What prescription and management should be given for acute bronchitis in an adult, including indications for antibiotics and recommended drug choices?

Management of Acute Bronchitis in Adults

For immunocompetent adult outpatients with acute bronchitis, do not prescribe antibiotics, antitussives, bronchodilators, corticosteroids, or NSAIDs routinely—provide patient education on the expected 10-14 day cough duration and symptomatic relief measures only. 1, 2

Initial Assessment: Rule Out Pneumonia First

Before diagnosing acute bronchitis, you must exclude pneumonia by checking four vital parameters 1, 2:

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

If ANY of these are present, obtain a chest radiograph to rule out pneumonia rather than treating as simple bronchitis. 1, 2 In adults <70 years without comorbidities, if all four parameters are normal, pneumonia is unlikely and chest X-ray is not needed. 2

Why Antibiotics Should NOT Be Prescribed

The evidence against routine antibiotics is compelling 1, 2, 3:

• Respiratory viruses cause 89-95% of acute bronchitis cases—antibiotics are completely ineffective against the underlying cause 2, 4
• Antibiotics shorten cough by only 0.5 days (approximately 12 hours) 1, 2, 3
• Antibiotics increase adverse events (RR 1.20; 95% CI 1.05-1.36), including diarrhea, rash, and yeast infections 1, 2
• Purulent (green/yellow) sputum occurs in 89-95% of viral cases and does NOT indicate bacterial infection 2, 5
• Cough duration is NOT a marker of bacterial infection—viral bronchitis cough normally lasts 10-14 days 2, 6

The ONE Exception: Pertussis

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

What TO Prescribe: Symptomatic Management

First-Line Options for Cough and Congestion

For acute viral cough with congestion, prescribe first-generation antihistamine/decongestant combinations (e.g., brompheniramine/pseudoephedrine) unless contraindications exist. 7 Contraindications include glaucoma, benign prostatic hypertrophy, uncontrolled hypertension, renal failure, and heart failure. 7

Naproxen is an alternative for patients who cannot take antihistamine-decongestant combinations, but avoid in patients with GI bleeding, renal failure, or heart failure. 7

Antitussives: Limited Role

• Dextromethorphan or codeine may provide modest relief for bothersome dry cough, especially when it disrupts sleep 2, 7
• These agents are more effective in acute bronchitis than in early viral upper respiratory infections 7
• Codeine is NOT recommended for common cold-related cough as it lacks proven efficacy 7

Bronchodilators: Only for Wheezing

Reserve short-acting β₂-agonists (albuterol) ONLY for patients with wheezing accompanying the cough. 1, 2, 7 Do not use bronchodilators routinely in the absence of wheezing. 1, 2

Supportive Measures

• Acetaminophen or ibuprofen for pain, fever, or general discomfort 7
• Nasal saline irrigation for congestion relief with minimal adverse effects 7
• Humidified air and removal of environmental irritants (dust, dander) 2, 7
• Topical intranasal corticosteroids may provide modest congestion relief 7

What NOT to Prescribe

The 2020 CHEST Expert Panel recommends against routine use of 1, 2:

• Expectorants or mucolytics (including guaifenesin)—no consistent favorable effect 2, 7
• Inhaled or oral corticosteroids—not effective for uncomplicated bronchitis 1, 2
• Oral NSAIDs at anti-inflammatory doses—no benefit demonstrated 1, 2
• Newer-generation nonsedating antihistamines—ineffective for acute viral cough 7

Patient Education: The Key to Satisfaction

Patient satisfaction depends more on physician-patient communication than whether medications are prescribed. 2, 7, 6 Your communication should include 2:

• Cough typically lasts 10-14 days after the visit and may persist up to 3 weeks even without treatment 1, 2, 7
• Antibiotics do not shorten the illness and expose patients to side effects (diarrhea, rash, candidiasis) 2
• Antibiotics contribute to antimicrobial resistance without meaningful clinical benefit 2
• Referring to the illness as a "chest cold" rather than "bronchitis" reduces patient expectations for antibiotics 2

When to Reassess (Red Flags)

Advise patients to return if 2:

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

Common Diagnostic Pitfalls

Undiagnosed Asthma or COPD

Approximately one-third of patients diagnosed with "recurrent acute bronchitis" actually have undiagnosed asthma or COPD. 1, 2 Consider spirometry or peak-flow testing in patients with 2:

• Recurrent episodes of "acute bronchitis"
• Smoking history or risk factors
• Persistent cough >2-3 weeks that worsens at night or with cold/exercise

Diagnostic thresholds: ≥12% and ≥200 mL FEV₁ improvement after bronchodilator, or ≥20% peak-flow improvement. 2

Do NOT Assume Bacterial Infection Based On

• Purulent sputum color—occurs in 89-95% of viral cases 2, 5
• Cough duration alone—viral cough normally lasts 10-14 days 2
• Early fever (first 1-3 days)—only fever >3 days suggests bacterial superinfection 2

Special Populations (Different Management Required)

These recommendations apply ONLY to otherwise healthy adults. Patients with the following conditions require individualized management and are outside the scope of uncomplicated bronchitis guidelines 2, 5, 8:

• COPD or chronic bronchitis
• Heart failure
• Immunosuppression
• Age >75 years with significant comorbidities (cardiac failure, insulin-dependent diabetes)
• Bronchiectasis or cystic fibrosis

For elderly patients with comorbidities or COPD exacerbations, consider antibiotics if the patient has at least one key symptom (increased dyspnea, increased sputum volume, or increased sputum purulence) plus risk factors. 5, 8

Special Consideration: Influenza

If influenza is suspected and the patient presents within 48 hours of symptom onset, initiate antiviral treatment (neuraminidase inhibitors). 7 Antiviral treatment may decrease antibiotic usage, hospitalization, and improve outcomes. 7