What is the recommended treatment for a patient with acute bronchitis?

Treatment for Acute Bronchitis

Antibiotics should NOT be prescribed for acute bronchitis in otherwise healthy adults, as they provide minimal benefit (reducing cough by only about half a day) while exposing patients to adverse effects and contributing to antibiotic resistance. 1, 2

Initial Assessment: Rule Out Pneumonia First

Before diagnosing acute bronchitis, you must exclude pneumonia by evaluating for the following findings 1, 2:

• Heart rate >100 beats/min
• Respiratory rate >24 breaths/min
• Oral temperature >38°C
• Chest examination findings of focal consolidation, egophony, or fremitus

If ANY of these are present, obtain chest radiography to rule out pneumonia rather than treating as simple bronchitis. 1, 2

Understanding the Disease

Acute bronchitis is caused by respiratory viruses in 89-95% of cases, with fewer than 10% having bacterial infections. 2 The cough typically lasts 10-14 days after the office visit, sometimes extending to 3 weeks. 1, 2 Purulent sputum does NOT indicate bacterial infection—it occurs in 89-95% of viral bronchitis cases. 2

Primary Treatment: Symptomatic Management Only

What TO Use

• Patient education is the cornerstone of management: Inform patients that cough typically lasts 10-14 days and the condition is self-limiting. 1, 2
• Codeine or dextromethorphan may provide modest effects on severity and duration of cough, especially when dry cough is bothersome and disturbs sleep. 2
• β2-agonist bronchodilators should be used ONLY in select adult patients with wheezing accompanying the cough—not routinely for all patients. 1, 2

What NOT to Use

Do not prescribe the following, as they lack evidence of benefit 2:

• Antibiotics (unless pertussis or high-risk patient—see exceptions below)
• Expectorants or mucolytics
• Antihistamines
• Inhaled or oral corticosteroids
• Oral NSAIDs at anti-inflammatory doses

Critical Exception: Pertussis (Whooping Cough)

For confirmed or suspected pertussis, prescribe a macrolide antibiotic (erythromycin or azithromycin) immediately. 1, 2 Suspect pertussis if 1:

• Cough persisting >2 weeks with paroxysms
• Whooping sound or post-tussive vomiting
• Recent pertussis exposure

Patients with pertussis should be isolated for 5 days from the start of treatment. 1, 2 Early treatment within the first few weeks diminishes coughing paroxysms and prevents disease spread. 1, 2

High-Risk Patients: When to Consider Antibiotics

Consider antibiotics ONLY in high-risk patients with significant comorbidities 2, 3:

• Age ≥75 years with fever
• Cardiac failure
• Insulin-dependent diabetes
• Immunosuppression
• Serious neurological disorders
• COPD with FEV1 <50%

For these high-risk patients, prescribe antibiotics only if they have at least 2 of the 3 Anthonisen criteria 2, 3:

1. Increased dyspnea
2. Increased sputum volume
3. Increased sputum purulence

Recommended regimen for high-risk patients: Doxycycline 100 mg twice daily for 7-10 days. 2 For severe exacerbations, consider high-dose amoxicillin/clavulanate 625 mg three times daily for 14 days or a respiratory fluoroquinolone. 2

When to Reassess

Instruct patients to return if 2:

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

Patient Communication Strategy

Patient satisfaction depends more on physician-patient communication than whether an antibiotic is prescribed. 1, 2 Key strategies include 2, 4:

• Refer to the condition as a "chest cold" rather than bronchitis to reduce antibiotic expectations
• Explain that antibiotics expose patients to adverse effects (allergic reactions, nausea, Clostridium difficile infection) without providing benefit
• Emphasize that antibiotic overuse contributes to antibiotic resistance, harming both the individual and community
• Set aside office time to address patient expectations, as many expect antibiotics based on previous experiences

Common Pitfalls to Avoid

• Do not assume bacterial infection based on purulent sputum color or presence—this 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 prescribe antibiotics immediately for fever—wait to see if fever persists beyond 3 days before considering bacterial superinfection. 2
• Do not diagnose acute bronchitis in patients with known asthma or COPD exacerbations—approximately one-third of patients diagnosed with acute bronchitis actually have undiagnosed asthma. 2