Should I prescribe antibiotics for an otherwise healthy adult who calls after hours with an acute productive cough but no evidence of bacterial infection?

Do Not Prescribe Antibiotics for Acute Productive Cough Without Evidence of Bacterial Infection

For an otherwise healthy adult calling after hours with an acute productive cough and no signs of pneumonia or bacterial infection, antibiotics should NOT be prescribed. This is a viral illness in 89-95% of cases, and antibiotics provide no meaningful benefit while causing harm. 1, 2

Why Antibiotics Are Not Indicated

The Evidence Is Clear

• Respiratory viruses cause 89-95% of acute bronchitis cases in otherwise healthy adults 1, 2
• Antibiotics shorten cough duration by only approximately 0.5 days (12 hours) 1, 2
• Antibiotics increase adverse events with a relative risk of 1.20 (95% CI 1.05-1.36), meaning more harm than benefit 1, 2
• Purulent (green or yellow) sputum occurs in 89-95% of viral cases and does NOT indicate bacterial infection 1, 2

Common Misconceptions to Address

• Sputum color is NOT a criterion for antibiotics – purulent sputum reflects inflammatory cells, not bacteria 1, 3
• Cough duration alone does not justify antibiotics – viral cough typically lasts 10-14 days and may persist up to 3 weeks 1, 2
• The FDA removed uncomplicated acute bronchitis from approved antibiotic indications in 1998 2

When to Suspect Pneumonia Instead (Requires Different Management)

Before diagnosing simple acute bronchitis, pneumonia must be excluded by checking for ANY of the following: 1, 3

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

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

In healthy adults <70 years, if ALL four criteria are absent, pneumonia is unlikely and antibiotics are not needed. 3

What to Tell the Patient

Set Realistic Expectations

• Cough typically lasts 10-14 days after the call and may persist up to 3 weeks, even without antibiotics 1, 2
• The illness is self-limiting and viral in origin 1, 2
• Patient satisfaction depends more on clear communication than receiving an antibiotic prescription 2

Explain Why No Antibiotics

• Antibiotics do not shorten the illness and expose patients to side effects (diarrhea, rash, yeast infections) 1, 2
• Antibiotics contribute to antimicrobial resistance without providing benefit 1, 2
• The number needed to harm (8) exceeds the number needed to treat (18) 3

Symptomatic Management Options

Recommended Measures

• Antitussives (codeine or dextromethorphan) for bothersome dry cough, especially if disrupting sleep 1, 2
• Short-acting β₂-agonists (e.g., albuterol) ONLY if wheezing is present 1, 2
• Environmental measures: remove irritants (dust, allergens) and use humidified air 2

Do NOT Prescribe

• Expectorants, mucolytics, antihistamines 1, 2
• Inhaled or oral corticosteroids 1, 2
• NSAIDs at anti-inflammatory doses 1, 2

Red-Flag Criteria for Follow-Up

Instruct the patient to seek reassessment if: 1, 2

• Fever persists >3 days (suggests possible bacterial superinfection or pneumonia)
• Cough persists >3 weeks (consider asthma, COPD, pertussis, GERD)
• Symptoms worsen rather than gradually improve
• Development of dyspnea at rest, chest pain, or inability to maintain oral intake 3

The One Exception: Pertussis

If pertussis is confirmed or strongly suspected (paroxysmal cough, post-tussive vomiting, inspiratory "whoop," cough >2 weeks): 1, 2

• Prescribe a macrolide antibiotic (azithromycin or erythromycin) immediately
• Isolate the patient for 5 days from treatment start
• Early treatment reduces cough paroxysms and limits transmission

Critical Pitfalls to Avoid

• Do NOT prescribe antibiotics based on purulent sputum alone – this occurs in 89-95% of viral cases 1, 2
• Do NOT use cough duration as justification – viral cough normally lasts 10-14 days 1, 2
• Do NOT assume early fever (first 1-3 days) indicates bacterial infection – only fever >3 days raises concern 3
• Do NOT prescribe antibiotics to meet patient expectations – focus on education and communication instead 1, 2