What is the appropriate antibiotic treatment for a patient with an ongoing cough, with or without productive sputum, and with or without symptoms such as fever, shortness of breath, or chest pain?

Antibiotics for Ongoing Cough: Evidence-Based Recommendations

Do NOT Prescribe Antibiotics for Uncomplicated Acute Bronchitis

For immunocompetent adults with ongoing cough due to acute bronchitis, antibiotics should NOT be routinely prescribed, as they provide minimal benefit (reducing cough by only half a day) while causing significant adverse effects and contributing to antibiotic resistance. 1, 2

Key Diagnostic Steps Before Any Treatment Decision

• Rule out pneumonia first by checking vital signs: heart rate >100 bpm, respiratory rate >24 breaths/min, oral temperature >38°C, or focal chest findings (rales, egophony, tactile fremitus) all suggest pneumonia rather than bronchitis 1, 2
• Obtain chest radiography if any vital sign abnormalities or focal lung findings are present 1, 3
• Exclude asthma/COPD exacerbations, especially with recurrent episodes, as approximately one-third of patients diagnosed with acute bronchitis actually have undiagnosed asthma 2

When Antibiotics Are Absolutely NOT Indicated

• Purulent sputum does NOT indicate bacterial infection - it occurs in 89-95% of viral bronchitis cases and is not an indication for antibiotics 1, 2
• Cough duration alone does NOT justify antibiotics - viral bronchitis cough typically lasts 10-14 days, sometimes up to 3 weeks 1, 2
• Normal vital signs and lung examination - no antibiotics should be prescribed 1, 2

The ONE Exception: Confirmed or Suspected Pertussis

For confirmed or suspected pertussis (whooping cough), prescribe a macrolide antibiotic immediately: 1, 2

• Azithromycin (preferred): 500 mg on day 1, then 250 mg daily for days 2-5 4
• Erythromycin (alternative): 500 mg four times daily for 14 days 1
• Isolate the patient for 5 days from the start of treatment to prevent disease spread 2
• Early treatment (within first few weeks) diminishes coughing paroxysms and prevents transmission 2

When to Reassess and Consider Antibiotics

Reassess the patient if: 2

• Fever persists beyond 3 days - strongly suggests bacterial superinfection or pneumonia, not simple viral bronchitis 2, 5
• Cough persists beyond 3 weeks - consider other diagnoses (asthma, COPD, pertussis, gastroesophageal reflux) 1, 2
• Symptoms worsen rather than gradually improve 2

For Chronic Bronchitis/COPD Exacerbations ONLY

Antibiotics are appropriate for acute exacerbations of chronic bronchitis if the patient has at least 2 of 3 Anthonisen criteria: 2

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

AND has high-risk features: age >65 years with moderate-to-severe COPD, cardiac failure, insulin-dependent diabetes, or serious neurological disorders 2

Recommended antibiotics for COPD exacerbations: 2

• Doxycycline 100 mg twice daily for 7-10 days (first-line for moderate severity)
• Amoxicillin-clavulanate 625 mg three times daily for 14 days (for severe exacerbations or frequent exacerbations)
• Clarithromycin 500 mg twice daily for 7-14 days (alternative for beta-lactam allergy)

Symptomatic Treatment for Uncomplicated Acute Bronchitis

What TO use: 2, 6

• Codeine or dextromethorphan for bothersome dry cough, especially when disturbing sleep 1, 2, 6
• β2-agonist bronchodilators (albuterol) ONLY in select patients with accompanying wheezing 2
• Inhaled ipratropium for postinfectious cough (cough persisting 3-8 weeks after acute respiratory infection) 1, 5

What NOT to use: 1, 2

• Antibiotics (unless pertussis or COPD exacerbation with criteria met)
• Inhaled corticosteroids (no routine benefit)
• Oral corticosteroids (no routine benefit)
• NSAIDs at anti-inflammatory doses (no consistent evidence)
• Montelukast (no evidence for acute bronchitis)

Critical Patient Education Points

Inform every patient: 2

• Cough typically lasts 10-14 days after the visit, even without antibiotics, and may persist up to 3 weeks 2
• The condition is self-limiting and resolves within 3 weeks in most cases 2
• Antibiotics expose patients to adverse effects (diarrhea, allergic reactions, C. difficile infection) while providing no benefit for viral bronchitis 1, 2
• Patient satisfaction depends more on physician-patient communication than whether an antibiotic is prescribed 2

Common Pitfalls to Avoid

• Do NOT assume bacterial infection based on sputum color, cough duration, or patient expectation for antibiotics 1, 2
• Do NOT miss pneumonia by failing to check vital signs and obtain chest radiography when indicated 1, 3
• Do NOT prescribe antibiotics immediately even if fever is present, unless it persists beyond 3 days or pneumonia is confirmed 2
• Do NOT use simple aminopenicillins (amoxicillin alone) for COPD exacerbations, as up to 25% of H. influenzae and 50-70% of M. catarrhalis produce β-lactamase 2