What is the recommended treatment approach for acute bronchitis?

Treatment of Acute Bronchitis

Antibiotics should NOT be routinely 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

Understanding the Disease

• Acute bronchitis is primarily a viral infection (89-95% of cases), with fewer than 10% having bacterial causes 1, 2
• Common viral pathogens include influenza, rhinovirus, coronavirus, adenovirus, parainfluenza, and respiratory syncytial virus 3, 2
• The only established non-viral causes are Bordetella pertussis, Mycoplasma pneumoniae, and Chlamydophila pneumoniae, accounting for only 5-10% of cases 3
• Critical pitfall: Purulent (green/yellow) sputum does NOT indicate bacterial infection—it results from inflammatory cells and sloughed epithelial cells, occurring in 89-95% of viral cases 1, 4, 2

Rule Out Pneumonia First

Before diagnosing acute bronchitis, exclude pneumonia by checking 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, tactile fremitus) 1

If any of these are present, obtain chest radiography to rule out pneumonia 1, 5

Antibiotic Recommendations

Do NOT Prescribe Antibiotics For:

• Uncomplicated acute bronchitis, regardless of cough duration 3, 1
• Presence of purulent sputum or sputum color change 1, 2
• Patient expectation or demand for antibiotics 1
• Cough lasting up to 3 weeks (this is the normal course) 1, 6

Evidence Against Antibiotics:

• Multiple randomized controlled trials show no consistent impact on duration or severity of illness 3
• Meta-analyses demonstrate antibiotics reduce cough by only 0.5 days (RR 1.07; 95% CI, 0.99-1.15) 1, 2
• Adverse events are significantly increased with antibiotics (RR 1.20; 95% CI, 1.05-1.36) compared to placebo 1
• The FDA removed uncomplicated acute bronchitis as an indication for antibiotic therapy in 1998 3

The ONE Exception—Pertussis:

• For confirmed or suspected pertussis (whooping cough), prescribe a macrolide antibiotic such as erythromycin or azithromycin 1, 2
• Isolate patients for 5 days from the start of treatment 1, 2
• Early treatment within the first few weeks diminishes coughing paroxysms and prevents disease spread 1, 2
• Suspect pertussis when cough persists >2 weeks with paroxysmal cough, whooping, post-tussive emesis, or known exposure 5

High-Risk Patients (Consider Antibiotics Cautiously):

• Patients aged ≥75 years with fever 1, 4
• Cardiac failure 1, 4
• Insulin-dependent diabetes 1
• Immunocompromised patients 1
• If antibiotics are used in high-risk patients, prescribe amoxicillin 500 mg three times daily for 5-8 days 1

Symptomatic Treatment

Bronchodilators:

• β2-agonist bronchodilators (albuterol) should NOT be routinely used for cough in most patients with acute bronchitis 1, 2
• Consider albuterol only in select adult patients with wheezing accompanying the cough 1, 4
• Albuterol may reduce cough duration in patients with evidence of bronchial hyperresponsiveness 4

Cough Suppressants:

• Codeine or dextromethorphan may provide modest relief for dry, bothersome cough, especially when sleep is disturbed 1, 2
• These agents offer short-term symptomatic relief but do not alter disease course 4, 2

What NOT to Use:

• Avoid expectorants, mucolytics, antihistamines, inhaled corticosteroids, oral corticosteroids, and NSAIDs at anti-inflammatory doses—no consistent evidence of benefit 1, 4

Antiviral Therapy:

• Consider antiviral medications (oseltamivir, zanamivir) for influenza-related bronchitis only if within 48 hours of symptom onset 1, 2

Patient Education Strategy

Set Realistic Expectations:

• Inform patients that cough typically lasts 10-14 days after the office visit, even with treatment 1, 4, 2
• Explain that symptoms may persist for 2-3 weeks total 1, 6

Communication Techniques to Reduce Antibiotic Demand:

• Refer to the condition as a "chest cold" rather than "bronchitis" to reduce antibiotic expectations 1, 4, 2
• Emphasize that patient satisfaction depends more on physician-patient communication quality than on receiving antibiotics 1, 4, 2
• Discuss the risks of unnecessary antibiotic use: adverse effects (nausea, vomiting, allergic reactions, C. difficile infection) and contribution to antibiotic resistance 1, 4, 2

Delayed Prescription Strategy:

• Consider providing a delayed antibiotic prescription with instructions to fill only if symptoms worsen or persist beyond 10-14 days 6, 5

Common Pitfalls to Avoid

• Do not prescribe antibiotics based on sputum color or purulence alone—this occurs in viral infections 1, 2
• Do not assume bacterial infection based on cough duration—viral bronchitis cough normally lasts 10-14 days 1, 2
• Do not use fever <3 days as an indication for antibiotics—most cases are viral 1
• Do not fail to distinguish between acute bronchitis and pneumonia—always check vital signs and lung examination 1, 4
• Remember these guidelines may not apply to elderly patients or those with COPD, heart failure, or immunosuppression—use clinical judgment for these populations 1, 2