What is the appropriate first-line management for an adult presenting with acute bronchitis?

Management of Acute Bronchitis in Adults

Antibiotics should NOT be prescribed for acute uncomplicated bronchitis in otherwise healthy adults, regardless of cough duration, sputum color, or patient expectations—this is a viral illness in 89-95% of cases where antibiotics provide no meaningful benefit while causing harm. 1, 2, 3

First-Line Management: Symptomatic Care Only

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 ANY of these are present, obtain a chest radiograph to rule out pneumonia—do not treat as simple bronchitis. 1, 2, 3

Why Antibiotics Don't Work

The evidence against routine antibiotic use is overwhelming:

• Respiratory viruses cause 89-95% of acute bronchitis cases, making antibiotics completely ineffective against the underlying pathogen 1, 2
• Antibiotics shorten cough by only 0.5 days (approximately 12 hours) 1, 2
• Antibiotics increase adverse events (diarrhea, rash, yeast infections) with a risk ratio of 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, 4, 2

Recommended Symptomatic Treatment

Patient Education (most important intervention):

• Inform patients that cough typically lasts 10-14 days and may persist up to 3 weeks even without treatment 1, 2, 3
• Explain that patient satisfaction depends more on clear communication than antibiotic prescription 1, 2
• Consider referring to the illness as a "chest cold" rather than "bronchitis" to reduce antibiotic expectations 2

Pharmacologic Options for Symptom Relief:

• Antitussives (codeine or dextromethorphan): Provide modest relief for bothersome dry cough, especially when it disturbs sleep 1, 2, 3
• Short-acting β₂-agonists (albuterol): Use ONLY in patients with wheezing accompanying the cough 1, 2, 3

Environmental Measures:

• Remove environmental cough triggers (dust, dander, irritants) 1, 2
• Use humidified air, especially in low-humidity settings 1, 2

What NOT to Prescribe

Do not routinely use 1, 2:

• Expectorants or mucolytics
• Antihistamines
• Inhaled or oral corticosteroids
• NSAIDs at anti-inflammatory doses
• Antibiotics of any class

The ONE Exception: Pertussis (Whooping Cough)

If pertussis is confirmed or strongly suspected (paroxysmal cough, post-tussive vomiting, inspiratory "whoop," cough >2 weeks):

• Prescribe a macrolide antibiotic immediately (azithromycin or erythromycin) 1, 2, 3
• Isolate the patient for 5 days from treatment start 1, 2
• Early treatment reduces coughing paroxysms and prevents disease spread 1, 2

When to Reassess (Red Flags)

Instruct patients to return if 1, 2, 3:

• 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

High-Risk Patients Who May Need Different Management

These recommendations apply only to otherwise healthy adults. The following populations require individualized assessment and may need antibiotics 1, 2, 3:

• Age >75 years with cardiac failure, insulin-dependent diabetes, or serious neurological disorders 1, 2
• Patients with COPD or chronic bronchitis (see chronic bronchitis exacerbation criteria below)
• Immunocompromised patients 2, 3
• Patients with heart failure 2, 3

Management of Acute Exacerbations of Chronic Bronchitis (COPD Patients)

This is a different disease from acute bronchitis in healthy adults. Consider antibiotics if the patient has chronic respiratory insufficiency (dyspnea at rest, FEV₁ <35%, PaO₂ <60 mmHg) 1 OR meets at least 2 of 3 Anthonisen criteria 1, 2:

1. Increased dyspnea
2. Increased sputum volume
3. Increased sputum purulence

First-line antibiotics for chronic bronchitis exacerbations 1, 2:

• Amoxicillin 500 mg three times daily for 5-8 days
• Doxycycline 100 mg twice daily for 5-8 days
• Macrolides (azithromycin, clarithromycin)

For severe exacerbations or frequent exacerbations 1, 2:

• Amoxicillin-clavulanate 625 mg three times daily for 7-14 days
• Respiratory fluoroquinolones (levofloxacin)

Critical Pitfalls to Avoid

• Do NOT prescribe antibiotics based on purulent sputum color alone—this occurs in 89-95% of viral cases 1, 4, 2
• Do NOT assume bacterial infection based on cough duration—viral cough normally lasts 10-14 days 1, 2
• Do NOT prescribe antibiotics for early fever (first 1-3 days)—only fever persisting >3 days suggests bacterial superinfection 2, 3
• Do NOT confuse acute bronchitis with asthma or COPD exacerbations—approximately one-third of patients diagnosed with "recurrent acute bronchitis" actually have undiagnosed asthma 1
• Do NOT prescribe cefoperazone-sulbactam for outpatient bronchitis—it is reserved for hospital-acquired infections 4