Antibiotics Should NOT Be Prescribed for Acute Bronchitis
Antibiotics are not indicated for acute uncomplicated bronchitis in otherwise healthy adults, as this condition is viral in 89-95% of cases and antibiotics provide minimal benefit (reducing cough by only half a day) while causing significant adverse effects and promoting antibiotic resistance. 1
When Antibiotics Are Absolutely Contraindicated
- Do not prescribe antibiotics based on purulent sputum color or presence, as this occurs in 89-95% of viral bronchitis cases and does not indicate bacterial infection 1
- Do not prescribe antibiotics based on cough duration alone, as viral bronchitis cough typically lasts 10-14 days and can persist up to 3 weeks 1
- Do not prescribe antibiotics simply because patients expect them—patient satisfaction depends more on physician-patient communication than antibiotic prescription 1
Critical First Step: Rule Out Pneumonia
Before diagnosing acute bronchitis, you must exclude pneumonia by checking for: 1
- Heart rate >100 beats/min
- Respiratory rate >24 breaths/min
- Oral temperature >38°C
- Abnormal chest examination findings (rales, egophony, tactile fremitus)
If any of these are present, obtain chest radiography to rule out pneumonia rather than treating as simple bronchitis. 1
The ONE Exception: Confirmed or Suspected Pertussis
If pertussis (whooping cough) is confirmed or suspected, prescribe a macrolide antibiotic such as azithromycin or erythromycin immediately. 1
- Isolate the patient for 5 days from the start of treatment 1
- Early treatment within the first few weeks diminishes coughing paroxysms and prevents disease spread 1
High-Risk Patients Who MAY Require Antibiotics
Consider antibiotics ONLY in patients with significant comorbidities AND fever persisting >3 days: 2, 1
High-risk criteria include:
- Age >75 years with cardiac failure 1
- Insulin-dependent diabetes mellitus 2
- Serious neurological disorders 2
- Immunosuppression 1
If antibiotics are indicated in high-risk patients, the recommended regimen is:
- Amoxicillin 500 mg three times daily for 5-8 days (first-line choice) 2, 1
- Doxycycline 100 mg twice daily for 5-8 days (alternative, especially if β-lactam allergy) 2, 1
What NOT to Prescribe
The following have no proven benefit in acute bronchitis: 2, 1
- Cough suppressants, expectorants, or mucolytics
- Antihistamines
- Inhaled corticosteroids
- NSAIDs at anti-inflammatory doses
- Systemic corticosteroids
Appropriate Symptomatic Management
- Inform patients that cough typically lasts 10-14 days after the visit, even without antibiotics, and may persist up to 3 weeks 1
- β2-agonist bronchodilators may be useful ONLY in select patients with wheezing accompanying the cough 1
- Codeine or dextromethorphan may provide modest effects on severity and duration of cough, particularly when dry cough is bothersome and disturbs sleep 1
- Low-cost measures such as elimination of environmental cough triggers and vaporized air treatments are reasonable 1
When to Reassess
Instruct patients to return if: 1
- 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
Critical Pitfall to Avoid
The presence of fever does NOT automatically indicate bacterial infection requiring antibiotics. Fever persisting beyond 3 days strongly suggests bacterial superinfection, but initial fever in the first 1-3 days is consistent with viral bronchitis. 2, 1