Antibiotic and Bronchodilator Prescribing for Acute Bronchitis in the Emergency Department

Jason C. Kroening-Roche, MD; Arash Soroudi, MD; Edward M. Castillo, PHD, MPH; Gary M. Vilke, MD, FACEP, FAAEM

Disclosures

J Emerg Med. 2012;43(2):221-227. 

In This Article

Abstract and Introduction

Abstract

Background Although the overuse of antibiotics and underuse of bronchodilators for treatment of acute bronchitis is well known, few studies have analyzed these trends in the emergency department (ED).
Study Objectives 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.
Methods A computer database was searched retrospectively for all patients with an ED discharge diagnosis of acute bronchitis, and analyzed, looking at the frequency of antibiotic prescriptions, the class of antibiotic prescribed, and several other related factors including age, gender, chief complaint, duration of cough, and comorbid conditions.
Results During the study period, there were 836 cases of acute bronchitis in adults. Of these, 622 (74.0%) were prescribed antibiotics. Of those prescribed antibiotics, 480 (77.2%) were prescribed broad-spectrum antibiotics. Using multivariate analysis (odds ratio, 95% confidence interval), antibiotics were prescribed significantly more often in patients aged 50 years or older (1.7, 1.2–2.5) and in smokers (1.5, 1.0–2.2). Of patients without asthma, 346 (49.9%) were discharged without a bronchodilator, and 631 (91.1%) were discharged without a spacer device.
Conclusion Antibiotics are over-prescribed in the ED for acute bronchitis, with broad-spectrum antibiotics making up the majority of the antibiotics prescribed. Age ≥ 50 years and smoking are associated with higher antibiotic prescribing rates.

Introduction

Epidemiological studies have shown that the majority of cases of acute bronchitis are caused by viruses, with bacterial pathogens accounting for 5–10% of acute bronchitis in cases uncomplicated by underlying pulmonary disease.[1–5] In adults with otherwise healthy lungs, the most common bacterial causes of acute bronchitis are Mycoplasma pneumoniae, Chlamydia pneumoniae, and Bordetella pertussis.[4,6] Of these, antibiotic therapy is recommended only for treatment of suspected pertussis (Centers for Disease Control and Prevention guidelines), and it is believed that pertussis is the causative agent in only 1% of cases of acute bronchitis.[5–7] In fact, multiple studies demonstrate no benefit from antibacterial use in the treatment of acute bronchitis, with one citing the superiority of albuterol to antibiotics.[6–12]

Current recommendations suggest that antibiotics should not be prescribed for cases of uncomplicated acute bronchitis.[13–15] In keeping with these recommendations, one study demonstrated an almost 50% reduction in antibiotics prescribed for acute bronchitis in adults from 1993–1999.[16] Many studies since then, however, do not report a similar reduction. Recent studies suggest that antibiotics are prescribed between 57% and 97% of the time for acute bronchitis in the emergency department (ED), with fever, purulent sputum, shortness of breath, and a provider age ≥ 30 years independently associated with provider prescribing.[16–18]

The purpose of this study is to characterize the antibiotic and bronchodilator prescribing practices of physicians at two EDs in the diagnosis of acute bronchitis, and to identify factors that are, and are not, associated with these practices.

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