Are antibiotics necessary to get over bronchitis?

Even if you’re diligent about taking immune-boosting vitamins and supplements, eating right and getting rest, the occasional bug gets you.

This time of year, I see a lot of patients presenting with bronchitis when I work at the busy Urgent Care near my home in San Diego, California. Many of you have or will likely experience a productive (or dry) cough this winter too — and you may be wondering how best to treat it.

Let me share what I’ve come to discover about bronchitis — and lingering cough.

Bronchitis: viral or bacterial?

You probably know that antibiotics do nothing for illnesses caused by viruses. So then why do some doctors so often prescribe antibiotics for viral bronchitis? And, why do other doctors try to talk you out of getting a prescription for an antibiotic therapy?

There is good reason for both approaches. But it’s important to consider the threat of antibiotic resistance when doling out antibiotics. When doctors prescribe them unnecessarily, and patients demand them when they aren’t warranted — or don’t take them as directed — it contributes to an already serious problem.

But first, how do you know if you have bronchitis?

Typically, it causes the following symptoms: Cough (productive or dry) with fatigue and usually chest pain, poor appetite, and the initial fever, chills or sweats.

How did you catch it? You catch a virus from breathing infected air. Or you may have come in touch an infected surface or person.

Once you inhale bacteria, they penetrate your mucosa (the skin of your nose, lungs, mouth) rather quickly and enter your bloodstream. There they replicate rapidly and spread throughout your body quickly. That’s why fatigue is the hallmark symptom of a viral infection, and not a localized pain/symptom alone.

After a few days, the skin of your respiratory tree and the associated mucus/sputum that your body produces in an attempt to protect you, may or may not become secondarily infected with bacteria. The bacteria were already there, but morph and grow because of your new sick condition.

Treating bronchitis

Bronchitis can make you feel terrible. And there’s no reason not to try to ease symptoms to help you feel comfortable, especially if you have a strong cough that causes chest pain and keeps you awake. After all, rest is an important part of getting over a viral illness.

My most recommended cough suppressant is Delsym (dextromethorphan polystyrex), a long-acting cough suppressant ingredient that you find in all the over-the-counter cough and cold medicines.

Tessalon Perles (Benzonatate) are non-drowsy prescription cough suppressants jelly caps that work quite well for most people.

But inevitably the big question turns to antibiotics… and the discussion about the color of sputum begins.

Do you need antibiotics when your sputum turns from clear to yellow, green, or brown? It all depends on how sickly you are… and how sickly your lungs are.

If you have chronic bronchitis, bronchiectasis or chronic obstructive pulmonary disease (COPD), then the color of your sputum is the strongest predictor of having a bacterial infection causing your symptoms.

But even then it’s not a sure thing…

According to one study, out of 4,003 colored sputum samples, “1,898 (46.4 percent) were culture-positive” and “green or yellow sputum samples were most likely to yield bacteria (58.9 percent and 45.5 percent of samples, respectively), compared with 18 percent of clear and 39 percent of rust-colored samples.”

So, even in the sickest of lung disease patients, most of the colored sputum is still just a viral infection.

Interestingly, the yellow or green color of sputum is thought to be caused from a green-colored enzyme called myeloperoxidase, which is formed by the white blood cells (neutrophils) that fight bacteria. Less predictive signs/symptoms of bacterial infection were thickness of sputum (i.e. purulence) and shortness of breath according to these researchers.

What about the majority of us who do not have a chronic lung disease? Are antibiotics needed?  As you imagined, colored sputum poorly correlates with bacterial infection in the rest of us.

A study from 42 family medicine clinics in Düsseldorf, Germany, sputum samples were obtained from 241 patients who were suffering from bronchitis. Only 28 (12 percent) grew out bacteria. When using the yellow or green color to predict bacterial growth in sputum, the researchers concluded that “the color of sputum or discharge cannot be used to differentiate between viral and bacterial infections in otherwise healthy adults. The color of sputum should not be used to make a decision on whether to prescribe an antibiotic within this group of patients.”

To prescribe or not

The American Academy of Family Physicians tells us that bronchitis is caused by a viral infection in 95 percent of cases, and that there is little evidence supporting the use of antibiotics.

Yet most people who I treat in the Urgent Care want antibiotics for this condition.

How do I make my patients happy, but meet my most important goal of healing them?

First, I briefly describe how they contracted a viral infection… and how this virus spread in their blood and produced their symptoms.

Next, I reassure them that antibiotics will work well to heal bacterial infections.

Finally, I describe the symptoms that correlate with a complicated bronchitis or impending pneumonia. These are symptoms that persist or are worsening after a week and include fever, shortness of breath, localized chest pain, persistent body weakness or fatigue, poor appetite, along with persistent thick yellow or green sputum.

I offer a prescription of an antibiotic if they feel they are at this point of worsening bronchitis, or to begin taking it if and when this time comes.

Clearly many of us do benefit, although not consistently, as shown in placebo-controlled studies using doxycycline, erythromycin and trimethoprim-sulfamethoxazole (Bactrim, Septra).

The favorite of most patients is the Z-pack (Azithromycin), which is indicated for community-acquired pneumonia, not for bronchitis.  I think the placebo-effect has a lot to do with the improvement seen by many patients, who tell me, “the Z-pack got me better last time I had this.”

Just remember, your doctor wants to do what’s best for you and should discuss all of this with you.

But if you have a better understanding of how antibiotics affect viral and bacterial infections, and the danger of using them when not justified, and what to expect if your illness progresses, you can feel empowered about having input on treatment that could have long-lasting impacts on your future health.

To feeling good all winter long,

Michael Cutler, M.D.

Sources:

1. Marc Miravitlles, Frank Kruesmann, Daniel Haverstock, Renee Perroncel, Shurjeel H. Choudhri, Pierre Arvis. Sputum colour and bacteria in chronic bronchitis exacerbations: a pooled analysis. European Respiratory Journal Jun 2012, 39 (6) 1354-1360

2. et al.

3. Altiner A, Wilm S, Däubener W, et al. Sputum colour for diagnosis of a bacterial infection in patients with acute cough. Scandinavian Journal of Primary Health Care. 2009;27(2):70-73. Find online at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3410464/

4. http://www.aafp.org/afp/1998/0315/p1270.html