What is the treatment for acute bronchitis?

Treatment of Acute Bronchitis

Antibiotics should not be routinely prescribed for acute bronchitis, as they provide minimal benefit (reducing cough by only about half a day) while exposing patients to unnecessary adverse effects and contributing to antibiotic resistance. 1, 2

Initial Assessment and Diagnosis

Before treating acute bronchitis, rule out pneumonia by assessing for:

• Tachycardia (heart rate >100 beats/min) 1
• Tachypnea (respiratory rate >24 breaths/min) 1
• Fever (oral temperature >38°C) 1
• Abnormal chest examination findings (rales, egophony, or tactile fremitus) 1

If any of these findings are present, consider pneumonia and obtain chest radiography. 3

Consider pertussis if cough persists beyond 2 weeks with paroxysmal features, whooping, post-tussive vomiting, or known exposure. 3

Primary Treatment Approach: Supportive Care

Patient Education (Critical Component)

• Inform patients that cough typically lasts 10-14 days after the office visit 1, 4
• Refer to the condition as a "chest cold" rather than bronchitis to reduce antibiotic expectations 1, 4
• Explain that patient satisfaction depends more on physician-patient communication than receiving antibiotics 1, 4
• Discuss risks of unnecessary antibiotic use, including side effects and antibiotic resistance 1, 4

Symptomatic Management

• Eliminate environmental cough triggers and consider vaporized air treatments 1
• Dextromethorphan or codeine may provide modest effects on cough severity and duration 1, 4
• Low-cost, low-risk interventions are reasonable first-line options 1

When NOT to Use Antibiotics

Do not prescribe antibiotics based on:

• Presence of purulent or colored sputum (this does not indicate bacterial infection) 1, 4
• Patient expectation alone 1
• Routine cases of uncomplicated acute bronchitis 1, 4

The evidence is clear: antibiotics reduce cough duration by approximately 0.5 days while causing adverse effects including allergic reactions, nausea, vomiting, and Clostridium difficile infection. 2, 3

Bronchodilator Use

β2-agonist bronchodilators should NOT be routinely used for cough in most patients with acute bronchitis. 5, 1, 4

Exception: In select adult patients with wheezing accompanying the cough, β2-agonist bronchodilators (such as albuterol) may be useful and can reduce cough duration and severity. 5, 1, 4

Ipratropium bromide may improve cough in some patients with bronchial hyperresponsiveness. 4

Critical Exception: Pertussis (Whooping Cough)

For confirmed or suspected pertussis, prescribe a macrolide antibiotic immediately:

• Erythromycin is the first-line agent 5, 1
• Alternative: trimethoprim/sulfamethoxazole when macrolides cannot be given 5
• Isolate the patient for 5 days from the start of treatment 5, 1
• Early treatment within the first few weeks diminishes coughing paroxysms and prevents disease spread 5, 1
• Treatment is unlikely to be effective beyond the first few weeks of illness 5

Special Considerations for High-Risk Patients

Consider antibiotics only in specific high-risk populations:

• Patients aged ≥75 years with fever 4
• Patients with cardiac failure 4
• Elderly or immunocompromised patients 1

For these patients, if antibiotics are deemed necessary, appropriate choices include:

• Newer macrolides (azithromycin) 6, 7
• Extended-spectrum cephalosporins 7
• Doxycycline 7, 2

Antiviral Consideration

Consider antiviral agents for influenza-related bronchitis if within 48 hours of symptom onset. 1

Common Pitfalls to Avoid

• Do not prescribe antibiotics based solely on colored sputum 4
• Do not use NSAIDs at anti-inflammatory doses or systemic corticosteroids for uncomplicated acute bronchitis 1
• Do not overuse expectorants, mucolytics, or antihistamines, which lack evidence of benefit 4
• Do not fail to distinguish between acute bronchitis and pneumonia 4
• Do not use theophylline for acute bronchitis 4