Treatment of Acute Bronchitis
Do not prescribe antibiotics for uncomplicated acute bronchitis—they provide minimal benefit (reducing cough by only half a day) while causing adverse effects and promoting antibiotic resistance. 1, 2
Initial Assessment and Diagnosis
Rule out pneumonia first by checking for these red flags 2, 3:
- Heart rate >100 beats/min
- Respiratory rate >24 breaths/min
- Fever (oral temperature >38°C)
- Abnormal chest examination findings (rales, egophony, tactile fremitus)
If all four are absent, pneumonia is unlikely and chest X-ray is not needed. 3
Key diagnostic points:
- Acute bronchitis is viral in 89-95% of cases 2
- Purulent or colored sputum does NOT indicate bacterial infection—it occurs in 89-95% of viral cases 2
- Cough typically lasts 10-14 days after the visit, even with treatment 1, 2
First-Line Symptomatic Treatment
Albuterol (short-acting β-agonist) is the primary treatment for patients with bothersome cough 1:
- Reduces duration and severity of cough consistently in randomized trials
- Approximately 50% fewer patients report cough after 7 days of treatment 1
- Most beneficial in patients with wheezing or clinical evidence of bronchial hyperresponsiveness 4, 2
For dry, bothersome cough without wheezing:
- Dextromethorphan or codeine may provide modest relief 4, 2, 3
- These agents work better for chronic cough (>3 weeks) than early acute cough 4
Additional supportive measures 4, 1:
- Eliminate environmental cough triggers (dust, dander)
- Humidified air treatments, especially in low-humidity environments
When to Consider Antibiotics
Antibiotics are indicated ONLY in these specific situations:
Confirmed or Suspected Pertussis
- Prescribe a macrolide antibiotic (azithromycin or erythromycin) 2
- Isolate patient for 5 days from start of treatment 2
- Early treatment within first few weeks diminishes coughing paroxysms and prevents spread 2
High-Risk Patients with Bacterial Superinfection
Consider antibiotics if fever persists >3 days AND patient has 2:
- Age >75 years
- Cardiac failure
- Insulin-dependent diabetes
- Immunosuppression
- Serious neurological disorders
If antibiotics are warranted, use: 2
- Amoxicillin 500 mg three times daily for 5-8 days, OR
- Doxycycline 100 mg twice daily for 7-10 days, OR
- Azithromycin 500 mg daily for 3 days 5
Critical Pitfalls to Avoid
Do NOT prescribe antibiotics based on: 2
- Purulent or green sputum color (present in 89-95% of viral cases)
- Duration of cough alone (viral bronchitis cough normally lasts 10-14 days)
- Patient expectation for antibiotics
Do NOT assume bacterial infection unless fever persists beyond 3 days 2
Do NOT use these ineffective treatments: 2
- Expectorants or mucolytics
- Antihistamines (except first-generation with decongestant for common cold symptoms)
- Inhaled corticosteroids
- NSAIDs at anti-inflammatory doses
Patient Communication Strategy
Patient satisfaction depends on communication, not antibiotic prescribing 4, 1, 2:
- Explain that bronchitis is viral and antibiotics won't help
- Set realistic expectations: cough will last 10-14 days
- Refer to the condition as a "chest cold" rather than "bronchitis" to reduce antibiotic expectations 2
- Discuss risks of unnecessary antibiotics: adverse effects, allergic reactions, C. difficile infection, antibiotic resistance 2, 6
Special Consideration: Influenza
If influenza is suspected during documented outbreaks 4:
- Antiviral agents (neuraminidase inhibitors or rimantadine) are effective only if started within 48 hours (preferably <30 hours) of symptom onset
- Clinical diagnosis during outbreaks has ~70% accuracy 4
Chronic Bronchitis (Different Management)
If patient has chronic bronchitis (daily expectoration for ≥3 months during ≥2 consecutive years) 3: