What is the most appropriate care for a patient with a mild to moderate respiratory infection, presenting with a cough, fever, and productive green sputum, but stable vital signs and normal chest auscultation?

Supportive Care is the Most Appropriate Management

This patient should receive supportive care only, without antibiotics, prednisone, or sputum cultures. 1

Clinical Reasoning

This patient presents with acute bronchitis—a self-limited viral illness that does not warrant antibiotic therapy. The key clinical features support this diagnosis:

• One week duration of cough with fever fits the typical presentation of acute bronchitis, which lasts up to 6 weeks 1
• Normal vital signs (low-grade fever at 100.2°F, normal heart rate, respiratory rate, and oxygen saturation) argue strongly against pneumonia 1
• Normal chest auscultation further excludes pneumonia 1
• Green sputum does NOT indicate bacterial infection—purulent sputum color is due to inflammatory cells or sloughed mucosal epithelial cells, not bacteria 1, 2

Why Pneumonia is Unlikely

Pneumonia can be confidently excluded in this patient because she lacks ALL of the following clinical criteria required to suspect pneumonia in healthy adults under 70 years 1, 3:

• Tachycardia (heart rate >100 bpm)—this patient has HR 88 bpm 1
• Tachypnea (respiratory rate >24/min)—this patient has RR 12/min 1
• Fever >38°C (100.4°F)—this patient has only 100.2°F 1
• Abnormal chest examination findings (rales, egophony, tactile fremitus)—this patient has normal auscultation 1

Why Each Option is Inappropriate

Azithromycin (Incorrect)

• Antibiotics are not indicated for acute bronchitis in the absence of pneumonia, as more than 90% of cases are viral 1
• The American College of Physicians and CDC explicitly recommend against routine antibiotic treatment for acute uncomplicated bronchitis 1, 3
• Systematic reviews show limited benefit from antibiotics in acute bronchitis with a trend toward increased adverse effects 1
• The number needed to harm (8) exceeds the number needed to treat (18) in similar respiratory infections 1
• Azithromycin specifically showed no benefit over placebo in patients with acute bronchitis and cough 1

Prednisone (Incorrect)

• Corticosteroids have no established role in acute bronchitis in otherwise healthy adults 1
• There is no evidence supporting prednisone for this clinical presentation 1

Sputum Cultures (Incorrect)

• Sputum cultures are not indicated for uncomplicated acute bronchitis in outpatient settings 1
• The green color of sputum does not justify microbiological testing, as it does not reliably indicate bacterial infection 1, 2
• Point-of-care microbiological tests should not determine care at first presentation for acute respiratory infections 1

Recommended Supportive Care Measures

Provide symptomatic treatment and patient education 1:

• Analgesics for any discomfort 1
• Antipyretics for fever management 1
• Antitussives may provide symptomatic relief 1
• Patient education that symptoms can last up to 2 weeks and are self-limited 1

Safety Netting Advice

Instruct the patient to return if 1:

• Symptoms worsen or persist beyond 2-3 weeks 1
• Development of high fever (>102.2°F/39°C), significant dyspnea, or chest pain 1
• Clinical deterioration occurs 1

Common Pitfall to Avoid

The presence of green or yellow sputum frequently leads to inappropriate antibiotic prescribing, but this is a critical error. Purulent sputum color reflects inflammatory cells, not bacterial infection, and should never be the sole justification for antibiotics 1, 2. Acute bronchitis leads to more inappropriate antibiotic prescribing than any other acute respiratory tract infection syndrome in adults, with over 70% of visits resulting in unnecessary antibiotic prescriptions 1.