What is the best approach to manage common cold and acute bronchitis?

Management of Common Cold and Acute Bronchitis

For the common cold, use first-generation antihistamine/decongestant combinations or naproxen for symptomatic relief; for acute bronchitis, avoid antibiotics entirely and focus on patient education about the expected 2-3 week duration of cough, with consideration of short-term antitussives only for bothersome symptoms. 1

Common Cold Management

First-Line Symptomatic Treatment

• First-generation antihistamine/decongestant combinations are strongly recommended to decrease cough severity and hasten resolution of cough and postnasal drip 1
• Naproxen (a nonsteroidal anti-inflammatory drug) is an effective alternative shown in controlled trials to favorably affect cough 1
• Newer-generation nonsedating antihistamines should NOT be used as they are ineffective for common cold symptoms 1

Contraindications to Consider

Avoid first-generation antihistamine/decongestants in patients with: 1

• Glaucoma
• Benign prostatic hypertrophy
• Uncontrolled hypertension
• Renal failure
• History of gastrointestinal bleeding
• Congestive heart failure

Additional Symptomatic Options

• Zinc supplements may reduce symptom duration if started within 24 hours of onset, though weigh against adverse effects (nausea, bad taste) 1
• Combination antihistamine-analgesic-decongestant products provide significant relief in 1 out of 4 patients 1
• Vitamin C and echinacea lack supporting evidence 1

Critical Diagnostic Point

The common cold must be ruled out before diagnosing acute bronchitis, as their definitions overlap and misdiagnosis leads to inappropriate antibiotic prescribing 1, 2

Acute Bronchitis Management

Antibiotic Use: The Evidence is Clear

• Antibiotics should NOT be prescribed for uncomplicated acute bronchitis 1, 2, 3
• Antibiotics reduce cough duration by only approximately 0.5 days while exposing patients to adverse effects including allergic reactions, nausea, vomiting, and Clostridium difficile infection 1, 4, 5
• More than 90% of acute bronchitis cases are viral in origin 1, 3, 6
• The presence of purulent or colored (green/yellow) sputum does NOT indicate bacterial infection and is not an indication for antibiotics—purulence results from inflammatory cells and sloughed epithelial cells 1, 3

Rule Out Pneumonia First

Before diagnosing acute bronchitis, pneumonia must be excluded. Pneumonia is unlikely in healthy adults under 70 years without ALL of the following: 1, 3

• Tachycardia (heart rate >100 beats/min)
• Tachypnea (respiratory rate >24 breaths/min)
• Fever (oral temperature >38°C)
• Abnormal chest examination findings (rales, egophony, tactile fremitus)

Symptomatic Treatment Options

β2-agonist bronchodilators:

• Should NOT be routinely used in most patients with acute bronchitis 1, 2, 3
• May be useful in select patients with wheezing accompanying the cough 1, 2, 3

Antitussives:

• Codeine or dextromethorphan may provide modest short-term symptomatic relief for bothersome cough 1, 2, 3, 7
• These are recommended only for short-term use to help with sleep or severe symptoms 1

Ineffective therapies to avoid:

• Antitussives (for routine use) 4
• Honey 4
• Oral antihistamines 4
• Anticholinergics 4
• Oral NSAIDs 3, 4
• Inhaled or oral corticosteroids 1, 4
• Expectorants (guaifenesin) 2, 8

Patient Education is Critical

• Inform patients that cough typically lasts 2-3 weeks after the office visit 3, 4, 5
• Refer to the condition as a "chest cold" rather than "bronchitis" to reduce antibiotic expectations 3, 4, 5
• Explain that patient satisfaction depends more on physician-patient communication than whether antibiotics are prescribed 3
• Discuss risks of unnecessary antibiotic use including side effects and antibiotic resistance 3

The Pertussis Exception

If pertussis (whooping cough) is confirmed or suspected: 1, 3

• Prescribe a macrolide antibiotic (such as erythromycin)
• Isolate patient for 5 days from start of treatment
• Early treatment within the first few weeks diminishes coughing paroxysms and prevents disease spread
• Suspect pertussis when cough persists >2 weeks with paroxysmal cough, whooping, post-tussive emesis, or recent pertussis exposure 5

Common Pitfalls to Avoid

• Do not prescribe antibiotics based on colored sputum alone 2, 3
• Do not diagnose acute bronchitis without first ruling out common cold, pneumonia, asthma exacerbation, and chronic bronchitis exacerbation 1, 2
• Do not use over-the-counter combination cold medications unless they contain older antihistamine/decongestant ingredients 1
• Avoid delayed antibiotic prescriptions as a compromise—the evidence supports no antibiotics at all 1, 4

Strategies to Reduce Inappropriate Antibiotic Prescribing

When patients expect antibiotics: 1, 3

• Explain the viral etiology and natural course of the illness
• Emphasize that antibiotics provide minimal benefit (half-day reduction in cough) while causing harm
• Use terminology like "chest cold" instead of "bronchitis"
• Focus on the expected timeline and symptomatic management options