Pediatric Infectious Disease

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VOLUME 2 , ISSUE 1 ( January-March, 2020 ) > List of Articles


Protracted Bacterial Bronchitis: An Underdiagnosed Cause for Chronic Wet Cough in Children

KR Bharath K Reddy, Karambir S Gill, Susha Nair, Barnali G Bhattacharya

Citation Information : Reddy KB, Gill KS, Nair S, Bhattacharya BG. Protracted Bacterial Bronchitis: An Underdiagnosed Cause for Chronic Wet Cough in Children. Pediatr Inf Dis 2020; 2 (1):19-22.

DOI: 10.5005/jp-journals-10081-1239

License: CC BY-NC 4.0

Published Online: 21-10-2020

Copyright Statement:  Copyright © 2020; The Author(s).


Protracted bacterial bronchitis (PBB) is a common cause for chronic wet cough in children. Protracted bacterial bronchitis is defined by persistent productive cough in a child lasting for more than 4 weeks duration in the absence of symptoms or signs of other causes of chronic wet cough and which resolves following a 2–4-week course of an appropriate oral antibiotic. The microbiological criteria in certain situations include a positive bronchoalveolar lavage (BAL) culture. The most common organisms responsible for PBB are non-typable Hemophilus influenzae (NTHi) (47–81%), Streptococcus pneumoniae, and Moraxella catarrhalis. Human adenovirus (HAdV) is a known viral pathogen. The pathophysiology is an initial viral insult to the respiratory tract that disrupts the normal morphology and mucociliary function that leads to chronic inflammation and formation of biofilms that reduce the antibiotic penetration. Persistent neutrophilic inflammation, caused by the presence of capsulated organisms in the respiratory tract results in a loss of ciliary function, increased mucus production and bacterial stasis, resulting is a vicious cycle of chronic inflammation and infection and eventually bronchiectasis. Protracted bacterial bronchitis can be associated other chronic conditions with impaired mucociliary clearance and large airway malacias. It is most common in the preschoolers aged between 10 months and 4.8 years. These children appear generally healthy with normal growth and development and lack signs of chronic suppurative lung disease such as clubbing, chest deformities, or crepitations. A child with PBB typically presents with history of prolonged wet cough that is more at night and with postural changes. They can also present with shortness of breath and noisy breathing. The symptoms can also be aggravated with viral infections, resulting in exacerbations during these acute episodes. All these symptoms may be similar to asthma, and hence PBB is commonly misdiagnosed and treated as asthma. Chest radiography in PBB shows occasional perihilar changes due to peribronchial wall thickening. A computed tomography (CT) scan is indicated only if there is a recurrence, treatment failure, or suspicion of bronchiectasis. Flexible bronchoscopy with BAL is reserved in recurrent PBB and in those with treatment failure, as it is not easily available in most settings. Protracted bacterial bronchitis, which is not treated adequately, can predispose to bronchiectasis and chronic suppurative lung disease. Protracted bacterial bronchitis typically responds to a 2–4-week course of appropriate antibiotics. The antibiotic of choice is amoxicillin-clavulanate followed by macrolides, trimethoprim-sulfamethoxazole, or cephalosporins in select patients.

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  1. Chang AB, Robertson CF, Van Asperen PP, et al. A multi centre study on chronic cough in children: burden and etiologies based on a standardized management pathway. Chest 2012;142(4):943–950. DOI: 10.1378/chest.11-2725.
  2. Chang AB, Redding GJ, Everard ML. State of the art—chronic wet cough: Protracted bronchitis, chronic suppurative lung disease and bronchiectasis. Pediatr Pulmonol 2008;43(6):519–531. DOI: 10.1002/ppul.20821.
  3. Marchant JM, Masters IB, Taylor SM, et al. Evaluation and outcome of young children with chronic cough. Chest 2006;129(5):1132–1141. DOI: 10.1378/chest.129.5.1132.
  4. Kantar A, Chang AB, Shields MD, et al. ERS statement on protracted bacterial bronchitis in children. Eur Respir J 2017;50(2):1602139. DOI: 10.1183/13993003.02139-2016.
  5. Chang AB, Upham JW, Masters IB, et al. Protracted bacterial bronchitis: the last decade and the road ahead. Pediatr Pulmonol 2016;51(3):225–242. DOI: 10.1002/ppul.23351.
  6. Craven V, Everard ML. Protracted bacterial bronchitis: reinventing an old disease. Arch Dis Child 2013;98(1):72–76. DOI: 10.1136/archdischild-2012-302760.
  7. Marchant JM, Gibson PG, Grissell TV, et al. Prospective assessment of protracted bacterial bronchitis: airway inflammation and innate immune activation. Pediatr Pulmonol 2008;43(11):1092–1099. DOI: 10.1002/ppul.20906.
  8. Kompare M, Weinberger M. Protracted bacterial bronchitis in young children: association with airway malacia. J Pediatr 2012;160(1):88–92. DOI: 10.1016/j.jpeds.2011.06.049.
  9. Priftis KN, Litt D, Manglani S, et al. Bacterial bronchitis caused by Streptococcus pneumoniae and nontypable Haemophilus influenzae in children: the impact of vaccination. Chest 2013;143(1):152–157. DOI: 10.1378/chest.12-0623.
  10. Marchant J, Masters IB, Champion A, et al. Randomised controlled trial of amoxycillin clavulanate in children with chronic wet cough. Thorax 2012;67(8):689–693. DOI: 10.1136/thoraxjnl-2011-201506.
  11. Narang R, Bakewell K, Peach J, et al. Bacterial distribution in the lungs of children with protracted bacterial bronchitis. PLoS ONE 2014;9(9):e108523. DOI: 10.1371/journal.pone.0108523.
  12. Wurzel DF, Marchant JM, Yerkovich ST, et al. Prospective characterisation of protracted bacterial bronchitis in children. Chest 2014;145(6):1271–1278. DOI: 10.1378/chest.13-2442.
  13. Stewart PS. Mechanisms of antibiotic resistance in bacterial biofilms. Int J Med Microbiol 2002;292(2):107–113. DOI: 10.1078/1438-4221-00196.
  14. Chang AB, Boyce NC, Masters IB, et al. Bronchoscopic findings in children with non-cystic fibrosis chronic suppurative lung disease. Thorax 2002;57(11):935–938. DOI: 10.1136/thorax.57.11.935.
  15. Baines KJ, Upham JW, Yerkovich ST, et al. Mediators of neutrophil function in children with protracted bacterial bronchitis. Chest 2014;146(4):1013–1020. DOI: 10.1378/chest.14-0131.
  16. Hodge S, Upham JW, Pizzutto S, et al. Is alveolar macrophage phagocytic dysfunction in children with protracted bacterial bronchitis a forerunner to bronchiectasis? Chest 2016;149(2):508–515. DOI: 10.1016/j.chest.2015.10.066.
  17. Chattoraj SS, Ganesan S, Jones AM, et al. Rhinovirus infection liberates planktonic bacteria from biofilm and increases chemokine responses in cystic fibrosis airway epithelial cells. Thorax 2011;66(4):333–339. DOI: 10.1136/thx.2010.151431.
  18. Bush A. Persistent bacterial bronchitis: time to venture beyond the umbrella. Front Pediatr 2017;5:264. DOI: 10.3389/fped.2017.00264.
  19. Chang AB, Landau LI, Van Asperen PP, et al. Cough in children: definitions and clinical evaluation. Med J Aust 2006;184(8):398–403. DOI: 10.5694/j.1326-5377.2006.tb00290.x.
  20. Chang AB, Van Asperen PP, Glasgow N, et al. Children with chronic cough: when is watchful waiting appropriate? Development of likelihood ratios for assessing children with chronic cough. Chest 2015;147(3):745–753. DOI: 10.1378/chest.14-2155.
  21. Al Subie H, Fitzgerald DA. Non-cystic fibrosis bronchiectasis. J Paediatr Child Health 2012;48(5):382–388. DOI: 10.1111/j.1440-1754.2010.01871.x.
  22. Goyal V, Grimwood K, Marchant J, et al. Does failed chronic wet cough response to antibiotics predict bronchiectasis? Arch Dis Child 2014;99(6):522–525. DOI: 10.1136/archdischild-2013-304793.
  23. Donnelly DE, Critchlow A, Everard ML. Outcomes in children treated for persistent bacterial bronchitis. Thorax 2007;62(1):80–84. DOI: 10.1136/thx.2006.058933.
  24. Pichichero ME, Zagursky R. Penicillin and cephalosporin allergy. Ann Allergy Asthma Immunol 2014;112(5):404–412. DOI: 10.1016/j.anai.2014.02.005.
  25. Gross-Hodge E, Carroll WD, Rainford N, et al. Duration of initial antibiotic course is associated with recurrent relapse in protracted bacterial bronchitis. Arch Dis Child 2019. 317917. DOI: 10.1136/archdischild-2019-317917.
  26. Valery PC, Morris PS, Byrnes CA, et al. Long-term azithromycin for indigenous children with non-cystic-fibrosis bronchiectasis or chronic suppurative lung disease (bronchiectasis intervention study): a multicentre, double-blind, randomised controlled trial. Lancet Respir Med 2013;1(8):610–620. DOI: 10.1016/S2213-2600(13) 70185-1.
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