Do I Need Antibiotics for My Cough?

tissue box, thermometer, and flu medication
Dr. Sharon Orrange
Dr. Orrange is an Associate Professor of Clinical Medicine in the Division of Geriatric, Hospitalist and General Internal Medicine at the Keck School of Medicine of USC.
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Coughing brings many of you to the doctor. Most of this is acute bronchitis, an inflammation of the bronchi (airways) due to upper airway infection. For almost all of you, it is self-limited and will go away on its own. It may surprise you to know this respiratory condition is generally caused by a virus, but reports indicate that more than 60 to 90 percent of patients with acute bronchitis who come to the doctor are given antibiotics. A startling 75 percent of all antibiotic prescriptions are written for upper respiratory infections. Most of these, you don’t need. We should all care about this because in addition to promoting antibiotic resistance, antibiotic use accounts for over 19 percent of all emergency department visits for adverse drug events.

Here are 10 things that will reassure you that supportive care may be all you need:

  1. What to expect. With an acute bronchitis you may have a cough lasting more than five days, typically one to three weeks, and you may cough up sputum. Cough goes along with other viral upper respiratory infections but if you have a cough that persists more than five days you likely have acute bronchitis.
  1. What about antibiotics? This has been well studied and doing nothing (placebo) or taking ibuprofen, compared to either Augmentin or amoxicillin, did not significantly decrease the number of days with cough or the probability of cough resolution. Multiple studies indicate that people with acute bronchitis do not experience significant benefit from antibiotic therapy.
  1. How do I know I have bronchitis and not pneumonia? Pneumonia, unlike acute bronchitis, does require antibiotic therapy. Fever is an unusual sign in patients with acute bronchitis and suggests instead either influenza or pneumonia. If you have the combination of cough, fever, sputum production, and constitutional symptoms (body ache, headache, fatigue, nausea, no appetite) you are more likely to have influenza or pneumonia.
  1. With acute bronchitis you will have few systemic symptoms (nausea, body aches, etc) though you may have chest wall tenderness related to muscle strain from coughing. Wheezing may also occur.
  1. But I’m still coughing, is that ok? Cough in patients with acute bronchitis usually lasts from 10 to 20 days. Cough disappeared by day 14 in three-quarters of patients with viral bronchitis in one study, but in other studies it’s longer with an average of 24 days. Yes, I know that is LONG.
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  1. If I cough up green or yellow sputum doesn’t it mean I need an antibiotic? No. Purulent sputum is reported in 50 percent of patients with acute bronchitis (viral). This usually represents sloughing of cells from the trachea and airways, along with inflammatory cells. Purulence does not signify bacterial infection, contrary to what many of you think.
  1. Do I need blood tests or chest x-ray? For most patients with acute bronchitis, the diagnosis is based upon the history and physical examination, and further testing is not needed. A chest x-ray may be done if you have abnormal vital signs (pulse faster than 100 beats/minute, respiratory rate greater than 24 breaths/minute, or temperature higher than 100.4 degrees). This is different for patients over 75 who may have pneumonia without mounting a significant fever so fast breathing, decreased oxygen saturation, and decreased mental status with cough should still lead to a chest x-ray.
  1. But, I’m also wheezing. Yes, this is common with acute bronchitis where your cough may be accompanied by bronchospasm. Mild shortness of breath may also be present in some patients. Physical examination of the chest may reveal wheezing and if you are short of breath you should check in with your doctor.
  1. What should I take for my acute bronchitis? You may benefit from symptomatic treatment using a nonsteroidal anti-inflammatory drug: ibuprofen (Motrin, Advil), aspirin or acetaminophen (Tylenol). Routine use of inhalers like albuterol (Proventil, Proair) for the treatment of acute bronchitis is not helpful either and no significant differences were noted in daily cough scores or persistence of coughing at seven days.
  1. What does work for my cough? Many cough suppressants don’t work well to suppress the cough from acute bronchitis. Prescription cough suppressants like Tessalon (benzonatate) capsules or codeine cough syrups work but not very well. A review of over-the-counter (OTC) medications for acute cough found variable results for effectiveness of guaifenesin (Mucinex) or antihistamine-decongestants (Dimetapp, Delsym, Theraflu) and concluded that there is no evidence for or against the effectiveness of OTC preparations for acute cough. Honey suppresses cough better than over the counter meds in children (and possibly adults) by forming a soothing film over irritated mucous membranes.

What has worked for you?

Dr O.

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