What is the recommended 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 half a day) while exposing patients to adverse effects and contributing to antibiotic resistance. 1, 2

Antibiotic Avoidance Strategy

• Acute bronchitis is viral in 89-95% of cases, making antibiotics ineffective for the vast majority of patients 1, 3
• The presence of purulent or discolored sputum does NOT indicate bacterial infection and is NOT an indication for antibiotics 1
• When patients expect antibiotics, dedicate time to explaining why they are not indicated and discuss the potential harm of unnecessary antibiotic use to both the individual and community 1
• Referring to the condition as a "chest cold" rather than bronchitis reduces patient expectations for antibiotics 1, 2
• Patient satisfaction depends more on physician-patient communication quality than whether an antibiotic is prescribed 1, 4

Rule Out Pneumonia First

Before diagnosing acute bronchitis, exclude pneumonia in patients with any of the following 1:

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

Symptomatic Treatment Approach

For most patients:

• β2-agonist bronchodilators should NOT be routinely used for cough in acute bronchitis 1
• Codeine or dextromethorphan may provide modest effects on cough severity and duration 1, 5
• Low-cost interventions such as elimination of environmental cough triggers and vaporized air treatments are reasonable options 1

For select patients with wheezing:

• β2-agonist bronchodilators may be useful when wheezing accompanies the cough 1, 5

Avoid these interventions:

• NSAIDs at anti-inflammatory doses should NOT be used 1
• Systemic corticosteroids should NOT be used 1, 5

Exception: Pertussis (Whooping Cough)

• For confirmed or suspected pertussis, prescribe a macrolide antibiotic such as erythromycin 1
• Isolate patients for 5 days from the start of treatment 1, 6
• Early treatment within the first few weeks diminishes coughing paroxysms and prevents disease spread 1

High-Risk Patient Considerations

• Consider antibiotics only for elderly, immunocompromised patients, or those with comorbidities like COPD or heart failure 1
• Consider antibiotics if the condition significantly worsens, suggesting bacterial superinfection 1
• Consider antiviral agents for influenza-related bronchitis if within 48 hours of symptom onset 1

Patient Education

• Inform patients that cough typically lasts 10-14 days after the office visit, but can extend to 2-3 weeks 1, 2
• Explain that this is a self-limiting viral condition that will resolve without antibiotics 1, 2
• Discuss the risks of unnecessary antibiotic use, including side effects and contribution to antibiotic resistance 1

Common Pitfalls to Avoid

• Do not prescribe antibiotics based on sputum color or purulence alone 1
• Do not routinely use bronchodilators unless wheezing is present 1, 5
• Do not confuse acute bronchitis with chronic bronchitis (productive cough for ≥3 months over 2 consecutive years), which requires different management 5, 7