Treatment of Acute Bronchitis
Primary Recommendation
For immunocompetent adult outpatients with acute bronchitis, do not prescribe antibiotics, routine investigations, or most medications—the condition is self-limiting and requires only symptomatic management and patient education. 1, 2
Diagnostic Approach
Confirm the Diagnosis
- Acute bronchitis is a clinical diagnosis characterized by acute cough (with or without sputum) lasting up to 3 weeks, with normal chest radiograph findings. 2
- Rule out pneumonia first by checking for these red flags: heart rate >100 bpm, respiratory rate >24 breaths/min, oral temperature >38°C, or focal chest findings (rales, egophony, fremitus). 1, 2
- If none of these findings are present, pneumonia is sufficiently unlikely that chest radiography is unnecessary. 1
- Exclude other diagnoses including common cold, acute asthma exacerbation, COPD exacerbation, and pertussis before settling on acute bronchitis. 1
No Routine Testing
- Do not order routine investigations including chest x-ray, spirometry, peak flow, sputum culture, viral PCR, CRP, or procalcitonin at initial presentation. 1
- Respiratory viruses cause 89-95% of cases; bacterial infections account for fewer than 10%. 2
- Purulent or discolored sputum does NOT indicate bacterial infection and is not an indication for antibiotics. 2
Treatment Algorithm
What NOT to Prescribe (for Most Patients)
The 2020 CHEST guidelines explicitly recommend against routine use of: 1
- Antibiotics
- Antiviral therapy
- Antitussives
- Inhaled beta-agonists
- Inhaled anticholinergics
- Inhaled corticosteroids
- Oral corticosteroids
- Oral NSAIDs
Antibiotic Use: The Evidence is Clear
- Antibiotics provide minimal benefit—reducing cough duration by only approximately half a day—while significantly increasing adverse events (RR 1.20; 95% CI, 1.05-1.36). 2
- Routine antibiotic treatment is not justified and should not be offered (Grade D recommendation). 1
- Antibiotics expose patients to allergic reactions, gastrointestinal side effects, and contribute to antibiotic resistance. 3
The Critical Exception: Pertussis
If pertussis is confirmed or suspected (cough >2 weeks with paroxysms, whooping, post-tussive vomiting, or known exposure): 1, 2
- Prescribe a macrolide antibiotic (erythromycin or azithromycin)
- Isolate the patient for 5 days from treatment start
- Early treatment within the first few weeks diminishes coughing paroxysms and prevents spread
- Treatment beyond this period is unlikely to help
Symptomatic Management Options
Beta-2-agonist bronchodilators: 1, 2
- Do not routinely prescribe for most patients (Grade D recommendation)
- May be useful in select patients with wheezing accompanying the cough (Grade C recommendation)
- Studies show no benefit in patients without airflow obstruction or wheezing at baseline
Antitussive agents (codeine or dextromethorphan): 1, 2
- May provide modest symptomatic relief for short-term use (Grade C recommendation)
- Can be offered occasionally when cough significantly affects quality of life
- Evidence is limited but suggests possible benefit
Low-risk supportive measures: 2
- Elimination of environmental cough triggers
- Vaporized air treatments
- Adequate hydration
Patient Communication Strategy
Set Realistic Expectations
- Inform patients that cough typically lasts 10-14 days after the visit, but can persist for 2-3 weeks. 2, 3
- This is the most important intervention to reduce antibiotic expectations. 2
Address Antibiotic Expectations Directly
- Many patients expect antibiotics based on previous experiences—dedicate office time to explaining why they are not indicated. 1, 2
- Discuss the potential harm of unnecessary antibiotics to both the individual (side effects) and community (resistance). 2
- Patient satisfaction depends more on physician-patient communication than whether an antibiotic is prescribed. 2, 4
Use Strategic Language
- Refer to the condition as a "chest cold" rather than "bronchitis" to reduce antibiotic expectations. 2, 3
- This simple terminology change can significantly impact patient perceptions.
When to Reassess
If Symptoms Persist or Worsen
- Advise patients to seek reassessment if acute bronchitis persists or worsens. 1
- Consider targeted investigations at that time: chest x-ray, sputum culture, peak flow, CBC, inflammatory markers. 1
- Consider antibiotics only if bacterial superinfection becomes likely (significant worsening suggesting complication). 1, 2
Important Differential Diagnoses to Reconsider
- In retrospective studies, 65% of patients with recurrent "acute bronchitis" episodes actually had mild asthma. 1
- Consider COPD exacerbation, asthma exacerbation, or bronchiectasis exacerbation if symptoms persist. 1
Common Pitfalls to Avoid
Pitfall #1: Prescribing antibiotics for purulent sputum 2
- Sputum color change does not indicate bacterial infection in acute bronchitis
- This is a viral inflammatory response, not bacterial superinfection
Pitfall #2: Routine bronchodilator use 1
- Only beneficial in the subset of patients with documented wheezing
- No benefit in patients without airflow obstruction
Pitfall #3: Ordering unnecessary tests 1
- Chest x-rays, sputum cultures, and inflammatory markers add no value at initial presentation
- Reserve for patients who worsen or fail to improve
Pitfall #4: Missing pertussis 1, 3
- Suspect when cough persists >2 weeks with characteristic features
- This is the one scenario where antibiotics are essential for treatment and prevention of spread