What is the appropriate treatment for acute bronchitis in an otherwise healthy adult?

Treatment for Acute Bronchitis

Antibiotics should not be prescribed for acute bronchitis in otherwise healthy adults, regardless of cough duration or sputum color, because the illness is viral in 89-95% of cases and antibiotics shorten cough by only half a day while causing significant adverse effects. 1, 2

Initial Assessment: Rule Out Pneumonia First

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

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

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

If all four criteria are absent in patients <70 years without comorbidities, pneumonia is unlikely and chest radiography is not needed. 1

Why Antibiotics Don't Work

The evidence against antibiotics is compelling:

• Viral etiology: Respiratory viruses cause 89-95% of acute bronchitis cases 1, 2
• Minimal benefit: Antibiotics reduce cough duration by only 0.5 days (approximately 12 hours) 1, 4
• Increased harm: Antibiotics increase adverse events with a relative risk of 1.20 (95% CI 1.05-1.36), including diarrhea, rash, and yeast infections 1

Common pitfall: Purulent (green/yellow) sputum occurs in 89-95% of viral bronchitis cases and does NOT indicate bacterial infection—it reflects inflammatory cells, not bacteria. 1, 5

Appropriate Symptomatic Management

For Bothersome Cough

• Antitussives (codeine or dextromethorphan) provide modest relief, especially for dry cough that disrupts sleep 1, 3

For Wheezing Only

• Short-acting β₂-agonists (albuterol) should be used ONLY in patients with accompanying wheezing 1, 3
• Do not use bronchodilators routinely in the absence of wheeze 1

Environmental Measures

• Remove irritants (dust, allergens) and use humidified air 1

What NOT to Use

Avoid the following—they lack evidence of benefit: 1, 3

• Expectorants or mucolytics
• Antihistamines
• Inhaled or oral corticosteroids
• NSAIDs at anti-inflammatory doses
• Inhaled anticholinergics

The Pertussis Exception

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 and isolate the patient for 5 days from treatment start. 1

Early macrolide therapy reduces cough paroxysms and prevents disease spread. 1

Essential Patient Education

Set realistic expectations about illness duration: 1, 3

• Cough typically lasts 10-14 days after the visit
• Cough may persist up to 3 weeks even without treatment
• The condition is self-limiting and viral

Explain why antibiotics are being withheld: 1

• Antibiotics do not shorten the illness
• They expose patients to side effects (diarrhea, rash, yeast infections)
• Previous antibiotic use increases carriage of resistant bacteria

Communication matters more than prescriptions: Patient satisfaction depends more on clear physician-patient communication than whether an antibiotic is prescribed. 1

Terminology tip: Referring to the illness as a "chest cold" rather than "bronchitis" reduces patient expectations for antibiotics. 1

When to Reassess

Advise patients to return if: 1, 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

Consider Alternative Diagnoses

Approximately one-third of patients with "recurrent acute bronchitis" actually have undiagnosed asthma or COPD. 1

Perform spirometry or peak-flow testing if: 1

• Patient smokes or has other risk factors
• Recurrent episodes occur
• Cough worsens at night or with exercise

A ≥12% and ≥200 mL increase in FEV₁ after bronchodilator (or ≥20% peak-flow improvement) confirms reversible airway disease. 1

Special Populations (Different Management)

These recommendations apply ONLY to otherwise healthy adults. The following groups require individualized management and may need antibiotics: 1

• Patients ≥75 years with fever and comorbidities (heart failure, insulin-dependent diabetes, serious neurologic disease)
• Chronic lung disease (COPD, chronic bronchitis, bronchiectasis, cystic fibrosis)
• Immunosuppressed patients
• Patients with cardiac failure

For COPD exacerbations, antibiotics are considered when at least two of the three Anthonisen criteria are met: increased dyspnea, increased sputum volume, and increased sputum purulence. 1