What is the plan of care for an otherwise healthy adult with acute bronchitis and no significant medical history?

Plan of Care for Acute Bronchitis

Antibiotics should NOT be prescribed for uncomplicated acute bronchitis in otherwise healthy adults, 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 Evaluation: Rule Out Serious Illness

The primary goal is to exclude pneumonia and other serious conditions before confirming acute bronchitis. 1

Key clinical indicators that suggest pneumonia rather than bronchitis:

• Heart rate >100 beats/min 2
• Respiratory rate >24 breaths/min 2
• Oral temperature >38°C 2
• Abnormal lung examination findings (rales, egophony, tactile fremitus, or asymmetrical lung sounds) 1, 2

When chest radiography is indicated:

• If any vital sign abnormalities or focal lung findings are present 1
• If cough persists ≥3 weeks without other known causes 1
• In healthy, nonelderly adults without these findings, chest radiography is usually not indicated 1

Other diagnoses to exclude:

• Common cold (predominantly upper respiratory symptoms) 1
• Asthma exacerbation (wheezing, history of asthma) 1, 2
• COPD exacerbation (in patients with known COPD) 1, 2

Antibiotic Treatment: When NOT to Prescribe

The evidence is unequivocal: routine antibiotic treatment is not recommended regardless of cough duration. 1, 2

Critical points about antibiotics:

• Respiratory viruses cause 89-95% of acute bronchitis cases 2
• Purulent sputum occurs in 89-95% of viral cases and does NOT indicate bacterial infection 2
• Sputum color change is NOT an indication for antibiotics 2
• Antibiotics reduce cough duration by only approximately 0.5 days 2, 3
• Antibiotics cause adverse effects including allergic reactions, nausea, vomiting, and Clostridium difficile infection 3

The ONE Exception: Pertussis

If pertussis is suspected or confirmed, prescribe a macrolide antibiotic immediately. 1, 2

Pertussis should be suspected when:

• Cough persists >2 weeks with paroxysmal coughing, whooping cough, or post-tussive vomiting 2
• Recent pertussis exposure is documented 1

Treatment for pertussis:

• Prescribe erythromycin or azithromycin 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

Symptomatic Treatment Recommendations

Bronchodilators:

• β2-agonist bronchodilators should NOT be routinely used for cough in acute bronchitis 2
• Consider β2-agonists only in select patients with wheezing accompanying the cough 2

Cough suppressants:

• Codeine or dextromethorphan may provide modest effects on cough severity and duration 2
• These agents are most useful when dry cough is bothersome and disturbs sleep 2

What NOT to prescribe:

• Oral corticosteroids (including prednisone) are NOT recommended for uncomplicated acute bronchitis 4
• NSAIDs at anti-inflammatory doses are NOT recommended 2
• Expectorants, mucolytics, antihistamines, or inhaled corticosteroids lack evidence of benefit 2

Low-risk supportive measures:

• Elimination of environmental cough triggers (smoke, irritants) 2
• Vaporized air treatments or humidification 2
• Adequate hydration 2

Patient Education: The Key to Satisfaction

Patient satisfaction depends more on physician-patient communication than whether an antibiotic is prescribed. 1, 2

Essential points to communicate:

• Cough typically lasts 10-14 days after the office visit, even without antibiotics 2, 3
• The condition is self-limiting and resolves within 3 weeks 1, 2
• Antibiotics will not significantly shorten the illness and carry risks 2, 3
• Referring to the condition as a "chest cold" rather than "bronchitis" may reduce patient expectations for antibiotics 2, 3

When to Reassess

Instruct patients to return if:

• Fever persists >3 days (suggests bacterial superinfection or pneumonia) 2
• Cough persists >3 weeks (consider asthma, COPD, pertussis, or gastroesophageal reflux) 1, 2
• Symptoms worsen rather than gradually improve 2

Special Populations Requiring Different Management

These guidelines apply ONLY to otherwise healthy adults with uncomplicated acute bronchitis. 1

Patients requiring individualized management:

• Underlying COPD or chronic bronchitis 1, 2
• Congestive heart failure 1
• Immunosuppression (AIDS, chemotherapy) 1, 2
• Elderly patients (≥75 years) with comorbidities 2

Common Pitfalls to Avoid

• Do not assume purulent sputum indicates bacterial infection – it occurs in 89-95% of viral cases 2
• Do not prescribe antibiotics based on cough duration alone – viral bronchitis cough normally lasts 10-14 days 2
• Do not miss undiagnosed asthma – approximately one-third of patients diagnosed with recurrent "acute bronchitis" actually have asthma 1, 2
• Do not prescribe antibiotics over the phone – physical examination is essential to rule out pneumonia 5