Guideline sources The following summarized guidelines for the evaluation and management of acute bronchitis are prepared by our editorial team based on guidelines from the American College of Physicians (ACP 2021), the American College of Chest Physicians (ACCP 2020; 2006), the American Association of Family Physicians (AAFP 2016), the American College of Physicians (ACP/CDC 2016), and the Infectious Diseases Society of America (IDSA 2016). 1 2 3 4 5 6 7 7 7 8 Definition Acute bronchitis is a transient inflammation of the tracheobronchial tree in response to infection without a history of chronic pulmonary disease or evidence of pneumonia or sinusitis. 7 Epidemiology The most common cause of acute bronchitis are viruses (90%) including adenovirus, influenza, measles, respiratory syncytial, parainfluenza, and HSV. Nonvirus (10%) causes include bacteria (Mycoplasma pneumoniae, Bordetella pertussis, and Chlamydia pneumoniae) and inhaled lung irritants. 7 Disease course Inflammation of the tracheobronchial tree results in acute bronchitis, which causes clinical manifestations of cough (dry or productive), chest tightness, burning with or without wheezing, headache, low-grade fever, rhinorrhea, sore throat, malaise, and myalgia. 7 https://web.pathway.md/diseases/recHyEthkR74ppYwt 1/5 6/23/23, 1:37 AM Acute bronchitis Pathway Prognosis and risk of recurrence Acute bronchitis is not associated with an increase in mortality. 8 Pathway Calculator Acute bronchitis Diagnostic criteria for acute bro Diagnosis and management Guidelines 1. Screening and diagnosis Diagnostic criteria: diagnose acute bronchitis in patients with an acute respiratory infection manifested predominantly by cough, with or without sputum production, lasting 3 weeks, if there is no clinical or radiographic evidence of pneumonia, common cold, acute asthma, and COPD exacerbation. E 2. Diagnostic investigations Chest X-ray: As per ACCP 2020 guidelines, avoid obtaining routine CXRs in immunocompetent adult outpatients with cough due to suspected acute bronchitis. As per ACCP 2006 guidelines, avoid obtaining CXRs routinely in patients with acute cough and sputum production meeting all of the following criteria: HR 100 beats/min respiratory rate 24 breaths/min oral body temperature of 38 C normal chest examination. D Laboratory tests: As per ACCP 2020 guidelines, avoid obtaining routine investigation with sputum for microbial culture, respiratory tract samples for viral PCR, CRP, and procalcitonin in immunocompetent adult outpatients with cough due to suspected acute bronchitis. As per ACCP 2006 guidelines, do not obtain sputum analyses, viral cultures, or serologic assays routinely in patients with a presumed diagnosis of acute bronchitis, since the causative pathogen is rarely identified in clinical practice. D Spirometry: avoid obtaining routine spirometry and peak flow measurements in immunocompetent adult outpatients with cough due to suspected acute bronchitis. https://web.pathway.md/diseases/recHyEthkR74ppYwt 2/5 6/23/23, 1:37 AM Acute bronchitis Pathway Further evaluation: consider obtaining reassessment and targeted investigations to help establish the etiology in immunocompetent adult outpatients with persisting or worsening acute bronchitis. 3. Medical management Antibiotic therapy: As per ACP 2021 guidelines, limit antibiotic treatment duration to 5 days when managing patients with acute uncomplicated bronchitis with clinical signs of a bacterial infection (presence of increased sputum purulence in addition to increased dyspnea, and/or increased sputum volume). B Updated evidence: TRAP-LRTI In adults with clinically suspected non-pneumonia lower respiratory tract infection and symptom duration from 24 hours to 28 days, placebo was not noninferior to azithromycin with respect to clinical improvement at day 5. Ephraim L Tsalik et al. Lancet Infect Dis. 2023 Apr. As per ACCP 2020 guidelines: Avoid initiating antibiotics routinely in immunocompetent adult outpatients with cough due to acute bronchitis. Consider initiating antibiotics in patients with worsening acute bronchitis if a complicating bacterial infection is thought likely. As per AAFP 2016 guidelines: Avoid initiating antibiotics routinely in patients with uncomplicated acute bronchitis. D Implement strategies to reduce antibiotic use, such as asking patients to call for or pick up an antibiotic, or to hold an antibiotic prescription for a set amount of time. A As per CDC 2016 guidelines, do not initiate antibiotic therapy in patients with bronchitis unless pneumonia is suspected. D As per ACCP 2006 guidelines, do not initiate antibiotics routinely in patients with a presumed diagnosis of acute bronchitis. D Address the issue of not prescribing antibiotics individually and provide explanations because many patients expect to receive an antibiotic based on previous experiences and public expectations. D Antiviral therapy: avoid initiating antibiotics routinely in immunocompetent adult outpatients with cough due to acute bronchitis. Symptomatic therapy: As per ACCP 2020 guidelines, avoid initiating antitussives, inhaled -agonists, inhaled anticholinergics, ICSs, oral corticosteroids, oral NSAIDs, or other therapies in immunocompetent https://web.pathway.md/diseases/recHyEthkR74ppYwt 3/5 6/23/23, 1:37 AM Acute bronchitis Pathway adult outpatients with cough due to acute bronchitis. As per AAFP 2016 guidelines, consider offering dextromethorphan, guaifenesin, or honey for the management of acute bronchitis symptoms. C Show 2 more As per ACCP 2006 guidelines, do not use -2 agonist bronchodilators routinely to alleviate cough in most patients with acute bronchitis. D Consider offering -2 agonist bronchodilators in selected adult patients with acute bronchitis and wheezing accompanying the cough. D Show 2 more 4. Specific circumstances Patients with Aspergillus bronchitis: Obtain both PCR and galactomannan on respiratory secretions, usually sputum, for the detection of Aspergillus species to confirm the diagnosis of Aspergillus bronchitis in non- transplant patients. B Consider initiating oral itraconazole or voriconazole with therapeutic drug monitoring in non- transplant patients with Aspergillus bronchitis. C References 1. Braman SS. Chronic cough due to acute bronchitis: ACCP evidence-based clinical practice guidelines. Chest. 2006 Jan;129 1 Suppl):95S 103S. Open 2. Rachael A Lee, Robert M Centor, Linda L Humphrey et al. Appropriate Use of Short-Course Antibiotics in Common Infections: Best Practice Advice From the American College of Physicians. Ann Intern Med. 2021 Apr 6. Open 3. Kinkade S, Long NA. Acute Bronchitis. Am Fam Physician. 2016 Oct 1;94 7 560 565. Open 4. Aaron M Harris, Lauri A Hicks, Amir Qaseem et al. Appropriate Antibiotic Use for Acute Respiratory Tract Infection in Adults: Advice for High-Value Care From the American College of Physicians and the Centers for Disease Control and Prevention. Ann Intern Med. 2016 Mar 15;164 6 425 34. Open 5. Maeve P Smith, Mark Lown, Sonal Singh et al. Acute Cough Due to Acute Bronchitis in Immunocompetent Adult Outpatients: CHEST Expert Panel Report. Chest. 2020 May;157 5 1256 1265. Open 6. Patterson TF, Thompson GR rd, Denning DW et al. Practice Guidelines for the Diagnosis and Management of Aspergillosis: 2016 Update by the Infectious Diseases Society of America. Clin Infect Dis. 2016 Aug 15;63 4):e1-e60. Open 7. James L Whiteside, John W Whiteside. Acute bronchitis: a review of diagnosis and evidence-based management. May-Jun 2002;9 3 105 109.May-Jun 2002;9 3 105 109. Open 8. Peter Wark. Bronchitis (acute). 2015 Jul 17;2015 1508.2015 Jul 17;2015 1508. Open 9. Albert RH. Diagnosis and treatment of acute bronchitis. Am Fam Physician. 2010 Dec 1;82 11 1345 50. Open https://web.pathway.md/diseases/recHyEthkR74ppYwt 4/5 6/23/23, 1:37 AM Acute bronchitis Pathway 10. Infectious Diseases Society of America. Choosing Wisely: Recommendations of the Infectious Diseases Society of America. Choosing Wisely. 2015 Feb. Open 11. American Academy of Pediatrics. Choosing Wisely AAP recommendations. Choosing Wisely. 2018. Open https://web.pathway.md/diseases/recHyEthkR74ppYwt 5/5