What is the initial treatment approach for an adult patient presenting with bronchitis, without underlying conditions?

Treatment of Acute Bronchitis

For immunocompetent adult outpatients presenting with acute bronchitis, do not prescribe antibiotics or routine medications—provide supportive care and patient education only. 1, 2

Initial Assessment and Diagnosis

Before confirming acute bronchitis, you must actively exclude pneumonia by checking:

• Heart rate >100 beats/min 2
• Respiratory rate >24 breaths/min 2
• Oral temperature >38°C 2
• Focal lung findings (rales, egophony, tactile fremitus) 2

If any of these are present, obtain chest radiography to rule out pneumonia rather than treating as simple bronchitis. 2, 3

Also consider and exclude:

• Asthma exacerbation (approximately one-third of patients diagnosed with acute bronchitis actually have undiagnosed asthma) 2, 3
• COPD exacerbation in patients with known chronic lung disease 1
• Pertussis if cough persists >2 weeks with paroxysmal features, post-tussive vomiting, or whooping 2, 3

What NOT to Prescribe

The following medications should NOT be routinely prescribed for acute bronchitis: 1, 2

• Antibiotics (including amoxicillin, azithromycin, clarithromycin, fluoroquinolones) 1, 2, 4
• Inhaled beta-agonists (except in select patients with wheezing) 1, 2
• Inhaled anticholinergics 1, 2
• Inhaled or oral corticosteroids 1, 2
• Oral NSAIDs at anti-inflammatory doses 1, 2
• Montelukast or other leukotriene modifiers 2

Why Antibiotics Don't Work

The evidence is conclusive: 2, 4, 5

• Viruses cause 89-95% of acute bronchitis cases 2, 4
• Antibiotics reduce cough duration by only approximately 0.5 days 2, 4, 5
• Antibiotics significantly increase adverse events (RR 1.20; 95% CI, 1.05-1.36) 2
• Purulent or green sputum occurs in 89-95% of viral cases and does NOT indicate bacterial infection 2, 4

What TO Do: Patient Education and Supportive Care

Essential Patient Education 2, 4, 3, 5

Inform patients that:

• Cough typically lasts 10-14 days after the visit, even without treatment 2, 4, 3
• The condition is self-limiting and resolves within 3 weeks 2, 3, 5
• Antibiotics will not help and may cause harm 2, 4, 5

Communication Strategy to Reduce Antibiotic Expectations 2, 4, 5

• Refer to the condition as a "chest cold" rather than "bronchitis" to reduce patient expectation for antibiotics 2, 4, 5
• Explain that patient satisfaction depends more on physician-patient communication than whether an antibiotic is prescribed 2
• Discuss the risks of unnecessary antibiotic use, including side effects and antibiotic resistance 2, 4

Symptomatic Treatment Options (Limited Efficacy)

Antitussives: 2

• Codeine or dextromethorphan may provide modest effects on severity and duration of cough 2
• Consider only when dry cough is bothersome and disturbs sleep 2

Bronchodilators: 1, 2

• β2-agonist bronchodilators should NOT be routinely used 1, 2
• May be useful only in select adult patients with wheezing accompanying the cough 1, 2

Other supportive measures: 2

• Elimination of environmental cough triggers 2
• Humidification of air 2

Critical Exception: Pertussis

If pertussis is confirmed or strongly suspected: 2, 3

• Prescribe a macrolide antibiotic immediately (erythromycin or azithromycin) 2, 3
• Isolate the patient for 5 days from the start of treatment 2
• Early treatment within the first few weeks diminishes coughing paroxysms and prevents disease spread 2

When to Reassess

Instruct patients to return if: 2

• Fever persists >3 days (suggests bacterial superinfection or pneumonia) 2
• Cough persists >3 weeks (consider other diagnoses: asthma, COPD, pertussis, GERD) 2, 6
• Symptoms worsen rather than gradually improve 2

Special Populations: When Antibiotics MAY Be Considered

For patients with chronic lung disease (COPD) experiencing acute exacerbation: 1, 7

Consider antibiotics if the patient has:

• At least 2 of 3 Anthonisen criteria: increased dyspnea, increased sputum volume, increased sputum purulence 2, 7
• AND at least one risk factor: age ≥65 years, FEV1 <50% predicted, ≥4 exacerbations in 12 months, or significant comorbidities 2, 7

Preferred antibiotic regimens for COPD exacerbation: 1, 2, 7

• Moderate severity: Doxycycline 100 mg twice daily for 7-10 days, or newer macrolide (azithromycin, clarithromycin) 1, 2, 7
• Severe exacerbation: High-dose amoxicillin/clavulanate 625 mg three times daily for 7-14 days, or respiratory fluoroquinolone (levofloxacin 500 mg daily, moxifloxacin 400 mg daily) 1, 2, 7

Common Pitfalls to Avoid

• Do NOT assume purulent sputum indicates bacterial infection—it occurs in 89-95% of viral cases 2, 4
• Do NOT prescribe antibiotics based on cough duration alone—viral bronchitis cough normally lasts 10-14 days 2, 4
• Do NOT miss underlying asthma—65% of patients with recurrent "acute bronchitis" episodes actually have mild asthma 1, 2
• Do NOT order routine investigations (chest x-ray, spirometry, sputum culture, viral PCR, CRP, procalcitonin) unless clinical features suggest pneumonia or another specific diagnosis 1