Management of Acute Bronchitis with Upper Respiratory Symptoms
For a patient with one week of productive cough, mucopurulent sputum, sore throat, and nasal congestion without red-flag features, antibiotics should NOT be prescribed—this is acute bronchitis, which is viral in origin and requires only symptomatic management. 1
Initial Diagnostic Approach
Rule out pneumonia first by assessing for the following red-flag features 1:
- Heart rate > 100 beats/min
- Respiratory rate > 24 breaths/min
- Oral temperature > 38°C (100.4°F)
- Focal consolidation, egophony, or fremitus on chest examination
If all four findings are absent, chest radiograph is not needed and pneumonia is sufficiently unlikely. 1 The presence of mucopurulent sputum does NOT indicate bacterial infection—sputum color alone cannot distinguish viral from bacterial etiology. 2
Diagnosis: Acute Bronchitis
This clinical presentation—cough with sputum production lasting ≤3 weeks, accompanied by upper respiratory symptoms (sore throat, nasal congestion), without pneumonia or COPD exacerbation—meets criteria for acute bronchitis. 1 The vast majority of cases are caused by viruses including coronavirus, rhinovirus, and adenovirus. 2
Evidence-Based Management
What NOT to Do
Antibiotics are explicitly contraindicated and provide no benefit. 1 The American College of Chest Physicians states with high-quality evidence that routine antibiotic treatment is not justified, has no role, and should not be offered. 1 Antibiotics reduce cough duration by only half a day while causing adverse effects including allergic reactions, nausea, vomiting, and Clostridium difficile infection. 3
Recommended Treatment
Symptomatic management is the appropriate approach 1:
- Antitussive agents (dextromethorphan or codeine) can be offered for short-term symptomatic relief of cough 1, 4
- β2-agonist bronchodilators should NOT be routinely used, but may be useful in select patients with wheezing accompanying the cough 1
- Mucokinetic agents are not recommended due to lack of consistent favorable effect 1
Patient education is critical: Explain that the cough typically lasts 2-3 weeks, the illness is viral (not bacterial), and antibiotics will not help. 1, 3 Many patients expect antibiotics based on previous experiences, so this conversation should be individualized to address their expectations. 1
When to Reassess
Consider pertussis if cough persists ≥2 weeks with paroxysmal coughing, post-tussive vomiting, or inspiratory whooping sound. 1 In confirmed or probable pertussis, a macrolide antibiotic should be prescribed within the first few weeks to diminish paroxysms and prevent spread. 1
If cough persists 3-8 weeks, this becomes postinfectious cough—a distinct entity that also does NOT require antibiotics. 1 First-line treatment is inhaled ipratropium bromide. 1, 5
If cough persists >8 weeks, reclassify as chronic cough and systematically evaluate for upper airway cough syndrome, asthma, and gastroesophageal reflux disease. 1, 5
Common Pitfalls to Avoid
- Do not prescribe antibiotics based on sputum color or purulence—this does not predict bacterial infection 2
- Do not assume "bronchitis" requires antibiotics—92% of providers prescribe them inappropriately 6
- Do not obtain chest X-ray if all four red-flag features are absent 1
- Do not use β2-agonists routinely—reserve for patients with documented wheezing 1