Can systemic corticosteroids be given for acute infective bronchitis with a white blood cell count of 16,000/µL and C‑reactive protein of 18 mg/L in a patient without asthma or chronic obstructive pulmonary disease?

Systemic Corticosteroids Should NOT Be Given for Acute Infective Bronchitis

Systemic corticosteroids are not indicated for acute infective bronchitis, even with elevated inflammatory markers (WBC 16,000/µL, CRP 18 mg/L), because this condition is viral in 89–95% of cases and steroids provide no clinical benefit while exposing patients to unnecessary adverse effects. 1, 2

Why Steroids Don't Work in Acute Bronchitis

• Respiratory viruses cause 89–95% of acute bronchitis episodes in otherwise healthy adults, making anti-inflammatory therapy biologically ineffective against the underlying pathogen. 1, 2

• The 2020 CHEST Expert Panel explicitly recommends against routine prescription of oral corticosteroids for immunocompetent adult outpatients with acute bronchitis, stating no evidence supports their safety or efficacy in making cough less severe or resolve sooner. 1, 2

• Purulent sputum occurs in 89–95% of viral bronchitis and reflects inflammatory cells rather than bacterial infection—it does not justify steroid therapy. 2

Your Patient's Elevated Inflammatory Markers Do Not Change This Recommendation

• A WBC of 16,000/µL and CRP of 18 mg/L are common in viral bronchitis and do not indicate bacterial superinfection requiring steroids. 1

• Fever persisting beyond 3 days (not just elevated inflammatory markers at presentation) is the threshold that suggests possible bacterial superinfection or pneumonia and warrants reassessment—not immediate steroid therapy. 2

Critical Diagnostic Step: Rule Out Conditions That DO Require Steroids

Before labeling this as simple acute bronchitis, you must exclude:

• Pneumonia: Check for heart rate >100 bpm, respiratory rate >24 breaths/min, temperature >38°C, or focal lung findings (crackles, egophony, increased fremitus)—any of these warrant chest radiography rather than a bronchitis diagnosis. 1, 2

• Asthma exacerbation: Approximately one-third of patients labeled with "recurrent acute bronchitis" actually have undiagnosed asthma, which does benefit from steroids; look for wheezing, nocturnal cough worsening, or response to bronchodilators. 2

• COPD exacerbation: If the patient has known chronic bronchitis or COPD and meets at least two of three Anthonisen criteria (increased dyspnea, increased sputum volume, increased sputum purulence), then systemic corticosteroids are indicated—but this is a different disease entity. 2, 3, 4

What TO Do Instead

• Patient education: Explain that cough typically lasts 10–14 days and may persist up to 3 weeks even without treatment, that the illness is self-limiting and viral, and that steroids provide no benefit while causing adverse effects (hyperglycemia, weight gain, insomnia, immunosuppression). 2, 3

• Symptomatic relief:

  • Use antitussives (codeine or dextromethorphan) for bothersome dry cough, especially if it disrupts sleep. 2
  • Reserve short-acting β₂-agonists (albuterol) only for patients with wheezing. 2
  • Recommend environmental measures: removal of irritants and humidified air. 2

• Reassessment criteria (advise return if):

  • Fever persists >3 days (suggesting bacterial superinfection or pneumonia). 2
  • Cough persists >3 weeks (consider asthma, COPD, pertussis, GERD). 2
  • Symptoms worsen rather than gradually improve. 2

Common Pitfalls to Avoid

• Do not prescribe steroids based on elevated WBC or CRP alone—these markers are elevated in viral bronchitis and do not indicate bacterial infection or steroid-responsive disease. 1, 2

• Do not assume purulent sputum means bacterial infection—it occurs in 89–95% of viral cases. 2

• Do not use "bilateral rhonchi" or other auscultatory findings as justification for steroids—these are typical of acute bronchitis and do not constitute an indication for corticosteroid therapy. 2

• Do not confuse acute bronchitis with acute exacerbation of chronic bronchitis—only the latter benefits from steroids (prednisone 40 mg daily for 5–7 days). 3, 4

Evidence Summary

Intervention	Outcome	Evidence Quality
Systemic corticosteroids for acute bronchitis	No benefit in symptom duration, clinical scores, or hospital outcomes	High (guideline recommendation) [1,2]
Systemic corticosteroids for COPD exacerbation	Improves lung function, shortens recovery, reduces treatment failure	Moderate-to-strong [3,4]
Systemic corticosteroids for bronchiolitis (children)	No benefit in length of stay or clinical outcomes	High (meta-analysis of 1,200 patients) [1,5]

The French guidelines explicitly state that systemic corticosteroids are not justified in the treatment of acute bronchitis in healthy adults, and this recommendation is echoed by the American College of Chest Physicians, the American Academy of Family Physicians, and the European Respiratory Society. 3