Bronchitis - Uncomplicated Acute (1 of 8)

1 Patient presents w/ symptoms of lower resp tract infection (LRTI)

2 EVALUATION Yes ALTERNATIVE Comorbid condition DIAGNOSIS present or is patient >60 years?

3 DIAGNOSIS No ALTERNATIVE Uncomplicated acute DIAGNOSIS bronchitis

Yes

Is No pertussis Yes suspected?

A Pharmacological therapy A Pharmacological therapy Symptomatic therapy Oral Antibiotic • Analgesics (non-opioid) & Any one of the following: Antipyretics • Co-trimoxazole • Bronchodilator: Beta2-agonist • Macrolide (inhaled) MIMS • Cough & Cold Preparations B Patient education

C Follow-up ©• Not usually necessary

Not all products are available or approved for above use in all countries. Speciﬁ c prescribing information may be found in the latest MIMS.

B26 © MIMS 2019 Bronchitis - Uncomplicated Acute (2 of 8)

1 BRONCHITIS - UNCOMPLICATED ACUTE

Signs & Symptoms of Lower Respiratory Tract Infection: • Cough &/or increase in sputum production • Breathlessness/wheeze • Chest pain/aches • Sweats &/or sore throat • BRONCHITIS - ACUTE Increase in temperature Uncomplicated Acute Bronchitis • A self-limiting acute respiratory tract infection characterized by the sudden onset of cough, w/ or without sputum production, in an otherwise healthy individual - Diagnosis is based on clinical fi ndings Pathogenesis • An infl ammatory response to infections of the bronchial epithelium of the large airways of the lungs - Begins w/ mucosal injury, epithelial cell damage & release of proinfl ammatory mediators - Transient airfl ow obstruction & bronchial hyperresponsiveness • Purulence can result from either bacterial or viral infection Etiology Viral • e most common cause (90% of cases) of bronchial infl ammation in otherwise healthy adults presenting w/ acute bronchitis - Infl uenza A & B, parainfl uenza 3 & respiratory syncytial virus (RSV) produce primarily lower respiratory tract disease - Corona virus, adenovirus & rhinoviruses more commonly produce upper respiratory tract symptoms Non-viral • Mycoplasma pneumoniae, Chlamydia pneumoniae, Bordetella pertussis (5-10% of cases) • Environmental cough triggers (eg dust, dander, toxic fume inhalation) Typical Clinical Presentation Signs & Symptoms • Predominant symptom: Cough that is usually productive that persists <3 weeks - e cough generally lasts 7-10 days but occasionally persists for >1 month - Infl uenza (fl u) virus typically causes a nonproductive cough - If cough has been >3 weeks, consider investigation of other diagnoses (eg tuberculosis in endemic areas) • Sputum may be clear, white, yellow, green or even tinged w/ blood - Green/yellow (purulent) sputum production is indicative of an infl ammatory reaction & it can result from either viral or bacterial infection • Cough may be accompanied by clinical features that suggest an acute respiratory tract infection (eg sore throat, rhinorrhea, hoarseness) • Patient may also present w/ retrosternal chest pain on coughing, dyspnea, wheezing, fever, fatigue or night cough

2 EVALUATION

Patients w/ Comorbidity • Comorbid conditions: Chronic obstructiveMIMS pulmonary disease (COPD), cardiovascular diseases, neurological diseases, diabetes mellitus (DM), chronic liver or renal failure, recent viral infection, immunodeﬁ ciency, etc • Evaluation & management must be tailored in light of the patient’s comorbid condition - Eg please see Bronchitis - Chronic in Acute Exacerbation disease management chart if patient has underlying COPD Elderly Patients • Require a more careful evaluation & management - Eg chest X-ray, sputum culture, ECG - Appropriate antibiotic therapy should not be withheld since clinical features are less reliable & pneumococcal infection© is common in these patients

Not all products are available or approved for above use in all countries. Speciﬁ c prescribing information may be found in the latest MIMS.

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3 DIAGNOSIS

History • Perform a complete & detailed medical history including tobacco use & exposure to respiratory infections or toxic inhalants Physical Exam • Wheezing, rhonchi, coarse rales, a prolonged expiratory phase or other obstructive signs may be present - Forced expiration may be done to detect wheezing BRONCHITIS - ACUTE Diagnostic Studies • No available test can provide a defi nitive diagnosis of acute bronchitis • In patients presumed to have acute bronchitis, viral cultures, serologic assays & sputum analyses should not be done routinely because the responsible organism is rarely identifi ed in clinical practice • Gram stain or sputum culture in the healthy adult w/ acute bronchitis is not helpful as most cases are caused by a virus • Transient pulmonary function abnormalities (very similar to those of mild asthma) may occur in acute bronchitis; peak expiratory fl ow rate may be measured in these patients • Chest X-ray is typically unnecessary - Purulent sputum is not an indication for a chest X-ray - Consider performing a chest X-ray if vital signs show a heart rate of >100 beats/minute, respiratory rate of >24 breaths/minute, & an oral temperature of >100.4°F (>38°C), & if focal pulmonary consolidation is present on exam Diff erential Diagnoses Pertussis • An uncommon cause of uncomplicated acute bronchitis • May be present in up to 10-20% of adults w/ cough lasting >2-3 weeks - Adults immunized as children but no longer having eff ective immunity may be a reservoir of B pertussis - No classic features of pertussis in adults (as there are in children) but generally presents as severe bronchitis • Pertussis may be considered in children suff ering from severe spasmodic coughing, especially if terminated by vomiting or associated w/ redness of the face & catching of the breath - e incidence of pertussis in children has decreased due to widespread pertussis vaccination • Physicians should limit suspicion & treatment of adult pertussis to patients w/ a high probability of exposure (during outbreak in the community or if there is history of contact w/ a patient who has a known case) • If pertussis is suspected, a diagnostic test should be performed & antimicrobial therapy initiated - Diagnosis may be diffi cult to establish because of delay in suspicion of disease (cultures of nasopharyngeal secretions are usually negative after 2 weeks & reliable serologic tests may not be available) - Polymerase chain reaction (PCR) of nasopharyngeal swabs or aspirates improves detection Asthma • Should be considered in patients w/ repetitive episodes of acute bronchitis - Full spirometric testing w/ bronchodilatation or provocative testing w/ a Methacholine challenge test can be given to help diff erentiate asthma from recurrent bronchitis • Acute bronchitis may cause transient pulmonary abnormalities & the diagnosis of asthma should be considered if abnormalities in pulmonary function persist after the acute phase of the illness • Please see Asthma disease management chart for further information Infl uenza (Flu) • Flu viruses are the most common pathogens found in patients w/ uncomplicated acute bronchitis • During times of outbreak, diagnosis by clinical presentation is as accurate as rapid diagnostic tests - Patient may benefi t from anti-infl uenzaMIMS agents if treated within 48 hours of symptom onset • Please see Infl uenza disease management chart for further information Pneumonia • Potentially the most serious cause of acute cough illness & should be ruled out • In healthy non-elderly adults, the absence of vital sign abnormalities (eg heart rate ≥100 beats/minute, respiratory rate >24 breaths/minute, oral temperature ≥38°C & signs of focal consolidation on chest exam) suffi ciently reduces the likelihood of pneumonia to eliminate the need for a chest X-ray • Please see Pneumonia - Community-Acquired disease management chart for further information Upper Respiratory Tract Infection (URTI) • In these settings, cough is not a predominant symptom (eg common cold) Non-pulmonary Causes • Chronic heart© failure (CHF) in elderly patients, gastroesophageal refl ux disease (GERD) & bronchogenic tumor • Please see Heart Failure - Chronic & Gastroesophageal Refl ux Disease disease management charts for further information

Not all products are available or approved for above use in all countries. Speciﬁ c prescribing information may be found in the latest MIMS.

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A PHARMACOLOGICAL THERAPY

• Routine use of antibiotics is highly discouraged & should only be considered in patients w/ bacterial infection or pneumonia; consider local resistance patterns when planning use of antibiotics Symptomatic erapy Choice of therapy depends on which symptoms are most bothersome to the patient Analgesics (Non-Opioid) & Antipyretics • Eg Paracetamol, Ibuprofen

BRONCHITIS - ACUTE • Benefi cial when infl uenza symptoms eg malaise & fever are prominent • Avoid salicylates in children ≤18 years of age because of the risk of Reye Syndrome Bronchodilators: Beta₂-Agonists • Eg Salbutamol • May be used to reduce the duration & severity of cough in some patients, but routine use for cough palliation is not recommended • Use should be individualized to those who are most likely to benefi t - Justifi ed in patients w/ clinical evidence of airfl ow obstruction or bronchial hyperresponsiveness (eg wheezing or bothersome cough) • Studies have shown that more patients report decrease in cough after 7 days of inhaled bronchodilator as compared to placebo or antibiotic Cough & Cold Preparations • Codeine or Dextromethorphan - May be justifi ed for a nonproductive irritating cough, given short term for cough relief - Codeine is a weak, centrally acting opioid that suppresses cough - Dextromethorphan is a nonopioid that acts centrally to decrease cough - Patients w/ cough lasting >2-3 weeks are the most likely to benefi t - Suppress the cough refl ex by a direct action on the cough center in the medulla of the brain - Modest eff ect on severity & duration of cough - Typically not very eff ective in patients w/ acute or early cough due to colds or other viral upper respiratory tract infection • ough evidence is lacking to recommend mucolytic monotherapy for acute bronchitis, studies show changes in the character of sputum & improvement in respiratory symptoms w/ its use • Guiafenesin is an expectorant which acts by stimulating respiratory tract secretions leading to increased respiratory fl uid volumes & decreased mucus viscosity - Also have antitussive activity - Eff ectiveness in reducing cough frequency & intensity was shown in several clinical trials Other Treatments • Pelargonium sidoides - May be used as monotherapy or in combination w/ symptomatic therapy &/or antibiotics - Modulates immune response, has bacteriostatic properties preventing proliferation of bacteria that cause secondary bacterial superinfection & has expectorant & mucolytic properties - Reduces duration & severity of respiratory tract infections caused by viruses • Vitex negundo L. (Lagundi leaf) - Studies show improvement of respiratory symptoms w/ Lagundi treatment when compared w/ eophylline Antibiotics for Pertussis • Use is supported only for confi rmed or suspected B pertussis cases when there is a high probability of exposure or during an outbreak • Erythromycin is the drug of choice for treatment & prophylaxis of pertussis in people of all ages • Two small comparative studies suggest that Clarithromycin & Azithromycin are at least as eff ective as Erythromycin for pertussis treatment • Co-trimoxazole may be used as an alternativeMIMS when macrolides cannot be given • Antibiotics are primarily used to decrease shedding of the pathogen & therefore decrease the spread of the disease - Patient isolation for 5 days from the start of treatment is a necessary precaution - Antibiotic therapy does not appear to resolve symptoms if it is initiated 7-10 days after the onset of illness but does prevent spread to others

B PATIENT EDUCATION

Supportive Measures • Encourage patient to increase ﬂ uid intake to help prevent drying of bronchial secretions & to assist in clearing of sputum • Advise bed© rest especially when fatigue & fever are prominent • Patient should eliminate cough triggers (eg dust & dander) • Increase humidity w/ vaporized air treatments in dry environments

Not all products are available or approved for above use in all countries. Speciﬁ c prescribing information may be found in the latest MIMS.

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B PATIENT EDUCATION (CONT’D)

Smoking Cessation • Severity of acute bronchitis attacks may be increased by exposure to cigarette smoke & air pollutants, thus avoid second-hand smoke exposure • In a patient who smokes, this may be a good opportunity to encourage smoking cessation Emphasize Lack of Beneﬁ t of Antibiotic Treatment • Antibiotic therapy is not justiﬁ ed because acute bronchitis is primarily a viral illness

BRONCHITIS - ACUTE - Exception is confi rmed or probable bacterial infection (eg whooping cough) - Management should be individualized & adequately explained to patients • ere is evidence that patient satisfaction does not depend on receiving antibiotics but on the quality of the patient-physician communication • Quality of patient-physician communication may be increased by reviewing the following w/ the patient: - Antibiotics provide little or no benefi t in treatment of the disease - Risk of unnecessary antibiotic use (eg infection w/ resistant bacteria, GI side eff ects, risk of allergic reactions) - Condition is not serious & is expected to improve without antibiotics - Cough is part of the body’s defense mechanism & duration of cough may last 10-21 days Other • Patient should be advised to contact their health care provider if their condition worsens

C FOLLOW-UP

• ough routine follow-up is not usually necessary, it provides an opportunity to check on patient’s response to therapy & compliance to lifestyle modiﬁ cation • Consider alternate diagnoses if symptoms worsen • Further investigation is recommended if: - Symptoms recur >3x/year - If symptoms persist for >1 month

Dosage Guidelines

ANTIBACTERIAL COMBINATION

Drug Dosage Remarks

Co-trimoxazole SMZ 800 mg & TM 160 Adverse Reactions [Sulfamethoxazole mg PO 12 hrly x 14 days • GI eff ects (N/V, anorexia, diarrhea, rarely (SMZ) & antibiotic-associated diarrhea/colitis, glossitis); Trimethoprim Dermatologic eff ects (rash, pruritus, photosensitivity); (TM)] Hypersensitivity reactions can range from mild (eg rash) to severe/life-threatening (eg Stevens-Johnson syndrome); Urogenital eff ect (crystallization in the urine) • Rarely hematologic eff ects which may be more common if given for long periods or w/ high doses; rarely hepatic MIMSeff ects, renal eff ects; aseptic meningitis has occurred Special Instructions • Maintain adequate fl uid intake • Contraindicated in patients allergic to sulfonamides • Use w/ extreme caution or not at all in patients w/ hematological disorders especially megaloblastic anemia due to folic acid defi ciency • Use w/ caution in patients w/ renal impairment or severe hepatic dysfunction & w/ caution in patients w/ folate © defi ciency (may consider administration of Folinic acid) All dosage recommendations are for non-pregnant & non-breastfeeding women, & non-elderly adults w/ normal renal & hepatic function unless otherwise stated. Not all products are available or approved for above use in all countries. Products listed above may not be mentioned in the disease management chart but have been placed here based on indications listed in regional manufacturers’ product information. Specifi c prescribing information may be found in the latest MIMS.

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Dosage Guidelines

CEPHALOSPORINS

Drug Dosage1 Remarks

BRONCHITIS - ACUTE Second Generation Cefaclor 250-500 mg PO 8 hrly or Adverse Reactions 375-500 mg PO 12 hrly • Hypersensitivity reactions (urticaria, pruritus, rash, Max dose: 4 g/day anaphylaxis); GI eff ects (diarrhea, N/V); Other eff ect (candidal infections) Cefprozil 500 mg PO 12 hrly • High doses may be associated w/ CNS eff ects Cefuroxime 250-500 mg PO 12 hrly (encephalopathy, convulsions) ird Generation • Prolonged prothrombin time (PT), prolonged activated partial thromboplastin time (aPTT), &/or Cefi xime 100-200 mg PO 12 hrly hypoprothrombinemia (w/ or without bleeding) have Cefpodoxime 100 mg PO 12 hrly been reported & occur most frequently w/ Ceftibuten 400 mg PO 24 hrly N-methylthiotetrazole (NMTT) side chain-containing cephalosporins Special Instructions • May be taken w/ food to decrease gastric distress • Use w/ caution in patients allergic to Penicillin as there may be 10% chance of cross sensitivity & w/ renal impairment

¹Duration of therapy unless otherwise stated: 7-10 days

COUGH & COLD PREPARATIONS

Drug Dosage Remarks

Acetylcysteine 200 mg PO 8 hrly Adverse Reactions (N-acetylcysteine) • GI disturbances, N/V; Hypersensitivity reactions Ambroxol 60-120 mg PO divided (bronchospasm, rashes); Other eff ect (hypotension) 8-12 hrly Special Instruction Extended-release: • Use w/ caution in patients w/ gastric or duodenal ulcer 75 mg PO 24 hrly Bromhexine 8-16 mg PO 6-8 hrly Carbocisteine Initial dose: 750 mg PO (Carbocysteine) 6-8 hrly, then 1.5 g/day PO in divided doses Cyclidrol 200 mg PO 12 hrly or Adverse Reactions (Sobrerol) up to 800 mg daily in • GI eff ect (stomach pain); Hypersensitivity reaction (rashes) divided doses MIMSSpecial Instruction • Use w/ caution in patients w/ renal failure Erdosteine 300 mg PO 8-12 hrly Adverse Reactions • GI disturbances (GI discomfort, rarely taste alterations); Other eff ects (rarely, headache, dyspnea, urticaria, erythema, dermatitis) Special Instruction • Contraindicated in patients w/ hepatic cirrhosis, hepatic impairment, cystathionine-synthetase enzyme defi ciency © & severe renal failure All dosage recommendations are for non-pregnant & non-breastfeeding women, & non-elderly adults w/ normal renal & hepatic function unless otherwise stated. Not all products are available or approved for above use in all countries. Products listed above may not be mentioned in the disease management chart but have been placed here based on indications listed in regional manufacturers’ product information. Specifi c prescribing information may be found in the latest MIMS.

Dosage Guidelines

COUGH & COLD PREPARATIONS (CONT’D)

Drug Dosage Remarks

BRONCHITIS - ACUTE Guaifenesin 600 mg PO 12 hrly or Adverse Reactions 200 mg PO 4 hrly • GI disturbances (GI discomfort, N/V) Max dose: 1200 mg in Special Instruction 24 hr • Use w/ caution in patients w/ persistent or chronic cough, asthma, chronic bronchitis or emphysema • Discontinue use if cough persists for >7 days w/ fever, rash or persistent headache Vitex negundo L. 300-600 mg PO 6-8 Adverse Reactions (Lagundi leaf) hrly • GI eff ects (diarrhea, N/V); Other eff ect (itchiness) Special Instruction • May be taken w/ or without food Levodropropizine 60 mg PO 8 hrly Adverse Reactions • CNS eff ects (somnolence, faintness, clouding of consciousness, dizziness, headache); Other eff ects (palpitation, GI disturbance) Special Instructions • Use w/ caution in patients w/ excessive mucus discharge, limited mucociliary function, hepatic dysfunction, renal insuffi ciency, & diabetes

MACROLIDES

Drug Dosage Remarks

Erythromycin Childn: 30-50 mg/kg/day PO divided Adverse Reactions 6-12 hrly x 14 days • GI eff ects (N/V, abdominal discomfort, Adults: 500 mg PO 6 hrly x 14 days diarrhea & other GI disturbances, antibiotic-associated diarrhea/colitis); Roxithromycin Childn <40 kg: 5-8 mg/kg/day PO Other eff ect (candidal infections) divided 12 hrly x 7-10 days • Hypersensitivity reactions are Adults: 150 mg PO 12 hrly x 7-10 days or uncommon (urticaria, pruritus, rash, 300 mg PO 24 hrly x 7-10 days rarely anaphylaxis); rarely Advanced Macrolides cardiotoxicity, hepatotoxicity; dose-related tinnitus/hearing loss have Azithromycin Childn: 10 mg/kg PO 24 hrly x 5-7 days occurred w/ some macrolides Adults: 500 mg PO 24 hrly x 3 days or • Azithromycin & Clarithromycin tend to 500 mg PO 24 hrly x 1 day followed cause less GI disturbances than by 250 mg PO 24 hrlyMIMS x 4 days Erythromycin Clarithromycin Childn: 7.5 mg/kg PO 12 hrly x 5-10 days Special Instructions • Adults: 500 mg PO 12 hrly x 7-14 days May take w/ food to decrease gastric distress Extended-release: • Use w/ caution in patients w/ hepatic 1000 mg PO 12 hrly x 7-14 days © dysfunction All dosage recommendations are for non-pregnant & non-breastfeeding women, & non-elderly adults w/ normal renal & hepatic function unless otherwise stated. Not all products are available or approved for above use in all countries. Products listed above may not be mentioned in the disease management chart but have been placed here based on indications listed in regional manufacturers’ product information. Specifi c prescribing information may be found in the latest MIMS.

Dosage Guidelines

OTHER DRUGS ACTING ON THE RESPIRATORY SYSTEM

Drug Dosage¹ Remarks Pelargonium BRONCHITIS - ACUTE Childn 1-5 yr: Adverse Reactions sidoides 6.25 mg PO 8 hrly • GI eﬀ ects (N/V, diarrhea); Hypersensitivity reactions Childn 6-12 yr: (rash, urticaria, pruritus) associated w/ initial dose 12.5 mg PO 8 hrly or 20 mg Special Instructions PO 12 hrly • Contraindicated in patients w/ severe renal & hepatic Childn >12 yr & Adults: impairment 20-40 mg PO 8 hrly • Use w/ caution in patients w/ hematologic disorders & in patients taking anticoagulants • After symptoms subsides, advise patient to continue use for additional 2 days

¹Duration of therapy unless otherwise stated: 10-14 days

QUINOLONES

Drug Dosage1 Remarks

Levofl oxacin 250 or 500 mg PO 12 or Adverse Reactions 24 hrly • GI eff ects (N/V, diarrhea, abdominal pain, dyspepsia, Prulifl oxacin 200-300 mg PO 12 hrly diarrhea, rarely antibiotic-associated diarrhea/colitis); CNS eff ects (headache, dizziness, sleep disorders, restlessness, drowsiness); Dermatologic eff ects (rash, pruritus, photosensitivity); Hypersensitivity reactions can range from mild (eg rash) to severe/ life-threatening (eg Stevens-Johnson syndrome) • Rarely hematologic eff ects; hepatic & renal eff ects • Some quinolones have the potential to prolong the QT interval Special Instructions • Administer at least 2 hr before or 3 hr after Al- or Mg-containing antacids, dietary supplements containing Zn or Fe or buff ered Didanosine preparations • Avoid exposure to strong sunlight or tanning beds • Use w/ caution in patients w/ epilepsy or history of CNS disorders, in patients w/ impaired renal or hepatic function & in those w/ G6PD defi ciency ¹Duration of therapy unless otherwise stated: 7-10 daysMIMS

All dosage recommendations are for non-pregnant & non-breastfeeding women, ©& non-elderly adults w/ normal renal & hepatic function unless otherwise stated. Not all products are available or approved for above use in all countries. Products listed above may not be mentioned in the disease management chart but have been placed here based on indications listed in regional manufacturers’ product information. Speciﬁ c prescribing information may be found in the latest MIMS. Please see the end of this section for the reference list.