What is the treatment for acute bronchitis?

Treatment of Acute Bronchitis

Antibiotics are not recommended for routine treatment of acute bronchitis as over 90% of cases are caused by viral infections, and antibiotics do not improve outcomes in these patients. 1

Etiology and Diagnosis

• Acute bronchitis is primarily caused by viral pathogens (90-95% of cases) including:
  • Influenza A and B
  • Parainfluenza virus
  • Respiratory syncytial virus (RSV)
  • Coronavirus
  • Adenovirus
  • Rhinovirus 1
• Only 5-10% of cases are caused by bacterial pathogens such as:
  • Bordetella pertussis
  • Mycoplasma pneumoniae
  • Chlamydia pneumoniae 1
• Clinical diagnosis is characterized by:
  • Acute cough lasting up to 3 weeks
  • May include sputum production
  • Normal chest radiograph
  • Absence of pneumonia, common cold, acute asthma, or COPD exacerbation 1

Treatment Approach

Antibiotic Therapy

• Routine antibiotic treatment is not justified and should not be offered for uncomplicated acute bronchitis (Grade D recommendation) 2
• The presence of colored (e.g., green) sputum does not reliably differentiate between bacterial and viral infections 3
• Meta-analyses show no significant impact of antibiotics on illness duration, activity limitation, or work loss 2

Exceptions for Antibiotic Use

• Suspected or confirmed pertussis: Macrolide antibiotics (e.g., erythromycin) are recommended with 5-day isolation from start of treatment (Grade A recommendation) 2, 1
• Patients with underlying pulmonary disease at high risk for complications 1

Symptomatic Treatment

1. Cough suppressants:

   • Short-term use of codeine or dextromethorphan may provide symptomatic relief (Grade C recommendation) 1
   • These agents have not been systematically studied in double-blind, placebo-controlled trials specifically for acute bronchitis 2

2. Bronchodilators:

   • Not routinely recommended for cough relief in acute bronchitis (Grade D recommendation) 2
   • May be useful in select adult patients with wheezing accompanying cough (Grade C recommendation) 2, 1
   • Tremor, nervousness, and shakiness are common side effects 2

3. Other supportive measures:

   • Adequate hydration
   • Avoidance of respiratory irritants
   • Rest as needed 1

Patient Education

• Inform patients about:
  • Expected cough duration (typically 2-3 weeks) 1
  • The viral nature of most cases 1
  • The risks of unnecessary antibiotic use (including development of resistant bacteria) 2, 1
• Refer to the condition as a "chest cold" rather than "bronchitis" to reduce antibiotic expectations 2
• Patient satisfaction depends more on effective communication than receiving antibiotics 2

Special Considerations

• If cough persists or worsens beyond 3 weeks, or if new symptoms develop suggesting bacterial superinfection, further evaluation is necessary 1
• Patients with underlying conditions (COPD, heart failure, immunosuppression) or elderly patients may require closer monitoring 1
• Differentiate acute bronchitis from pneumonia, asthma, COPD exacerbation, and common cold 1

Common Pitfalls

• Prescribing antibiotics based on patient expectations rather than clinical evidence
• Misinterpreting purulent sputum as an indication for antibiotics
• Failing to recognize pertussis, which does require antibiotic treatment
• Not providing adequate patient education about the expected course of illness and symptom management

By following these evidence-based guidelines, clinicians can provide appropriate care for acute bronchitis while reducing unnecessary antibiotic use and its associated risks.