Treatment of Acute Bronchitis
Primary Recommendation
Antibiotics should not be prescribed for acute bronchitis in otherwise healthy patients, 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
Diagnostic Exclusions Before Treatment
Before diagnosing uncomplicated acute bronchitis, rule out pneumonia by assessing for:
- Tachycardia (heart rate >100 beats/min) 1
- Tachypnea (respiratory rate >24 breaths/min) 1
- Fever (oral temperature >38°C) 1
- Abnormal chest examination findings (rales, egophony, or tactile fremitus) 1
Also exclude asthma exacerbation, COPD exacerbation, and pertussis before proceeding with symptomatic management. 1
Why Antibiotics Are Not Indicated
- Viral etiology dominates: Respiratory viruses cause 89-95% of acute bronchitis cases, with fewer than 10% having bacterial infections. 1, 4
- Purulent sputum is NOT an indication for antibiotics: Color change results from inflammatory cells or sloughed epithelial cells, not bacterial infection. 1, 2
- Minimal clinical benefit: Antibiotics reduce cough duration by approximately 0.5 days (RR 1.07; 95% CI, 0.99-1.15) while significantly increasing adverse events (RR 1.20; 95% CI, 1.05-1.36). 1, 3
Symptomatic Treatment Approach
What TO Use:
- Cough suppressants for bothersome dry cough: Codeine or dextromethorphan provide modest effects on severity and duration of cough, particularly when sleep is disturbed. 1, 2
- β2-agonist bronchodilators ONLY if wheezing is present: Short-acting β-agonists like albuterol may reduce cough duration and severity in patients with bronchial hyperresponsiveness or wheezing. 1, 2
- Low-cost environmental measures: Eliminate cough triggers and use vaporized air treatments. 1
What NOT to Use:
- Do NOT routinely prescribe β2-agonists in patients without wheezing. 1, 2
- Do NOT prescribe: Expectorants, mucolytics, antihistamines, inhaled corticosteroids, systemic corticosteroids, or NSAIDs at anti-inflammatory doses—these lack consistent evidence for benefit. 1, 2, 3
Exception: Pertussis (Whooping Cough)
If pertussis is confirmed or suspected, prescribe a macrolide antibiotic (erythromycin or azithromycin). 1, 5
- Isolate the patient for 5 days from the start of treatment to prevent disease spread. 1
- Early treatment (within the first few weeks) diminishes coughing paroxysms and prevents transmission. 1
High-Risk Patients Requiring Special Consideration
Consider antibiotics ONLY in high-risk patients with significant comorbidities:
For these patients, if antibiotics are warranted, use:
- Doxycycline 100 mg twice daily for 7-10 days as first-line for moderate exacerbations 1
- Amoxicillin/clavulanate 625 mg three times daily for 14 days for severe exacerbations 1
Critical pitfall: Up to 25% of H. influenzae and 50-70% of M. catarrhalis produce β-lactamase, making simple aminopenicillins ineffective. 1
Patient Education Strategy
Set realistic expectations to reduce antibiotic demand:
- Inform patients that cough typically lasts 10-14 days after the office visit, and may persist up 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 that patient satisfaction depends more on physician-patient communication than on receiving antibiotics. 1, 2, 6
- Discuss the risks of unnecessary antibiotic use, including side effects and contribution to antibiotic resistance. 1, 2
Common Pitfalls to Avoid
- Do NOT prescribe antibiotics based solely on colored sputum. 1, 2
- Do NOT fail to distinguish between acute bronchitis and pneumonia—check vital signs and perform chest examination. 1, 2
- Do NOT overuse expectorants, mucolytics, and antihistamines, which lack evidence of benefit. 1, 2
- Do NOT ignore underlying conditions (asthma, COPD, cardiac failure, diabetes) that may be exacerbated by bronchitis. 2