What is the recommended treatment for acute bronchitis?

Treatment of Acute Bronchitis

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

Antibiotic Therapy: Not Recommended

• Routine antibiotic use is not justified for uncomplicated acute bronchitis because respiratory viruses cause 89-95% of cases, with fewer than 10% having bacterial infections 1, 2, 3
• Multiple systematic reviews demonstrate antibiotics reduce cough duration by only approximately 0.5 days while increasing adverse events (16% vs 11% with placebo) 1, 2
• The presence of purulent or discolored (green/yellow) sputum does NOT indicate bacterial infection and is NOT an indication for antibiotics—this is due to inflammatory cells or sloughed mucosal epithelial cells 1, 2
• The American Academy of Family Physicians, American College of Chest Physicians, and WHO Essential Medicines guidelines all recommend against routine antibiotic treatment 4, 1

Critical Exception: Pertussis (Whooping Cough)

• For confirmed or suspected pertussis, prescribe a macrolide antibiotic (erythromycin or azithromycin) 4, 1, 2
• Patients must be isolated for 5 days from the start of treatment 4, 1
• Early treatment within the first few weeks diminishes coughing paroxysms and prevents disease spread 4, 1
• If macrolides cannot be given, use trimethoprim/sulfamethoxazole 4

Symptomatic Management

Bronchodilators

• β2-agonist bronchodilators should NOT be routinely used in most patients with acute bronchitis 4, 1
• Consider β2-agonists ONLY in select patients with wheezing accompanying the cough, as this subgroup may show benefit 4, 1
• Studies show approximately 50% fewer patients report cough after 7 days when bronchodilators are used in patients with wheezing or bronchial hyperresponsiveness 4, 5

Cough Suppressants

• Codeine or dextromethorphan may provide modest effects on severity and duration of cough in acute bronchitis 4, 1
• Evidence for antitussive benefit is stronger for chronic cough (>3 weeks duration) than for acute viral respiratory infections 4

Other Symptomatic Options

• Consider low-cost, low-risk interventions such as elimination of environmental cough triggers (dust, dander) and vaporized air treatments, particularly in low-humidity environments 4, 1
• Over-the-counter treatments (guaifenesin, diphenhydramine, phenylephrine) may be considered but can cause minor adverse effects including nausea, vomiting, headache, and drowsiness 2

What NOT to Use

• NSAIDs at anti-inflammatory doses are not justified 4, 1
• Systemic corticosteroids are not justified 4, 1
• Inhaled corticosteroids have no role in acute bronchitis 1

Rule Out Pneumonia First

Before diagnosing acute bronchitis, rule out pneumonia in patients with:

• Tachycardia (heart rate >100 beats/min) 1, 2
• Tachypnea (respiratory rate >24 breaths/min) 1, 2
• Fever (oral temperature >38°C) 1, 2
• Abnormal chest examination findings (rales, egophony, tactile fremitus) 1, 2

Patient Communication Strategy

Patient satisfaction depends more on physician-patient communication than whether an antibiotic is prescribed. 4, 1, 2

Key Discussion Points:

• Inform patients that cough typically lasts 10-14 days after the office visit, and may persist up to 3 weeks 4, 1, 2
• Refer to the condition as a "chest cold" rather than "bronchitis" to reduce antibiotic expectations 4, 1, 2
• Explain that antibiotics do not improve outcomes and expose patients to unnecessary side effects and contribute to antibiotic resistance 4, 1, 2
• Discuss the viral nature of the illness and the self-limited course 1, 2

Delayed Prescribing Strategy

• Consider providing a delayed antibiotic prescription (to be filled only if symptoms significantly worsen) as this strategy has been shown to decrease antibiotic use without increasing patient dissatisfaction 4, 1

Special Considerations

• These recommendations apply to otherwise healthy adults without comorbidities 2
• Patients with COPD, congestive heart failure, or immunosuppression may require different management approaches 1, 2
• For influenza-related bronchitis, consider antiviral medications if within 48 hours of symptom onset 1, 2
• In smokers without COPD, there is no evidence that antibiotics are more beneficial than in non-smokers 2