What is the recommended management for a patient with acute bronchitis, considering their past medical history, age, and presence of underlying conditions such as asthma or chronic obstructive pulmonary disease (COPD)?

Management of Acute Bronchitis

Antibiotics should not be prescribed for acute bronchitis in otherwise healthy adults, regardless of cough duration or sputum color, 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

Initial Assessment: Rule Out Serious Illness

Before diagnosing acute bronchitis, exclude pneumonia by checking for these findings 1, 2:

• Heart rate >100 beats/min
• Respiratory rate >24 breaths/min
• Oral temperature >38°C
• Focal consolidation, egophony, or fremitus on chest examination

If all four findings are absent, chest radiography is not needed. 1, 2

Consider alternative diagnoses 2, 3:

• Asthma exacerbation (up to one-third of patients diagnosed with acute bronchitis actually have undiagnosed asthma) 2
• COPD exacerbation (requires different management approach)
• Pertussis (if severe paroxysms, whooping sound, or posttussive vomiting present)
• Influenza or COVID-19 (if within appropriate epidemiologic context)

Primary Management: Supportive Care Only

Inform patients that cough typically lasts 10-14 days after the visit, with most symptoms resolving within 3 weeks. 2, 4, 3 This education is critical for patient satisfaction, which depends more on physician-patient communication than antibiotic prescription. 1, 2

Refer to the condition as a "chest cold" rather than "bronchitis" to reduce patient expectations for antibiotics. 2, 4, 3

Symptomatic Treatment Options

For bothersome dry cough, especially disturbing sleep:

• Dextromethorphan or codeine may provide modest relief, reducing cough counts by 40-60% 2, 4, 5, 6
• These are the only symptomatic treatments with evidence of benefit 2

Do NOT routinely prescribe 2, 4:

• β2-agonist bronchodilators (unless wheezing present and asthma suspected)
• Expectorants or mucolytics 2, 7
• Antihistamines 2
• Inhaled or oral corticosteroids 2, 3
• NSAIDs at anti-inflammatory doses 2

When Antibiotics ARE Indicated

Exception #1: Confirmed or Suspected Pertussis

Prescribe a macrolide antibiotic (erythromycin or azithromycin) if pertussis is confirmed or strongly suspected. 1, 2

• Isolate patient for 5 days from start of treatment 2
• Early treatment within first few weeks diminishes coughing paroxysms and prevents disease spread 2

Exception #2: High-Risk Patients with Bacterial Superinfection

Consider antibiotics ONLY if the patient has both 2, 8:

At least one key symptom (Anthonisen criteria):

• Increased dyspnea
• Increased sputum volume
• Increased sputum purulence

AND at least one risk factor:

• Age ≥65 years 2, 8
• FEV1 <50% predicted (COPD patients) 8
• ≥4 exacerbations in past 12 months 8
• Significant comorbidities (cardiac failure, insulin-dependent diabetes, immunosuppression) 2, 8

If antibiotics are warranted in high-risk patients, use: 2

• Moderate severity: Doxycycline 100 mg twice daily for 7-10 days, or newer macrolide
• Severe exacerbation: High-dose amoxicillin/clavulanate 625 mg three times daily for 14 days, or respiratory fluoroquinolone

Management of Patients with Underlying Lung Disease

COPD Patients with Acute Exacerbation

This is NOT uncomplicated acute bronchitis and requires different management 1, 2, 5:

First-line therapy:

• Short-acting β-agonists and anticholinergics (ipratropium bromide 36 μg four times daily) 5
• Short course of systemic corticosteroids (10-15 days) 5

Antibiotics indicated if:

• Patient meets Anthonisen criteria (at least one key symptom) AND has risk factors 2, 5, 8
• Severe airflow obstruction (FEV1 <50%) or frequent exacerbations 5

Asthma Patients

If wheezing is present, consider undiagnosed asthma or asthma exacerbation rather than simple acute bronchitis. 2

• β2-agonist bronchodilators are appropriate in this context 1, 2
• Consider trial of bronchodilator therapy and reassess 2

Critical Pitfalls to Avoid

Do NOT use purulent sputum as indication for antibiotics - it occurs in 89-95% of viral bronchitis cases and does not indicate bacterial infection. 1, 2, 4, 9

Do NOT prescribe antibiotics based on:

• Duration of cough alone 1, 2
• Sputum color or purulence 1, 2, 9
• Patient expectation 1, 2

Avoid simple aminopenicillins - up to 25% of H. influenzae and 50-70% of M. catarrhalis produce β-lactamase, making them ineffective. 2

When to Reassess

Reevaluate if: 2, 4

• Fever persists >3 days (suggests bacterial superinfection or pneumonia)
• Cough persists >3 weeks (consider asthma, COPD, pertussis, GERD, or other diagnoses)
• Symptoms worsen rather than gradually improve