What is the recommended treatment and duration for a patient with bronchitis, including signs and symptoms indicating the need for antibiotic prescription, considering underlying conditions such as chronic obstructive pulmonary disease (COPD)?

Treatment of Acute Bronchitis: When to Prescribe Antibiotics

Direct Answer

Antibiotics should NOT be prescribed for uncomplicated 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 causing significant adverse effects. 1, 2

Signs and Symptoms of Acute Bronchitis

Clinical Presentation:

• Cough lasting up to 3 weeks (typically 10-14 days after consultation) is the predominant symptom 3, 1, 4
• May be accompanied by sputum production (clear or purulent) 3, 1
• Upper respiratory symptoms such as rhinorrhea, sore throat, or nasal congestion suggest viral etiology 1
• Mild constitutional symptoms may be present 4
• Purulent (green or yellow) sputum occurs in 89-95% of viral cases and does NOT indicate bacterial infection 1, 4

Rule Out Pneumonia First

Before diagnosing acute bronchitis, pneumonia MUST be excluded by checking for: 3, 1

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

If ANY of these are present, obtain chest radiography rather than treating as simple bronchitis. 3, 1

Duration and Natural Course

• Cough typically lasts 10-14 days after the office visit, even without treatment 1, 4
• Most symptoms resolve within 3 weeks 3, 1
• Cough persisting beyond 3 weeks warrants reevaluation for other diagnoses (asthma, COPD, pertussis, gastroesophageal reflux) 3, 1

When Antibiotics ARE Indicated

The ONLY exceptions for antibiotic use in acute bronchitis are: 1

1. Confirmed or Suspected Pertussis (Whooping Cough)

• Prescribe a macrolide antibiotic (erythromycin or azithromycin) 1, 5
• Isolate patient for 5 days from start of treatment 1
• Early treatment (within first few weeks) diminishes coughing paroxysms and prevents disease spread 1

2. High-Risk Patients with Specific Criteria

Consider antibiotics ONLY if the patient has: 1, 4

• Age ≥75 years with fever, OR
• Cardiac failure, OR
• Insulin-dependent diabetes, OR
• Serious neurological disorders, OR
• Immunosuppression

AND fever persists beyond 3 days (suggesting bacterial superinfection rather than viral bronchitis) 1

When Antibiotics Are NOT Indicated

Do NOT prescribe antibiotics based on: 1, 4

• Presence of purulent (colored) sputum alone
• Duration of cough
• Patient expectation for antibiotics
• Smoking status (smokers without COPD do not benefit more than nonsmokers) 5

Symptomatic Treatment Options

Recommended:

• Codeine or dextromethorphan for bothersome dry cough, especially when disturbing sleep 1, 4
• β2-agonist bronchodilators (albuterol) ONLY in select patients with wheezing 1, 4
• Elimination of environmental irritants and humidification 1

NOT Recommended: 1, 4

• Expectorants or mucolytics
• Antihistamines
• Inhaled corticosteroids
• NSAIDs at anti-inflammatory doses
• Systemic corticosteroids

Special Consideration: Chronic Bronchitis Exacerbations

For patients with known COPD or chronic bronchitis experiencing acute exacerbation, antibiotics ARE indicated if: 3, 1, 6

At least 2 of 3 Anthonisen criteria:

• Increased dyspnea
• Increased sputum volume
• Increased sputum purulence

PLUS at least one risk factor:

• Age ≥65 years
• FEV1 <50% predicted
• ≥4 exacerbations in past 12 months
• Significant comorbidities

Antibiotic selection for AECB: 1, 6

• Moderate severity: Doxycycline 100 mg twice daily for 7-10 days, OR newer macrolide (azithromycin), OR extended-spectrum cephalosporin
• Severe exacerbations: High-dose amoxicillin/clavulanate 625 mg three times daily for 14 days, OR respiratory fluoroquinolone

Patient Communication Strategy

To maintain satisfaction without prescribing unnecessary antibiotics: 1, 4

• Refer to the condition as a "chest cold" rather than "bronchitis" to reduce antibiotic expectations
• Explain that acute bronchitis is primarily viral (89-95% of cases) and antibiotics are ineffective against viruses 1, 2
• Set realistic expectations: cough will last 10-14 days regardless of treatment 1
• Emphasize that patient satisfaction depends more on quality of communication than receiving antibiotics 1, 7
• Discuss risks of unnecessary antibiotic use: side effects and contribution to antibiotic resistance 1

When to Reevaluate

Instruct patients to return if: 1, 4

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

Critical Pitfalls to Avoid

• Do NOT assume bacterial infection based on sputum color – purulent sputum is present in 89-95% of viral cases 1, 4
• Do NOT prescribe antibiotics for cough duration alone – viral bronchitis cough normally lasts 10-14 days 1
• Do NOT fail to distinguish acute bronchitis from pneumonia – always check vital signs and chest examination 3, 1
• Do NOT overlook pertussis – consider in patients with prolonged paroxysmal cough 1
• Do NOT confuse acute bronchitis with COPD exacerbation – patients with underlying COPD require different management 3, 1