What is the treatment for acute bronchitis?

Treatment of Acute Bronchitis

For immunocompetent adult outpatients with acute bronchitis, antibiotics should not be routinely prescribed as they provide minimal benefit while exposing patients to adverse effects. 1, 2

Diagnosis and Assessment

• Acute bronchitis is an acute respiratory infection with normal chest radiograph findings, manifested by cough with or without phlegm production lasting up to 3 weeks 1
• Respiratory viruses cause 89-95% of cases, with fewer than 10% having bacterial infections 1, 2
• Rule out pneumonia in patients with tachycardia (>100 beats/min), tachypnea (>24 breaths/min), fever (>38°C), or abnormal chest examination findings 1
• The presence of purulent sputum or change in sputum color does not indicate bacterial infection 1, 2

Antibiotic Treatment

• Antibiotics should not be routinely prescribed for acute bronchitis 3, 1, 2
• Multiple systematic reviews show antibiotics provide minimal benefit, reducing cough duration by only about half a day 2
• Antibiotics are associated with increased adverse events compared to placebo (16% vs. 11%) 2
• When patients expect antibiotics, explain the decision not to use them and discuss potential harms of unnecessary antibiotic use 1, 2

Exception for Pertussis

• For confirmed or suspected pertussis (whooping cough), a macrolide antibiotic such as erythromycin should be prescribed 3, 1
• Patients with pertussis should be isolated for 5 days from the start of treatment 3, 1
• Early treatment within the first few weeks will diminish coughing paroxysms and prevent disease spread 3, 1

Symptomatic Treatment

• No routine medications should be prescribed until they have been shown to be safe and effective at making cough less severe or resolve sooner 3
• β2-agonist bronchodilators should not be routinely used for cough in most patients with acute bronchitis 3, 1
• In select adult patients with wheezing accompanying the cough, β2-agonist bronchodilators may be useful 3, 1, 4
• Antitussives like dextromethorphan may provide modest effects on severity and duration of cough 1, 5
• Expectorants like guaifenesin may help loosen phlegm and thin bronchial secretions 6

Patient Education

• Inform patients that cough typically lasts 10-14 days after the office visit 1, 2
• Referring to the condition as a "chest cold" rather than bronchitis may reduce patient expectation for antibiotics 1, 2
• Patient satisfaction depends more on physician-patient communication than whether an antibiotic is prescribed 1, 2, 7

Monitoring and Follow-up

• If acute bronchitis persists or worsens, reassessment and consideration of targeted investigations should be performed 3
• Consider antibiotic therapy if a complicating bacterial infection is thought likely in worsening cases 3
• Targeted investigations could include chest x-ray, sputum for microbial culture, peak expiratory flow rate recordings, complete blood count, and inflammatory markers 3

Common Pitfalls to Avoid

• Prescribing antibiotics based solely on patient expectations or presence of purulent sputum 1, 2
• Failing to consider differential diagnoses such as asthma, COPD exacerbation, or pneumonia 3, 1
• Using bronchodilators in patients without evidence of bronchospasm 3, 1
• Not providing adequate patient education about the expected duration of symptoms 1, 2