Original Contributions - ANTIBIOTIC AND BRONCHODILATOR PRESCRIBING FOR ACUTE BRONCHITIS IN THE EMERGENCY DEPARTMENT
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The Journal of Emergency Medicine, Vol. -, No. -, pp. 1–7, 2012
Copyright Ó 2012 Elsevier Inc.
Printed in the USA. All rights reserved
0736-4679/$ - see front matter
doi:10.1016/j.jemermed.2011.06.143
Original
Contributions
ANTIBIOTIC AND BRONCHODILATOR PRESCRIBING FOR ACUTE BRONCHITIS
IN THE EMERGENCY DEPARTMENT
Jason C. Kroening-Roche, MD,* Arash Soroudi, MD,† Edward M. Castillo, PHD, MPH,†
and Gary M. Vilke, MD, FACEP, FAAEM†
*University of California (UC) San Diego School of Medicine, San Diego, California and †Department of Emergency Medicine, UC San Diego,
San Diego, California
Reprint Address: Jason Kroening, Department of Emergency Medicine, UC San Diego, 2751 Broadway, San Diego, CA 92102
, Abstract—Background: Although the overuse of antibi- INTRODUCTION
otics and underuse of bronchodilators for treatment of acute
bronchitis is well known, few studies have analyzed these Epidemiological studies have shown that the majority
trends in the emergency department (ED). Study Objectives: of cases of acute bronchitis are caused by viruses, with
To characterize the antibiotic and bronchodilator prescribing
bacterial pathogens accounting for 5–10% of acute
practices of physicians at two academic EDs in the diagnosis of
bronchitis in cases uncomplicated by underlying pulmo-
acute bronchitis, and to identify factors that may or may not
be associated with these practices. Methods: A computer data- nary disease (1–5). In adults with otherwise healthy
base was searched retrospectively for all patients with an ED lungs, the most common bacterial causes of acute
discharge diagnosis of acute bronchitis, and analyzed, looking bronchitis are Mycoplasma pneumoniae, Chlamydia
at the frequency of antibiotic prescriptions, the class of antibi- pneumoniae, and Bordetella pertussis (4,6). Of these,
otic prescribed, and several other related factors including antibiotic therapy is recommended only for treatment of
age, gender, chief complaint, duration of cough, and comorbid suspected pertussis (Centers for Disease Control and
conditions. Results: During the study period, there were 836 Prevention guidelines), and it is believed that pertussis
cases of acute bronchitis in adults. Of these, 622 (74.0%) is the causative agent in only 1% of cases of acute
were prescribed antibiotics. Of those prescribed antibiotics, bronchitis (5–7). In fact, multiple studies demonstrate
480 (77.2%) were prescribed broad-spectrum antibiotics.
no benefit from antibacterial use in the treatment of
Using multivariate analysis (odds ratio, 95% confidence inter-
acute bronchitis, with one citing the superiority of
val), antibiotics were prescribed significantly more often in pa-
tients aged 50 years or older (1.7, 1.2–2.5) and in smokers (1.5, albuterol to antibiotics (6,8–12).
1.0–2.2). Of patients without asthma, 346 (49.9%) were dis- Current recommendations suggest that antibiotics
charged without a bronchodilator, and 631 (91.1%) were dis- should not be prescribed for cases of uncomplicated
charged without a spacer device. Conclusion: Antibiotics are acute bronchitis (13–15). In keeping with these recom-
over-prescribed in the ED for acute bronchitis, with broad- mendations, one study demonstrated an almost 50%
spectrum antibiotics making up the majority of the antibiotics reduction in antibiotics prescribed for acute bronchitis in
prescribed. Age $ 50 years and smoking are associated with adults from 1993–1999 (16). Many studies since then,
higher antibiotic prescribing rates. Ó 2012 Elsevier Inc. however, do not report a similar reduction. Recent studies
suggest that antibiotics are prescribed between 57% and
, Keywords—acute bronchitis; antibiotics; bronchodila- 97% of the time for acute bronchitis in the emergency
tors; emergency department; broad-spectrum antibiotics department (ED), with fever, purulent sputum, shortness
RECEIVED: 24 November 2010; FINAL SUBMISSION RECEIVED: 14 April 2011;
ACCEPTED: 5 June 2011
12 J. C. Kroening-Roche et al.
of breath, and a provider age $ 30 years independently of 50 years. Of the charts reviewed, 694 included
associated with provider prescribing (16–18). information on tobacco use, 447 on alcohol use, and
The purpose of this study is to characterize the 484 on illicit drug use: 282 (40.6%) were identified as
antibiotic and bronchodilator prescribing practices of smokers on history, 87 (19.5%) reported alcohol use,
physicians at two EDs in the diagnosis of acute bronchi- and 39 (8.0%) used recreational drugs. Asthma was the
tis, and to identify factors that are, and are not, associated most common comorbid condition (17.1%), with COPD
with these practices. (10.8%) and diabetes mellitus (7.9%) being the second
and third most common, respectively. There were 56
MATERIALS AND METHODS (6.5%) patients recorded as having more than one comor-
bid condition. Table 1 provides patient demographics,
This is a retrospective study conducted via structured chart and vital signs are displayed in Figure 1.
data extraction of all patients presenting to the EDs of two There were 552 (66%) patients who reported 7 or
urban academic medical centers in San Diego, California fewer days of cough, with only 50 (6%) reporting a cough
from January 1 through December 31, 2008 with a primary
diagnosis of acute bronchitis. This diagnosis was defined Table 1. Patient Characteristics (n = 836)
by attending and resident physician entry of acute bronchi-
Characteristics n (%)
tis into the patient’s electronic medical chart on discharge
from the ED. All resident physician chart entry was subject Gender
to required review by the attending physician on duty, and a Female 449 (53.7)
Male 386 (46.2)
separate attending note was written. A total of 836 patients Age (mean 6 SD) 46.4 6 16.7
fit this criterion, and were included in the study. Factors < 50 years 499 (59.6)
such as patient age, gender, chief complaint, and medica- $ 50 years 337 (40.3)
Social
tions prescribed during the visit were obtained from the Smoker (n = 694) 282 (40.6)
database. Additionally, the attending physician notes Alcohol abuse (n = 447) 87 (19.5)
were queried for information regarding duration of cough, Drug use (n = 484) 39 (8.0)
Comorbid conditions
comorbid conditions, and social history (e.g., smoking, al- COPD 90 (10.8)
cohol abuse, and drug use) as documented by the physician Asthma 143 (17.1)
at the time of the patient interview. Severity of substance DM 66 (7.9)
HIV/AIDS, immunosuppressive medication 30 (3.6)
abuse was not reported. If no history of a comorbid condi- > 1 Comorbidity 54 (6.5)
tion (e.g., chronic obstructive pulmonary disease [COPD], Duration of cough (mean 6 SD) 9.3 6 17.7
asthma, human immunodeficiency virus/acquired immune 1–7 days 552 (66.0)
>7 days 236 (28.3)
deficiency syndrome [HIV/AIDS]) was noted in the history Unknown 48 (5.7)
of present illness or in nurses’ or physicians’ notes on past Chief complaint
medical history, it was assumed none existed. No patients Cough 426 (60.0)
Shortness of breath 133 (15.9)
with a diagnosis of acute bronchitis during our specified Sinus pain 12 (1.4)
study timeframe were excluded from the study. Fever 62 (7.4)
Institutional Review Board approval was obtained Chest pain 52 (6.2)
Sore throat 45 (5.4)
through the University of California San Diego’s Human Weakness 16 (1.9)
Subject’s Protection Program. Other 90 (10.8)
Frequencies, percentages, means, and associated SDs Prescribed antibiotics 622 (74.0)
Macrolide 416 (50.0)
were used to describe the patient population. The rela- Tetracycline 124 (15.0)
tionship between patient factors and the frequency of Quinolone 56 (6.7)
antibiotic prescribing was then analyzed using chi- Penicillin 17 (2.0)
Sulfa 7 (0.84)
squared analysis. p-Values < 0.05 were considered signif- Augmentin 5 (0.6)
icant. Logistic regression was used to assess factors that Cephalosporin 3 (0.36)
might be independently associated with prescribing anti- Other treatments
Inhaled bronchodilator 400 (48)
biotics. Odds ratios (ORs), 95% confidence intervals Aerosol spacer device 76 (9.1)
(CIs), and associated p-values are reported. Data were an- Dilators (oral) 22 (2.6)
alyzed with SPSS, version 17.0 (SPSS, Inc., Chicago, IL). Corticosteroids (oral) 88 (11.0)
Cough suppressant 276 (33.0)
Narcotics 140 (17.0)
RESULTS Ibuprofen 54 (6.5)
COPD = chronic obstructive pulmonary disease; DM = diabetes
Of the 836 patients included in our study, 449 (53.7%) mellitus; HIV/AIDS = human immunodeficiency virus/acquired
were women, and 499 (59.7%) were under the age immune deficiency syndrome.Antibiotic Prescribing for Acute Bronchitis 3
Figure 1. Temperature data were not present in 11 patients,
heart rate data in 15 patients, respiratory rate data in 14 pa- Figure 2. Of patients prescribed antibiotics, macrolide anti-
tients, and systolic blood pressure data in 10 patients. biotics were prescribed to 66%, tetracyclines to 19.9%,
quinolones to 9%, and penicillin to 2.7%. Overall, broad-
of > 21 days duration before presentation. Of the charts spectrum antibiotics were prescribed to 77.2% of patients
prescribed antibiotics.
reviewed, 48 reported no information on the duration of
cough. Cough was the most common chief complaint bronchodilator, compared to 124 (35.7%) who were
(60%), with shortness of breath being the next most com- prescribed a bronchodilator but not antibiotics. Patients
mon (15.9%). A variety of complaints made up portions with a historical finding of asthma were excluded from
smaller than 1%, and was included in a category labeled these calculations because they were likely to have a bron-
‘‘other,’’ making up 10.8% of the total complaints. chodilator and spacer at home.
Antibiotics were prescribed to 622 (74.0%) patients in Patients 50 years of age and older were found to be 1.7
this study. Among patients with comorbid conditions, an- times more likely to be prescribed antibiotics than those
tibiotics were prescribed to 81.1% with COPD, 76.2% under 50 years of age (95% CI 1.2–2.3, p = 0.002).
with asthma, 86.7% with HIV/AIDS or those taking im- Furthermore, smokers were 1.5 times more likely to be
munosuppressive medication, and 77.3% with diabetes prescribed antibiotics than non-smokers (95% CI
mellitus. Antibiotics were prescribed to 74.1% of patients 1.0–2.2, p = 0.025), independent of age. No other statisti-
for whom >1 comorbid condition was reported (Table 2). cally significant relationships were found relating the
The three most common classes of antibiotics prescribed prescription of antibiotics to patient factors (Tables 3–5).
were macrolides (50.0%), tetracyclines (15.0%), and qui-
nolones (6.7%). Of all the patients in the study, 480 DISCUSSION
(57.4%) received broad-spectrum antibiotics (defined as
a macrolide, quinolone, cephalosporin, or Augmentin Acute bronchitis is a self-limited inflammatory disorder
[GlaxoSmithKline, Brentford, Middlesex, UK]). In total, of the upper airways that affects approximately 5% of
broad-spectrum antibiotics made up 77.2% of all antibi- people in the United States each year (13). It is included
otics prescribed (Figure 2). under the broader heading of acute respiratory tract infec-
Other treatments prescribed included inhaled bron- tion along with other illnesses such as non-specific upper
chodilators in 400 (48%) patients, with 76 (9.1%) patients respiratory tract infection (URI), pharyngitis, and acute
receiving an aerosol spacer device. Of those patients bacterial sinusitis.
without asthma, 346 (49.9%) were discharged without Many studies report that antibiotics are frequently
a bronchodilator, and 631 (91.1%) were discharged prescribed for URIs despite evidence that they provide
without a spacer device. Again, in patients without little to no benefit to the patients (16–18). Recent
asthma, 289 (41.7%) were prescribed antibiotics but no studies, however, show that in cases of URI, antibiotic
Table 2. Comorbid Conditions and Antibiotic Prescribing
HIV/AIDS,
COPD Asthma Immunosuppression Diabetes Mellitus > 1 Comorbid Condition None Recorded
Patient Factors n = 90 n (%) n = 143 n (%) n = 30 n (%) n = 66 n (%) n = 54 n (%) n = 562 n (%)
Antibiotic 73 (81.1) 109 (76.2) 26 (86.7) 51 (77.3) 40 (74.1) 406 (72.2)
No antibiotic 17 (18.9) 34 (23.8) 4 (13.3) 15 (22.7) 14 (25.9) 156 (27.8)
COPD = chronic obstructive pulmonary disease; HIV/AIDS = human immunodeficiency virus/acquired immune deficiency syndrome.4 J. C. Kroening-Roche et al.
Table 3. Factors Affecting Antibiotic Prescribing
Factor Antibiotic n = 622 n (%) No Antibiotic n = 214 n (%) p Value
Gender 0.261
Female 341 (54.9) 108 (50.5)
Male 280 (45.1) 106 (49.5)
Age 0.002
< 50 years 352 (56.6) 147 (68.7)
$ 50 years 270 (43.4) 67 (31.3)
Comorbid conditions
COPD 0.159
No 549 (88.3) 197 (92.1)
Yes 73 (11.7) 17 (7.9)
Asthma 0.674
No 513 (82.5) 180 (84.1)
Yes 109 (17.5) 34 (15.9)
HIV/AIDS, immunosuppressive medication 0.138
No 596 (95.8) 210 (98.1)
Yes 26 (4.2) 4 (1.9)
DM 0.660
No 571 (91.8) 199 (93.0)
Yes 51 (8.2) 15 (7.0)
More than one comorbidity 0.954
No 582 (93.6) 200 (93.5)
Yes 40 (6.4) 14 (6.5)
Duration of cough 0.956
1–7 days 412 (66.2) 140 (65.4)
> 7 days 176 (28.3) 60 (28.0)
Unknown 34 (5.5) 14 (6.5)
Vital signs
Temperature 0.117
< 38.3 C (101 F) 571 (93.3) 205 (96.2)
$ 38.3 C (101 F) 41 (6.7) 8 (3.8)
Heart rate 0.220
# 100 beats/min 473 (77.3) 170 (81.3)
> 100 beats/min 139 (22.7) 39 (18.7)
Respiratory rate 0.913
# 20 breaths/min 566 (92.0) 191 (92.3)
> 20 breaths/min 49 (8.0) 16 (7.7)
Systolic blood pressure 0.837
< 140 mm Hg 421 (68.2) 141 (67.5)
$ 140 mm Hg 196 (31.8) 68 (32.5)
COPD = chronic obstructive pulmonary disease; HIV/AIDS = human immunodeficiency virus/acquired immune deficiency syndrome;
DM = diabetes mellitus.
prescribing is declining overall, with < 10% of patients Our data suggest that antibiotic prescribing for acute
receiving antibiotics in one ED study (16,19–22). Never- bronchitis has not significantly decreased from prior stud-
theless, this decrease is not present in the treatment of ies. Antibiotics were prescribed to 74% of patients in our
acute bronchitis. study. Patients with underlying COPD were prescribed
antibiotics over 81% of the time. One would expect, given
Table 4. Social History
evidence that antibiotics improve outcomes in acute
Antibiotic No Antibiotic COPD exacerbations, that this difference in antibiotic pre-
n = 622 n (%) n = 214 n (%) p Value scribing would be larger (23). Other than age and smoking
Smoking 0.025 status, no specific factors were associated with a greater
No 302 (48.6) 110 (51.4) likelihood of antibiotic prescribing by the physician. Prior
Yes 226 (36.3) 56 (26.2) studies suggest important factors to be the presence of
Not recorded 94 (15.1) 48 (22.4)
Alcohol abuse 0.543 fever, more than one comorbid condition, and shortness
No 276 (44.4) 84 (39.3) of breath. We did not find these relationships to be signif-
Yes 64 (10.3) 23 (10.7) icant in our sample. Furthermore, neither length of illness,
Not recorded 282 (45.3) 107 (50.0)
Drug use 0.145 underlying pulmonary disease, or vital sign abnormalities
No 343 (55.1) 102 (47.7) was associated with greater antibiotic prescribing.
Yes 34 (5.5) 5 (2.3) A common misconception among practitioners is that
Not recorded 245 (39.4) 107 (48.6)
antibiotics provide benefit to smokers with acuteAntibiotic Prescribing for Acute Bronchitis 5
Table 5. Use of Inhaled Bronchodilators and Spacers in energy intensive. In addition, there remain strong expecta-
Patients without Asthma
tions among patients who desire a ‘‘quick fix.’’ It then falls
Patient Factors n (%) on the emergency physician, often limited for time, to dis-
cuss the important ramifications of unnecessary antibiotics.
Patients discharged without 346 (49.9) Responsibility sharing among ancillary staff should be con-
bronchodilator
Patients discharged without a spacer 631 (91.1) sidered in these instances where education is needed.
Patients discharged with 294 (84.7) Furthermore, educational materials that may help alleviate
a bronchodilator but not spacer patient concerns are rarely readily available in the ED. Our
Patients prescribed antibiotics and no 289 (41.7)
bronchodilator study demonstrates an increasing need for resources in the
Patients prescribed a bronchodilator and 124 (35.7) area of physician and patient education to reduce antibiotic
no antibiotics prescribing, with an emphasis on broad-spectrum, in an
effort to combat antimicrobial resistance.
bronchitis. One ED study shows that smokers are 4.3 In addition to these antibiotic-related findings, our
times more likely to be prescribed antibiotics than non- study also found that 50% of patients were not prescribed
smokers (24). A review article of 109 studies looking at a bronchodilator. Although data recommending the use of
the effectiveness of antibiotics in smokers with acute bronchodilators in acute bronchitis are scarce, there is
bronchitis, however, reports that antibiotics are no more widespread anecdotal evidence that they are helpful in re-
effective in this population than in non-smokers (25). ducing symptom severity. Additionally, studies suggest
Our study also found that smokers are more likely to be that bronchodilators may be helpful in patients with un-
prescribed antibiotics at a rate 1.5 times greater than derlying pulmonary disease (33–37). In our study,
that of non-smokers. This shows an improvement from aerosol spacer devices were prescribed in only 15.3% of
prior reports, but it continues to suggest that physicians patients who were prescribed a bronchodilator, despite
do not fully understand the relationship between smoking evidence that these devices improve bioavailability in
and antibiotic usage for this diagnosis. the lungs, especially in those who may not be educated
Several more studies show a disturbing trend toward on the proper use of metered-dose inhalers (38–44).
increasing use of broad-spectrum antibiotics (22,26).
One study of acute bronchitis in the elderly reported Limitations
that antibiotics were prescribed in 83% of patients, and
one-half of the antibiotics prescribed were broad- Our study included all patients with a primary diagnosis of
spectrum (27). Our study demonstrates an even more acute bronchitis during our specified time period. Although
troubling trend toward broad-spectrum antibiotic use. this enabled a large study group, complete data were not
More than 75% of patients who received antibiotics available for every patient for the variables studied. This
were prescribed a broad-spectrum type, and the vast ma- limited the power in several areas, namely, those relating
jority was of the macrolide class (Figure 2). It is unclear to social history. As this was a retrospective study, the
why broad-spectrum antibiotics are prescribed more fre- accuracy of the data set must be questioned. In our study,
quently than narrow-spectrum. no formal teaching was performed, nor a consensus present
It is clear from our study that further education of regarding how to diagnose acute bronchitis, allowing for
physicians is needed regarding antibiotic prescribing in possible misrepresentation of our primary outcome.
cases of acute bronchitis, as it is well known that a positive This retrospective study is limited to describing the cur-
relationship exists between antibiotic usage and antimicro- rent antibiotic-prescribing state. It follows that we are
bial resistance (28). In addition, unnecessary antibiotic pre- unable to definitively state a causal relationship between
scribing is costly, time consuming, and associated with the characteristics identified and greater antibiotic presc-
allergic and adverse drug reactions. A variety of programs ribing. For instance, antibiotics are prescribed for a pleth-
have been carried out in an effort to reduce antibiotic pre- ora of diagnoses that may not be reflected in our data.
scribing practices, but have had minimal success (29,30). Similarly, in a retrospective study it is difficult to control
One such study records a modest success: decreasing for bias and confounders, although efforts were made in
antibiotic use from 75% to 60% in cases of acute this regard.
bronchitis; however, the use of broad-spectrum antibiotics
increased from 24% to 48% during the same period (31). CONCLUSION
Another study utilized household- and office-based patient
education, and describes a decrease in antibiotic prescrib- This study demonstrates that antibiotics are still over-
ing in acute bronchitis from 74% to 48% (32). prescribed in the diagnosis of acute bronchitis in the
As described above, the promising efforts that have been ED. Furthermore, broad-spectrum antibiotics are pre-
made to decrease antibiotic prescribing are often time and scribed in a surprisingly large proportion of cases.6 J. C. Kroening-Roche et al.
Although there is ample evidence directing providers to dinal study using the General Practice Research Database. J Public
Health Med 2004;26:268–74.
avoid antibiotics in cases of acute bronchitis, this practice 22. Steinman MA, Landefeld CS, Gonzales R. Predictors of broad-
continues. Further efforts and resources are needed to re- spectrum antibiotic prescribing for acute respiratory tract infections
verse this disturbing trend. Additionally, our study sheds in adult primary care. JAMA 2003;289:719–25.
23. Ram FS, Rodriguez-Roisin R, Granados-Navarrete A, et al.
new light on prescribing practices of inhaled bronchodi-
Antibiotics for exacerbations of chronic obstructive pulmonary
lators and spacers in acute bronchitis. disease. Cochrane Database Syst Rev 2006;19:CD004403.
24. Stone S, Gonzales R, Maselli J. Antibiotic prescribing for patients
with colds, upper respiratory tract infections, and bronchitis:
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ARTICLE SUMMARY
1. Why is this topic important?
Acute bronchitis affects 5% of Americans annually.
Antibiotics prescribed in the majority of these cases
represent a considerable antibiotic burden among the
population.
2. What does this study attempt to show?
This study sought to characterize the antibiotic and
bronchodilator prescribing practices of physicians at
two academic EDs in the diagnosis of acute bronchitis,
and to identify factors that may or may not be associated
with these practices.
3. What are the key findings?
This study shows that antibiotics are grossly over-
prescribed in acute bronchitis, with age and smoking re-
lated to increased prescribing. Patients 50 years of age
and older, and patients who smoke, are more likely to
be prescribed antibiotics. No other factors, however,
were shown to increase antibiotic prescribing.
4. How is patient care impacted?
Armed with this information, emergency physicians
may commit to reducing microbial antibiotic resistance
by avoiding prescribing antibiotics, specifically broad-
spectrum antibiotics, in the diagnosis of acute bronchitis.You can also read
