Principles of Appropriate Antibiotic Use for Treatment of Uncomplicated Acute Bronchitis
Abstract & Commentary
Synopsis: The evaluation of immunocompetent adults with an acute cough or a presumptive diagnosis of uncomplicated acute bronchitis should focus on ruling out serious illness, particularly pneumonia. Routine antibiotic treatment of uncomplicated acute bronchitis is not recommended, regardless of duration of cough. Patient satisfaction with care for acute bronchitis depends mostly on physician-patient communication rather than on antibiotic treatment. These guidelines are for adults with acute bronchitis without comorbid conditions, such as chronic lung or heart disease.
Source: Gonzales R, et al. Ann Intern Med. 2001;134:521-529.
The term "acute bronchitis" usually designates an acute respiratory tract infection in which cough, with or without phlegm, is a predominant feature. In the United States, about 5% of adults self-report an episode of acute bronchitis each year, and up to 90% of these persons seek medical attention. In 1997, adults in the United States made more than 10 million office visits for bronchitis. As a result, acute bronchitis consistently ranks among the 10 most common conditions leading to outpatient physician visits.
Evaluation of Acute Cough
A wide variety of infections and inflammatory disorders can lead to an acute cough illness. The American College of Chest Physicians defines acute cough illness as lasting less than 3 weeks.1 Acute upper respiratory tract infections account for approximately 70% of primary diagnoses, with asthma (6%) and pneumonia (5%) being the next most common. Previously undiagnosed asthma is a consideration in patients presenting with an acute cough. The diagnosis of asthma is difficult to establish because many patients with acute bronchitis will have transient bronchial hyperresponsiveness. The primary objective in a healthy adult with uncomplicated acute cough is to exclude the presence of pneumonia. An evidence-based review concluded that absence of abnormalities in vital signs (heart rate > 100 beats/min, respiratory rate > 24 breaths/min, or oral temperature > 38°) and chest examination (rales, egophony, or fremitus) sufficiently reduces the likelihood of pneumonia to the point where further diagnostic testing is usually not necessary.2
Microbiology of Acute Uncomplicated Bronchitis
As in community-acquired pneumonia, microbiological studies of uncomplicated acute bronchitis identify a pathogen in the minority of cases, ranging from 16-40%. Specific viruses most frequently associated with acute bronchitis are influenza B, influenza A, parainfluenza 3, respiratory syncytial virus, corona virus, adenovirus, and rhinovirus. To date, only Bordetella pertussis, Mycoplasma pneumoniae, and C pneumoniae (TWAR) have been established as nonviral causes of uncomplicated acute bronchitis in adults.
Treatment of Uncomplicated Acute Bronchitis
Routine antibiotic treatment of uncomplicated acute bronchitis is not recommended, regardless of the duration of cough. The one uncommon circumstance for which evidence supports antibiotic treatment of patients with uncomplicated acute bronchitis is suspicion of pertussis.
Influenza is the most common pathogen isolated in patients with uncomplicated acute bronchitis. The neuraminidase inhibitors zanamivir and oseltamivir have demonstrated some efficacy in reducing illness duration in adults with naturally acquired influenza A and B if treatment begins within 48 hours of symptom onset.3
In most cases, cough is the major symptom for which patients seek relief. Randomized, controlled trials have demonstrated a consistent benefit of therapy with albuterol vs. placebo in reducing the duration and severity of cough.4 Preparations containing dextromethorphan or codeine probably have a modest effect on severity and duration of cough. Cough of more than 3 weeks duration, cough associated with underlying lung disease, or experimentally induced cough have been shown to respond to dextromethorphan or codeine. Elimination of environmental cough triggers such as dust and dander, as well as the use of vaporized air treatments in low-humidity environments, such as high altitude, are also reasonable options.
Clinicians should be encouraged to discuss the lack of benefit of antibiotic treatment for treatment for uncomplicated acute bronchitis and stop prescribing antibiotics for this condition as a standard of practice. Mounting evidence indicates that patient satisfaction with the office encounter does not depend on receipt of antibiotic therapy but instead is related to the patient-centered quality of the encounter.5
Comment by DAVID OST, MD, FACP, & NAJMA USMANI, MD
Most cases of acute bronchitis occur in otherwise healthy adults, in whom this acute cough illness can be called "uncomplicated acute bronchitis." The principles in this guideline are intended to apply to such patients, and do not necessarily apply to patients with chronic lung diseases such as chronic obstructive pulmonary disease.
The recommendations given in this article for discussing the management of acute bronchitis with patients include the following steps:
1. Provide realistic expectations of the duration of the patient’s cough, which will typically last for 10-14 days after the office visit.
2. Refer to the cough illness as a "chest cold" rather than bronchitis.6
3. Personalize the risk of unnecessary antibiotic use.
4. Explain to patients why we need to be more selective in treating only those conditions for which a major clinical benefit of antibiotics has been proven. Alert them to the current epidemic in antibiotic resistance among community bacterial pathogens and explain the public health concern. (Dr. Usmani is an Internal Medicine Fellow, Northshore University Hospital, Manhasset, NY.)
References
1. Irwin RS, et al. Chest. 1998;114:133S-181S.
2. Metlay JP, et al. JAMA. 1997;278:1440-1445.
3. Hayden FG, et al. N Engl J Med. 1997;337:874-880.
4. Melbye H, et al. Fam Pract. 1991;8:216-222.
5. Hamm RM, et al. J Fam Pract. 1996;43:56-62.
6. Gonzales R, et al. Am J Med. 2000;108:83-85.
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