Treatment of Bronchitis
Acute Bronchitis: Antibiotics Are Not Indicated
Antibiotics should not be prescribed for uncomplicated acute bronchitis, regardless of cough duration or sputum color. 1, 2, 3 Viruses cause more than 90% of acute bronchitis cases, and antibiotics provide minimal benefit—reducing cough by only half a day while causing adverse effects including allergic reactions, gastrointestinal symptoms, and promoting antibiotic resistance. 4, 5
Key Diagnostic Considerations
- Rule out pneumonia before diagnosing acute bronchitis by assessing for tachycardia (>100 bpm), tachypnea (>24 breaths/min), fever (>38°C), and asymmetric lung findings on examination. 2, 5
- Chest radiography is not indicated in healthy, nonelderly adults without vital sign abnormalities or asymmetric lung sounds. 2
- Purulent (green or yellow) sputum does not indicate bacterial infection—it results from inflammatory cells and sloughed epithelial cells, not bacteria. 3, 4
Symptomatic Treatment for Acute Bronchitis
- Short-acting β-agonists (albuterol) should be offered to patients with wheezing or evidence of bronchial hyperresponsiveness to reduce cough duration and severity. 1, 2, 6
- Ipratropium bromide may improve cough in some patients. 2, 3, 6
- Dextromethorphan or codeine are recommended for short-term symptomatic relief of bothersome cough, though evidence shows limited benefit for cough lasting less than 3 weeks. 1, 2
- Expectorants and mucolytics lack evidence of benefit and should not be used. 2, 3, 6
Patient Communication Strategy
- Set realistic expectations: cough typically lasts 10-14 days after the visit, sometimes up to 3 weeks. 1, 3, 5
- Refer to the illness as a "chest cold" rather than "bronchitis" to reduce patient expectations for antibiotics. 1, 3
- Explain that patient satisfaction depends on quality communication and time spent, not antibiotic prescribing. 1, 3
- Personalize antibiotic risks: previous use increases carriage of resistant bacteria, common side effects occur, and rare serious reactions like anaphylaxis can happen. 1
Chronic Bronchitis: Avoidance and Bronchodilators
The cornerstone of chronic bronchitis treatment is complete avoidance of respiratory irritants, particularly smoking cessation, which resolves cough in 90% of patients. 1, 2, 6 Chronic bronchitis is defined as cough with sputum production on most days for at least 3 months per year for 2 consecutive years. 1, 2, 3
Pharmacologic Management for Stable Chronic Bronchitis
- Short-acting β-agonists should be used to control bronchospasm and may reduce chronic cough. 1, 2
- Ipratropium bromide should be offered to improve cough. 1, 2
- Long-acting β-agonists combined with inhaled corticosteroids should be offered to control chronic cough. 1, 2, 6
- Inhaled corticosteroids should be offered to patients with FEV1 <50% predicted or those with frequent exacerbations (≥4 per year). 1, 3, 6
- Theophylline may be considered but requires careful monitoring for complications. 1
What NOT to Use in Stable Chronic Bronchitis
- Prophylactic antibiotics are not recommended. 1, 6
- Oral corticosteroids have no proven benefit in stable disease. 1
- Expectorants lack evidence of effectiveness. 1, 6
- Postural drainage and chest physiotherapy are not beneficial. 1
Acute Exacerbations of Chronic Bronchitis: When Antibiotics ARE Indicated
Antibiotics are recommended for acute exacerbations of chronic bronchitis, particularly in patients with severe exacerbations or baseline airflow obstruction. 2, 6, 7 An acute exacerbation is characterized by sudden worsening with increased dyspnea, increased sputum volume, and/or increased sputum purulence. 1
Identifying Patients Who Need Antibiotics
The Anthonisen criteria guide antibiotic decisions: antibiotics should be given when at least 2 of these 3 cardinal symptoms are present: 1
- Increased dyspnea
- Increased sputum volume
- Increased sputum purulence
Additional high-risk features warranting antibiotics include: 1, 8
- Age ≥65 years
- FEV1 <50% predicted (moderate to severe obstruction)
- ≥4 exacerbations in the past 12 months
- Presence of comorbidities (cardiac disease, diabetes)
Antibiotic Selection Strategy
For infrequent exacerbations (<3 per year) with FEV1 >35%: 1
- First-line: Amoxicillin or first-generation cephalosporins
- Alternatives: Macrolides (azithromycin, clarithromycin), doxycycline, or pristinamycin (especially for β-lactam allergy)
For frequent exacerbations (≥4 per year) or FEV1 <35%: 1, 9
- Second-line agents: Extended-spectrum cephalosporins, amoxicillin/clavulanate, or respiratory fluoroquinolones
- These target resistant organisms including β-lactamase producing H. influenzae and M. catarrhalis
Azithromycin dosing for acute exacerbations: 500 mg once daily for 3 days achieves 85% clinical cure rate at day 21-24. 7
Additional Treatments for Acute Exacerbations
- Short-acting β-agonists or anticholinergic bronchodilators should be administered immediately; if no prompt response, add the other agent. 1, 2, 6
- Systemic corticosteroids (oral or IV in severe cases) for 10-15 days are effective and should be used. 1, 2, 6
- Theophylline should NOT be used for acute exacerbations. 1, 3, 6
Critical Pitfalls to Avoid
- Do not prescribe antibiotics based solely on colored sputum—this is inflammatory debris, not bacterial infection. 2, 3
- Do not confuse acute bronchitis with pneumonia—check vital signs and lung examination carefully. 2, 3
- Do not use expectorants, mucolytics, or antihistamines—they lack evidence of benefit. 2, 3
- Do not overlook underlying conditions (asthma, COPD, heart failure, diabetes) that may be exacerbated by bronchitis. 2, 3
- Do not use theophylline for acute exacerbations of chronic bronchitis despite its potential role in stable disease. 1, 3, 6