Treatment of Bronchitis
For immunocompetent adults with acute bronchitis, antibiotics should NOT be routinely prescribed, as they provide minimal benefit and contribute to antibiotic resistance; treatment should focus on symptomatic management with cough suppressants only when cough is dry and bothersome. 1
Acute Bronchitis in Otherwise Healthy Adults
Antibiotic Therapy: NOT Recommended
Antibiotics are not indicated for uncomplicated acute bronchitis in immunocompetent adults, as the condition is viral in over 90% of cases and antibiotics show no meaningful clinical benefit. 1, 2
The 2020 CHEST guidelines explicitly recommend against routine prescription of antibiotic therapy for acute bronchitis. 1
A meta-analysis found antibiotics decreased cough duration by only 0.5 days—a benefit that does not outweigh the risks of side effects and antibiotic resistance. 3
Colored or purulent sputum does NOT indicate bacterial infection and should not trigger antibiotic prescription. 1, 2
When to Consider Antibiotics
Antibiotics should only be considered if:
The acute bronchitis worsens and a complicating bacterial infection is suspected. 1
High-risk patients with specific risk factors are present (see below). 1
Symptomatic Treatment
Cough suppressants (dextromethorphan or codeine) can be prescribed for dry, frequent, bothersome cough, especially when sleep is disturbed. 1, 4
Do NOT prescribe: expectorants, mucolytics, antihistamines, inhaled bronchodilators, inhaled corticosteroids, oral corticosteroids, or NSAIDs for acute bronchitis—these have no proven benefit. 1
Acute Exacerbations of Chronic Bronchitis
Antibiotic Indications
Antibiotics ARE indicated for patients with chronic bronchitis exacerbations who have:
- At least one cardinal symptom: increased dyspnea, increased sputum production, OR increased sputum purulence. 1, 5
AND at least one risk factor:
- Age ≥75 years with fever 1
- Cardiac failure 1
- Insulin-dependent diabetes 1
- Serious neurological disorder 1
- FEV₁ <50% predicted 5
- ≥4 exacerbations in 12 months 5
Antibiotic Selection
Moderate exacerbations: newer macrolide (azithromycin), extended-spectrum cephalosporin, or doxycycline. 5
Severe exacerbations: high-dose amoxicillin/clavulanate or respiratory fluoroquinolone. 5, 6
Azithromycin 500 mg daily for 3 days shows 85% clinical cure rates for acute exacerbations. 7
Bronchodilator Therapy
Short-acting β-agonists OR anticholinergic bronchodilators should be administered during acute exacerbations; if no prompt response, add the other agent. 1
Ipratropium bromide is first-line for stable chronic bronchitis to reduce cough frequency, severity, and sputum volume. 1, 4
Theophylline should NOT be used during acute exacerbations due to lack of benefit and risk of side effects. 1
Corticosteroid Therapy
Systemic corticosteroids (oral or IV) should be given for 10-15 days during acute exacerbations of chronic bronchitis. 1
Inhaled corticosteroids are recommended only when FEV₁ <50% or with frequent exacerbations, preferably combined with a long-acting β-agonist. 1
Long-term oral corticosteroids should be avoided in stable chronic bronchitis due to lack of benefit and high risk of serious side effects. 1, 4
Common Pitfalls to Avoid
Do not prescribe antibiotics based on sputum color alone—this does not reliably indicate bacterial infection. 1, 2
Do not use expectorants or mucolytics—they have no proven efficacy and waste resources. 1, 4
Do not confuse acute bronchitis with pneumonia, asthma exacerbation, or COPD exacerbation—these require different management. 1, 2
Consider temporarily adjusting chronic medications (for asthma, COPD, cardiac failure, diabetes) when patients with these conditions develop acute respiratory infections. 1
Reassess patients whose cough persists beyond 3 weeks—consider alternative diagnoses. 1