Last reviewed: 25 Sep 2021
Last updated: 26 May 2021
26 May 2021

US guidance recommends limiting antibiotic treatment to 5 days in patients with bronchitis and acute exacerbations of COPD

Short-course antibiotics are preferable to longer treatment durations for patients with acute uncomplicated bronchitis and COPD exacerbations, according to new best practice advice from the American College of Physicians (ACP).

The ACP recommends a 5-day course in patients with an exacerbation of COPD and acute uncomplicated bronchitis presenting with increased purulent sputum plus increased dyspnea, sputum volume, or both.

  • This contrasts with the 5- to 7-day course proposed by the Global Initiative for Chronic Obstructive Lung Disease for patients with COPD exacerbations in general.[1]

  • The ACP recommendation is underpinned by a meta-analysis (21 randomized controlled trials; n=10,698 patients) of short-course antibiotic use in patients with acute exacerbations of chronic bronchitis and COPD, which showed no difference in clinical improvement between groups that included patients receiving short-course antibiotics (mean 4.9 days) and those receiving long treatment (mean 8.3 days).[139]¬†

  • The ACP notes that unnecessarily long durations of antibiotic therapy in patients with common bacterial infections such as acute bronchitis with COPD exacerbation contribute to antibiotic resistance and other adverse events.

  • Clinicians should reassess patients who do not improve with appropriate antibiotics for other causes of symptoms rather than defaulting to a longer duration of antibiotic therapy.

See Management: approach

See Management: treatment algorithm

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History and exam

Key diagnostic factors

  • dyspnea
  • cough
  • wheeze
  • changes in sputum volume/color/thickness
  • tachypnea
  • cyanosis

Other diagnostic factors

  • past medical history of COPD
  • tobacco use
  • past medical history of gastroesophageal reflux/swallowing dysfunction
  • malaise and fatigue
  • chest tightness
  • features of cor pulmonale
  • environmental/occupational exposure to pollutants or dust
  • change in mental status
  • fever
  • accessory muscle use
  • paradoxical movements of abdomen

Risk factors

  • viral infection
  • bacterial infection
  • gastroesophageal reflux/swallowing dysfunction
  • smoking
  • atypical bacterial infection
  • air pollutants
  • change in weather

Diagnostic investigations

1st investigations to order

  • oxygen saturation on pulse oximetry
  • chest x-ray
  • ECG
  • ABG
  • CBC with platelets
  • electrolytes, BUN, + creatinine

Investigations to consider

  • sputum culture + Gram stain
  • respiratory virus diagnostics
  • cardiac troponin
  • CT scan of chest

Emerging tests

  • procalcitonin
  • C-reactive protein

Treatment algorithm



Carolyn L. Rochester, MD

Professor of Medicine

Yale School of Medicine

New Haven

VA Connecticut Healthcare System

West Haven



CLR serves on the COPD scientific advisory board for GlaxoSmithKline Pharmaceuticals but has no competing interests pertaining to this publication.

Richard A. Martinello, MD

Associate Professor

Yale School of Medicine

New Haven



RAM declares that he has no competing interests.

Peer reviewers

Sanjay Sethi, MD

Professor of Medicine

Division Chief

Pulmonary/Critical Care/Sleep Medicine

University at Buffalo

State University of New York

Section Chief

Pulmonary/Critical Care/Sleep Medicine

VA Western New York Healthcare System




SS declares that he has no competing interests.

Francis Thien, MD, FRACP, FCCP


Box Hill Hospital and Monash University




FT declares that he has no competing interests.

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