What is the recommended treatment for an adult patient with acute bronchitis and no underlying conditions?

Treatment of Acute Bronchitis in Adults

Antibiotics should NOT be prescribed for acute bronchitis in otherwise healthy adults, regardless of cough duration or sputum appearance, as they provide minimal benefit (reducing cough by only half a day) while causing significant adverse effects and contributing to antibiotic resistance. 1, 2, 3

Initial Assessment: Rule Out Pneumonia First

Before diagnosing acute bronchitis, you must exclude pneumonia by checking these specific vital signs and examination findings: 1, 2

• Heart rate >100 beats/min 2
• Respiratory rate >24 breaths/min 2
• Oral temperature >38°C 2
• Asymmetrical lung sounds, rales, egophony, or tactile fremitus 1, 2

If any of these are present, obtain chest radiography and consider pneumonia rather than treating as simple bronchitis. 1, 2 In healthy, nonelderly adults without these abnormalities, chest radiography is not indicated. 1, 3

The Evidence Against Antibiotics

The case against routine antibiotic use is overwhelming:

• Respiratory viruses cause 89-95% of acute bronchitis cases, making antibiotics completely ineffective regardless of which agent is chosen. 2
• Antibiotics reduce cough duration by only 0.5 days (approximately 12 hours) while significantly increasing adverse events (RR 1.20; 95% CI 1.05-1.36). 2
• Purulent sputum occurs in 89-95% of viral cases and does not indicate bacterial infection or need for antibiotics. 2
• Multiple randomized controlled trials show no significant difference in clinical outcomes between antibiotic and placebo groups. 2, 4, 3

Recommended Treatment: Symptomatic Management

The cornerstone of acute bronchitis management is patient education and symptomatic treatment only. 2, 5

Patient Education (Critical for Satisfaction)

• Inform patients that cough typically lasts 10-14 days after the visit, even without antibiotics, and may persist up to 3 weeks. 1, 2
• Patient satisfaction depends more on physician-patient communication than whether an antibiotic is prescribed. 1, 3
• Explain that antibiotics expose them to adverse effects while contributing to antibiotic resistance without providing benefit. 2
• Consider referring to the condition as a "chest cold" rather than bronchitis to reduce patient expectation for antibiotics. 2

Symptomatic Treatment Options

• Codeine or dextromethorphan may provide modest effects on severity and duration of cough, especially when dry cough is bothersome and disturbs sleep. 1, 2
• β2-agonist bronchodilators (albuterol) should ONLY be used in select patients with accompanying wheezing, not routinely for all patients with cough. 2, 4
• Elimination of environmental cough triggers and vaporized air treatments are reasonable low-risk options. 1, 2

What NOT to Use

Do not prescribe the following for uncomplicated acute bronchitis: 2

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

The ONE Exception: Pertussis

If pertussis (whooping cough) is confirmed or strongly suspected, prescribe a macrolide antibiotic (erythromycin or azithromycin) immediately. 1, 2, 5

• Patients with pertussis must be isolated for 5 days from the start of treatment to prevent disease spread. 2
• Early treatment within the first few weeks diminishes coughing paroxysms and prevents transmission. 2

When to Reassess

Instruct patients to return if: 2

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

Special Populations Requiring Different Approach

These guidelines apply to otherwise healthy adults without underlying conditions. 1, 3 The following patients require individualized management beyond the scope of uncomplicated acute bronchitis: 1, 2

• Patients with COPD or chronic bronchitis
• Immunocompromised patients
• Patients with congestive heart failure
• Elderly patients (>75 years) with cardiac failure, insulin-dependent diabetes, or serious neurological disorders

For these high-risk patients, consider antibiotics if they meet the Anthonisen criteria (at least 2 of 3): increased dyspnea, increased sputum volume, or increased sputum purulence. 2

Common Pitfalls to Avoid

• Do NOT assume bacterial infection based on sputum color or purulence alone – 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 over the phone – you need to examine the patient to rule out pneumonia. 6
• Do NOT assume "recurrent acute bronchitis" – approximately one-third of these patients actually have undiagnosed asthma or COPD. 2