Medication Summary
Therapy for patients with acute bronchitis is generally aimed toward alleviation of symptoms and includes the use of analgesics, antipyretics, antitussives, and expectorants.
Among otherwise healthy individuals, antibiotics have not demonstrated consistent benefit in the symptomatology or natural history of acute bronchitis. [12, 29] Nonetheless, surveys from Europe, Australia, and the United States show that 80% of patients with acute bronchitis receive antibiotics.
Antibiotic overuse contributes to the emergence of drug-resistant organisms. Cognizant of this, the Centers for Disease Control and Prevention recently collaborated with numerous medical societies to publish a series of articles on the judicious use of antibiotics for several common conditions, including bronchitis, and have recommended against routine antibiotic use in uncomplicated bronchitis.
Patients are up to 4 times more likely to expect antibiotics for the diagnosis of bronchitis than for a chest cold. Therefore, limiting use of the diagnosis of bronchitis may make reduction of antibiotic use more acceptable to patients.
Reviews have also noted that antibiotic use in smokers without chronic obstructive pulmonary disease is no more effective than use in nonsmokers. [30]
Antimicrobials
Class Summary
Studies have focused on healthy individuals (patients with asthma excluded) or patients with chronic obstructive pulmonary disease (COPD). Antimicrobials appear to offer a small benefit when treating patients with COPD, and trimethoprim-sulfamethoxazole remains a good and inexpensive choice. Amoxicillin and doxycycline are also good alternatives. Therefore, extending antimicrobial use to patients with asthma and others with limited cardiopulmonary reserve may be reasonable.
Amoxicillin and clavulanate (Augmentin)
This agent inhibits bacterial cell wall synthesis by binding to penicillin-binding proteins. The addition of clavulanate inhibits beta-lactamase–producing bacteria.
It is a good alternative antibiotic for patients allergic to or intolerant of the macrolide class. It is usually well tolerated and provides good coverage of most infectious agents, but it is not effective against Mycoplasma and Legionella species. The half-life of the oral dosage is 1-1.3 hours. It has good tissue penetration but does not enter the cerebrospinal fluid.
For children older than 3 months, base the dosing protocol on amoxicillin content. Because of different amoxicillin/clavulanic acid ratios in the 250-mg tab (250/125) vs the 250-mg chewable tab (250/62.5), do not use the 250-mg tab until the child weighs more than 40 kg.
Erythromycin (E.E.S., E-Mycin, Ery-Tab)
Erythromycin inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest. It is indicated for staphylococcal, streptococcal, chlamydial, and mycoplasmal infections.
Azithromycin (Zithromax)
Azithromycin acts by binding to the 50S ribosomal subunit of susceptible microorganisms and blocks dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest. Nucleic acid synthesis is not affected.
It concentrates in phagocytes and fibroblasts, as demonstrated by in vitro incubation techniques. In vivo studies suggest that the concentration in phagocytes may contribute to drug distribution to inflamed tissues. Azithromycin treats mild-to-moderate microbial infections.
Tetracycline (Sumycin)
Tetracycline may be an option outside the United States. It treats gram-positive and gram-negative organisms, as well as mycoplasmal, chlamydial, and rickettsial infections. This agent inhibits bacterial protein synthesis by binding with the 30S and, possibly, the 50S ribosomal subunit(s). It is less effective than erythromycin.
Cefditoren (Spectracef)
Cefditoren is a semisynthetic cephalosporin administered as a prodrug. It is hydrolyzed by esterases during absorption and is distributed in circulating blood as active cefditoren.
Bactericidal activity results from inhibition of cell wall synthesis via an affinity for penicillin-binding proteins. No dose adjustment is necessary for mild renal impairment (CrCl 50-80 mL/min/1.73 m2) or mild-to-moderate hepatic impairment. It is indicated for acute exacerbation of chronic bronchitis caused by susceptible strains of S pyogenes.
The 400-mg dose is indicated for AECB caused by susceptible strains of H influenzae, H parainfluenzae, S pneumoniae (penicillin-susceptible strains only), or M catarrhalis.
Trimethoprim-sulfamethoxazole (Bactrim DS, Septra)
Trimethoprim-sulfamethoxazole inhibits bacterial synthesis of dihydrofolic acid by competing with para-aminobenzoic acid, resulting in inhibition of bacterial growth. Antibacterial activity of trimethoprim-sulfamethoxazole includes common urinary tract pathogens, except Pseudomonas aeruginosa. As with tetracycline, it has in vitro activity against B pertussis. It is not useful in mycoplasmal infections.
Amoxicillin (Biomox, Trimox, Amoxil)
Amoxicillin interferes with synthesis of cell wall mucopeptides during active multiplication, resulting in bactericidal activity against susceptible bacteria.
Levofloxacin (Levaquin)
Levofloxacin has a bacteriocidal property by inhibiting the DNA gyrase and, consequently, cell growth.
Clarithromycin (Biaxin)
Clarithromycin is a semisynthetic macrolide antibiotic that reversibly binds to the P site of the 50S ribosomal subunit of susceptible organisms and may inhibit RNA-dependent protein synthesis by stimulating dissociation of peptidyl t-RNA from ribosomes, causing bacterial growth inhibition.
Doxycycline (Bio-Tab, Doryx, Vibramycin)
Doxycycline is a broad-spectrum, synthetically derived bacteriostatic antibiotic in the tetracycline class. It is almost completely absorbed, concentrates in bile, and is excreted in urine and feces as a biologically active metabolite in high concentrations.
It inhibits protein synthesis and, thus, bacterial growth by binding to 30S and possibly 50S ribosomal subunits of susceptible bacteria. It may block dissociation of peptidyl t-RNA from ribosomes, causing RNA-dependent protein synthesis to arrest.
Antitussives/expectorants
Class Summary
Sparse data attest to the efficacy of expectorants outside the test tube.
Dextromethorphan/guaifenesin (Children's Delsym Cough + Chest Congestion, Coricidin HBP Chest Congestion & Cough, Delsym Cough + Chest Congestion)
This agent treats minor cough resulting from bronchial and throat irritation.
Codeine/guaifenesin (Robitussin AC)
The prototype antitussive, codeine, has been used successfully in some chronic cough and induced-cough models, but scant clinical data exist for upper respiratory tract infections.
Bronchodilators
Class Summary
Studies (although limited) have shown an advantage to using bronchodilators and possible superiority to antibiotics for relieving bronchitis symptoms.
Albuterol (Proventil, Ventolin)
Albuterol relaxes bronchial smooth muscle by action on beta2-receptors with little effect on cardiac muscle contractility.
Metaproterenol
Metaproterenol is a beta agonist for bronchospasms that relaxes bronchial smooth muscle by action on beta2 receptors with little effect on cardiac muscle contractility.
Theophylline (Theo-24, Uniphyl)
Theophylline is used to control symptoms such as bronchospasm, dyspnea, and chronic cough in stable patients with chronic bronchitis. It potentiates exogenous catecholamines and stimulates endogenous catecholamine release and diaphragmatic muscular relaxation, which, in turn, stimulates bronchodilation.
Ipratropium
Ipratropium is an anticholinergic bronchodilator that is often used to control symptoms such as bronchospasm, dyspnea, and chronic cough in stable patients with chronic bronchitis.
Corticosteroids, Systemic
Class Summary
For patients with an acute exacerbation of chronic bronchitis, a short course of systemic corticosteroid therapy may be given and has been proven to be effective.
Prednisolone (Pediapred, Orapred)
Prednisolone works by decreasing inflammation by suppressing migration of polymorphonuclear leukocytes and reducing capillary permeability.
Prednisone (Sterapred)
Prednisone may decrease inflammation by reversing increased capillary permeability and suppressing polymorphonuclear leukocyte activity. Prednisone stabilizes lysosomal membranes and suppresses lymphocytes and antibody production.
Corticosteroids, Inhaled
Class Summary
Corticosteroids are the most potent anti-inflammatory agents. Inhaled forms are topically active, poorly absorbed, and least likely to cause adverse effects. In patients who are stable with chronic bronchitis, treatment with a long-acting beta-agonist coupled with an inhaled corticosteroid may offer relief of chronic cough.
Beclomethasone (Qvar)
Beclomethasone inhibits bronchoconstriction mechanisms, causes direct smooth muscle relaxation, and may decrease the number and activity of inflammatory cells, which, in turn, decrease airway hyperresponsiveness. It is available in a metered-dose inhaler (MDI) that delivers 40 or 80 mcg/actuation.
Fluticasone (Flovent HFA, Flovent Diskus)
Fluticasone has extremely potent vasoconstrictive and anti-inflammatory activity. It is available in an MDI (44-mcg, 110-mcg, or 220-mcg per actuation) and Diskus powder for inhalation (50-mcg, 100-mcg, or 250-mcg per actuation).
Budesonide (Pulmicort Flexhaler, Pulmicort Respules)
Budesonide reduces inflammation in airways by inhibiting multiple types of inflammatory cells and decreasing production of cytokines and other mediators involved in the asthmatic response. It is available as Flexhaler powder for inhalation (90 mcg/actuation [delivers approximately 80 mcg/actuation]) and Respules suspension for inhalation.
Antiviral Agents
Class Summary
Influenza vaccinations offer greater protection for the appropriate populations because they offer coverage for influenza A and B. Influenza vaccine provides reasonable protection against immunized strains. The vaccination becomes effective 10-14 days after administration. Specific recommendations for individuals who should be immunized can be obtained from the CDC, which publishes regular updates of this information (see Seasonal Influenza Vaccination Resources for Health Professionals).
Influenza A viruses, including the 2 subtypes H1N1 and H3N2, and influenza B viruses currently circulate worldwide, but the prevalence of each can vary among communities and within a single community over the course of an influenza season.
In the 2009-2010 flu season, approximately 99% of typed influenza viruses were H1N1. In the United States, 4 prescription antiviral medications (ie, oseltamivir, zanamivir, amantadine, rimantadine) are approved for treatment and chemoprophylaxis of influenza.
The vast majority of the 2009-2010 influenza was susceptible to oseltamivir and zanamivir but resistant to the adamantanes (amantadine, rimantadine). In addition, the FDA issued an emergency use authorization for a third neuraminidase inhibitor, peramivir, for the treatment of hospitalized patients with H1N1 influenza who have potentially life-threatening suspected or laboratory-confirmed infection. Peramivir IV is available through the CDC upon request of a licensed physician.
Complete recommendations are available in a CDC Health Advisory.
Zanamivir (Relenza)
Zanamivir is an inhibitor of neuraminidase, which is a glycoprotein on the surface of the influenza virus that destroys the infected cell's receptor for viral hemagglutinin. By inhibiting viral neuraminidase, release of viruses from infected cells and viral spread are decreased. It is effective against both influenza A and B and is inhaled through Diskhaler oral inhalation device. Circular foil disks containing 5-mg blisters of drug are inserted into the supplied inhalation device.
Rimantadine (Flumadine)
Rimantadine inhibits viral replication of influenza A virus H1N1, H2N2, and H3N2 and prevents viral penetration into a host by inhibiting uncoating of influenza A. NOTE: Because of resistance, it is not recommended by the CDC as of the 2005-2006 influenza season. Laboratory testing by the CDC on the predominant strain of influenza (H3N2) currently circulating in the United States shows that it is resistant to these drugs.
Oseltamivir (Tamiflu)
Oseltamivir inhibits neuraminidase, which is a glycoprotein on the surface of influenza virus that destroys an infected cell's receptor for viral hemagglutinin. By inhibiting viral neuraminidase, this agent decreases release of viruses from infected cells and thus viral spread. It is effective in treating influenza A or B. Start within 40 hours of symptom onset. It is available as a capsule and oral suspension.
Peramivir (Rapivab)
Peramivir elicits antiviral activity by inhibiting influenza virus neuraminidase, an enzyme that releases viral particles from the plasma membrane of infected cells. It is indicated for treatment of acute uncomplicated influenza in patients aged 6 months and older who have been symptomatic for less than 2 days.
Analgesics/antipyretics
Class Summary
Analgesics and antipyretics are often helpful in relieving the associated lethargy, malaise, and fever associated with illness.
Ibuprofen (Ibuprin, Advil, Motrin)
Ibuprofen is usually the drug of choice for the treatment of mild to moderate pain, if no contraindications exist.
Acetaminophen (Tylenol, Panadol, Aspirin-Free Anacin)
Acetaminophen is the drug of choice for the treatment of pain in patients who have documented hypersensitivity to aspirin or NSAIDs, who have upper gastrointestinal disease, or who are taking oral anticoagulants.
