II. Indications: Antibiotic indications if 3 criteria met

  1. Increased Dyspnea
  2. Increased Sputum
  3. Purulent Sputum

III. Management: Antibiotics for Uncomplicated Chronic Bronchitis

  1. Criteria
    1. Under age 65 years old
    2. FEV1 > 50% of predicted
    3. Under 4 acute exacerbations per year
    4. No significant comorbid disease
  2. Coverage
    1. HaemophilusInfluenzae
    2. Streptococcus Pneumoniae
    3. Moraxella catarrhalis
    4. Chlamydia pneumoniae
    5. Mycoplasma pneumoniae
  3. Antibiotics (5 day course)
    1. First-Line
      1. Bactrim DS one tablet PO bid
      2. Doxycycline 100 mg PO bid
      3. Amoxicillin 500 mg PO tid
        1. Equivalent to Moxifloxacin in clinical outcome
        2. Wilson (2004) Chest 125:953-64 [PubMed]
    2. Alternative Antibiotics
      1. Augmentin 875 mg PO bid
      2. Second generation Macrolide
        1. Clarithromycin 500 mg PO bid
        2. Azithromycin 500 mg day 1, then 250 mg PO x4 days
          1. Also available as 3 day preparation
          2. Similar outcomes to Levofloxacin for 7 days
          3. Amsden (2003) Chest 123:772-7 [PubMed]

IV. Management: Antibiotics for Complicated Chronic Bronchitis

  1. Criteria
    1. Uncomplicated criteria not met (see above)
  2. Coverage
    1. Uncomplicated Chronic BronchitisBacteria (see above)
    2. Gram Negative Rods (e.g. Pseudomonas)
  3. Dosing for 5 day course
    1. Augmentin 875 mg PO bid
    2. Fluoroquinolone
      1. Levofloxacin (Levaquin) 250 mg po qd
      2. Moxifloxacin (Avelox) 400 mg PO qd

V. Management: Antibiotics for Severe Exacerbation requiring hospitalization

  1. Co-administer Corticosteroids
    1. Initially use intravenous Corticosteroids
      1. Methylprednisolone (Solumedrol) 60 mg IV every 6 hours
      2. Avoid high doses (e.g. 125 mg) as they offer no added benefit
    2. Transition to oral Corticosteroids as soon as prudent
      1. Prednisone 30-40 mg orally daily
      2. Taper off over 2 weeks (no benefit to previously used longer taper over 8 weeks)
  2. Protocol: Two parenteral drug combination
    1. Drug 1: Cephalosporin or Antipseudomonal Penicillin
    2. Drug 2: Fluoroquinolone or Aminoglycoside
  3. Cephalosporins
    1. Ceftriaxone (Rocephin) 1 to 2 grams IV q24 hours
    2. Cefotaxime (Claforan) 1 gram IV q8-12 hours
    3. Ceftazidime (Fortaz) 1-2 grams IV q8-12 hours
  4. Antipseudomonal Penicillins
    1. Piperacillin-Tazobactam (Zosyn) 3.375 g IV q6 hours
    2. Ticarcillin-Clavulanate (Timentin) 3.1 g IV q4-6 hour
  5. Fluoroquinolones
    1. Levofloxacin (Levaquin) 500 mg IV q24 hours
    2. Gatifloxacin (Tequin) 400 mg IV q24 hours
  6. Aminoglycoside
    1. Tobramycin (Tobrex)
      1. Split dosing: 1 mg/kg IV q8-12 hours
      2. Once daily: 5 mg/kg IV q24 hours

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