Treatment for Bronchitis
Do NOT Use Antibiotics for Uncomplicated Acute Bronchitis
Antibiotics should not be prescribed for uncomplicated acute bronchitis, regardless of cough duration or presence of colored sputum, 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
First-Line Treatment: Symptomatic Management
Bronchodilators (Albuterol)
- Albuterol (short-acting β-agonist) is the first-line symptomatic treatment for immunocompetent adults with acute bronchitis, particularly those with wheezing or evidence of bronchial hyperresponsiveness 2, 4
- Approximately 50% fewer patients report cough after 7 days when treated with albuterol 2
- FDA-approved for relief of bronchospasm in patients 2 years and older with reversible obstructive airway disease 4
Cough Suppressants
- Dextromethorphan or codeine provide modest effects on cough severity and duration, particularly for dry, bothersome cough that disturbs sleep 2, 3, 5
- These agents are reasonable for short-term symptomatic relief 2, 5
Low-Risk Interventions
- Eliminate environmental cough triggers (smoking, irritants) 2, 3
- Vaporized air treatments or humidification 2, 3
What NOT to Use
- NSAIDs at anti-inflammatory doses - no evidence of benefit 3
- Systemic corticosteroids - not indicated for acute bronchitis 3
- Expectorants or mucolytics - lack consistent evidence 3, 5
- Antihistamines - not effective 3
- Inhaled corticosteroids - not indicated 3
When to Consider Antibiotics: Specific Exceptions
Pertussis (Whooping Cough)
- Prescribe a macrolide antibiotic (erythromycin or azithromycin) if pertussis is confirmed or suspected 1, 3
- Isolate patient for 5 days from start of treatment 3
- Early treatment within first few weeks diminishes coughing paroxysms and prevents disease spread 3
High-Risk Patients with Bacterial Superinfection
Consider antibiotics ONLY if patient meets ALL of the following:
- Fever >38°C persisting beyond 3 days (strongly suggests bacterial superinfection) 3
- At least one Anthonisen criterion: increased dyspnea, increased sputum volume, or increased sputum purulence 3, 6
- At least one risk factor: age ≥65 years, FEV1 <50% predicted, ≥4 exacerbations in 12 months, or significant comorbidities (cardiac failure, insulin-dependent diabetes, immunosuppression) 3, 6
Recommended antibiotic regimens for high-risk patients:
- Moderate severity: Doxycycline 100 mg twice daily for 7-10 days, OR newer macrolide, OR extended-spectrum cephalosporin 3, 6
- Severe exacerbations: High-dose amoxicillin/clavulanate 625 mg three times daily for 14 days, OR respiratory fluoroquinolone 3, 6
Critical Diagnostic Considerations
Rule Out Pneumonia First
Check for these findings that suggest pneumonia rather than bronchitis:
- Tachycardia (heart rate >100 bpm) 3
- Tachypnea (respiratory rate >24 breaths/min) 3
- Fever (oral temperature >38°C) 3
- Abnormal chest examination (rales, egophony, tactile fremitus) 3
- Chest radiography usually NOT needed in healthy adults without these findings 1, 5
Duration of Symptoms
- Inform patients that cough typically lasts 10-14 days after the visit, even with treatment 2, 3
- Cough may persist up to 3 weeks in uncomplicated cases 3, 7
- Consider chest radiography if cough persists beyond 3 weeks without other known cause 1
Common Pitfalls to Avoid
- Purulent or colored sputum occurs in 89-95% of VIRAL bronchitis cases and does NOT indicate bacterial infection or need for antibiotics 3, 7
- Do not prescribe antibiotics based on cough duration alone - viral bronchitis cough normally lasts 10-14 days 3
- Do not assume bacterial infection before the 3-day fever threshold - most cases are viral 3
- Patient satisfaction depends more on physician-patient communication than whether antibiotics are prescribed 1, 2, 8
- Consider referring to the condition as a "chest cold" rather than "bronchitis" to reduce patient expectations for antibiotics 3
Chronic Bronchitis Management (Different Approach)
For patients with chronic bronchitis (cough with sputum production on most days for ≥3 months over 2 consecutive years):
- Smoking cessation is cornerstone - 90% experience resolution of cough after quitting 5
- Short-acting β-agonists for bronchospasm control 5
- Ipratropium bromide to improve cough 5
- Long-acting β-agonists combined with inhaled corticosteroids for chronic cough control 5
Acute exacerbations of chronic bronchitis require different management with antibiotics and short course of systemic corticosteroids (10-15 days) 5, 6