What is the best medication for an adult patient with bronchitis and no underlying health conditions?

Best Medication for Acute Bronchitis

For an otherwise healthy adult with acute bronchitis, antibiotics should NOT be prescribed—they provide no clinical benefit while causing adverse effects and contributing to antibiotic resistance. 1, 2, 3

The Evidence Against Antibiotics

The most important fact to understand is that more than 90% of acute bronchitis cases are viral, making antibiotics completely ineffective regardless of which one you choose. 2, 3, 4

• Antibiotics reduce cough duration by only approximately 0.5 days (12 hours) while significantly increasing adverse events (RR 1.20; 95% CI 1.05-1.36). 2
• Multiple systematic reviews of randomized controlled trials found limited evidence supporting antibiotics with a trend toward increased adverse events in antibiotic-treated patients. 2, 3
• Purulent or colored sputum does NOT indicate bacterial infection—it occurs in 89-95% of viral bronchitis cases and is the most common reason clinicians inappropriately prescribe antibiotics. 2, 3

First: Rule Out Pneumonia

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

• Heart rate >100 beats/min
• Respiratory rate >24 breaths/min
• Oral temperature >38°C (100.4°F)
• Abnormal chest examination findings (focal consolidation, rales, egophony, or tactile fremitus)

If ALL of these are absent, pneumonia is unlikely and chest radiography is not needed. 1 If any are present, obtain chest radiography and treat for pneumonia if confirmed. 2, 3

What TO Prescribe: Symptomatic Treatment Only

Antitussive Agents (For Bothersome Cough)

• Codeine or dextromethorphan can be offered for short-term symptomatic relief, particularly when dry cough is bothersome and disturbs sleep. 1, 2
• These provide modest effects on severity and duration of cough. 1, 2

Bronchodilators (Only If Wheezing Present)

• β2-agonist bronchodilators should NOT be routinely used in most patients with acute bronchitis. 1, 2
• Use β2-agonists ONLY in select adult patients with wheezing accompanying the cough. 1, 2
• Approximately one-third of patients diagnosed with "recurrent acute bronchitis" actually have undiagnosed asthma. 2

What NOT to Prescribe

• Mucokinetic agents/expectorants: No consistent favorable effect on cough. 1
• Inhaled corticosteroids: Not effective for acute bronchitis. 2
• Oral corticosteroids: Not indicated. 2
• NSAIDs at anti-inflammatory doses: Not recommended. 2

The ONE Exception: Pertussis (Whooping Cough)

If pertussis is confirmed or suspected, prescribe a macrolide antibiotic immediately (erythromycin or azithromycin). 1, 2, 3

• Patients 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

Patient Education: The Key to Satisfaction

Patient satisfaction depends more on physician-patient communication than whether an antibiotic is prescribed. 2, 4, 5

What to Tell Every Patient

• Cough typically lasts 10-14 days after the visit, even without antibiotics, and may persist up to 3 weeks. 2, 3, 4
• The condition is self-limiting and resolves within 3 weeks. 2
• Antibiotics expose them to adverse effects while contributing to antibiotic resistance without providing benefit. 2, 3
• Consider referring to the condition as a "chest cold" rather than bronchitis to reduce antibiotic expectations. 2

When to Return for Reassessment

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, gastroesophageal reflux)
• Symptoms worsen rather than gradually improve

Special Populations Requiring Different Approach

These guidelines apply to otherwise healthy adults. Consider antibiotics more readily in: 2

• Elderly patients (>65 years) with comorbidities such as cardiac failure or insulin-dependent diabetes
• Patients with COPD or chronic bronchitis experiencing acute exacerbations
• Immunocompromised patients

For these high-risk patients with acute exacerbations of chronic bronchitis, antibiotics should be prescribed if they have at least 2 of the 3 Anthonisen criteria: 2, 6

• Increased dyspnea
• Increased sputum volume
• Increased sputum purulence

Common Pitfalls to Avoid

• Don't prescribe antibiotics based on sputum color or purulence alone—this occurs in 89-95% of viral cases. 2, 3
• Don't prescribe antibiotics based on cough duration alone—viral bronchitis cough normally lasts 10-14 days. 2
• Don't assume bacterial infection before the 3-day fever threshold—most cases are viral. 2
• Acute bronchitis leads to more inappropriate antibiotic prescribing than any other respiratory infection in adults, with over 70% of visits resulting in unnecessary prescriptions. 3