What are the current recommendations for the treatment of acute bronchitis?

Treatment of Acute Bronchitis

Antibiotics should NOT be prescribed for acute bronchitis in otherwise healthy adults, regardless of cough duration, sputum color, or patient expectations—the illness is viral in 89-95% of cases, antibiotics shorten cough by only half a day while increasing adverse events, and symptomatic management with patient education is the appropriate treatment. 1, 2, 3

Exclude Pneumonia First

Before diagnosing acute bronchitis, you must rule out pneumonia by checking four vital signs and performing a focused chest examination 1, 3:

• Heart rate >100 beats/min 1, 3
• Respiratory rate >24 breaths/min 1, 3
• Oral temperature >38°C 1, 3
• Abnormal chest findings (rales, egophony, tactile fremitus, focal consolidation) 1, 3

If all four are absent, pneumonia is very unlikely and chest radiography is not needed 1, 4. If any one is present, obtain a chest X-ray before treating as bronchitis 1, 3.

Why Antibiotics Don't Work

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

• Respiratory viruses cause 89-95% of cases—antibiotics are completely ineffective against the underlying pathogen 1, 2, 3, 5, 6
• Antibiotics reduce cough by only 0.5 days (≈12 hours) while significantly increasing adverse events (RR 1.20; 95% CI 1.05-1.36) 1, 2
• 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, 3
• Cough duration is NOT a marker of bacterial infection—viral bronchitis cough normally lasts 10-14 days and may persist up to 3 weeks 1, 2, 3, 5

The ONE Exception: Pertussis

For confirmed or suspected pertussis (whooping cough), prescribe a macrolide antibiotic (azithromycin or erythromycin) immediately 1, 2, 3:

• Suspect pertussis if cough persists >2 weeks with paroxysmal cough, post-tussive vomiting, inspiratory "whoop," or recent pertussis exposure 1, 5
• Isolate the patient for 5 days from treatment start 1, 2
• Early treatment (within first few weeks) diminishes coughing paroxysms and prevents disease spread 1, 2

Symptomatic Management

What TO Use

• Antitussives (codeine or dextromethorphan) for bothersome dry cough, especially if it disturbs sleep—provides modest relief 1, 2, 3, 6
• Short-acting β₂-agonists (albuterol) ONLY in patients with wheezing accompanying the cough—not for routine use 1, 3, 4, 6
• Environmental measures: remove irritants (dust, dander) and use humidified air 1, 3

What NOT to Use

The following have no proven benefit and should NOT be prescribed 1:

• Expectorants or mucolytics
• Antihistamines
• Inhaled or oral corticosteroids
• NSAIDs at anti-inflammatory doses
• Routine bronchodilators (without wheezing)

Patient Education Strategy

Physician-patient communication has a greater impact on satisfaction than whether an antibiotic is prescribed 1, 2, 7. Your communication plan should include 1, 2, 3:

• Explain expected duration: "Your cough will typically last 10-14 days and may persist up to 3 weeks, even without antibiotics" 1, 2, 3, 5
• Refer to it as a "chest cold" rather than "bronchitis" to reduce antibiotic expectations 1, 2
• Clarify that antibiotics don't help: "Antibiotics shorten the illness by only 12 hours but expose you to side effects like diarrhea, rash, and yeast infections" 1, 2
• Emphasize resistance: "Previous antibiotic use increases your carriage of resistant bacteria" 1, 2

When to Reassess (Red Flags)

Instruct patients to return if 1, 3:

• Fever persists >3 days—suggests possible bacterial superinfection or pneumonia 1, 3
• Cough persists >3 weeks—consider asthma, COPD, pertussis, gastroesophageal reflux, or upper-airway cough syndrome 1, 3
• Symptoms worsen rather than gradually improve 1, 3

High-Risk Patients (Different Approach)

These recommendations apply only to otherwise healthy adults. Consider antibiotics more readily in 1, 3:

• Age ≥75 years with fever 1, 3
• Cardiac failure 1, 3
• Insulin-dependent diabetes 1, 3
• Immunosuppression 1, 3
• COPD with FEV₁ <50% 1, 3

For these high-risk patients, prescribe antibiotics only if they have at least 2 of the 3 Anthonisen criteria: increased dyspnea, increased sputum volume, increased sputum purulence 1, 3.

Common Pitfalls to Avoid

• Do NOT prescribe antibiotics based on purulent sputum—this occurs in 89-95% of viral cases 1, 2, 3
• Do NOT prescribe antibiotics based on cough duration alone—viral cough normally lasts 10-14 days 1, 2, 3
• Do NOT assume early fever (first 1-3 days) indicates bacterial infection—only fever persisting >3 days suggests bacterial superinfection 1, 3
• Do NOT diagnose acute bronchitis in patients with known asthma or COPD—approximately one-third of patients diagnosed with "recurrent acute bronchitis" actually have undiagnosed asthma 1, 3