Antibiotic Recommendation for Respiratory Infections

Diagnosis and Treatment

The American College of Physicians recommends against antibiotic therapy in patients with bronchitis unless pneumonia is suspected, as more than 90% of acute cough illnesses in otherwise healthy adults are viral 1, 2
In healthy immunocompetent adults younger than 70 years, pneumonia is unlikely if all of the following are absent: tachycardia, tachypnea, fever, and abnormal chest examination findings 1, 2
If pneumonia is suspected, first-line antibiotic therapy is aminopenicillin, such as amoxicillin, with alternative options including tetracycline, oral cephalosporin, third-generation quinolones, or macrolides 3, 4
For patients with chronic lung disease, recent antibiotic treatment, or high local prevalence of beta-lactamase-producing Haemophilus influenzae, use aminopenicillin plus beta-lactamase inhibitor, such as amoxicillin-clavulanate 3, 4
Treatment duration for pneumonia is typically 5-7 days 3, 4

For acute bronchitis, consider symptomatic relief with β-agonists, such as albuterol, only if wheezing is present and patient has underlying airflow obstruction 5
Other symptomatic relief options include cough suppressants, expectorants, first-generation antihistamines, and decongestants 1, 5

Do not prescribe antibiotics based on phlegm color alone, as this leads to the highest rate of inappropriate antibiotic prescribing among all acute respiratory tract infections 1, 2
Do not assume crackles always mean pneumonia, and use the full clinical criteria to distinguish bronchitis from pneumonia 1
Do not use macrolides, such as azithromycin, for acute bronchitis, as they increase adverse events without benefit 1, 2
Do not order chest X-rays or other testing for uncomplicated bronchitis, as testing should only be performed if pneumonia is suspected 1