What is the first line treatment for bronchitis?

First-Line Treatment for Acute Bronchitis

Antibiotics should not be routinely prescribed for uncomplicated acute bronchitis as they provide minimal benefit while exposing patients to adverse effects. 1

Understanding Acute Bronchitis

• Acute bronchitis is an acute respiratory infection manifested by cough with or without phlegm production lasting up to 3 weeks 1
• Respiratory viruses are the most common cause (89-95% of cases), with fewer than 10% of patients having bacterial infections 1, 2
• The clinical course is generally spontaneously favorable after about 10 days, although cough may persist for a longer period 3

Appropriate Management Algorithm

Step 1: Rule Out Other Conditions

• Pneumonia should be ruled out in patients with tachycardia (>100 beats/min), tachypnea (>24 breaths/min), fever (>38°C), or abnormal chest examination findings 1
• Consider other diagnoses such as asthma or COPD exacerbation 1

Step 2: Symptomatic Treatment (First-Line)

• Inform patients that cough typically lasts 10-14 days after the office visit 3, 1
• Consider the following symptomatic treatments:
  • Antitussive treatments with dextromethorphan or codeine may have modest effects on severity and duration of cough 3, 1
  • Low-cost interventions such as elimination of environmental cough triggers and vaporized air treatments (particularly in low-humidity environments) 3
  • In select adult patients with wheezing accompanying the cough, β2-agonist bronchodilators may be useful 1, 4

Step 3: Special Circumstances

For Pertussis (Whooping Cough):

• If pertussis is confirmed or suspected, prescribe a macrolide antibiotic (such as erythromycin) 1
• Patients with pertussis should be isolated for 5 days from the start of treatment 1

For Chronic Bronchitis Exacerbations:

• For exacerbation of simple chronic bronchitis, immediate antibiotic therapy is not recommended, even if fever is present 3
• For exacerbation of chronic obstructive bronchitis with chronic respiratory insufficiency (FEV1 <35% and hypoxemia at rest), immediate antibiotic therapy is recommended 3
• For exacerbation of chronic obstructive bronchitis (FEV1 between 35% and 80%), immediate antibiotic therapy is only recommended if at least two of the three Anthonisen criteria are present (increased dyspnea, increased sputum volume, increased sputum purulence) 3

Patient Communication

• Refer to the condition as a "chest cold" rather than bronchitis to reduce patient expectation for antibiotics 3, 1
• Patient satisfaction depends more on physician-patient communication than whether an antibiotic is prescribed 3, 1
• When patients expect antibiotics, explain the decision not to use these agents and discuss the potential harm of unnecessary antibiotic use 1
• Emphasize that the presence of purulent sputum or a change in its color does not signify bacterial infection and is not an indication for antibiotics 1

Common Pitfalls to Avoid

• Prescribing antibiotics for uncomplicated acute bronchitis - they provide minimal benefit (reducing cough by only about half a day) while exposing patients to adverse effects 1, 5
• Using NSAIDs at anti-inflammatory doses or systemic corticosteroids - their use is not justified in uncomplicated acute bronchitis 3
• Continuing bronchodilator treatment without documented benefit - studies show most patients with viral respiratory infections do not benefit from bronchodilators 4
• Failing to recognize pertussis, which requires specific antibiotic treatment 1

When to Consider Antibiotics

• Only if the condition significantly worsens, suggesting bacterial superinfection 1
• For patients with high risk factors such as severe COPD, immunocompromise, or other significant comorbidities 1, 6
• If fever (>38°C) persists for more than 3 days, which may indicate bacterial superinfection 3