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 and American Academy of Family Physicians recommend against routine use of: 1, 2
- Antibiotics - provide only 0.5 day reduction in cough duration while exposing patients to adverse effects (allergic reactions, nausea, vomiting, C. difficile infection) 2, 4
- Inhaled beta-agonists - not routinely beneficial except in select patients with wheezing 1, 2
- Inhaled anticholinergics - no routine benefit 1
- Inhaled or oral corticosteroids - not effective 1, 5
- Oral NSAIDs at anti-inflammatory doses - no demonstrated benefit 1, 5
- Antiviral therapy - unless influenza confirmed within 48 hours of symptom onset 2
What TO Recommend
- Patient education: Inform patients that cough typically lasts 10-14 days after the visit, but may persist up to 3 weeks 2, 4
- Refer to the condition as a "chest cold" rather than bronchitis to reduce antibiotic expectations 2, 6
- Symptomatic measures: Low-cost interventions like elimination of environmental cough triggers and vaporized air treatments 2
- Antitussives: Codeine or dextromethorphan may provide modest short-term relief for bothersome cough 2, 5
When to Consider Bronchodilators
- β2-agonist bronchodilators (e.g., albuterol) may be beneficial only in select adult patients with wheezing accompanying the cough, suggesting bronchial hyperresponsiveness 2, 5
Special Circumstances Requiring Different Management
Pertussis (Whooping Cough)
- Prescribe a macrolide antibiotic (such as erythromycin or azithromycin) for confirmed or suspected pertussis 2
- Isolate patients for 5 days from start of treatment 2
- Early treatment within the first few weeks diminishes coughing paroxysms and prevents disease spread 2
High-Risk Patients
Consider antibiotics only in: 2, 3
- Elderly patients (age ≥65 years)
- Immunocompromised individuals
- Patients with significant worsening suggesting bacterial superinfection
- Those with comorbidities (COPD, heart failure, asthma)
When Symptoms Persist or Worsen
If acute bronchitis persists or worsens, advise reassessment and consider targeted investigations: 1, 3
- Chest x-ray
- Sputum for microbial culture
- Peak expiratory flow measurements
- Complete blood count and inflammatory markers (CRP)
Important caveat: Approximately 65% of patients with recurrent episodes of acute bronchitis may have underlying mild asthma 1, 3. Consider alternative diagnoses including cough-variant asthma, COPD exacerbation, or bronchiectasis in patients with persistent symptoms 3.
Strategies to Improve Patient Satisfaction Without Antibiotics
- Emphasize physician-patient communication - satisfaction depends more on communication quality than antibiotic prescription 1, 2
- Explain the risks of unnecessary antibiotic use including side effects and contribution to antibiotic resistance 2
- Consider delayed antibiotic prescriptions as a strategy to reduce immediate antibiotic use 6
- Provide clear expectations about the natural course of the disease 2, 4