Should antibiotics be used to treat a patient with bronchitis?

Should Antibiotics Be Used for Bronchitis?

No, antibiotics should not be routinely prescribed for acute bronchitis in otherwise healthy adults, as more than 90% of cases are viral and antibiotics provide minimal benefit (reducing cough by only half a day) while exposing patients to adverse effects and contributing to antibiotic resistance. 1, 2

When to Withhold Antibiotics

The vast majority of acute bronchitis cases do not require antibiotics. 1

• Respiratory viruses cause 89-95% of acute bronchitis cases 2
• Antibiotics reduce cough duration by only approximately 0.5 days compared to placebo 1, 2
• Purulent (green or yellow) sputum does NOT indicate bacterial infection and is NOT an indication for antibiotics - purulence occurs in 89-95% of viral cases due to inflammatory cells and sloughed epithelial cells 1, 2
• Duration of cough alone (even if lasting 10-14 days) does not justify antibiotic use 1, 2
• Antibiotics significantly increase adverse effects including nausea, vomiting, rash, and diarrhea (odds ratio 1.64) 1

Critical First Step: Rule Out Pneumonia

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

• Heart rate >100 beats/min
• Respiratory rate >24 breaths/min
• Oral temperature >38°C (100.4°F)
• Abnormal chest examination findings: focal consolidation, rales, egophony, or tactile fremitus

If any of these are present, obtain a chest radiograph - these patients may have pneumonia requiring different management. 2

The ONE Exception: Pertussis (Whooping Cough)

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

• Use erythromycin or azithromycin 2
• Isolate the patient for 5 days from the start of treatment 2
• Early treatment (within first few weeks) diminishes coughing paroxysms and prevents disease spread 2
• Suspect pertussis during known outbreaks or with high probability of exposure 1

When Fever Persists: Consider Bacterial Superinfection

If fever >38°C persists beyond 3 days, this strongly suggests bacterial superinfection or pneumonia rather than viral bronchitis. 2

• Reevaluate the patient for pneumonia 2
• Consider antibiotics only if bacterial infection is confirmed 2
• Viral bronchitis typically resolves within 7-10 days 2

High-Risk Patients Requiring Different Approach

These guidelines do NOT apply to patients with: 1, 2

• Chronic obstructive pulmonary disease (COPD)
• Congestive heart failure
• Immunosuppression
• Age >75 years with significant comorbidities
• Insulin-dependent diabetes

For COPD patients with acute exacerbation, consider antibiotics when at least 2 of 3 Anthonisen criteria are present: increased dyspnea, increased sputum volume, or increased sputum purulence. 2, 3

Symptomatic Treatment Options

Focus on symptomatic relief rather than antibiotics: 2

• Codeine or dextromethorphan may provide modest relief for bothersome dry cough, especially when disturbing sleep 2
• β2-agonist bronchodilators (albuterol) should be used only in select patients with wheezing accompanying the cough 2, 3
• Do NOT routinely use β2-agonists for cough without wheezing 2
• Avoid NSAIDs at anti-inflammatory doses, systemic corticosteroids, expectorants, mucolytics, antihistamines, and inhaled corticosteroids - these lack evidence of benefit 2

Patient Communication Strategy

Patient satisfaction depends on communication quality, not whether antibiotics are prescribed. 1, 2

Tell patients specifically: 1, 2

• "You have a chest cold, not bacterial bronchitis" - using the term "chest cold" reduces antibiotic expectations 1, 2
• "Your cough will typically last 10-14 days after today's visit, even without antibiotics" 1, 2
• "Antibiotics won't help because this is caused by a virus, and they increase your risk of side effects and antibiotic-resistant infections in the future" 1, 2
• "Previous antibiotic use increases your likelihood of carrying and getting infected with antibiotic-resistant bacteria" 1

When to Reevaluate

Instruct patients to return if: 2

• Fever persists beyond 3 days (suggests bacterial superinfection)
• Cough persists beyond 3 weeks (consider other diagnoses: asthma, COPD, pertussis, gastroesophageal reflux)
• Symptoms worsen rather than gradually improve

Common Pitfalls to Avoid

• Do not prescribe antibiotics based on sputum color or purulence - this occurs in viral infections 1, 2
• Do not assume bacterial infection before the 3-day fever threshold - most cases are viral 2
• Do not use cough duration alone as justification - viral bronchitis cough normally lasts 10-14 days 1, 2
• Do not confuse acute bronchitis with COPD exacerbation - these require different management 2, 3