What is the recommended treatment for a patient with acute bronchitis, considering their unique medical history and demographics?

Treatment of Acute Bronchitis

Do NOT Prescribe Antibiotics for Uncomplicated Acute Bronchitis

Antibiotics should not be routinely prescribed for acute bronchitis in otherwise healthy adults, as they provide minimal benefit (reducing cough by only approximately half a day) while exposing patients to adverse effects and contributing to antibiotic resistance. 1

Why Antibiotics Don't Work

• Respiratory viruses cause 89-95% of acute bronchitis cases, making antibiotics completely ineffective 1, 2
• Purulent sputum does NOT indicate bacterial infection—it occurs in 89-95% of viral cases and is not an indication for antibiotics 1
• Cough duration alone does not indicate bacterial infection; viral bronchitis cough typically lasts 10-14 days, sometimes up to 3 weeks 1
• A systematic review found antibiotics significantly increase adverse events (RR 1.20; 95% CI, 1.05-1.36) with no meaningful clinical benefit 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—this is pneumonia, not simple bronchitis. 1

The ONE Exception: Pertussis

For confirmed or suspected pertussis (whooping cough), prescribe a macrolide antibiotic such as erythromycin or azithromycin immediately. 1

• Patients with pertussis should be isolated for 5 days from the start of treatment 1
• Early treatment within the first few weeks diminishes coughing paroxysms and prevents disease spread 1

Symptomatic Treatment Approach

What TO Offer

Antitussives (codeine or dextromethorphan) may provide modest effects on severity and duration of cough, especially when dry cough is bothersome and disturbs sleep 1

β2-agonist bronchodilators (albuterol/salbutamol) should NOT be routinely used in most patients 1, 3

• Exception: In select adult patients with wheezing accompanying the cough, β2-agonist bronchodilators may be useful 1, 4
• When used for wheezing: Albuterol 2-4 inhalations (200-400 μg) every 4 hours 3
• A Cochrane review found no significant benefit in reducing daily cough scores in patients without wheezing, with more adverse effects (tremors, nervousness, agitation) 3

Low-risk supportive measures: 1

• Elimination of environmental cough triggers
• Vaporized air treatments/humidification
• Nasal saline irrigation 1

What NOT to Use

Do not prescribe: 1

• Expectorants or mucolytics (no proven benefit) 3
• Inhaled corticosteroids
• Oral corticosteroids
• NSAIDs at anti-inflammatory doses
• Antihistamines

Patient Education: The Key to Satisfaction

Patient satisfaction depends more on physician-patient communication than whether an antibiotic is prescribed. 1, 5

What to Tell Every Patient

• Inform patients that cough typically lasts 10-14 days after the office visit, even without antibiotics, and may persist up to 3 weeks 1
• Refer to the condition as a "chest cold" rather than "bronchitis" to reduce antibiotic expectations 1
• Explain that antibiotics expose them to adverse effects while contributing to antibiotic resistance without providing benefit 1

When to Return for Reassessment

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

Special Populations Requiring Different Management

High-Risk Patients Who MAY Need Antibiotics

Consider antibiotics in patients with: 1

• Age >75 years with cardiac failure, insulin-dependent diabetes, or serious neurological disorders
• Immunocompromised state
• Chronic bronchitis/COPD with acute exacerbation meeting Anthonisen criteria (at least 2 of: increased dyspnea, increased sputum volume, increased sputum purulence) 6

For these patients, first-line antibiotics include: 1

• Doxycycline 100 mg twice daily for 7-10 days
• Amoxicillin/clavulanate 625 mg three times daily for 7-14 days (for severe exacerbations)

Common Pitfall to Avoid

Approximately one-third of patients diagnosed with "recurrent acute bronchitis" actually have undiagnosed asthma or COPD exacerbations. 1

• If recurrent episodes occur, rule out asthma/COPD before treating as simple bronchitis 1
• These patients require bronchodilators and different management algorithms 1