Treatment of Bronchitis
Acute Bronchitis: Antibiotics Are Not Indicated
For uncomplicated acute bronchitis, do not prescribe antibiotics regardless of cough duration or sputum color—this is the single most important recommendation. 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 significant harm including allergic reactions, gastrointestinal symptoms, and promoting antibiotic resistance. 4, 5
Symptomatic Management of Acute Bronchitis
Short-acting β-agonists (albuterol) should be offered to patients with evidence of bronchial hyperresponsiveness such as wheezing or prolonged bothersome cough, as they reduce cough duration and severity. 2, 3, 6
Ipratropium bromide may improve cough in some patients with acute bronchitis. 2, 3, 6
Dextromethorphan or codeine are recommended for short-term symptomatic relief of bothersome cough, though evidence shows they work better for chronic cough (>3 weeks) than early acute cough. 1, 2, 3
Expectorants and mucolytics have no proven benefit and should not be used. 2, 3, 6
Patient Communication Strategy
Set realistic expectations by explaining that cough typically lasts 10-14 days after the visit. 1, 3 Refer to the illness as a "chest cold" rather than "bronchitis"—this terminology reduces patient expectation for antibiotics. 1, 3 Emphasize that patient satisfaction depends on quality communication, not antibiotic prescribing. 1, 3
Chronic Bronchitis: Avoidance of Irritants is Cornerstone
Smoking cessation is the most effective intervention for chronic bronchitis, with 90% of patients experiencing cough resolution after quitting. 2, 3, 6 Remove all respiratory irritants including passive smoke and workplace/environmental pollutants. 1
Maintenance Therapy for Stable Chronic Bronchitis
Short-acting β-agonists should be used to control bronchospasm, relieve dyspnea, and may reduce chronic cough. 1, 2, 3, 6
Ipratropium bromide should be offered to improve cough and reduce sputum volume. 1, 2, 3, 6
Long-acting β-agonists combined with inhaled corticosteroids should be offered to control chronic cough. 1, 2, 3, 6
Inhaled corticosteroids alone should be offered to patients with FEV1 <50% predicted or those with frequent exacerbations (≥4 per year). 1, 6
Theophylline may be considered to control chronic cough but requires careful monitoring for complications. 1
What NOT to Use in Stable Chronic Bronchitis
- Long-term prophylactic antibiotics are not recommended. 1, 6
- Oral corticosteroids have no proven benefit and high risk of side effects. 3
- Expectorants, postural drainage, and chest physiotherapy have no proven benefit. 1, 6
Acute Exacerbations of Chronic Bronchitis: The Anthonisen Criteria Matter
When to Treat with Antibiotics
Antibiotics are recommended for acute exacerbations when at least 2 of the 3 Anthonisen criteria are present: increased dyspnea, increased sputum volume, and increased sputum purulence. 1 Antibiotics are particularly important for patients with severe exacerbations and baseline FEV1 <50%. 2, 6, 7
The French guidelines provide a more nuanced approach based on disease severity:
Simple chronic bronchitis (FEV1 >80%, no dyspnea): Antibiotics NOT recommended initially; only if fever >38°C persists beyond 3 days. 1
Obstructive chronic bronchitis (FEV1 35-80%, exertional dyspnea): Antibiotics recommended immediately if ≥2 Anthonisen criteria present. 1
Severe obstructive chronic bronchitis with respiratory insufficiency (FEV1 <35%, dyspnea at rest, hypoxemia): Antibiotics recommended immediately. 1
Antibiotic Selection
First-line antibiotics (for infrequent exacerbations <3/year, FEV1 ≥35%): Amoxicillin remains the reference; alternatives include first-generation cephalosporins, macrolides, or doxycycline. 1
Second-line antibiotics (for frequent exacerbations ≥4/year or FEV1 <35%): Use amoxicillin/clavulanate, respiratory fluoroquinolones, or extended-spectrum agents. 1, 8
Azithromycin 500mg daily for 3 days showed 85% clinical cure rate at day 21-24 for acute exacerbations, comparable to 10 days of clarithromycin. 7
Bronchodilators and Corticosteroids for Exacerbations
Short-acting β-agonists or anticholinergic bronchodilators should be administered immediately; if no prompt response, add the other agent. 1, 2, 3, 6
Systemic corticosteroids (10-15 day course) are effective for acute exacerbations and should be given. 2, 6
Theophylline should NOT be used for acute exacerbations. 1, 6
Critical Pitfalls to Avoid
Do not prescribe antibiotics based solely on colored/purulent sputum—this reflects inflammatory cells, not bacterial infection. 2, 3
Rule out pneumonia before diagnosing bronchitis by assessing for tachycardia, tachypnea, fever >100.4°F, and focal lung findings; obtain chest X-ray if any are present. 2, 3, 5
Consider pertussis if cough persists >2 weeks with paroxysmal features, whooping, or post-tussive emesis. 5
Recognize congestive heart failure as a mimic of chronic bronchitis exacerbation, especially in patients with known cardiac disease. 9
Do not overlook high-risk populations where antibiotics may be considered for acute bronchitis: age ≥75 years with fever, or patients with cardiac failure. 3