What is the appropriate treatment for an otherwise healthy adult with acute bronchitis?

Treatment of Acute Bronchitis in Otherwise Healthy Adults

Antibiotics should NOT be prescribed for acute uncomplicated bronchitis in otherwise healthy adults, as this condition is viral in 89-95% of cases and antibiotics provide minimal benefit (reducing cough by only half a day) while causing significant adverse effects and promoting antibiotic resistance. 1, 2, 3

Initial Assessment: Rule Out Pneumonia First

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

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

If ALL four are absent in adults <70 years without comorbidities, pneumonia is unlikely and chest radiography is not needed 1, 4. If any one is present, obtain chest radiography to rule out pneumonia before treating as bronchitis 2, 3.

Why Antibiotics Don't Work

The evidence against routine antibiotic use is compelling 1, 2:

• Respiratory viruses cause 89-95% of cases – antibiotics are completely ineffective against the underlying cause 2, 3
• Purulent (green/yellow) sputum occurs in 89-95% of viral cases and does NOT indicate bacterial infection; it reflects inflammatory cells, not bacteria 1, 2
• Meta-analysis of randomized trials shows antibiotics reduce cough duration by only 0.5 days (12 hours) but increase adverse events (RR 1.20; 95% CI 1.05-1.36) 2, 5
• The FDA removed acute bronchitis from approved antibiotic indications in 1998 due to lack of efficacy 2

The ONE Exception: Pertussis

If pertussis (whooping cough) is confirmed or strongly suspected, prescribe a macrolide antibiotic (azithromycin or erythromycin) immediately 1, 2, 3. Isolate the patient for 5 days from treatment start, as early treatment diminishes coughing paroxysms and prevents disease spread 2, 3.

Appropriate Symptomatic Management

What TO Use:

• Antitussives (codeine or dextromethorphan) for bothersome dry cough, especially when disturbing sleep – provides modest symptom relief 2, 3, 6
• Short-acting β₂-agonists (albuterol) ONLY in select patients with wheezing accompanying the cough 2, 3, 6
• Environmental measures: eliminate cough triggers and use humidified air 2, 6

What NOT to Use:

• Do NOT routinely prescribe: expectorants, mucolytics, antihistamines, inhaled corticosteroids, oral corticosteroids, or NSAIDs at anti-inflammatory doses – no consistent evidence of benefit 2, 6

Patient Education: The Key to Satisfaction

Patient satisfaction depends MORE on physician-patient communication than whether an antibiotic is prescribed 1, 2, 4. Essential counseling points include:

• Cough typically lasts 10-14 days after the visit and may persist up to 3 weeks even without antibiotics 1, 2, 3
• The condition is self-limiting and viral in nature 2, 3
• Antibiotics expose patients to adverse effects (diarrhea, rash, yeast infections) while contributing to antibiotic resistance without providing meaningful benefit 1, 2
• Consider referring to the condition as a "chest cold" rather than "bronchitis" to reduce antibiotic expectations 2

When to Reassess

Instruct patients to return if 2, 3:

• 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

High-Risk Patients Requiring Different Approach

These recommendations apply exclusively to otherwise healthy adults. Patients with the following conditions may require antibiotics and are beyond the scope of uncomplicated acute bronchitis 2, 3, 6:

• Age >75 years with comorbidities (cardiac failure, insulin-dependent diabetes, serious neurological disorders)
• Chronic lung disease (COPD, chronic bronchitis, bronchiectasis, cystic fibrosis)
• Immunosuppression (HIV, transplant recipients, chronic immunosuppressive therapy)
• Congestive heart failure

For these high-risk patients, if fever persists >3 days, consider amoxicillin 500 mg three times daily for 5-8 days or doxycycline 100 mg twice daily for 5-8 days 3.

Common Pitfalls to Avoid

• Do NOT prescribe antibiotics based on purulent sputum color – this occurs in 89-95% of viral cases 1, 2
• Do NOT prescribe antibiotics based on cough duration alone – viral bronchitis cough normally lasts 10-14 days 2, 3
• Do NOT assume fever in the first 1-3 days indicates bacterial infection – this is consistent with viral bronchitis; only fever persisting >3 days suggests bacterial superinfection 3
• Do NOT diagnose "recurrent acute bronchitis" without considering undiagnosed asthma or COPD – approximately one-third of such patients actually have these conditions 2, 6