What is the treatment for acute bronchitis?

Treatment of Acute Bronchitis

Antibiotics should not be prescribed for acute bronchitis in healthy adults as the condition is primarily viral in nature and antibiotics provide minimal benefit while carrying risks of side effects. 1, 2

Understanding Acute Bronchitis

Acute bronchitis 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

The clinical course is generally spontaneously favorable after about 10 days, although cough may persist for a longer period 2. It's important to note that:

• Onset of purulent sputum during acute bronchitis is not associated with bacterial superinfection 2
• Viral infections account for an estimated 89% to 95% of cases 3

First-Line Treatment Approach

Symptomatic Management

1. Patient education:

   • Explain the viral nature of the condition
   • Inform patients that cough typically lasts 2-3 weeks
   • Refer to the condition as a "chest cold" rather than "bronchitis" to reduce antibiotic expectations 1

2. Non-pharmacological measures:

   • Adequate hydration
   • Avoidance of respiratory irritants 1

3. Pharmacological options for symptom relief:

   • Short-acting β-agonists for bronchospasm and dyspnea relief, particularly in patients with wheezing 1
   • Short-term use of codeine or dextromethorphan may provide symptomatic relief for cough 1

Treatments to Avoid

• Antibiotics: Not recommended for routine use in acute bronchitis in healthy adults 1, 2
• Expectorants: Should be avoided due to lack of evidence of effectiveness 1
• NSAIDs at anti-inflammatory doses: Not justified 2
• Systemic corticosteroids: Not justified in uncomplicated cases 2

Special Considerations

When to Consider Further Evaluation

• Fever persisting more than 7 days (may indicate bacterial superinfection) 2
• Cough persisting beyond 3 weeks 1
• Development of tachypnea, tachycardia, dyspnea, or focal chest findings (consider pneumonia) 4
• Suspected pertussis (paroxysmal cough, whooping cough, post-tussive emesis) 4

Acute Exacerbation of Chronic Bronchitis (AECB)

This is different from acute bronchitis in otherwise healthy adults and may require:

• Short-acting β-agonists or anticholinergic bronchodilators 1
• Antibiotics may be indicated when at least two Anthonisen criteria are present (increased dyspnea, sputum volume, and purulence) 1
• In cases requiring antibiotics, options include:
  • Amoxicillin (preferred) 1
  • Macrolides, pristinamycin, or doxycycline (for beta-lactam allergy) 1

Evidence on Antibiotic Use

The benefit of antibiotic therapy on the clinical course of acute bronchitis or on the occurrence of complications has not been confirmed in clinical trials versus placebo 2. Meta-analysis suggests only a small benefit from antibiotics (decreasing duration of cough and sputum production by approximately one-half day), which must be weighed against the risk of side effects and increasing antibiotic resistance 5.

Key Pitfalls to Avoid

1. Overuse of antibiotics: Antibiotics have been shown to provide only minimal benefit while carrying risks of adverse effects including allergic reactions, nausea, vomiting, and C. difficile infection 4

2. Misdiagnosis: Ensure that pneumonia is ruled out, particularly in patients with tachypnea, tachycardia, dyspnea, or lung findings suggestive of pneumonia 4

3. Inadequate patient education: Patient satisfaction depends more on effective communication about the condition and expected recovery time than on receiving antibiotics 1

4. Failure to recognize high-risk patients: Patients with underlying conditions (COPD, heart failure, immunosuppression) or elderly patients (≥65 years) require closer monitoring 1

By following these evidence-based guidelines, clinicians can provide appropriate care for patients with acute bronchitis while avoiding unnecessary antibiotic use.