What is the treatment for acute bronchitis?

Treatment for 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

Initial Assessment and Diagnosis

Before diagnosing acute bronchitis, rule out pneumonia by evaluating 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

Acute bronchitis is characterized by cough with or without phlegm production lasting up to 3 weeks, with normal chest radiograph findings. 1 Respiratory viruses cause 89-95% of cases, with fewer than 10% having bacterial infections. 1

Primary Treatment Approach: Symptomatic Management

What NOT to Prescribe

• Antibiotics are NOT indicated for uncomplicated acute bronchitis, regardless of purulent sputum or cough duration 1, 2
• Purulent sputum does NOT signify bacterial infection and is present in 89-95% of viral cases 1
• β2-agonist bronchodilators should NOT be routinely used for cough in most patients 1
• NSAIDs at anti-inflammatory doses should not be used 1
• Systemic corticosteroids should not be used 1
• Expectorants, mucolytics, and antihistamines lack evidence of benefit 3

Symptomatic Treatment Options

For patients with bothersome cough:

• Codeine or dextromethorphan may provide modest effects on severity and duration of cough 1
• β2-agonist bronchodilators (such as albuterol) may be useful in select adult patients with wheezing accompanying the cough 1
• Low-cost interventions: Elimination of environmental cough triggers and vaporized air treatments 1

Exception: Pertussis (Whooping Cough)

For confirmed or suspected pertussis, prescribe a macrolide antibiotic (such as erythromycin or azithromycin). 1

• Isolate patients for 5 days from the start of treatment 1
• Early treatment within the first few weeks diminishes coughing paroxysms and prevents disease spread 1

High-Risk Patients Requiring Special Consideration

Consider antibiotics ONLY in high-risk patients with significant comorbidities:

• Age ≥75 years with fever 1, 3
• Cardiac failure 1, 3
• Insulin-dependent diabetes 1
• Immunosuppression 1
• Serious neurological disorders 1

When to Consider Antibiotics in High-Risk Patients

If fever >38°C persists beyond 3 days, this strongly suggests bacterial superinfection rather than viral bronchitis and warrants treatment. 1

For high-risk patients meeting criteria, recommended regimens include:

• Doxycycline 100 mg twice daily for 7-10 days (first-line for moderate severity) 1
• High-dose amoxicillin/clavulanate 625 mg three times daily for 14 days (for severe exacerbations) 1
• Amoxicillin 500 mg three times daily for 5-8 days (when bacterial infection is confirmed) 1

Patient Education and Communication

Inform patients that cough typically lasts 10-14 days after the office visit, even without antibiotics. 1

Key communication strategies:

• Refer to the condition as a "chest cold" rather than bronchitis to reduce antibiotic expectations 1
• Explain that patient satisfaction depends more on physician-patient communication than whether an antibiotic is prescribed 1
• Discuss the risks of unnecessary antibiotic use, including side effects and contribution to antibiotic resistance 1

Critical Pitfalls to Avoid

• Do NOT prescribe antibiotics based solely on purulent sputum color or presence, as this occurs in 89-95% of viral cases 1
• Do NOT assume bacterial infection based on cough duration alone, as viral bronchitis cough normally lasts 10-14 days 1
• Do NOT prescribe antibiotics before the 3-day fever threshold, as most cases are viral 1
• Always rule out pneumonia first by checking vital signs and lung examination for focal findings 1

Distinguishing Acute Bronchitis from Chronic Bronchitis Exacerbation

This guidance applies to acute bronchitis in otherwise healthy patients. 1 For patients with chronic bronchitis (defined as productive cough on most days for at least 3 months over 2 consecutive years), different management applies, including consideration of antibiotics for acute exacerbations with purulent sputum and increased dyspnea. 4, 5