Treatment of Acute Bronchitis
Do not prescribe antibiotics for acute bronchitis in otherwise healthy adults—this is a viral illness that requires only symptomatic management and patient education. 1, 2, 3
Initial Assessment: Rule Out Pneumonia First
Before diagnosing acute bronchitis, evaluate for pneumonia by checking these specific vital signs and examination findings 1, 2, 4:
- Heart rate >100 beats/min (tachycardia)
- Respiratory rate >24 breaths/min (tachypnea)
- Oral temperature >38°C (fever)
- Chest examination findings: focal consolidation, egophony, or fremitus
If all four findings are absent, pneumonia is unlikely and chest x-ray is not needed. 1
What NOT to Do (Critical Pitfalls)
Antibiotics provide no meaningful benefit in uncomplicated acute bronchitis—they reduce cough duration by only half a day while causing adverse effects in 20% of patients (nausea, vomiting, diarrhea, allergic reactions, C. difficile infection). 2, 4, 5
Do not be misled by purulent sputum—this occurs in 89-95% of viral bronchitis cases and does NOT indicate bacterial infection. 2, 3, 6
Avoid these medications that lack evidence of benefit 1, 2, 6:
- Routine antibiotics
- Expectorants or mucolytics
- Antihistamines
- Inhaled corticosteroids
- Oral corticosteroids
- NSAIDs at anti-inflammatory doses
Symptomatic Treatment Options
- Codeine or dextromethorphan may provide modest symptom relief
- These are the only medications with evidence for short-term symptomatic benefit
For patients with wheezing 1, 2, 3:
- β2-agonist bronchodilators (like albuterol) may be useful in select patients with audible wheezing
- Do NOT use routinely in patients without wheezing
Low-risk supportive measures 2:
- Eliminate environmental irritants (smoke, pollutants)
- Humidified air treatments
- Adequate hydration
Patient Education (Essential for Satisfaction)
Set realistic expectations about cough duration 2, 3, 4:
- Cough typically lasts 10-14 days after the office visit
- Some patients may have cough persisting up to 3 weeks
- This is normal and does not indicate bacterial infection
Communication strategies to reduce antibiotic expectations 2, 3, 6:
- Refer to the illness as a "chest cold" rather than "bronchitis"
- Explain that patient satisfaction depends on communication quality, not antibiotic prescribing
- Discuss risks of unnecessary antibiotics: side effects, antibiotic resistance, C. difficile infection
The ONE Exception: Pertussis (Whooping Cough)
Suspect pertussis if 4:
- Cough persisting >2 weeks
- Paroxysmal cough, whooping cough, or post-tussive vomiting
- Recent pertussis exposure
Treatment for confirmed/suspected pertussis 1, 2, 7:
- Macrolide antibiotic (azithromycin or erythromycin)
- Isolate patient for 5 days from start of treatment
- Early treatment (within first few weeks) diminishes coughing paroxysms and prevents spread
When to Consider Antibiotics: High-Risk Patients Only
Reserve antibiotics for high-risk patients with specific criteria 2, 3, 6:
High-risk populations include:
- Age ≥75 years with fever
- Cardiac failure
- Insulin-dependent diabetes
- Immunosuppression
- Serious neurological disorders
AND patient must have worsening symptoms suggesting bacterial superinfection 1, 2:
- Fever >38°C persisting beyond 3 days
- Significantly worsening dyspnea
- Clinical deterioration despite supportive care
If antibiotics are warranted in high-risk patients 2:
- Doxycycline 100 mg twice daily for 7-10 days (first-line for moderate severity)
- High-dose amoxicillin/clavulanate 625 mg three times daily for 14 days (for severe cases)
Reassessment Plan
Advise patients to return if 1, 2:
- Cough persists or worsens beyond 10-14 days
- New fever develops after initial improvement
- Dyspnea worsens significantly
- Any signs of pneumonia develop
At reassessment, consider targeted investigations 1:
- Chest x-ray
- Sputum culture (if bacterial infection suspected)
- Peak flow measurements
- Complete blood count and inflammatory markers (CRP)