Adult acute bronchitis

1
Adult acute bronchitis

• Acute inflammation of the mucous membranes of the
  trachea and bronchi (duration lt 4 weeks)
• productive cough
• upper respiratory tract symptoms
• general symptoms (in 10 - 50)

2
Aetiology of acute bronchitis

• Common respiratory tract viruses (80)
• Bacteria (in about 20 of cases)
• Pneumococci ( in 2 - 30)?
• Haemophilus ( in 2 - 8)?
• Mycoplasma (in 0.5 - 11)
• Chlamydia (in 0 -18)
• (Pertussis (in 0 - 7))

3
Diagnosis of acute bronchitis

• The aim is to
• identify, among all patients with cough, those
  with other illnesses needing specific treatment
  (e.g. pneumonia, sinusitis, asthma)
• identify, among all patients with bronchitis,
  those who would benefit from antibiotics

4
(Differential) diagnosis

• History (e.g. asthma)
• Health status (general condition, auscultation)
• X-ray (to exclude pneumonia)
• CRP (high CRP refers to bacterial aetiology or
  pneumonia)
• Sinus ultrasound (to exclude sinusitis)
• Antibody testing (of a few representative
  patients if needed to establish an epidemic)
• Easy access to a follow-up visit (inform your
  assistants!)

5
When is chest x-ray needed?

• patient is particularly unwell
• patient is particularly prone to pneumonia due to
  underlying disease, age or alcoholism
• history of pneumonia within the preceding year
• upper respiratory tract symptoms absent
• patient requests x-ray (pneumonia can not be
  excluded on clinical symptoms and findings only)

6
Treatment of acute bronchitis

• First choice no antibiotics!
• Factors supporting antibiotic treatment
• CRP gt 50 mg/l
• patient is particularly unwell or becoming so
• pyrexia of over weeks duration or patient
  pyrexial following a period of apyrexia
• epidemiological state
• patient is immunocompromised

7
Antimicrobial therapy of acute bronchitis 1

• First choice
• in most cases good effect on pneumococci is
  sufficient
• penicillin resistance in pneumococci in Finland
  is low (R lt 1) (A)
• penicillin V 1-1.5 mega units 8 hourly for 5 7
  days
• for patients with penicillin allergy a first
  -generation cephalosporin

8
Antimicrobial therapy of acute bronchitis 2

• Other choices
• probable mycoplasma or chlamydia infection
• doxycycline 100-150 mg daily for 5 7 days
• a macrolide erythromycin 500mg 3 - 4 times
  daily, roxithromycin 150 mg twice daily,
  klarithromycin 250mg twice daily or azithromycin
  250 mg daily for 5 7 days
• underlying chronic lung disease
• amoxicillin, sulphatrimethoprim

9
Symptomatic treatment of acute bronchitis

• Symptomatic treatment assists the patient to
  cope with his/her symptoms and thus aims at
  reducing the unnecessary use of antimicrobial
  agents
• no benefit is gained on cough with codeine,
  salbutamol or dextromethorphan as compared with a
  placebo,
• ...but cough improves considerably even during a
  placebo-treatment
• patient often presents with additional symptoms,
  which can be eased with antihistamines,
  anticholinergic and/or sympatomimetic agents, but
  their benefit remains controversial!

10
Quality criteria to develop treatment

• as a general rule a young, or middle-aged,
  previously well patient with bronchitis not to be
  prescribed antibiotics, at least not at the first
  consultation.
• if antibiotics are considered for the treatment
  of bronchitis, CRP is to be determined first
• follow-up appointment arrangements to be patient
  friendly