What is the recommended treatment for acute bronchitis?

Treatment of Acute Bronchitis

Antibiotics should not be 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, 3

Antibiotic Use: The Evidence is Clear

• Routine antibiotic treatment is not recommended for uncomplicated acute bronchitis in otherwise healthy patients, regardless of the presence or absence of fever 1, 2
• Multiple systematic reviews demonstrate antibiotics show no difference in clinical improvement compared to placebo (RR 1.07; 95% CI, 0.99-1.15), while adverse events are significantly more frequent (16% vs. 11%) 2
• The presence of purulent sputum or green/yellow sputum color does not indicate bacterial infection—this is due to inflammatory cells and sloughed epithelial cells, not bacteria 1, 2
• Acute bronchitis is viral in 89-95% of cases, with fewer than 10% having bacterial infections 1, 2

The Critical Exception: Pertussis

• For confirmed or suspected pertussis (whooping cough), prescribe a macrolide antibiotic such as erythromycin or azithromycin 4, 1, 2
• Isolate patients for 5 days from the start of treatment 4, 1
• Early treatment within the first few weeks diminishes coughing paroxysms and prevents disease spread 4, 1

Rule Out Pneumonia First

Before diagnosing acute bronchitis, evaluate for pneumonia by checking:

• Heart rate >100 beats/min (tachycardia) 1, 2
• Respiratory rate >24 breaths/min (tachypnea) 1, 2
• Oral temperature >38°C (fever) 1, 2
• Abnormal chest examination findings: rales, egophony, or tactile fremitus 1, 2

If any of these are present, consider pneumonia and obtain chest radiography. 1

Symptomatic Treatment Options

Bronchodilators

• β2-agonist bronchodilators should not be routinely used for cough in most patients with acute bronchitis 4, 1, 2
• Exception: In select adult patients with wheezing accompanying the cough, β2-agonist bronchodilators may be useful 4, 1
• The Cochrane review found no significant benefit on daily cough scores or number of patients still coughing after 7 days in patients without baseline airflow obstruction 4

Cough Suppressants

• Codeine or dextromethorphan may provide modest effects on severity and duration of cough 4, 1, 2
• Both agents can be prescribed in patients with a dry and bothersome cough, especially when nights are disturbed 4

What NOT to Use

• Do not prescribe: expectorants, mucolytics, antihistamines, inhaled corticosteroids, or NSAIDs at anti-inflammatory doses 4, 1
• These agents lack consistent evidence for beneficial effects in acute bronchitis 4

Patient Communication Strategy: The Key to Satisfaction

Patient satisfaction depends more on physician-patient communication than whether an antibiotic is prescribed. 1, 2

Essential Patient Education Points:

• Inform patients that cough typically lasts 10-14 days after the office visit, and may extend to 3 weeks 1, 2, 3
• Refer to the condition as a "chest cold" rather than bronchitis to reduce antibiotic expectations 1, 2, 3
• Explain the risks of unnecessary antibiotic use: side effects, contribution to antibiotic resistance, and lack of benefit 1, 2
• Dedicate office time to explaining why antibiotics are not indicated 1

Low-Risk Symptomatic Measures

• Elimination of environmental cough triggers (smoke, irritants) 1
• Vaporized air treatments or humidification 4, 1
• These low-cost, low-risk actions may provide reasonable symptomatic relief 1

Special Considerations

When to Consider Antibiotics (Rare Exceptions):

• Patients aged >75 years with fever, cardiac failure, insulin-dependent diabetes, or serious neurological disorders 4
• Elderly or immunocompromised patients at high risk for complications 4
• These guidelines do not apply to patients with COPD exacerbations, asthma, congestive heart failure, or immunosuppression 2

Influenza-Related Bronchitis:

• Consider antiviral agents if within 48 hours of symptom onset 1, 2

Common Pitfalls to Avoid

• Do not prescribe antibiotics based on patient expectation alone—many patients expect antibiotics from previous experiences, but satisfaction correlates with communication quality, not prescriptions 1, 2
• Do not interpret purulent sputum as bacterial infection—this is the most common reason for inappropriate antibiotic prescribing 1, 2
• Do not use antibiotics to "prevent complications"—there is no evidence this strategy works in otherwise healthy patients 2, 3