Should systemic corticosteroids be given to an elderly male with uncomplicated acute bronchitis, bilateral rhonchi, leukocytosis (white‑cell count 15 × 10⁹/L) and elevated C‑reactive protein (20 mg/L)?

Should Systemic Corticosteroids Be Given to This Elderly Male with Acute Bronchitis?

No, systemic corticosteroids should NOT be given to this patient with uncomplicated acute bronchitis, even with bilateral rhonchi, leukocytosis (WBC 15,000), and elevated CRP (20 mg/L)—these findings do not indicate bacterial infection or justify steroid therapy. 1, 2

Why Steroids Are Not Indicated

The Evidence Is Clear and Consistent

• Multiple major guidelines explicitly recommend against systemic corticosteroids for acute bronchitis in otherwise healthy adults. The 2020 CHEST Expert Panel states that oral corticosteroids should not be routinely prescribed for immunocompetent adults with acute bronchitis until shown to be safe and effective. 1, 2

• French guidelines explicitly state that systemic corticosteroids are not justified in the treatment of acute bronchitis in healthy adults. 2

• Acute bronchitis is viral in 89–95% of cases—respiratory viruses (influenza, parainfluenza, respiratory syncytial virus, coronavirus, adenovirus, rhinovirus) cause the vast majority of episodes, making steroids biologically ineffective against the underlying pathogen. 1, 3

Your Patient's Lab Values Do Not Change This Recommendation

• Leukocytosis (WBC 15,000) and elevated CRP (20 mg/L) occur commonly in viral bronchitis and do NOT indicate bacterial superinfection. These inflammatory markers reflect the host immune response to viral infection, not bacterial invasion. 2, 3

• Purulent sputum (if present) occurs in 89–95% of viral bronchitis cases and does not justify antibiotics or steroids—it reflects inflammatory cells and shed epithelium, not bacteria. 1, 2, 3

• Bilateral rhonchi are typical findings in acute bronchitis and represent airway secretions and inflammation, not an indication for corticosteroid therapy. 1

Critical Diagnostic Step: Rule Out Pneumonia First

Before confirming acute bronchitis, you must exclude pneumonia by checking vital signs and performing a focused chest examination. 1, 2, 3

Obtain a chest X-ray if ANY of the following are present: 1, 2, 3

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

If pneumonia is present, the management changes entirely—but this would no longer be "uncomplicated acute bronchitis."

When Steroids ARE Indicated: The Critical Distinction

Systemic corticosteroids are indicated ONLY when the patient has an acute exacerbation of chronic bronchitis/COPD, NOT simple acute bronchitis. 1, 2, 4, 5

Acute Exacerbation of Chronic Bronchitis (Different Disease)

For patients with established chronic bronchitis or COPD experiencing an acute exacerbation, systemic corticosteroids improve outcomes: 1, 2, 5

• Prednisone 40 mg daily for 5–7 days (or equivalent) improves lung function (FEV₁), oxygenation, shortens recovery time, and reduces hospitalization duration. 2, 5

• Criteria for this diagnosis include: 1, 2

  • Known history of chronic bronchitis or COPD
  • Acute worsening with at least 2 of 3 Anthonisen criteria: increased dyspnea, increased sputum volume, increased sputum purulence
  • Often preceded by upper respiratory symptoms

Your patient's presentation does not meet these criteria unless he has documented underlying COPD/chronic bronchitis. 2

What You SHOULD Do Instead

Appropriate Management of Acute Bronchitis

1. Patient education is paramount: 1, 2, 3

   • Inform the patient that cough typically lasts 10–14 days and may persist up to 3 weeks even without treatment
   • Explain that the condition is self-limiting and viral in nature
   • Clarify that steroids (and antibiotics) provide no benefit while exposing him to unnecessary risks

2. Symptomatic relief only: 1, 2, 3

   • Codeine or dextromethorphan for bothersome dry cough, especially if disrupting sleep
   • Short-acting β₂-agonists (albuterol) ONLY if wheezing is present
   • Environmental measures: remove irritants, use humidified air

3. Reassessment criteria—instruct the patient to return if: 1, 2, 3

   • Fever persists >3 days (suggests bacterial superinfection or pneumonia)
   • Cough persists >3 weeks (consider asthma, COPD, pertussis, GERD)
   • Symptoms worsen rather than gradually improve

Common Pitfalls to Avoid

• Do NOT prescribe steroids based on elevated inflammatory markers (WBC, CRP) alone—these are non-specific and occur in viral infections. 2, 3

• Do NOT assume bacterial infection based on rhonchi or sputum characteristics—89–95% of acute bronchitis is viral regardless of these findings. 1, 2, 3

• Do NOT confuse acute bronchitis with asthma exacerbation—approximately one-third of patients labeled with "recurrent acute bronchitis" actually have undiagnosed asthma, which DOES benefit from steroids. 2, 3

• Do NOT use steroids hoping to shorten illness duration—no evidence supports this practice in acute bronchitis, and you expose the patient to hyperglycemia, immunosuppression, insomnia, and weight gain. 2

Special Consideration for Elderly Patients

While this patient is elderly, age alone does not justify steroids for acute bronchitis. 2, 3

However, elderly patients with significant comorbidities (heart failure, insulin-dependent diabetes, serious neurologic disease) may warrant closer monitoring and possibly antibiotics if fever persists >3 days—but still NOT routine steroids. 2, 3

If this patient has underlying COPD/chronic bronchitis that you are unaware of, then the diagnosis is NOT acute bronchitis but rather an acute exacerbation of chronic bronchitis, and steroids would be indicated. 1, 2, 5