What is the appropriate treatment for acute bronchitis presenting with green, productive sputum?

Acute Bronchitis with Green Productive Sputum: Do NOT Prescribe Antibiotics

For otherwise healthy adults with acute bronchitis presenting with green or purulent sputum, antibiotics should NOT be prescribed, as green sputum occurs in 89-95% of viral cases and does not indicate bacterial infection. 1, 2

Why Green Sputum Does NOT Mean Bacterial Infection

• Green or yellow sputum is present in 89-95% of viral bronchitis cases and reflects inflammatory cells and shed epithelial cells, not bacterial proliferation 1, 2
• Respiratory viruses cause 89-95% of acute bronchitis episodes, making antibiotics completely ineffective regardless of sputum color 1, 2
• Antibiotics shorten cough by only ~0.5 days (approximately 12 hours) while significantly increasing adverse events (RR 1.20; 95% CI 1.05-1.36) including diarrhea, rash, and yeast infections 1, 2

Critical First Step: Rule Out Pneumonia

Before diagnosing acute bronchitis, check vital signs and perform a focused lung examination to exclude pneumonia 1, 3:

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

If ANY of these are present, obtain a chest radiograph to rule out pneumonia rather than treating as simple bronchitis 1, 3

Recommended Management Algorithm

1. Patient Education (Most Important)

• Inform patients that cough typically lasts 10-14 days and may persist up to 3 weeks, even without antibiotics 1, 2, 3
• Refer to the condition as a "chest cold" rather than "bronchitis" to reduce antibiotic expectations 2, 3
• Explain that antibiotics provide no benefit while causing side effects and contributing to antibiotic resistance 1, 2
• Patient satisfaction depends more on physician-patient communication than whether an antibiotic is prescribed 2, 3

2. Symptomatic Treatment Options

• Codeine or dextromethorphan for bothersome dry cough, especially if disrupting sleep 1, 2, 3
• Short-acting β₂-agonists (albuterol) ONLY if wheezing is present accompanying the cough 1, 2, 3
• Environmental measures: remove irritants (dust, smoke) and use humidified air 2

3. What NOT to Use

• Do NOT prescribe antibiotics, expectorants, mucolytics, antihistamines, inhaled corticosteroids, oral corticosteroids, or NSAIDs at anti-inflammatory doses for uncomplicated acute bronchitis 1, 2

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

When to Reassess (Red Flags)

Advise patients to return if:

• Fever persists >3 days (suggests possible bacterial superinfection or pneumonia) 1, 2
• Cough persists >3 weeks (consider asthma, COPD, pertussis, GERD) 1, 2
• Symptoms worsen rather than gradually improve 1, 2

High-Risk Patients Requiring Different Approach

These recommendations apply ONLY to otherwise healthy adults. The following patients may require antibiotics and individualized management 2, 3:

• Age ≥75 years with fever and comorbidities (heart failure, insulin-dependent diabetes, serious neurologic disease)
• Chronic lung disease (COPD, chronic bronchitis, bronchiectasis)
• Immunosuppression
• Cardiac failure

For COPD exacerbations, consider antibiotics when at least 2 of 3 Anthonisen criteria are met: increased dyspnea, increased sputum volume, increased sputum purulence 2, 4

Common Pitfalls to Avoid

• Do NOT prescribe antibiotics based on purulent sputum color alone – this occurs in 89-95% of viral cases 1, 2
• Do NOT rely on cough duration to justify antibiotics – viral cough normally lasts 10-14 days 1, 2
• Do NOT assume fever in the first 1-3 days indicates bacterial infection – only fever persisting >3 days suggests possible bacterial superinfection 1, 2
• Do NOT miss undiagnosed asthma or COPD – approximately one-third of patients with "recurrent acute bronchitis" actually have undiagnosed reactive airway disease 1, 2