What is the recommended treatment for a patient with acute bronchitis, considering their past medical history, such as smoking or chronic obstructive pulmonary disease (COPD)?

Treatment of Acute Bronchitis

Antibiotics should NOT be prescribed for acute bronchitis in otherwise healthy adults, as they provide minimal benefit (reducing cough by only half a day) while causing significant adverse effects and contributing to antibiotic resistance. 1

Initial Assessment: Rule Out Other Diagnoses

Before confirming acute bronchitis, you must exclude pneumonia and other conditions:

• Check vital signs and lung examination - If the patient has heart rate >100 bpm, respiratory rate >24 breaths/min, oral temperature >38°C, or focal consolidation on chest exam, suspect pneumonia and obtain chest radiography rather than treating as simple bronchitis 1, 2
• Consider underlying asthma or COPD - Approximately one-third of patients diagnosed with "acute bronchitis" actually have undiagnosed asthma or will develop chronic bronchitis/COPD, especially with recurrent episodes 2, 3
• Evaluate for pertussis - If whooping cough is suspected or confirmed, this is the ONE exception requiring antibiotics (macrolide such as azithromycin or erythromycin), with patient isolation for 5 days from treatment start 1

Treatment for Uncomplicated Acute Bronchitis (Otherwise Healthy Adults)

The cornerstone of management is patient education and symptomatic treatment only - no routine medications including antibiotics, antivirals, bronchodilators, or corticosteroids are recommended 1, 3

Patient Education (Critical for Satisfaction)

• Inform patients that cough typically lasts 10-14 days after the visit, sometimes up to 3 weeks, and this is normal for viral bronchitis 1, 2
• Refer to the condition as a "chest cold" rather than "bronchitis" to reduce patient expectations for antibiotics 1, 3
• Explain that patient satisfaction depends on physician-patient communication, not antibiotic prescription 1, 4
• Discuss the harms of unnecessary antibiotics - adverse effects and contribution to antibiotic resistance 1

Symptomatic Relief Options (If Needed)

• For bothersome dry cough affecting quality of life: Dextromethorphan or codeine may provide modest short-term relief, reducing cough counts by 40-60% 2, 3
• For wheezing in select patients: β2-agonist bronchodilators may be useful ONLY if wheezing accompanies the cough, suggesting underlying reactive airways 1, 2
• Standard analgesics/antipyretics may provide symptomatic relief for associated discomfort and fever 3

When to Reassess

Instruct patients to return if:

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

Treatment for Acute Exacerbation of Chronic Bronchitis (AECB)

This is a completely different condition requiring different management - patients with known COPD or chronic bronchitis are NOT included in the "no antibiotics" recommendation for acute bronchitis 1, 2

When to Prescribe Antibiotics for AECB

Antibiotics are indicated if the patient has at least 1 key symptom (Anthonisen criteria) AND at least 1 risk factor: 1, 5

Key Symptoms (need ≥1):

• Increased dyspnea 1, 5
• Increased sputum volume 1, 5
• Increased sputum purulence 1, 5

Risk Factors (need ≥1):

• Age ≥65 years 1, 5
• FEV1 <50% predicted 1, 5
• ≥4 exacerbations in past 12 months 5
• Cardiac failure, insulin-dependent diabetes, or serious neurological disorders 1, 5
• Immunosuppression 1

Antibiotic Selection for AECB

For moderate-severity exacerbations (infrequent exacerbations, FEV1 >50%):

• First-line: Doxycycline 100 mg twice daily for 7-10 days 1
• Alternatives: Newer macrolide (azithromycin 500 mg daily for 3 days or clarithromycin 500 mg twice daily for 7-14 days) 1, 6

For severe exacerbations (frequent exacerbations, FEV1 <35%, or high-risk features):

• Preferred: High-dose amoxicillin/clavulanate 625 mg three times daily for 14 days 1
• Alternative: Respiratory fluoroquinolone (levofloxacin) 1, 7

Critical Pitfalls to Avoid

• Do NOT assume bacterial infection based on purulent sputum alone - purulent sputum occurs in 89-95% of VIRAL bronchitis cases and does not indicate bacterial infection 1, 8
• Do NOT prescribe antibiotics for cough duration alone - viral bronchitis cough normally lasts 10-14 days 1
• Avoid simple aminopenicillins - up to 25% of H. influenzae and 50-70% of M. catarrhalis produce β-lactamase, making them ineffective 1
• Do NOT use expectorants, mucolytics, antihistamines, inhaled corticosteroids, or NSAIDs at anti-inflammatory doses for acute bronchitis - no consistent evidence of benefit 1, 2

Special Considerations for Patients with Past Medical History

Smoking History

• Mandatory smoking cessation counseling - this is the single most effective intervention, with 90% of patients experiencing cough resolution after quitting 2
• Smokers may have longer symptom duration, but this does NOT justify antibiotics for acute bronchitis 9

Known COPD

• These patients require different management - follow AECB guidelines above, not acute bronchitis guidelines 1, 2, 3
• Consider bronchodilators and systemic corticosteroids for COPD exacerbations 3
• Lower threshold for antibiotic use if meeting Anthonisen criteria 1, 5