Treatment for Viral Bronchitis
Antibiotics should NOT be prescribed for acute viral bronchitis—the condition is self-limiting, resolves in 10–14 days with supportive care alone, and antibiotics provide no clinical benefit while exposing patients to adverse effects and promoting resistance. 1, 2
Diagnostic Confirmation Before Treatment
- Rule out pneumonia first by checking for heart rate >100 bpm, respiratory rate >24 breaths/min, oral temperature >38°C, or abnormal chest findings (crackles, egophony, increased tactile fremitus)—if any are present, obtain a chest radiograph rather than treating as simple bronchitis. 1, 3
- Respiratory viruses cause 89–95% of acute bronchitis cases, making antibiotics completely ineffective regardless of which agent you choose. 1, 4
- Green or yellow sputum occurs in 89–95% of viral cases and does NOT indicate bacterial infection—it reflects inflammatory cells, not bacteria. 1, 5
- Cough duration is not a marker of bacterial infection—viral bronchitis cough typically lasts 10–14 days and may persist up to 3 weeks. 1, 2
Primary Treatment: Symptomatic Management & Patient Education
What TO Do
- Inform patients that cough will last 10–14 days (up to 3 weeks) even without treatment, and that the illness is self-limiting. 1, 3
- For bothersome dry cough (especially nocturnal): offer codeine or dextromethorphan for modest symptomatic relief. 1, 3
- For wheezing accompanying the cough: use short-acting β₂-agonists (e.g., albuterol) only in these select patients. 1, 3
- Environmental measures: remove irritants (dust, allergens) and use humidified air to reduce cough severity. 1
- Refer to the illness as a "chest cold" rather than "bronchitis" to lower patient expectations for antibiotics. 1, 2
What NOT to Do
- Do NOT prescribe antibiotics—they shorten cough by only
0.5 day (12 hours) while increasing adverse events (RR 1.20; 95% CI 1.05–1.36). 1, 2 - Do NOT use expectorants, mucolytics, antihistamines, inhaled or oral corticosteroids, or NSAIDs at anti-inflammatory doses—no consistent benefit demonstrated. 1, 3
- Do NOT prescribe antibiotics based on purulent sputum color or cough duration alone—these do not indicate bacterial infection. 1, 5
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 (azithromycin or erythromycin) immediately. 1, 3
- Isolate the patient for 5 days from treatment start—early therapy reduces cough paroxysms and limits transmission. 1, 3
High-Risk Populations Requiring Different Management
- Patients ≥75 years with fever and comorbidities (heart failure, insulin-dependent diabetes, serious neurologic disease), those with COPD/chronic bronchitis, or immunosuppressed patients may require antibiotics—these groups are outside the scope of uncomplicated viral bronchitis. 1, 3
- For COPD exacerbations, consider antibiotics when at least two of the three Anthonisen criteria are met: increased dyspnea, increased sputum volume, increased sputum purulence. 1
Red-Flag Criteria for Reassessment
- Fever persisting >3 days suggests possible bacterial superinfection or pneumonia—reassess and consider chest radiograph. 1, 3
- Cough persisting >3 weeks warrants evaluation for asthma, COPD, pertussis, or gastroesophageal reflux. 1, 3
- Symptoms worsening rather than gradually improving require re-evaluation. 1
Communication Strategy to Improve Patient Satisfaction
- Patient satisfaction depends more on physician-patient communication than on receiving an antibiotic prescription. 1, 5
- Explain that antibiotics expose patients to adverse effects (diarrhea, rash, yeast infections) and promote antibiotic resistance without providing benefit. 1, 2
- Personalize the risk of resistance by mentioning that previous antibiotic use increases colonization with resistant bacteria. 1
Common Pitfalls to Avoid
- Do NOT assume bacterial infection before the 3-day fever threshold—most cases are viral. 1
- Do NOT prescribe antibiotics to satisfy patient expectations—focus on communication instead. 1, 5
- Do NOT overlook undiagnosed asthma or COPD—approximately one-third of patients labeled with "recurrent acute bronchitis" actually have undiagnosed reversible airway disease. 1