Do Not Prescribe Azithromycin (Z-Pak) for Acute Uncomplicated Bronchitis
You should not prescribe azithromycin for this patient—acute uncomplicated bronchitis is a viral illness in over 90% of cases, and antibiotics provide no meaningful benefit while causing unnecessary adverse events and promoting resistance. 1
Why Antibiotics Are Not Indicated
- The American College of Physicians and CDC explicitly recommend against routine antibiotic treatment for acute bronchitis in the absence of pneumonia 1
- A systematic review of 15 randomized controlled trials found that patients with acute bronchitis treated with macrolides (including azithromycin) had significantly more adverse events than those receiving placebo, with no improvement in cough resolution 1
- Even when antibiotics showed any effect, the benefit was trivial—decreasing cough and sputum production by only approximately half a day 2
Rule Out Pneumonia First
Before dismissing antibiotics entirely, you must exclude pneumonia using clinical criteria. For healthy adults under 70 years, pneumonia is unlikely if ALL of the following are absent: 1
- Heart rate >100 beats/min
- Respiratory rate >24 breaths/min
- Oral temperature >38°C (100.4°F)
- Abnormal chest examination findings (rales, egophony, or tactile fremitus)
If pneumonia IS suspected based on these criteria, then chest radiography and antibiotics become appropriate 1. For penicillin-allergic patients with confirmed community-acquired pneumonia, a respiratory fluoroquinolone (such as levofloxacin or moxifloxacin) is the recommended alternative—not azithromycin monotherapy due to increasing macrolide resistance 3.
What to Prescribe Instead
Provide symptomatic relief rather than antibiotics: 1
- Cough suppressants, expectorants, and decongestants for symptom management 1
- β-agonists (albuterol) only if the patient has underlying asthma or COPD—not beneficial otherwise 1
The Penicillin Allergy Is Irrelevant Here
The penicillin allergy matters only if this were pneumonia requiring antibiotics. Since acute uncomplicated bronchitis does not warrant antibiotics regardless of allergy status, the penicillin allergy is a red herring in this clinical scenario.
Critical Pitfall to Avoid
Don't be fooled by colored sputum—this is the most common reason clinicians inappropriately prescribe antibiotics for viral bronchitis 1. Purulent-appearing sputum is caused by neutrophil peroxidase activity and occurs with viral infections; it does not indicate bacterial infection requiring antibiotics 1.
Acute bronchitis leads to more inappropriate antibiotic prescribing than any other respiratory infection in adults, with over 70% of visits resulting in unnecessary prescriptions 1. Your patient will recover without antibiotics in 2-3 weeks with supportive care alone.