 3, 4
Assessing disease severity through oxygen saturation, spirometry, and if needed, arterial blood gases is essential, according to the American Thoracic Society 3

The British Thoracic Society recommends inhaled colistin as the first-line inhaled antibiotic for patients with bronchiectasis and chronic P. aeruginosa infection 3, 5
Inhaled gentamicin is considered an alternative to colistin for P. aeruginosa infection, as suggested by the European Respiratory Society 3, 5
Amoxicillin-clavulanate is the reference antibiotic for exacerbations of chronic bronchitis, particularly effective against S. pneumoniae, H. influenzae, and M. catarrhalis, according to the Infectious Diseases Society of America 2, 6
Levofloxacin or moxifloxacin may be considered for patients with frequent exacerbations (≥4 per year) or FEV1 <35%, as recommended by the American College of Chest Physicians 6, 7

For patients with infrequent exacerbations (≤3 per year) and FEV1 ≥35%, adding amoxicillin if not already on azithromycin is recommended, as suggested by the European Respiratory Society 2, 6
For patients with frequent exacerbations (≥4 per year) or FEV1 <35%, adding amoxicillin-clavulanate if not already on combination therapy is recommended, according to the American Thoracic Society 2, 6
For confirmed P. aeruginosa infection, adding inhaled colistin to oral azithromycin is recommended, as suggested by the British Thoracic Society 3, 5

Reviewing patients on long-term antibiotics every 6 months to assess efficacy, toxicity, and continuing need is essential, according to the European Respiratory Society 8
Monitoring sputum culture and sensitivity regularly is crucial, although in vitro resistance may not affect clinical efficacy, as recommended by the American Thoracic Society 8
Being vigilant for adverse effects, particularly with fluoroquinolones (tendon issues) and aminoglycosides (renal and ototoxicity), is necessary, as suggested by the British Thoracic Society 3, 5