What is the best course of treatment for a patient presenting with symptoms of acute bronchitis, including a cough productive of mucus and pharyngitis, without fever, and with no known history of asthma or Chronic Obstructive Pulmonary Disease (COPD)?

Management of Acute Bronchitis

For a patient with acute bronchitis presenting with productive cough and pharyngitis without fever, and no history of asthma or COPD, antibiotics should NOT be prescribed—instead, provide symptomatic treatment and patient education that the cough will typically last 10-14 days. 1, 2

Initial Assessment: Rule Out Pneumonia First

Before confirming acute bronchitis, you must exclude pneumonia by evaluating these four vital parameters 1:

• Heart rate >100 beats/min
• Respiratory rate >24 breaths/min
• Oral temperature >38°C
• Chest examination findings of focal consolidation, egophony, or fremitus

If ANY of these are present, obtain chest radiography to rule out pneumonia rather than treating as simple bronchitis 1. Since your patient has no fever and presumably normal vital signs, pneumonia is unlikely and chest radiography is not needed 1.

Rule Out Asthma and COPD

Approximately one-third of patients diagnosed with "acute bronchitis" actually have undiagnosed asthma 2, 3. However, since your patient has no known history of asthma or COPD and this appears to be a first episode, acute bronchitis is the appropriate diagnosis 1. If the patient had recurrent episodes (≥2 similar episodes in the past 5 years), you would need to strongly consider underlying asthma 4.

Why Antibiotics Are NOT Indicated

Antibiotics should not be prescribed for this patient 1, 2. Here's the evidence:

• Viruses cause 89-95% of acute bronchitis cases 2, 5, 6
• Antibiotics reduce cough duration by only 0.5 days (approximately 12 hours) 2, 6, 3
• Antibiotics significantly increase adverse effects (RR 1.20; 95% CI 1.05-1.36), including allergic reactions, nausea, vomiting, and Clostridium difficile infection 2, 6
• The presence of purulent sputum does NOT indicate bacterial infection—it occurs in 89-95% of viral bronchitis cases and is caused by inflammatory cells and sloughed epithelial cells, not bacteria 1, 2

The only exception would be if pertussis (whooping cough) is suspected—look for paroxysmal cough, post-tussive vomiting, or whooping sound 1, 2. If pertussis is confirmed or strongly suspected, prescribe a macrolide antibiotic (erythromycin or azithromycin) and isolate the patient for 5 days 1, 2.

Appropriate Symptomatic Treatment

What TO Use (Selectively)

• Antitussive agents (codeine or dextromethorphan) may provide modest short-term relief, especially when dry cough is bothersome and disturbs sleep 1, 2, 3
• β2-agonist bronchodilators should NOT be routinely used 1, 2, but may be helpful in select adult patients with wheezing accompanying the cough 1, 2, 7

What NOT to Use

Do not prescribe 1, 2:

• Mucokinetic agents (expectorants, mucolytics)—no consistent favorable effect on cough
• Inhaled or oral corticosteroids—not effective for acute bronchitis
• Oral NSAIDs at anti-inflammatory doses—not beneficial
• Antihistamines or anticholinergics—no evidence of benefit

Critical Patient Education

Inform the patient that 2, 6, 3:

• Cough typically lasts 10-14 days after the visit, even without antibiotics, and may persist up to 3 weeks
• The condition is self-limiting and will resolve on its own
• Patient satisfaction depends more on physician-patient communication than whether an antibiotic is prescribed

When to Reassess

Instruct the patient to return if 2:

• Fever develops or 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

Common Pitfalls to Avoid

• Do not assume purulent or green sputum indicates bacterial infection—this is present in the vast majority of viral cases 1, 2
• Do not prescribe antibiotics based on cough duration alone—viral bronchitis cough normally lasts 10-14 days 2, 6
• Do not miss underlying asthma in patients with recurrent "bronchitis" episodes—65% of patients with recurrent episodes actually have mild asthma 8, 4
• Do not use the term "bronchitis" with patients—calling it a "chest cold" reduces antibiotic expectations 2, 6, 3