Acute Bronchitis in Adults

8/7/23, 20:31 Acute bronchitis in adults - UpToDate
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Acute bronchitis in adults

AUTHOR: Thomas M File, Jr, MD
SECTION EDITORS: Daniel J Sexton, MD, Mark D Aronson, MD
DEPUTY EDITORS: Sheila Bond, MD, Jane Givens, MD, MSCE
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Jun 2023.

This topic last updated: Apr 25, 2023.
INTRODUCTION
Acute bronchitis is a common clinical condition characterized by an acute onset but persistent
cough, with or without sputum production. It is typically self-limited, resolving within one to
three weeks. Symptoms result from inflammation of the lower respiratory tract and are most
frequently due to viral infection.
Treatment is focused on patient education and supportive care. Antibiotics are not needed for
the great majority of patients with acute bronchitis but are greatly overused for this condition.
Reducing antibiotic use for acute bronchitis is a national and international health care priority.
(See 'Avoiding antibiotic overuse' below.)
The clinical features, diagnosis, and management of acute bronchitis are addressed here.
Chronic bronchitis, a subtype of chronic obstructive pulmonary disease, is discussed separately.
(See "Management of infection in exacerbations of chronic obstructive pulmonary disease" and
"Chronic obstructive pulmonary disease: Diagnosis and staging".)
DEFINITIONS
● Acute bronchitis is a lower respiratory tract infection involving the large airways (bronchi),
without evidence of pneumonia, that occurs in the absence of chronic obstructive
pulmonary disease.
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● Chronic bronchitis is a subtype of chronic obstructive pulmonary disease and is defined as

a cough that lasts for at least three months in each of two successive years. (See "Chronic
obstructive pulmonary disease: Diagnosis and staging", section on 'Definitions'.)
EPIDEMIOLOGY
Acute bronchitis is one of the most common conditions encountered in clinical practice. It
accounts for approximately 10 percent of ambulatory care visits in the United States, or 100
million visits per year [1]. In the Northern hemisphere, the incidence of acute bronchitis is
highest in late fall and winter when transmission of respiratory viruses peaks ( figure 1) [2-4].
MICROBIOLOGY
Viruses — Viruses are the most commonly identified pathogens in patients with acute bronchitis
[5-9]. In two case series, viruses accounted for about 60 percent of cases in which pathogens
were identified [6,9]. The most common viral causes of acute bronchitis include [5,6]:
● Influenza A and B
● Parainfluenza
● Coronavirus types 1 to 3
● Rhinoviruses
● Respiratory syncytial virus
● Human metapneumovirus
Of the viral agents that cause acute bronchitis, influenza merits special consideration because of
its morbidity and the potential for specific therapy. (See "Seasonal influenza in nonpregnant
adults: Treatment" and "Seasonal influenza in adults: Clinical manifestations and diagnosis".)
Severe acute respiratory syndrome coronavirus 2, the virus that causes coronavirus disease 2019
(COVID-19), can also cause prolonged cough. (See "COVID-19: Clinical features" and "COVID-19:
Evaluation and management of adults with persistent symptoms following acute illness ("Long
COVID")".)
Other pathogens — Bacteria are uncommon causes of acute bronchitis, accounting for only 6
percent of cases in a single series evaluating adults hospitalized with acute bronchitis [6]. The
bacteria most commonly associated with acute bronchitis include Bordetella pertussis,
Mycoplasma pneumoniae, and Chlamydia pneumoniae [6,9,10].
Among these bacteria, B. pertussis is the most likely to cause prolonged cough. The overall
incidence of pertussis and associated outbreaks are rising worldwide [11]. In patients with
prolonged cough, reported rates of pertussis range from 1 to 12 percent [12,13]. Pertussis is one
of the few bacterial causes of acute bronchitis that may respond to antibiotic therapy.
M. pneumoniae and C. pneumoniae are each common causes of upper respiratory tract infections.
While each has the potential to cause lower respiratory tract infection, including both acute
bronchitis and pneumonia, rates of prolonged cough or acute bronchitis caused by these
bacteria vary among cases series, ranging from 0 to 6 percent [6,14,15].
Bordetella bronchiseptica, the cause of kennel cough in dogs, is a rarely reported but likely under-
recognized cause of cough in humans [16,17]. Clinical manifestations range from mild
respiratory illnesses, such as bronchitis or pertussis-like syndromes, to pneumonia and sepsis
[16,18]. Most infections occur in immunocompromised individuals exposed to farms or pets,
although infections in immunocompetent patients and hospital-acquired transmission have
been reported [16,17,19-25].
There is no convincing evidence to support the concept of "acute bacterial bronchitis," caused by
pathogens such as Streptococcus pneumoniae, Staphylococcus aureus, Haemophilus influenzae,
Moraxella catarrhalis, or other gram-negative bacilli in adults without airway instrumentation (eg,
tracheostomy, endotracheal intubation) or chronic obstructive pulmonary disease. (See
"Management of infection in exacerbations of chronic obstructive pulmonary disease".)
CLINICAL FEATURES
Cough is the cardinal symptom in patients presenting with acute bronchitis. In most patients,
the cough persists for 1 to 3 weeks, with a median duration of 18 days [3,12,26]. The cough may
be associated with either purulent or nonpurulent sputum production [3,27]. The presence of
purulent sputum is a nonspecific finding and does not appear to be predictive of bacterial
infection or response to antibiotics [28,29].
Upper respiratory tract infection (URI; eg, common cold) can precede the onset of acute
bronchitis. During the first few days of illness, symptoms associated with these two conditions
such as headache, nasal congestion, and sore throat can overlap [3,27]. For some patients, URI
symptoms resolve without lower tract involvement; for others, infection progresses to involve
the lower tract (ie, acute bronchitis) With involvement of the lower respiratory tract, cough
becomes the predominant symptom. The frequency with which URIs progress to acute
bronchitis is not known.
Wheezing and mild dyspnea may accompany the cough. Both wheezing and rhonchi may be
auscultated on physical examination; rhonchi usually clear with coughing. Although pulmonary
function testing is typically not indicated in clinical practice, bronchospasm, evidenced by
reduced forced expiratory volume in one second (FEV1), has been reported in 40 percent of
patients in a small case series [30], and bronchial hyperreactivity can be demonstrated with
provocative testing [7]. Bronchial hyper-responsiveness is typically transient, resolving in six
weeks, and is believed to be the mechanism that underlies the persistent cough [7,30].
With prolonged coughing, chest wall or substernal musculoskeletal pain can occur [3,27]. Other
complications are rare; most common among them are the development of pneumonia or
bacterial superinfection. For most patients, acute bronchitis is a self-limited illness that does not
require specific diagnostic testing or treatment.
Certain clinical features suggest a specific cause or an alternate diagnosis that may require
antimicrobial therapy ( table 1). For example, paroxysms of cough accompanied by an
inspiratory whoop or post-tussive emesis suggest pertussis, particularly during known
outbreaks. Fever, or other systemic symptoms, are rare in patients with acute bronchitis. These
findings, in addition to cough and sputum production, should raise suspicion for influenza or
pneumonia ( figure 2). On physical examination, signs of parenchymal consolidation such as
dullness to percussion, decreased or bronchial breath sounds, rales, egophony, or signs of
pleural inflammation such as a pleural rub suggest that disease extends beyond the bronchi,
and chest imaging should be considered. (See 'Chest radiograph' below.)
DIAGNOSIS
Clinical diagnosis — Acute bronchitis should be suspected in patients with an acute onset but
persistent cough (often lasting one to three weeks) who do not have clinical findings suggestive
of pneumonia (eg, fever, tachypnea, rales, signs of parenchymal consolidation) and do not have
chronic obstructive pulmonary disease. For most patients, the diagnosis can be made based
upon the history and physical examination. Testing for COVID-19 is recommended for all
patients during the COVID-19 pandemic. Otherwise, testing is generally reserved for cases in
which pneumonia is suspected, the clinical diagnosis is uncertain, or when results would change
management (eg, a positive influenza test result in a patient who meets criteria for antiviral
therapy) ( algorithm 1).
(Related Pathway(s): Acute bronchitis: Evaluation of suspected acute bronchitis in adults.)
Chest radiograph — Chest radiographs are unlikely to change management for most patients
with acute cough [31,32]. In patients with acute bronchitis, chest radiographs are either normal
or findings are nonspecific, though subtle changes consistent with thickening of the bronchial
walls in the lower lobes are occasionally reported [31].
The primary reason for obtaining a chest radiograph is to exclude pneumonia; reasonable
indications for suspecting pneumonia and obtaining imaging include the following [33-39]:
● Abnormal vital signs (pulse >100/minute, respiratory rate >22 breaths/minute, temperature
>38°C [100.4°F], or oxygen saturation <95 percent)
● Signs of consolidation on chest examination (rales, egophony, or tactile fremitus)
● Mental status or behavioral changes in patients >75 years old, who may not mount a fever
Additional factors, such as moderate or severe dyspnea, hemoptysis, immunocompromise, older

age, and/or dementia, raise the likelihood of pneumonia or other underlying pulmonary
disorders. The decision to obtain a chest radiograph or other imaging should always take the full
clinical picture into consideration.
Microbiologic testing — For most patients, testing for specific pathogens is not needed
because results will not change management. Gram stain and bacterial cultures of expectorated
sputum are specifically not recommended because bacterial pathogens are rare causes of acute
bronchitis [33,40-43].
Circumstances in which microbiologic testing may change treatment options include:
● Suspicion for COVID-19 – During the pandemic, testing for COVID-19 should be performed
in all patients presenting with possible respiratory tract infections. (See "COVID-19:
Diagnosis".)
● Suspicion for influenza – Testing for influenza may be indicated in patients who are at
high risk for complications ( table 2), hospitalized patients, and health care workers who
may benefit from treatment and/or when results would be helpful for providing local
surveillance data or implementing infection control measures. Testing options vary with
clinical setting. When indicated, treatment should not be withheld while awaiting the
results of diagnostic testing. (See "Seasonal influenza in adults: Clinical manifestations and
diagnosis".)
● Suspicion for pertussis – Microbiologic confirmation is usually not needed for patients
with pertussis. When confirmation is desired based on patient risk status or public health
concern, multiple testing options are available ( figure 3). Selection of the most
appropriate test varies by duration of cough. (See "Pertussis infection in adolescents and
adults: Clinical manifestations and diagnosis", section on 'Approach to diagnosis'.)
It is usually unrealistic and unnecessary to attempt to determine if Mycoplasma or Chlamydia are

the etiologic agents of acute bronchitis. Diagnostic testing may be justified in suspected
outbreaks, when antibiotics might limit spread [44]. (See "Mycoplasma pneumoniae infection in
adults", section on 'Diagnosis' and "Pneumonia caused by Chlamydia pneumoniae in adults",
section on 'Diagnosis'.)
Testing for Bordetella bronchiseptica, a rare cause of prolonged cough, may be warranted in
patients with exposures to sick animals, such as veterinary workers, or in immunocompromised
patients with respiratory illnesses that cannot be otherwise diagnosed. Culture of the organism
from the affected site is the gold standard for diagnosis. Use of specialized transport and culture
media is preferred when testing for B. bronchiseptica, and laboratories should be informed in
advance when this organism is suspected [16]. Some polymerase chain reaction (PCR) assays
designed for the detection of Bordetella pertussis also detect B. bronchiseptica [45,46].
Procalcitonin — Procalcitonin is a serum biomarker that helps distinguish bacterial infection

from other causes of infection or inflammation. We do not routinely use procalcitonin in the
evaluation of patients with a clinical diagnosis of bronchitis. We reserve procalcitonin testing for
cases in which there is diagnostic uncertainty and need for antibiotics is unclear. Testing should
only be performed at centers where results can be obtained in a timely manner. (See
"Procalcitonin use in lower respiratory tract infections", section on 'Acute bronchitis'.)
DIFFERENTIAL DIAGNOSIS
Because the diagnosis of acute bronchitis is based on history and physical examination, it is
important to assess carefully for other causes of acute cough that may be reversible or require
additional testing or treatment when evaluating the patient with acute cough. The most
common causes of acute cough are listed below and summarized in the table ( table 3) [47].
● Pneumonia – Cough accompanied by abnormal vital signs (fever, tachypnea, or

tachycardia), signs of consolidation or rales on physical examination, or mental status
changes in older adult patients each suggest the possibility of pneumonia. In such cases, a
confirmatory chest radiograph is needed to distinguish acute bronchitis from pneumonia
( figure 2) [34]. (See "Clinical evaluation and diagnostic testing for community-acquired
pneumonia in adults".)
● COVID-19 – COVID-19 can present as an acute upper or lower respiratory tract infection.
Cough and other symptoms such as dyspnea and fatigue can persist for prolonged periods
following acute infection. (See "COVID-19: Clinical features" and "COVID-19: Evaluation and
management of adults with persistent symptoms following acute illness ("Long COVID")".)
● Postnasal drip syndrome – The sensation of postnasal drainage, the need to frequently
clear their throat, and/or rhinorrhea are consistent with postnasal drip. Postnasal drip can
be caused by the common cold, allergic rhinitis, vasomotor rhinitis, postinfectious rhinitis,
rhinosinusitis, and/or environmental irritants. (See "An overview of rhinitis" and "Acute
sinusitis and rhinosinusitis in adults: Clinical manifestations and diagnosis".)
● Gastroesophageal reflux (GERD) – Heartburn, regurgitation, and dysphagia are common

symptoms of GERD, although cough may be the sole presenting symptom in some
patients. (See "Clinical manifestations and diagnosis of gastroesophageal reflux in adults".)
● Asthma – A history of episodic wheezing, cough, and shortness of breath suggest asthma,
particularly when these symptoms occur in response to triggers such as allergen or irritant
exposure, exercise, or viral infections.
For patients presenting with their first episode of asthma, it may not be possible to
distinguish this diagnosis from acute bronchitis [48]. In one study, 65 percent of patients
who had two or more episodes of bronchitis over a five-year period were found to have
mild asthma [49]. (See "Asthma in adolescents and adults: Evaluation and diagnosis" and
"Reactive airways dysfunction syndrome and irritant-induced asthma".)
For patients with known asthma, checking a peak flow expiratory rate can help determine
whether an asthma exacerbation is complicating acute bronchitis and what additional
treatment may be needed. (See "Acute exacerbations of asthma in adults: Home and office
management", section on 'Detecting an exacerbation'.)
● ACE inhibitor use – A nonproductive cough is a well-recognized complication of treatment

with angiotensin-converting enzyme (ACE) inhibitors, occurring in up to 15 percent of
patients treated with these agents. For most, ACE inhibitor-induced cough arises within
one week of starting therapy and presents as a tickling or scratchy sensation in the throat.
It typically resolves within one to four days of discontinuing therapy but can take up to four
weeks. (See "Causes and epidemiology of subacute and chronic cough in adults", section
on 'ACE inhibitors and other medications'.)
● Heart failure – Cough accompanied by shortness of breath, particularly with exertion or

when lying flat, should raise suspicion for heart failure. Physical examination findings such
as a gallop rhythm, displaced apical impulse, elevated jugular venous pressure, and
peripheral edema should further heighten suspicion and indicate need for further testing.
(See "Heart failure: Clinical manifestations and diagnosis in adults".)
● Pulmonary embolism (PE) – Dyspnea, pleuritic chest pain, and hemoptysis in addition to
cough are classic symptoms associated with PE. However, presenting symptoms vary and
can be mild and nonspecific. Physical examination findings also vary, but those that
support this diagnosis include tachypnea, tachycardia, and lower extremity swelling. Any
suspicion for PE warrants further evaluation. (See "Clinical presentation, evaluation, and
diagnosis of the nonpregnant adult with suspected acute pulmonary embolism".)
● Lung cancer – Lung cancer is an uncommon cause of acute cough but should be
considered in any current or prior smoker. Features that should raise suspicion for this
diagnosis include a recent change in a chronic "smoker's cough," hemoptysis, and signs of
focal airway obstruction on physical examination such as wheeze or decreased breath
sounds.
Additional causes of prolonged cough and an approach to evaluation of patients with cough
lasting >3 weeks are discussed separately. (See "Causes and epidemiology of subacute and
chronic cough in adults".)
The differential diagnosis of prolonged cough in immunocompromised patients is more

inclusive and discussed separately. (See "Epidemiology of pulmonary infections in
immunocompromised patients".)
TREATMENT
For most patients with acute bronchitis, symptoms are self-limited, resolving in about one to
three weeks. Reassurance and symptom control are the cornerstones of care. Antibiotics are not
recommended for routine use [1,50-52]. By definition, acute bronchitis occurs in the absence of
chronic obstructive pulmonary disease (COPD). Symptoms of acute bronchitis that occur in
patients with COPD typically indicate an acute exacerbation of COPD, which is managed
differently. (See "COPD exacerbations: Management".)
Patient education — We suggest having a discussion on the expected course of illness and
treatment plan with all patients. Reassuring patients that acute bronchitis is a self-limited illness
that typically resolves in one to three weeks without specific therapy can help improve patient
satisfaction and reduce inappropriate antibiotic use [3,27].
For patients who request antibiotics, we encourage having an explicit discussion on the risks and
benefits of their use (see 'Avoiding antibiotic overuse' below). For the great majority of patients,
use of antibiotics does not hasten recovery or prevent complications but puts patients at
increased risk of adverse effects including potentially severe complications such as Clostridioides
difficile infection and anaphylaxis [52,53]. Provision of patient handouts, offering nonantibiotic
medications for symptom control, engaging in shared decision-making [54,55], and using
delayed prescriptions (eg, providing a prescription to be filled only if symptoms persist) can also
help reduce antibiotic use; each has shown to be effective in randomized trials or meta-analyses
[56-62]. (See 'Information for patients' below.)
The United States Centers for Disease Control and Prevention (CDC) handout for patients on the
treatment and prevention of acute bronchitis can be found here.
Symptom control
For cough
● Nonpharmacologic therapy – For patients with acute bronchitis who are bothered by
cough, offering nonpharmacologic options for cough relief such as throat lozenges, hot
tea, honey, and/or smoking cessation or avoidance of secondhand smoke is a reasonable
first step. Most of these interventions have not been directly evaluated in clinical trials,
however, they may provide some benefit and expected harms are small ( table 4). (See
"Evaluation and treatment of subacute and chronic cough in adults", section on
'Nonpharmacologic interventions' and "Overview of smoking cessation management in
adults".)
● Pharmacologic therapy – For patients with acute bronchitis who desire medication for
cough relief, we suggest offering over-the-counter (OTC) medications, such as
dextromethorphan or guaifenesin. Selection of an OTC medication should take into
account patient comorbidities and drug interactions ( table 4).
As an example, selective serotonin reuptake inhibitors (SSRIs) may enhance the

serotonergic effect of dextromethorphan (eg, precipitate serotonin syndrome). Although
the benefits of these medications for symptom improvement in patients with acute
bronchitis are uncertain, multiple clinical practice guidelines suggest that offering
medications for symptom relief may help reduce requests for antibiotics [1,50]. No
randomized trials have directly evaluated the use of antitussives in patients with acute
bronchitis, and a large systematic review of OTC medications for acute cough, including 19
trials in over 3000 adults primarily with the common cold, concluded that there is no strong
evidence for or against the effectiveness of OTC cough medications [63]. We specifically
avoid use of opioid cough suppressants, such as codeine, due to their addictive potential
and side effect profile.
Antitussives for the treatment of cough are reviewed separately. (See "Evaluation and
treatment of subacute and chronic cough in adults".)
We suggest limiting use of inhaled beta-agonists, such as albuterol, and reserve their use for
patients with wheezing and underlying pulmonary disease. A single randomized controlled trial
evaluating 42 adults with acute bronchitis showed reduced rates of cough at 7 days in patients
taking inhaled albuterol compared with placebo (61 versus 91 percent) [64]. About one-half of
patients in this trial had wheezing at baseline. When this trial was analyzed in a meta-analysis of
studies comparing other oral beta-agonists as well as other inhaled beta-agonists, similar
reductions in cough were not detected [65].
We suggest not using ibuprofen, oral corticosteroids, or herbal remedies for cough related to
acute bronchitis, either due to lack of efficacy or safety concerns. Both ibuprofen and oral
corticosteroids were not shown to be more effective than placebo for reducing severity or
duration of cough in randomized trials [66,67]. A systematic review found no quality randomized
trials to support the use of Chinese herbs for acute bronchitis, with a note of concern about side
effects and safety [68]. A liquid herbal preparation derived from the roots of Pelargonium sidoides
(EPs 7630) appears to shorten the duration of symptoms in acute bronchitis based on two
randomized trials [69]; however, these trials were determined to be low quality and concerns
have been raised about potential liver injury with its use [70,71].
For concurrent cold symptoms — Many patients with acute bronchitis have associated
symptoms of the common cold, particularly early in the course of illness. Analgesics, either
acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs), may help relieve symptoms
such as headache, malaise, muscle pain, and joint pain. Antihistamine/decongestant
combinations, intranasal or inhaled cromolyn sodium, and intranasal ipratropium may also
provide relief for some patients, though the likelihood of benefit should be weighed against
potential side effects. A detailed discussion of options and their efficacy for treating the common
cold is presented separately. (See "The common cold in adults: Treatment and prevention".)
Antimicrobial therapy — Acute bronchitis usually is caused by viruses. Inappropriate use of

antibiotics for viral respiratory infections can cause adverse events and contribute to
development of antibiotic resistance.
Multiple major medical societies and health care organizations, including the CDC, American
College of Physicians, and the National Health Services in the United Kingdom, specifically
recommend against the routine use of empiric antibiotics for the treatment of acute bronchitis
[1,50,52]. Avoidance of antibiotics for the treatment of adults with acute bronchitis was also
included as a component of the Healthcare Effectiveness Data and Information Set reported to
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the National Committee for Quality Assurance in 2007 and included as a National Quality Forum
quality measure [51,72].
The rare instances in which antibiotics may improve outcomes are discussed below. (See 'Rare
indications for use' below.)
Avoiding antibiotic overuse — For the great majority of patients with acute bronchitis, we
recommend not using empiric antibiotics. We suggest having an explicit discussion on the risks
and benefits of antibiotic use for patients who desire antibiotics. For most patients, the risks
associated with antibiotic use outweigh the benefits. Discussion can also help align patient and
provider expectations. A systematic review found that a physician's perception of patient desire
for antibiotics was strongly associated with antibiotic prescription, more so than actual patient
desire [28].
Multiple high-quality trials and meta-analyses have shown that antibiotics do not provide
substantial benefit or enhance likelihood of cure in patients with acute bronchitis, and use can
result in adverse effects [1,53,73-76]. A large observational study found no increase in the rate of
complications in patients who were not prescribed antibiotics for acute lower respiratory tract
infections [77].
● A randomized trial evaluating over 2000 patients with acute bronchitis found no difference
in symptom severity or duration in adults treated with amoxicillin compared with placebo
[74]. Lack of antibiotic efficacy was also observed in a prespecified subgroup analysis of
over 500 adults >60 years old. This trial was included in a meta-analysis of 11 studies
comparing antibiotic treatment with placebo in 3841 patients with acute bronchitis [53,76].
Results were inconsistent across studies included in the meta-analysis, with some
suggesting marginal benefit.
● Antibiotic use has also been associated with an increased risk of adverse effects compared
with placebo in a meta-analysis of 11 trials with 3162 patients with acute bronchitis (risk
ratio 1.22, 95% CI 1.07-1.4) [53]. The most commonly reported adverse events were nausea,
vomiting, diarrhea, rash, headache, and vaginitis; serious adverse events reported included
anaphylaxis [53,73]. Based on the meta-analysis, the number needed to harm with
antibiotics is 24.
● The effect of antibiotic use on complication rates was assessed in a prospective cohort
study evaluating over 28,000 adults with acute cough lasting <3 weeks without
radiographic evidence of pneumonia. Major complications, including hospital admission
and death, occurred in <1 percent of patients; no significant difference in event rates was
detected when comparing patients given immediate antibiotic prescriptions with delayed
prescription or no prescription [77].
Antibiotic use also alters the patient's microbiome (which may actually impair immune function)
and carries the risk of inducing antibiotic-resistant organisms both in the individual patient and
in the community [78-80]. Furthermore, antibiotic use also comes at increased financial cost.
Despite these data, inappropriate antibiotic prescription for the treatment of bronchitis is
widespread. Studies indicate that 50 to 90 percent of patients with acute bronchitis who seek
care are given antibiotics, making acute bronchitis one of the most common reasons for
antibiotic overuse [28,60,81-86].
Reducing inappropriate use for the treatment of acute bronchitis is a national and international
health care priority [1,50-52]. To promote appropriate antibiotic use, the CDC has launched a
program that offers online educational resources for both patients and providers.
Of note, the COVID-19 pandemic has led to an overall reduction in outpatient visits and
antimicrobial prescribing for acute bronchitis [87]. This can be attributed in part to the impact of
mitigation practices (eg, masking, physical distancing, avoidance of crowds) leading to reduction
of respiratory viral infections.
Rare indications for use — Antimicrobial therapy is generally reserved for cases in which a
specific pathogen is suspected or diagnosed in patients who are at high risk for complications or
when treatment might limit spread of a contagious illness. The most common scenarios are
discussed below:
● Influenza – Most patients with influenza do not require therapy. Treatment is reserved for
hospitalized patients or those at high risk for complications ( table 2). Neuraminidase
inhibitors, either oseltamivir or zanamivir, are the recommended first-line agents, though
local antiviral resistance patterns should be taken into account when prescribing therapy
( table 5). Treatment is most effective when given early in the course of illness. When
indicated, treatment should not be withheld while awaiting the results of diagnostic
testing. (See "Seasonal influenza in nonpregnant adults: Treatment".)
● Pertussis – Antibiotic therapy is recommended for clinically suspected or confirmed

pertussis in patients with cough ≤3 weeks and suggested for pregnant women with cough
<6 weeks. Antibiotics can also be considered in other circumstances in which treatment
may limit spread ( algorithm 2A-B). Macrolides are first-line therapy ( table 6 and
algorithm 2B). (See "Pertussis infection in adolescents and adults: Treatment and
prevention".)
● COVID-19 – Treatment of COVID-19 is discussed separately. (See "COVID-19: Management

in hospitalized adults" and "COVID-19: Management of adults with acute illness in the
outpatient setting".)
Treatment for acute bronchitis due to M. pneumoniae or C. pneumoniae, in the absence of

pneumonia, is generally not recommended. Direct evidence supporting this approach is limited
to a single randomized trial that showed no difference in cough in patients given erythromycin
compared with patients given placebo [88].
There are limited data to guide the best treatment approach for patients with the rare diagnosis
of bronchitis due to B. bronchiseptica. Tetracyclines and fluoroquinolones have been used in
most cases reported in the literature with success [23,89]. However, resistance profiles vary
[16,23], and selection of antibiotic should be based on susceptibility testing results. Emergence
of resistance while on therapy has also been reported in immunocompromised patients [17].
FOLLOW-UP
Most patients with acute bronchitis recover without complications within 1 to 3 weeks and do
not require follow-up but should be educated on features that warrant concern such as new-
onset fever, difficulty breathing, symptoms lasting >3 to 4 weeks, or bloody sputum.
The evaluation of patients presenting with cough lasting >3 weeks is discussed separately. (See
"Causes and epidemiology of subacute and chronic cough in adults".)
INFORMATION FOR PATIENTS
UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics."
The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading
level, and they answer the four or five key questions a patient might have about a given
condition. These articles are best for patients who want a general overview and who prefer
short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more
sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading
level and are best for patients who want in-depth information and are comfortable with some
medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print
or email these topics to your patients. (You can also locate patient education articles on a variety
of subjects by searching on "patient info" and the keyword(s) of interest.)
● Basics topics (see "Patient education: Acute bronchitis (The Basics)" and "Patient education:
Cough in adults (The Basics)" and "Patient education: What you should know about
antibiotics (The Basics)" and "Patient education: Coughing up blood (The Basics)")
● Beyond the Basics topic (See "Patient education: Acute bronchitis in adults (Beyond the
Basics)".)
SUMMARY AND RECOMMENDATIONS
● Clinical features − Acute bronchitis is a common clinical condition characterized by cough,

with or without sputum production. It is typically self-limited, resolving within one to three
weeks. (See 'Definitions' above and 'Clinical features' above.)
● Causes − The majority of cases of acute bronchitis are caused by infection with respiratory
viruses, such as rhinoviruses, coronaviruses, influenza viruses, and respiratory syncytial
virus ( figure 1). Bacteria are rare causes, accounting for <10 percent of cases. The most
common bacterial causes are Bordetella pertussis, Mycoplasma pneumoniae, and Chlamydia
pneumoniae. (See 'Microbiology' above.)
● Diagnosis − Acute bronchitis should be suspected in patients with an acute onset but
persistent cough (often lasting one to three weeks) who do not have clinical findings
suggestive of pneumonia and who do not have chronic obstructive pulmonary disease. For
most patients, the diagnosis can be made based on history and physical examination.
Apart from testing for COVID-19 during the pandemic, additional testing is typically not
needed ( algorithm 1). (See 'Clinical diagnosis' above and 'Differential diagnosis' above.)
Chest radiographs are indicated when acute bronchitis cannot be clinically distinguished
from pneumonia ( figure 2). Reasonable indications for suspecting pneumonia and
obtaining imaging include abnormal vital signs (pulse >100/minute, respiratory rate >24
breaths/minute, temperature >38°C [100.4°F], or oxygen saturation <95 percent), signs of
consolidation on lung examination (rales, egophony, or tactile fremitus), and mental status
changes in patients >75 years old. (See 'Differential diagnosis' above and 'Chest radiograph'
above.)
● Treatment focus − For most patients, acute bronchitis is self-limited; patient education
and symptom control are the cornerstones of care ( table 4). We discuss the expected
course of illness with each patient. Reassurance that acute bronchitis typically resolves in
one to three weeks without specific therapy can improve patient satisfaction and reduce
inappropriate antibiotic use. (See 'Treatment' above and "Patient education: Acute
bronchitis (The Basics)".)
● Cough relief
• Nonpharmacologic − For patients with acute bronchitis who are bothered by cough,
we first offer nonpharmacologic options for cough relief such as throat lozenges, hot
tea, and smoking cessation or avoidance of secondhand smoke ( table 4). (See 'For
cough' above.)
• Pharmacologic − For patients with acute bronchitis who desire medication for cough
relief, we suggest over-the-counter medications such
as dextromethorphan or guaifenesin rather than other medications ( table 4) (Grade
2C). We avoid opioid cough suppressants (eg, codeine) due to their addictive potential
and adverse effect profile. We reserve inhaled beta-agonists, such as albuterol, for
patients with wheezing and underlying pulmonary disease. (See 'For cough' above.)
● Avoiding antibiotic overuse − For patients with clinically diagnosed acute bronchitis, we
recommend not treating with empiric antibiotic therapy (Grade 1B). Acute bronchitis is a
leading cause of antibiotic overuse; reducing inappropriate antibiotic use for this indication
is a global health care priority. (See 'Avoiding antibiotic overuse' above.)
● Rare indications for antimicrobials − Antimicrobial therapy is generally reserved for cases
in which a specific pathogen is suspected or diagnosed in patients who are at high risk for
complications or when treatment might limit spread of a contagious illness. Key examples
include suspicion for influenza in a high-risk patient and pertussis ( table 1). (See 'Rare
indications for use' above.)
Use of UpToDate is subject to the Terms of Use.
REFERENCES
1. Harris AM, Hicks LA, Qaseem A, High Value Care Task Force of the American College of
Physicians and for the Centers for Disease Control and Prevention. 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; 164:425.
2. Adams PF, Hendershot GE, Marano MA, Centers for Disease Control and
Prevention/National Center for Health Statistics. Current estimates from the National Health
Interview Survey, 1996. Vital Health Stat 10 1999; :1.
3. Wenzel RP, Fowler AA 3rd. Clinical practice. Acute bronchitis. N Engl J Med 2006; 355:2125.
4. Centers for Disease Control and Prevention, National Respiratory and Enteric Virus Surveilla
nce System https://www.cdc.gov/surveillance/nrevss/hmpv/natl-trend.html (Accessed on Ma
rch 16, 2017).
5. Falsey AR, Erdman D, Anderson LJ, Walsh EE. Human metapneumovirus infections in young
and elderly adults. J Infect Dis 2003; 187:785.
6. Clark TW, Medina MJ, Batham S, et al. Adults hospitalised with acute respiratory illness
rarely have detectable bacteria in the absence of COPD or pneumonia; viral infection
predominates in a large prospective UK sample. J Infect 2014; 69:507.
7. Boldy DA, Skidmore SJ, Ayres JG. Acute bronchitis in the community: clinical features,
infective factors, changes in pulmonary function and bronchial reactivity to histamine.
Respir Med 1990; 84:377.
8. Jonsson JS, Sigurdsson JA, Kristinsson KG, et al. Acute bronchitis in adults. How close do we
come to its aetiology in general practice? Scand J Prim Health Care 1997; 15:156.
9. Creer DD, Dilworth JP, Gillespie SH, et al. Aetiological role of viral and bacterial infections in
acute adult lower respiratory tract infection (LRTI) in primary care. Thorax 2006; 61:75.
10. MacKay DN. Treatment of acute bronchitis in adults without underlying lung disease. J Gen
Intern Med 1996; 11:557.
11. Centers for Disease Control and Prevention. Pertussis (whooping cough): Surveillance and r
eporting. https://www.cdc.gov/pertussis/surv-reporting.html (Accessed on March 13, 2017).
12. Ward JI, Cherry JD, Chang SJ, et al. Efficacy of an acellular pertussis vaccine among
adolescents and adults. N Engl J Med 2005; 353:1555.
13. Nennig ME, Shinefield HR, Edwards KM, et al. Prevalence and incidence of adult pertussis in
an urban population. JAMA 1996; 275:1672.
14. Wadowsky RM, Castilla EA, Laus S, et al. Evaluation of Chlamydia pneumoniae and
Mycoplasma pneumoniae as etiologic agents of persistent cough in adolescents and adults.
J Clin Microbiol 2002; 40:637.
15. Grayston JT, Kuo CC, Wang SP, Altman J. A new Chlamydia psittaci strain, TWAR, isolated in
acute respiratory tract infections. N Engl J Med 1986; 315:161.
16. Woolfrey BF, Moody JA. Human infections associated with Bordetella bronchiseptica. Clin
Microbiol Rev 1991; 4:243.
17. Goldberg JD, Kamboj M, Ford R, et al. 'Kennel cough' in a patient following allogeneic
hematopoietic stem cell transplant. Bone Marrow Transplant 2009; 44:381.
18. Dworkin MS, Sullivan PS, Buskin SE, et al. Bordetella bronchiseptica infection in human
immunodeficiency virus-infected patients. Clin Infect Dis 1999; 28:1095.
19. Mattoo S, Cherry JD. Molecular pathogenesis, epidemiology, and clinical manifestations of
respiratory infections due to Bordetella pertussis and other Bordetella subspecies. Clin
Microbiol Rev 2005; 18:326.
20. Berkowitz DM, Bechara RI, Wolfenden LL. An unusual cause of cough and dyspnea in an
immunocompromised patient. Chest 2007; 131:1599.
21. Huebner ES, Christman B, Dummer S, et al. Hospital-acquired Bordetella bronchiseptica

infection following hematopoietic stem cell transplantation. J Clin Microbiol 2006; 44:2581.
22. Brady C, Ackerman P, Johnson M, McNamara J. Bordetella bronchiseptica in a pediatric

Cystic Fibrosis center. J Cyst Fibros 2014; 13:43.
23. García-de-la-Fuente C, Guzmán L, Cano ME, et al. Microbiological and clinical aspects of
respiratory infections associated with Bordetella bronchiseptica. Diagn Microbiol Infect Dis
2015; 82:20.
24. Monti M, Diano D, Allegrini F, et al. Bordetella bronchiseptica pneumonia in a patient with
lung cancer; a case report of a rare infection. BMC Infect Dis 2017; 17:644.
25. Powers HR, Shah K. Bordetella bronchiseptica bloodstream infection in a renal transplant
patient. Transpl Infect Dis 2017; 19.
26. Ebell MH, Lundgren J, Youngpairoj S. How long does a cough last? Comparing patients'
expectations with data from a systematic review of the literature. Ann Fam Med 2013; 11:5.
27. Kinkade S, Long NA. Acute Bronchitis. Am Fam Physician 2016; 94:560.
28. McKay R, Mah A, Law MR, et al. Systematic Review of Factors Associated with Antibiotic
Prescribing for Respiratory Tract Infections. Antimicrob Agents Chemother 2016; 60:4106.
29. Altiner A, Wilm S, Däubener W, et al. Sputum colour for diagnosis of a bacterial infection in
patients with acute cough. Scand J Prim Health Care 2009; 27:70.
30. Williamson HA Jr. Pulmonary function tests in acute bronchitis: evidence for reversible
airway obstruction. J Fam Pract 1987; 25:251.
31. Bushyhead JB, Wood RW, Tompkins RK, et al. The effect of chest radiographs on the
management and clinical course of patients with acute cough. Med Care 1983; 21:661.
32. Cao AM, Choy JP, Mohanakrishnan LN, et al. Chest radiographs for acute lower respiratory
tract infections. Cochrane Database Syst Rev 2013; :CD009119.
33. Gonzales R, Bartlett JG, Besser RE, et al. Principles of appropriate antibiotic use for
treatment of uncomplicated acute bronchitis: background. Ann Intern Med 2001; 134:521.
34. Metlay JP, Kapoor WN, Fine MJ. Does this patient have community-acquired pneumonia?
Diagnosing pneumonia by history and physical examination. JAMA 1997; 278:1440.
35. Singal BM, Hedges JR, Radack KL. Decision rules and clinical prediction of pneumonia:
evaluation of low-yield criteria. Ann Emerg Med 1989; 18:13.
36. Braman SS. Chronic cough due to acute bronchitis: ACCP evidence-based clinical practice
guidelines. Chest 2006; 129:95S.
37. Metlay JP, Schulz R, Li YH, et al. Influence of age on symptoms at presentation in patients
with community-acquired pneumonia. Arch Intern Med 1997; 157:1453.
38. Bartlett JG, Breiman RF, Mandell LA, File TM Jr. Community-acquired pneumonia in adults:
guidelines for management. The Infectious Diseases Society of America. Clin Infect Dis
1998; 26:811.
39. Moore M, Stuart B, Little P, et al. Predictors of pneumonia in lower respiratory tract
infections: 3C prospective cough complication cohort study. Eur Respir J 2017; 50.
40. Gonzales R, Steiner JF, Sande MA. Antibiotic prescribing for adults with colds, upper
respiratory tract infections, and bronchitis by ambulatory care physicians. JAMA 1997;
278:901.
41. Gonzales R, Steiner JF, Lum A, Barrett PH Jr. Decreasing antibiotic use in ambulatory
practice: impact of a multidimensional intervention on the treatment of uncomplicated
acute bronchitis in adults. JAMA 1999; 281:1512.
42. Gonzales R, Sande M. What will it take to stop physicians from prescribing antibiotics in
acute bronchitis? Lancet 1995; 345:665.
43. Llor C, Bjerrum L. Antibiotic prescribing for acute bronchitis. Expert Rev Anti Infect Ther
2016; 14:633.
44. Klausner JD, Passaro D, Rosenberg J, et al. Enhanced control of an outbreak of Mycoplasma
pneumoniae pneumonia with azithromycin prophylaxis. J Infect Dis 1998; 177:161.
45. Martini H, Detemmerman L, Soetens O, et al. Improving specificity of Bordetella pertussis

detection using a four target real-time PCR. PLoS One 2017; 12:e0175587.
46. Burgos-Rivera B, Lee AD, Bowden KE, et al. Evaluation of Level of Agreement in Bordetella
Species Identification in Three U.S. Laboratories during a Period of Increased Pertussis. J
Clin Microbiol 2015; 53:1842.
47. Kauffmann F, Varraso R. The epidemiology of cough. Pulm Pharmacol Ther 2011; 24:289.
48. Jónsson JS, Gíslason T, Gíslason D, Sigurdsson JA. Acute bronchitis and clinical outcome
three years later: prospective cohort study. BMJ 1998; 317:1433.
49. Hallett JS, Jacobs RL. Recurrent acute bronchitis: the association with undiagnosed bronchial
asthma. Ann Allergy 1985; 55:568.
50. National Institute for Health and Care Excellence. Cough (acute): antimicrobial prescribing h
ttps://www.nice.org.uk/guidance/ng120/resources/cough-acute-antimicrobial-prescribing-p
df-66141652166341 (Accessed on February 26, 2021).
51. National Quality Forum (NQF). Avoidance of Antibiotic Treatment in Adults with Acute Bronc
hitis. Available at: http://www.qualityforum.org/MeasureDetails.aspx?actid=0&SubmissionId
=1216#p=5&s=n&so=a (Accessed on October 04, 2017).
52. Choosing Wisely Canada http://www.choosingwiselycanada.org/recommendations/emerge

ncy-medicine/ (Accessed on March 16, 2017).
53. Smith SM, Fahey T, Smucny J, Becker LA. Antibiotics for acute bronchitis. Cochrane Database
Syst Rev 2014; :CD000245.
54. Bakhit M, Del Mar C, Gibson E, Hoffmann T. Shared decision making and antibiotic benefit-
harm conversations: an observational study of consultations between general practitioners
and patients with acute respiratory infections. BMC Fam Pract 2018; 19:165.
55. Johnson MC, Hulgan T, Cooke RG, et al. Operationalising outpatient antimicrobial
stewardship to reduce system-wide antibiotics for acute bronchitis. BMJ Open Qual 2021;
10.
56. Macfarlane J, Holmes W, Gard P, et al. Reducing antibiotic use for acute bronchitis in primary
care: blinded, randomised controlled trial of patient information leaflet. BMJ 2002; 324:91.
57. Coxeter P, Del Mar CB, McGregor L, et al. Interventions to facilitate shared decision making
to address antibiotic use for acute respiratory infections in primary care. Cochrane
Database Syst Rev 2015; :CD010907.
58. de la Poza Abad M, Mas Dalmau G, Moreno Bakedano M, et al. Prescription Strategies in
Acute Uncomplicated Respiratory Infections: A Randomized Clinical Trial. JAMA Intern Med
2016; 176:21.
59. Meeker D, Linder JA, Fox CR, et al. Effect of Behavioral Interventions on Inappropriate
Antibiotic Prescribing Among Primary Care Practices: A Randomized Clinical Trial. JAMA
2016; 315:562.
60. Kraus EM, Pelzl S, Szecsenyi J, Laux G. Antibiotic prescribing for acute lower respiratory tract
infections (LRTI) - guideline adherence in the German primary care setting: An analysis of
routine data. PLoS One 2017; 12:e0174584.
61. Spurling GK, Del Mar CB, Dooley L, et al. Delayed antibiotic prescriptions for respiratory
infections. Cochrane Database Syst Rev 2017; 9:CD004417.
62. Tonkin-Crine SK, Tan PS, van Hecke O, et al. Clinician-targeted interventions to influence
antibiotic prescribing behaviour for acute respiratory infections in primary care: an overview
of systematic reviews. Cochrane Database Syst Rev 2017; 9:CD012252.
63. Smith SM, Schroeder K, Fahey T. Over-the-counter (OTC) medications for acute cough in
children and adults in community settings. Cochrane Database Syst Rev 2014; :CD001831.
64. Hueston WJ. Albuterol delivered by metered-dose inhaler to treat acute bronchitis. J Fam
Pract 1994; 39:437.
65. Becker LA, Hom J, Villasis-Keever M, van der Wouden JC. Beta2-agonists for acute cough or a
clinical diagnosis of acute bronchitis. Cochrane Database Syst Rev 2015; :CD001726.
66. Llor C, Moragas A, Bayona C, et al. Efficacy of anti-inflammatory or antibiotic treatment in

patients with non-complicated acute bronchitis and discoloured sputum: randomised
placebo controlled trial. BMJ 2013; 347:f5762.
67. Hay AD, Little P, Harnden A, et al. Effect of Oral Prednisolone on Symptom Duration and
Severity in Nonasthmatic Adults With Acute Lower Respiratory Tract Infection: A
Randomized Clinical Trial. JAMA 2017; 318:721.
68. Jiang L, Li K, Wu T. Chinese medicinal herbs for acute bronchitis. Cochrane Database Syst
Rev 2012; :CD004560.
69. Timmer A, Günther J, Motschall E, et al. Pelargonium sidoides extract for treating acute
respiratory tract infections. Cochrane Database Syst Rev 2013; :CD006323.
70. Douros A, Bronder E, Andersohn F, et al. Herb-Induced Liver Injury in the Berlin Case-
Control Surveillance Study. Int J Mol Sci 2016; 17.
71. Posadzki P, Watson LK, Ernst E. Adverse effects of herbal medicines: an overview of
systematic reviews. Clin Med (Lond) 2013; 13:7.
72. Barnett ML, Linder JA. Antibiotic prescribing for adults with acute bronchitis in the United
States, 1996-2010. JAMA 2014; 311:2020.
73. Little P, Rumsby K, Kelly J, et al. Information leaflet and antibiotic prescribing strategies for
acute lower respiratory tract infection: a randomized controlled trial. JAMA 2005; 293:3029.
74. Little P, Stuart B, Moore M, et al. Amoxicillin for acute lower-respiratory-tract infection in
primary care when pneumonia is not suspected: a 12-country, randomised, placebo-
controlled trial. Lancet Infect Dis 2013; 13:123.
75. Moore M, Stuart B, Coenen S, et al. Amoxicillin for acute lower respiratory tract infection in
primary care: subgroup analysis of potential high-risk groups. Br J Gen Pract 2014; 64:e75.
76. Smith SM, Fahey T, Smucny J, Becker LA. Antibiotics for acute bronchitis. Cochrane Database
Syst Rev 2017; 6:CD000245.
77. Little P, Stuart B, Smith S, et al. Antibiotic prescription strategies and adverse outcome for
uncomplicated lower respiratory tract infections: prospective cough complication cohort
(3C) study. BMJ 2017; 357:j2148.
78. Khanna S, Tosh PK. A clinician's primer on the role of the microbiome in human health and
disease. Mayo Clin Proc 2014; 89:107.
79. Langdon A, Crook N, Dantas G. The effects of antibiotics on the microbiome throughout
development and alternative approaches for therapeutic modulation. Genome Med 2016;
8:39.
80. Belkaid Y, Hand TW. Role of the microbiota in immunity and inflammation. Cell 2014;
157:121.
81. Ebell MH, Radke T. Antibiotic use for viral acute respiratory tract infections remains
common. Am J Manag Care 2015; 21:e567.
82. Ncube NB, Solanki GC, Kredo T, Lalloo R. Antibiotic prescription patterns of South African
general medical practitioners for treatment of acute bronchitis. S Afr Med J 2017; 107:119.
83. Silverman M, Povitz M, Sontrop JM, et al. Antibiotic Prescribing for Nonbacterial Acute Upper
Respiratory Infections in Elderly Persons. Ann Intern Med 2017; 166:765.
84. McCullough AR, Pollack AJ, Plejdrup Hansen M, et al. Antibiotics for acute respiratory
infections in general practice: comparison of prescribing rates with guideline
recommendations. Med J Aust 2017; 207:65.
85. Glinz D, Leon Reyes S, Saccilotto R, et al. Quality of antibiotic prescribing of Swiss primary
care physicians with high prescription rates: a nationwide survey. J Antimicrob Chemother
2017; 72:3205.
86. Stenehjem E, Wallin A, Fleming-Dutra KE, et al. Antibiotic Prescribing Variability in a Large
Urgent Care Network: A New Target for Outpatient Stewardship. Clin Infect Dis 2020;
70:1781.
87. Dilworth TJ, Brummitt CF. Reduction in ambulatory visits for acute, uncomplicated
bronchitis: an unintended but welcome result of the coronavirus disease 2019 (COVID-19)
pandemic. Infect Control Hosp Epidemiol 2021; 42:1291.
88. King DE, Williams WC, Bishop L, Shechter A. Effectiveness of erythromycin in the treatment
of acute bronchitis. J Fam Pract 1996; 42:601.
89. Rampelotto RF, Hörner A, Hörner C, et al. Pneumonia caused by Bordetella bronchiseptica in
two HIV-positive patients. Sao Paulo Med J 2016; 134:268.
Topic 6870 Version 85.0
GRAPHICS
Seasonality of respiratory viruses in the United States
The incidence of acute bronchitis is highest when the transmission of respiratory viruses peaks. In the North
hemisphere, the transmission of respiratory viruses peaks in the late fall and winter. In the Southern hemisp
transmission peaks in late spring and summer.
References:
1. Olsen SJ, Winn AK, Budd AP, et al. Changes in Influenza and Other Respiratory Virus Activity During the COVID-19 Pandemic — U
States, 2020–2021. MMWR Morb Mortal Wkly Rep 2021; 70:1013.
2. Obando-Pacheco P, Justicia-Grande AJ, Rivero-Calle I, et al. Respiratory Syncytial Virus Seasonality: A Global Overview. J Infect Dis
217:1356.
3. Wenzel RP, Fowler AA 3rd. Clinical practice. Acute bronchitis. N Engl J Med 2006; 355:2125.
Graphic 139455 Version 1.0
Clinical features and epidemiologic associations with selected pathogens

that can cause prolonged cough
Pathogen* Clinical features and epidemiologic associations
Influenza virus Acute onset fever, chills, myalgias, and cough during influenza season or in
patients with known exposure or recent travel
Bordetella pertussis Cough lasting ≥2 weeks without an apparent cause, with one of the
following symptoms: paroxysms of coughing, inspiratory whoop, or post-
tussive emesis, particularly during outbreaks or in patients with known
exposures
Bordetella Pertussis-like syndrome in a patient with animal exposure, particularly if

bronchiseptica immunocompromised
Mycoplasma No distinguishing clinical features, although outbreaks reported across

pneumoniae large geographic regions and among families or persons living in close
quarters
Chlamydia pneumoniae No distinguishing clinical features, although outbreaks reported in persons

living in close quarters
Severe acute Common features include cough, myalgias, and headache; diarrhea, sore
respiratory syndrome throat, and smell or taste abnormalities are frequently reported
coronavirus 2 (SARS-
CoV-2)
* There is a wide range of clinical features associated with each pathogen. For a comprehensive
review, refer to the UpToDate content on each pathogen.
Distinguishing acute bronchitis from pneumonia in adults
Evaluation of acute bronchitis in adults
Acute bronchitis should be suspected in patients with an acute onset

but persistent cough (often lasting approximately five days to three
weeks) who do not have clinical findings suggestive of pneumonia and
do not have COPD. For most patients, the diagnosis can be based the
history and physical examination. Apart from testing for COVID-19
during the pandemic, testing is generally reserved for cases in which
pneumonia suspected, when the clinical diagnosis is uncertain, or
when results would change management (eg, treatment of pertussis).
As multiplex molecular assays become increasingly available and
include testing for SARS-CoV-2, they will likely be used to make specific
microbiologic diagnoses in patients with respiratory tract infections,
but they have not had proven benefit at this juncture.
COPD: chronic obstructive pulmonary disease; URI: upper respiratory

infection; COVID-19: coronavirus disease 2019; GERD:
gastroesophageal reflux disease; ACE: angiotensin converting enzyme;
bpm: beats per minute; RT-PCR: reverse-transcription polymerase
chain reaction.
* By definition, acute bronchitis occurs in the absence of COPD. Similar

symptoms in a patient with COPD would be considered a COPD
exacerbation.
¶ RT-PCR on an upper respiratory tract specimen is the preferred text.

Refer to UpToDate content on COVID-19 for additional detail on clinical
features, testing, treatment, and infection control.
Δ Additional factors, such as moderate/severe dyspnea, hemoptysis,

older age, and/or dementia, may raise the likelihood of pneumonia or
other underlying pulmonary disorders.
◊ Most pathogens that cause acute bronchitis do not require specific

treatment; thus, testing is not needed. Circumstances that might
warrant testing include suspicion for pertussis (based on characteristic
cough or known exposure), COVID-19 during the pandemic, or
influenza (in a high-risk patient early in the course of illness). Refer to
UpToDate text for additional detail on when suspect specific
pathogens.
§ Refer to UpToDate content for detail on when additional testing is

needed for patients with known or suspected pneumonia.
Groups at higher risk for influenza complications
Children <5 years, but especially <2 years*
Adults ≥65 years of age
People who are pregnant or up to 2 weeks postpartum
Residents of nursing homes and long-term care facilities
Non-Hispanic Black persons, Hispanic or Latino persons, and American Indian or Alaska Native
persons ¶
People with medical conditions including:

Asthma
Neurologic and neurodevelopmental conditions (including disorders of the brain, spinal cord, and
peripheral nerve and muscle such as cerebral palsy, epilepsy, stroke, intellectual disability,
moderate-to-severe developmental delay, muscular dystrophy, and spinal cord injury)
Chronic lung disease (eg, chronic obstructive pulmonary disease, cystic fibrosis)
Heart disease (eg, congenital heart disease, congestive heart failure, coronary artery disease)
Blood disorders (eg, sickle cell disease)
Endocrine disorders (eg, diabetes mellitus)
Kidney diseases
Liver disorders
Metabolic disorders (eg, inherited metabolic disorders and mitochondrial disorders)
Weakened immune system due to disease (eg, HIV, AIDS, cancer) or medication (eg,
chemotherapy or radiation therapy, chronic glucocorticoids)
Children <19 years of age who are receiving long-term aspirin therapy
People with Class III obesity (body mass index [BMI] ≥40 or ≥140% of the 95 th percentile value)
* In young children, rates of hospitalization and mortality are greatest among those <6 months of
age.
¶ Possibly related to economic and social conditions (eg, poverty, multigenerational households,
limited access or barriers to influenza vaccination).
Adapted from: Influenza: People at higher risk of flu complications. Centers for Disease Control and Prevention. Available at:
cdc.gov/flu/highrisk/index.htm (Accessed on September 2, 2022).
Timeline for diagnosis of pertussis
PCR: polymerase chain reaction.
* Presumed period of lower sensitivity.
Reproduced from: Centers for Disease Control and Prevention. Pertussis (Whooping Cough).
Available at: http://www.cdc.gov/pertussis/clinical/diagnostic-testing/diagnosis-confirmation.html.
Common causes of acute cough
Diagnosis Associated clinical features
Upper respiratory tract Rhinorrhea, nasal obstruction, sneezing, scratchy or sore throat,
infection (URI) or common malaise, headache
cold
Acute bronchitis Antecedent (URI), absence of high fever or other systemic signs or

symptoms, absence of signs of consolidation on chest exam
Pneumonia Fever, tachycardia, tachypnea, signs of consolidation on chest exam,

mental status change in those >75 years old
Post-nasal drip Post-nasal drainage, need to clear throat, rhinorrhea
Gastroesophageal reflux Heartburn, regurgitation, dysphagia

disorder
Asthma History of episodic wheezing, shortness of breath, allergen

exposure or exercise
ACE inhibitor use Nonproductive cough, tickling or scratchy sensation in the throat
Heart failure Shortness of breath, orthopnea, gallop rhythm, elevated jugular

venous pulse, peripheral edema
Pulmonary embolism Tachycardia, shortness of breath, pleuric chest pain, hemoptysis
Lung cancer Past or present smoking history, change in a chronic "smoker's cough,"
hemoptysis, signs of focal airway obstruction on chest exam
ACE: angiotensin-converting enzyme.
Symptomatic management of cough in acute bronchitis in adults
Agent or
Dose/frequency Comments
intervention
Pharmacologic therapies*
Dextromethorphan ¶ Immediate release (liquids, Cough suppressant: Temporary

(OTC) lozenges, and capsules): 10 to 20 control of cough by interruption of
mg orally every 4 hours or 20 to central cough impulse and
30 mg every 6 to 8 hours as decreasing the sensitivity of
needed respiratory cough receptors.
Extended release (suspension): Serotonin syndrome may occur
60 mg orally twice daily as when used with pro-
needed serotonergic drugs (eg,
(maximum daily dose: 120 mg) SSRIs/SNRIs, linezolid),
especially at higher doses
Avoid use in patients at-risk for
respiratory compromise (eg,
acute asthma)
Guaifenesin ¶ (OTC) Immediate release (liquids and Expectorant: Helps loosen

tablets): 200 to 400 mg orally mucus/bronchial secretions.
every 4 hours as needed May reduce viscosity of
Extended release (tablets): 600 secretions but does not
mg to 1.2 g orally every 12 hours suppress cough. Adequate
as needed hydration is required for
(maximum daily dose: 2.4 g) maximal efficacy.
Albuterol Metered-dose inhaler or dry Beta2 agonist: Treatment of

powder inhaler (90 bronchospasm in patients with
mcg/actuation): 2 inhalations reversible obstructive airway
every 4 to 6 hours as needed disease.
Only appropriate in patients
who have wheezing or
underlying pulmonary disease
For acute asthma exacerbation
initial dosing is more frequent;
refer to clinical topic
Benzonatate 100 to 200 mg orally 3 times per Cough suppressant: Suppresses

day as needed cough by topical anesthetic action
(maximum daily dose: 600 mg) on respiratory stretch receptors.
Swallow capsule whole; do not
chew or break
Non-pharmacologic interventions
Throat lozenges As needed (per labelling Lozenges (typically nonmedicated or

(oral) instructions) with menthol) may relieve sore
throat and reduce cough frequency
and severity
Honey (oral) As needed Often taken in hot water or tea
May reduce cough frequency and

severity
Smoking cessation –– Smoke is an airway irritant

(and avoidance of
second-hand
smoke)
For adults with bothersome cough from acute bronchitis, we offer nonpharmacologic treatments (eg,
honey, hot tea, nonmedicated throat lozenges). While high-quality evidence supporting their efficacy
is lacking, patients may derive relief from these measures, and for most, the risk of harm is small.
OTC: over-the-counter (prescription not required); SSRI: selective serotonin reuptake inhibitor; SNRI:
serotonin-norepinephrine reuptake inhibitor.
* We avoid the use of opioid cough suppressants (including codeine) in adults with acute bronchitis
due their side effect profile and potential for dependency and addiction.
¶ Available guaifenesin-dextromethorphan combinations include: Liquids (guaifenesin 100 mg and

dextromethorphan 5 mg per 5 mL) and pills (guaifenesin 200 mg and dextromethorphan 10 mg per
capsule); alcohol-free preparations are preferred.
Antiviral regimens for treatment and/or prophylaxis of seasonal influenza in

adults
Antiviral agent Treatment dose Prophylaxis dose Contraindications
Oseltamivir* 75 mg orally twice daily 75 mg orally once daily; N/A

for 5 days ¶ usual duration
7 days* Δ
Zanamivir ◊ § 10 mg (two 5 mg 10 mg (two 5 mg Zanamivir (inhaled) is

inhalations) twice daily inhalations) once daily; contraindicated in
for 5 days usual duration 7 days patients with asthma
or chronic obstructive
pulmonary disease,
and it should not be
used for treatment of
severe influenza (given
limited data).
Peramivir* 600 mg intravenously N/A Peramivir should be

as a single dose ¶ ¥ reserved for patients
who cannot tolerate
oral or inhaled agents.
Baloxavir § ‡ 40 kg to <80 kg: 40 mg Postexposure Baloxavir should not be

orally as a single dose prophylaxis: same dose used for treatment of
as for treatment, single severe influenza (given
≥80 kg: 80 mg orally as
dose † limited data),
a single dose
immunocompromised
hosts (given concern
for emergence of
resistance), or
pregnant patients
(given limited data).
Refer to the UpToDate topic reviews on treatment and prevention of seasonal influenza for additional
details about indications for use of an antiviral agent, choice of agent, dosing, and duration.
* Dose reduction of oseltamivir and peramivir is recommended for patients with renal impairment.
¶ For patients with ongoing symptoms of severe lower respiratory tract disease (particularly in the
setting of immunosuppression), an extended duration of antiviral treatment (up to 10 days) may be
reasonable, particularly in those who continue to have detectable viral RNA from a respiratory
specimen after 5 days of antiviral treatment.
Δ Longer courses may be warranted in the setting of institutional outbreaks. Refer to UpToDate topic
on prevention of seasonal influenza for further discussion.
◊ Zanamivir is administered via oral inhalation by using a plastic device included in the package;
patients will benefit from instruction and demonstration of the correct use of the device.
§ During outbreaks caused by oseltamivir-resistant influenza virus, zanamivir or baloxavir may be

used. It is important to assess the risk of oseltamivir-resistant influenza before selecting an antiviral
drug; clinicians should review regional influenza surveillance data to determine which influenza types
and subtypes are circulating, as well as resistance patterns. This information is available via the
United States Centers for Disease Control and Prevention website.
¥ If peramivir is used for treatment of severe influenza, we favor administration for 5 days [5] .
‡ Coadministration of baloxavir with dairy products, calcium-fortified beverages, polyvalent cation-

containing laxatives, antacids, or oral supplements (eg, calcium, iron, magnesium, selenium, zinc)
should be avoided.
† Baloxavir is US Food and Drug Administration approved for postexposure prophylaxis but not for
pre-exposure prophylaxis.
Adapted from:
1. Influenza Division, National Center, for Immunization, and Respiratory. Antiviral agents for the treatment and
chemoprophylaxis of influenza -- recommendations of the Advisory Committee on Immunization Practices (ACIP).
MMWR Recomm Rep 2011; 60:1.
2. Centers for Disease Control and Prevention. Influenza antiviral medications: Summary for clinicians.
https://www.cdc.gov/flu/professionals/antivirals/summary-clinicians.htm (Accessed on December 9, 2019).
3. Xofluza (baloxavir marboxil) for oral use, prescribing information.
https://www.accessdata.fda.gov/drugsatfda_docs/label/2019/210854s001lbl.pdf (Accessed on October 17, 2019).
4. Uehara T, Hayden FG, Kawaguchi K, et al. Treatment-emergent influenza variant viruses with reduced baloxavir
susceptibility: Impact on clinical and virologic outcomes in uncomplicated influenza. J Infect Dis 2020; 221:346.
5. de Jong MD, Ison MG, Monto AS, et al. Evaluation of intravenous peramivir for treatment of influenza in hospitalized
patients. Clin Infect Dis 2014; 59:e172.
Diagnosis of pertussis
PCR: polymerase chain reaction.
* Close contact is defined as face-to-face exposure within three feet of a symptomatic

patient and/or direct contact with the respiratory, nasal, or oral secretions of a person
with active pertussis.
¶ Testing is not required for diagnosis and the initiation of treatment. However, we
generally test patients for public health surveillance.
Δ Direct PCR is more accurate and reliable than PCR performed as part of a multiplex
assay.
◊ PCR and culture should be performed on a nasopharyngeal specimen.
Antibiotic treatment of pertussis in adolescents

and adults
Antibiotic treatment is indicated in all patients with a clinical or

microbiologic diagnosis of pertussis who present within three weeks
of cough onset because this is the highest risk period for
transmission. After this period, cough may persist but is thought to
be caused by tissue damage rather than active infection. Because
shedding can persist for 6 weeks, the treatment window is extended
for pregnant women who are near term to prevent transmission to
neonates. We also extend the treatment window to 6 weeks in
patients at increased risk for pertussis-related morbidity (eg, age
≥65, immunocompromise, chronic lung disease).
Because pertussis is highly transmissible, post-exposure prophylaxis

is warranted within 21 days of exposure for household contacts as
well as for close contacts who are at high risk for severe pertussis
themselves or who are in close contact with others who at high risk
for severe pertussis. Antibiotic regimens for prophylaxis are identical
to those for treatment. Patients with B. pertussis infection should

avoid contact with young children, infants, and other vulnerable
populations until they have completed at least 5 days of antibiotic
therapy. Refer to UpToDate text for detail.
COPD: chronic obstructive pulmonary disease.
* The Centers for Disease Control and Prevention (CDC)

recommends extending the treatment window in pregnant women
but not other populations. Although limited, emerging data indicate
that pertussis-related morbidity, including the risk for
hospitalization, is highest in these specific subgroups.
¶ Azithromycin is the treatment of choice in pregnancy and is also

the preferred agent for most other adults and adolescents.
Clarithromycin can be used when azithromycin is not available.
Dosage and duration of treatment for adults and adolescents are:
Azithromycin orally for five days (500 mg once daily on day 1,
followed by 250 mg once daily on days 2 to 5)
Clarithromycin 500 mg orally twice daily for seven days
Trimethoprim-sulfamethoxazole (one double-strength tablet
orally twice daily for 14 days) is an alternative for non-
pregnant patients who cannot take a macrolide (eg, due to
prolonged QT interval, allergy or other intolerance)
Recommended oral antimicrobial treatment and postexposure prophylaxis

for pertussis, by age group
Alternate
Primary agents
Age group agent*
Azithromycin Erythromycin Clarithromycin TMP-SMX
<1 month Recommended Not preferred; Not Contraindicated

agent; 10 mg/kg erythromycin is recommended for infants aged
per day in a single associated with (safety data <2 months (risk
dose for 5 days infantile unavailable) for kernicterus)
(only limited hypertrophic
safety data pyloric stenosis;
available) use if
azithromycin is
unavailable; 40
mg/kg per day in
4 divided doses
for 14 days
1 through 5 10 mg/kg per day 40 mg/kg per day 15 mg/kg per day Contraindicated
months in a single dose in 4 divided doses in 2 divided doses at age <2 months;
for 5 days for 14 days for 7 days for infants aged
≥2 months, TMP
8 mg/kg per day,
SMX 40 mg/kg per
day in 2 divided
doses for 14 days
Infants (aged ≥6 10 mg/kg in a 40 mg/kg per day 15 mg/kg per day TMP 8 mg/kg per
months) and single dose on in 4 divided doses in 2 divided doses day, SMX 40
children day 1 (maximum: for 7 to 14 days for 7 days mg/kg per day in
500 mg); then 5 (maximum: 2 g (maximum: 1 g 2 divided doses
mg/kg per day per day) per day) for 14 days
(maximum: 250 (maximum TMP
mg) on days 2 320 mg, SMX 1600
through 5 ¶ mg per day)
Adults 500 mg in a single 2 g (base) per day 1 g per day in 2 TMP 320 mg per
(nonpregnant) Δ dose on day 1 in 4 divided doses divided doses for day, SMX 1600 mg
then 250 mg per for 7 to 14 days 7 days per day in 2
day on days 2 divided doses for
through 5 ¶ 14 days
TMP-SMX: trimethoprim-sulfamethoxazole (cotrimoxazole).
* TMP-SMX can be used as an alternative agent to macrolides in nonpregnant adults aged ≥2

months who are allergic to macrolides, who cannot tolerate macrolides, or who are infected with a
rare macrolide-resistant strain of Bordetella pertussis. One double-strength tablet contains
trimethoprim 160 mg with sulfamethoxazole 800 mg.
¶ A shorter course (ie, 3 days) of azithromycin for treatment or postexposure prophylaxis of B.

pertussis has not been validated and is not recommended.
Δ Azithromycin is preferred in pregnancy.
Data from:
1. American Academy of Pediatrics. Pertussis (whooping cough). In: Red Book: 2021-2024 Report of the Committee on
Infectious Diseases, 32 nd ed, Kimberlin DW, Barnett ED, Lynfield R, Sawyer MH (Eds), American Academy of Pediatrics,
2021. p.578.
2. Centers for Disease Control and Prevention. Recommended antimicrobial agents for the treatment and postexposure
prophylaxis of pertussis. 2005 CDC guidelines. MMWR 2005; 54:10.
Contributor Disclosures
Thomas M File, Jr, MD Consultant/Advisory Boards: HealthTrackRX [Diagnostic for respiratory infections
(provided input into study design but did not receive payment but did receive reimbursement for traveling
to a study development meeting)]; Nabriva Therapeutics [Community-acquired pneumonia]; ThermoFisher
[Biomarker for infection]. Other Financial Interest: Board of Directors of Infectious Diseases Society of
America (2017-2022) [Infections Diseases]; Wolters Kluwer-Editor-in-Chief, Infectious Diseases in Clinical
Practice [Infections Diseases]. All of the relevant financial relationships listed have been mitigated. Daniel J
Sexton, MD Equity Ownership/Stock Options: Magnolia Medical Technologies [Medical diagnostics – Ended
August 2022]. Consultant/Advisory Boards: Magnolia Medical Technologies [Medical diagnostics – Ended
August 2022]. All of the relevant financial relationships listed have been mitigated. Mark D Aronson,
MD No relevant financial relationship(s) with ineligible companies to disclose. Sheila Bond, MD No
relevant financial relationship(s) with ineligible companies to disclose. Jane Givens, MD, MSCE No relevant
financial relationship(s) with ineligible companies to disclose.
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
provided to support the content. Appropriately referenced content is required of all authors and must
conform to UpToDate standards of evidence.
Conflict of interest policy

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8/7/23, 20:31 Acute bronchitis in adults - UpToDate

Official reprint from UpToDate®

Literature review current through: Jun 2023.

● Chronic bronchitis is a subtype of chronic obstructive pulmonary disease and is defined as

Additional factors, such as moderate or severe dyspnea, hemoptysis, immunocompromise, older

Circumstances in which microbiologic testing may change treatment options include:

It is usually unrealistic and unnecessary to attempt to determine if Mycoplasma or Chlamydia are

Procalcitonin — Procalcitonin is a serum biomarker that helps distinguish bacterial infection

● Pneumonia – Cough accompanied by abnormal vital signs (fever, tachypnea, or

● Gastroesophageal reflux (GERD) – Heartburn, regurgitation, and dysphagia are common

● ACE inhibitor use – A nonproductive cough is a well-recognized complication of treatment

● Heart failure – Cough accompanied by shortness of breath, particularly with exertion or

The differential diagnosis of prolonged cough in immunocompromised patients is more

As an example, selective serotonin reuptake inhibitors (SSRIs) may enhance the

Antimicrobial therapy — Acute bronchitis usually is caused by viruses. Inappropriate use of

● Pertussis – Antibiotic therapy is recommended for clinically suspected or confirmed

● COVID-19 – Treatment of COVID-19 is discussed separately. (See "COVID-19: Management

Treatment for acute bronchitis due to M. pneumoniae or C. pneumoniae, in the absence of

INFORMATION FOR PATIENTS

SUMMARY AND RECOMMENDATIONS

● Clinical features − Acute bronchitis is a common clinical condition characterized by cough,

Use of UpToDate is subject to the Terms of Use.

Interview Survey, 1996. Vital Health Stat 10 1999; :1.

21. Huebner ES, Christman B, Dummer S, et al. Hospital-acquired Bordetella bronchiseptica

22. Brady C, Ackerman P, Johnson M, McNamara J. Bordetella bronchiseptica in a pediatric

45. Martini H, Detemmerman L, Soetens O, et al. Improving specificity of Bordetella pertussis

52. Choosing Wisely Canada http://www.choosingwiselycanada.org/recommendations/emerge

66. Llor C, Moragas A, Bayona C, et al. Efficacy of anti-inflammatory or antibiotic treatment in

Seasonality of respiratory viruses in the United States

Graphic 139455 Version 1.0

Clinical features and epidemiologic associations with selected pathogens

Pathogen* Clinical features and epidemiologic associations

Bordetella Pertussis-like syndrome in a patient with animal exposure, particularly if

Mycoplasma No distinguishing clinical features, although outbreaks reported across

Chlamydia pneumoniae No distinguishing clinical features, although outbreaks reported in persons

Graphic 114182 Version 4.0

Distinguishing acute bronchitis from pneumonia in adults

Graphic 135143 Version 3.0

Evaluation of acute bronchitis in adults

Acute bronchitis should be suspected in patients with an acute onset

COPD: chronic obstructive pulmonary disease; URI: upper respiratory

* By definition, acute bronchitis occurs in the absence of COPD. Similar

¶ RT-PCR on an upper respiratory tract specimen is the preferred text.

Δ Additional factors, such as moderate/severe dyspnea, hemoptysis,

◊ Most pathogens that cause acute bronchitis do not require specific

§ Refer to UpToDate content for detail on when additional testing is

Graphic 131527 Version 2.0

Groups at higher risk for influenza complications

Children <5 years, but especially <2 years*

Adults ≥65 years of age

People who are pregnant or up to 2 weeks postpartum

Residents of nursing homes and long-term care facilities

People with medical conditions including:

Graphic 72029 Version 28.0

Timeline for diagnosis of pertussis

PCR: polymerase chain reaction.

* Presumed period of lower sensitivity.

Graphic 83305 Version 3.0