What is the best treatment approach for an adult patient with a history of bronchitis?

Treatment of Recurrent Bronchitis

For a patient with a history of bronchitis, do not prescribe antibiotics unless there is confirmed pertussis or the patient has chronic bronchitis with significant comorbidities and meets specific criteria for bacterial superinfection. 1, 2, 3

Initial Assessment: Rule Out Other Diagnoses

Before treating as bronchitis, you must exclude:

• Pneumonia: Check for heart rate >100 bpm, respiratory rate >24 breaths/min, oral temperature >38°C, or focal lung findings (rales, egophony, tactile fremitus). If any are present, obtain chest radiography—this is pneumonia, not bronchitis. 1, 2, 3
• Asthma: Approximately one-third of patients diagnosed with "recurrent acute bronchitis" actually have undiagnosed asthma or COPD exacerbations. Consider this especially if there are recurrent episodes or wheezing. 2, 4
• Pertussis: Suspect if cough persists >2 weeks with paroxysmal cough, whooping, post-tussive vomiting, or known exposure. 2, 4

For Acute Bronchitis (Current Episode)

Primary Treatment: Symptomatic Management Only

Antibiotics should NOT be prescribed for uncomplicated acute bronchitis. 1, 2, 3, 5

Here's why this matters:

• Respiratory viruses cause 89-95% of acute bronchitis cases, making antibiotics completely ineffective. 2, 3, 5
• Antibiotics reduce cough duration by only 0.5 days (12 hours) while significantly increasing adverse events (RR 1.20; 95% CI 1.05-1.36). 2, 5
• Purulent or green sputum does NOT indicate bacterial infection—it occurs in 89-95% of viral cases and is the most common reason clinicians inappropriately prescribe antibiotics. 2, 5

Symptomatic Relief Options

• Cough suppressants: Codeine or dextromethorphan may provide modest effects on cough severity and duration, particularly when dry cough disturbs sleep. 2, 3
• Bronchodilators: β2-agonists (albuterol) should only be used in select patients with accompanying wheezing—not routinely beneficial otherwise. 2, 3
• Avoid these: Do NOT prescribe expectorants, mucolytics, antihistamines, inhaled corticosteroids, oral corticosteroids, or NSAIDs at anti-inflammatory doses—they lack evidence of benefit. 2, 3

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. 2, 3
• Refer to the condition as a "chest cold" rather than bronchitis to reduce antibiotic expectations. 2, 3
• Patient satisfaction depends more on physician-patient communication than whether an antibiotic is prescribed. 1, 2
• Explain the risks of unnecessary antibiotics: adverse effects, allergic reactions, C. difficile infection, and antibiotic resistance. 2, 4

When to Reassess

Instruct the patient to return if:

• Fever persists >3 days (suggests bacterial superinfection or pneumonia) 2, 3
• Cough persists >3 weeks (consider asthma, COPD, pertussis, GERD) 2, 3
• Symptoms worsen rather than gradually improve 2, 3

Exception: Confirmed or Suspected Pertussis

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

• Isolate the patient for 5 days from the start of treatment to prevent disease spread. 2, 3
• Early treatment within the first few weeks diminishes coughing paroxysms and prevents transmission. 2, 3

For Chronic Bronchitis/COPD Exacerbations (If Applicable)

If your patient has underlying chronic bronchitis or COPD, the approach differs:

When to Consider Antibiotics

Only prescribe antibiotics if the patient has at least 2 of the 3 Anthonisen criteria: 2, 6

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

AND the patient has high-risk features:

• Age ≥75 years with fever 2, 3
• Cardiac failure 2, 3
• Insulin-dependent diabetes 2, 3
• Immunosuppression 2, 3
• Severe airflow obstruction (FEV1 <35%) 2, 6
• Chronic respiratory insufficiency 2

Antibiotic Selection for High-Risk Patients

First-line for moderate severity: Doxycycline 100 mg twice daily for 7-10 days 2, 3

Alternative regimens based on suspected pathogen:

• H. influenzae (beta-lactamase negative): Amoxicillin 500 mg three times daily for 14 days 2
• H. influenzae (beta-lactamase positive) or M. catarrhalis: Amoxicillin/clavulanate 625 mg three times daily for 14 days 2
• S. pneumoniae: Amoxicillin 500 mg to 1 g three times daily for 14 days, or doxycycline 100 mg twice daily for 14 days 2

For severe exacerbations or FEV1 <35%: Consider amoxicillin/clavulanate or respiratory fluoroquinolones (levofloxacin). 2, 6

Critical Pitfalls to Avoid

• Up to 25% of H. influenzae and 50-70% of M. catarrhalis produce β-lactamase, making simple aminopenicillins ineffective. 2
• Obtain sputum cultures when possible before starting empirical antibiotics, then adjust therapy based on sensitivity results if no clinical improvement occurs. 2

Long-Term Management for Recurrent Episodes

• Smoking cessation is the most effective intervention—90% of patients experience resolution of chronic cough after quitting. 2, 7
• Ensure appropriate immunizations against influenza and pneumococcus. 7
• Consider pulmonary function testing to establish baseline obstruction and identify high-risk patients. 7
• For chronic bronchiectasis with ≥3 exacerbations per year, particularly with Pseudomonas aeruginosa infection, long-term azithromycin may have proven benefit. 5, 8