Initial Treatment for Acute Bronchitis
Do not prescribe antibiotics or routine medications for uncomplicated acute bronchitis in immunocompetent adults—focus on patient education about the expected 2-3 week duration of cough and symptomatic management only. 1, 2
Diagnostic Approach
Before diagnosing acute bronchitis, rule out pneumonia by assessing for:
- Heart rate >100 beats/min 3
- Respiratory rate >24 breaths/min 3
- Oral temperature >38°C 3
- Focal chest examination findings (rales, egophony, tactile fremitus) 2
In the absence of these findings, chest radiography is not indicated. 1, 3
Key Diagnostic Principles
- The presence of purulent sputum or colored sputum does NOT indicate bacterial infection and is NOT an indication for antibiotics 2, 3
- No routine investigations are recommended, including chest x-ray, spirometry, sputum cultures, viral PCR, or inflammatory markers 1, 3
- Consider pertussis if cough persists >2 weeks with paroxysmal features, whooping, or post-tussive emesis 4
Treatment Recommendations
What NOT to Prescribe
The CHEST Expert Panel (2020) explicitly recommends against routine prescription of: 1
- Antibiotics
- Antiviral therapy (except for confirmed influenza within 48 hours)
- Antitussives
- Inhaled beta-agonists
- Inhaled anticholinergics
- Inhaled corticosteroids
- Oral corticosteroids
- Oral NSAIDs at anti-inflammatory doses
Rationale Against Antibiotics
Antibiotics reduce cough duration by only approximately 0.5 days while significantly increasing adverse effects (RR 1.20; 95% CI, 1.05-1.36). 2 This minimal benefit does not justify the risks of:
- Allergic reactions 4
- Gastrointestinal side effects 4
- Clostridium difficile infection 4
- Contribution to antibiotic resistance 2
Symptomatic Treatment Options
- Antitussives (codeine or dextromethorphan) may provide modest short-term relief for bothersome cough 2, 5
- β2-agonist bronchodilators should NOT be routinely used, but may be considered in select patients with wheezing accompanying the cough 2, 3
- Low-cost, low-risk interventions such as elimination of environmental cough triggers and vaporized air treatments are reasonable 2
Patient Education Strategy
The most critical intervention is effective physician-patient communication, which determines patient satisfaction more than antibiotic prescription. 1, 2
Key Messages to Communicate
- Inform patients that cough typically lasts 10-14 days after the office visit and may persist up to 2-3 weeks 2, 6
- Refer to the condition as a "chest cold" rather than "bronchitis" to reduce antibiotic expectations 2, 6
- Explain that acute bronchitis is caused by viruses in 89-95% of cases 7, 6
- Discuss the risks of unnecessary antibiotic use, including side effects and antibiotic resistance 2
When to Reconsider or Reassess
Indications for Antibiotics (Exceptions)
- Confirmed or suspected pertussis: Prescribe a macrolide antibiotic (such as erythromycin) and isolate patient for 5 days from start of treatment 2
- Significant worsening of symptoms suggesting bacterial superinfection 1, 3
- High-risk patients: Elderly (≥65 years), immunocompromised, or those with comorbidities like COPD or heart failure 2, 3
When to Reassess
If symptoms persist or worsen, consider: 1, 3
- Targeted investigations (chest x-ray, sputum culture, peak flow measurements, CBC, inflammatory markers)
- Alternative diagnoses: asthma (65% of recurrent "acute bronchitis" may be mild asthma), COPD exacerbation, bronchiectasis, or cough-variant asthma 1, 3
Common Pitfalls to Avoid
- Do not prescribe antibiotics based solely on colored or purulent sputum 2, 3
- Do not routinely order chest radiography in healthy adults without vital sign abnormalities 1, 3
- Do not use the term "bronchitis" when educating patients—use "chest cold" instead to manage expectations 2, 6
- Do not assume patient satisfaction requires antibiotics—it depends on quality of communication 1, 8