Treatment of Acute Bronchitis in a 70-Year-Old Patient
Do not prescribe antibiotics for uncomplicated acute bronchitis in this 70-year-old patient—antibiotics provide no meaningful clinical benefit (reducing cough by only half a day) while causing significant adverse effects and promoting antibiotic resistance. 1, 2
Initial Assessment: Rule Out Pneumonia First
Before diagnosing acute bronchitis, you must exclude pneumonia by checking these four vital parameters 1, 3:
- Heart rate >100 beats/min
- Respiratory rate >24 breaths/min
- Oral temperature >38°C (100.4°F)
- Abnormal chest examination findings (rales, egophony, tactile fremitus)
If ALL four are absent, pneumonia is unlikely and chest radiography is not needed. 1, 4 If ANY ONE is present, obtain a chest X-ray before treating as bronchitis. 1
Why Antibiotics Don't Work
The evidence is unequivocal 1:
- 89-95% of acute bronchitis is viral—antibiotics cannot treat viruses 1, 5
- Antibiotics shorten cough by only 0.5 days (approximately 12 hours) 1
- Antibiotics increase adverse events (RR 1.20; 95% CI 1.05-1.36) 1
- Purulent (green/yellow) sputum occurs in 89-95% of viral cases and does NOT indicate bacterial infection 1, 5
Recommended Treatment: Symptomatic Management Only
Patient Education (Most Important)
Inform the patient that cough typically lasts 10-14 days and may persist up to 3 weeks, even without antibiotics. 6, 1, 2 Patient satisfaction depends more on clear physician-patient communication than on receiving antibiotics. 6, 7
Symptomatic Relief Options
For bothersome dry cough (especially disrupting sleep):
For wheezing accompanying the cough:
- Short-acting β₂-agonist (albuterol) only if wheezing is present 6, 1, 2
- Do NOT use routinely in patients without wheezing 1
Low-risk supportive measures:
- Remove environmental cough triggers (dust, dander) 6
- Humidified air, especially in low-humidity environments 6, 1
What NOT to Prescribe
Do not use these medications—they lack evidence of benefit 1, 3:
- Expectorants or mucolytics
- Antihistamines
- Inhaled or oral corticosteroids
- NSAIDs at anti-inflammatory doses
Special Exception: Pertussis
If pertussis (whooping cough) is suspected or confirmed, prescribe a macrolide antibiotic (azithromycin or erythromycin) immediately and isolate the patient for 5 days from treatment start. 1, 2 Early treatment reduces coughing paroxysms and prevents disease spread. 1
Age-Specific Consideration for This 70-Year-Old
While age 70 alone does not justify antibiotics for uncomplicated acute bronchitis 1, 2, consider antibiotics more readily if this patient has:
- Cardiac failure 1, 2
- Insulin-dependent diabetes 1, 2
- Immunosuppression 1
- Chronic lung disease (COPD, chronic bronchitis) 1, 3
If any of these comorbidities are present, this is no longer "uncomplicated" acute bronchitis and requires different management. 1, 3
When to Reassess
Instruct the patient 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
Common Pitfalls to Avoid
- Do NOT prescribe antibiotics based on purulent sputum color—this occurs in 89-95% of viral cases 1, 5
- Do NOT assume cough duration indicates bacterial infection—viral cough normally lasts 10-14 days 1
- Do NOT prescribe antibiotics to meet patient expectations—focus on communication instead 6, 7
- Do NOT use the term "bronchitis" with patients—call it a "chest cold" to reduce antibiotic expectations 6, 1
Communication Strategy
- Expected duration: Cough will last 10-14 days, possibly up to 3 weeks
- Why no antibiotics: This is viral, and antibiotics cause side effects (diarrhea, rash, yeast infections) without benefit
- Personalize the risk: Previous antibiotic use increases carriage of resistant bacteria
- Rare serious reactions: Anaphylaxis can occur with antibiotics