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

Discussion

Acute bronchitis is a self-limited inflammatory disorder of the upper airways that affects approximately 5% of people in the United States each year.[13] It is included under the broader heading of acute respiratory tract infection along with other illnesses such as non-specific upper respiratory tract infection (URI), pharyngitis, and acute bacterial sinusitis.

Many studies report that antibiotics are frequently prescribed for URIs despite evidence that they provide little to no benefit to the patients.[16–18] Recent studies, however, show that in cases of URI, antibiotic prescribing is declining overall, with < 10% of patients receiving antibiotics in one ED study.[16,19–22] Nevertheless, this decrease is not present in the treatment of acute bronchitis.

Our data suggest that antibiotic prescribing for acute bronchitis has not significantly decreased from prior studies. Antibiotics were prescribed to 74% of patients in our study. Patients with underlying COPD were prescribed antibiotics over 81% of the time. One would expect, given evidence that antibiotics improve outcomes in acute COPD exacerbations, that this difference in antibiotic prescribing would be larger.[23] Other than age and smoking status, no specific factors were associated with a greater likelihood of antibiotic prescribing by the physician. Prior studies suggest important factors to be the presence of fever, more than one comorbid condition, and shortness of breath. We did not find these relationships to be significant in our sample. Furthermore, neither length of illness, underlying pulmonary disease, or vital sign abnormalities was associated with greater antibiotic prescribing.

A common misconception among practitioners is that antibiotics provide benefit to smokers with acute bronchitis. One ED study shows that smokers are 4.3 times more likely to be prescribed antibiotics than non-smokers.[24] A review article of 109 studies looking at the effectiveness of antibiotics in smokers with acute bronchitis, however, reports that antibiotics are no more effective in this population than in non-smokers.[25] Our study also found that smokers are more likely to be prescribed antibiotics at a rate 1.5 times greater than that of non-smokers. This shows an improvement from prior reports, but it continues to suggest that physicians do not fully understand the relationship between smoking and antibiotic usage for this diagnosis.

Several more studies show a disturbing trend toward increasing use of broad-spectrum antibiotics.[22,26] One study of acute bronchitis in the elderly reported that antibiotics were prescribed in 83% of patients, and one-half of the antibiotics prescribed were broad-spectrum.[27] Our study demonstrates an even more troubling trend toward broad-spectrum antibiotic use. More than 75% of patients who received antibiotics were prescribed a broad-spectrum type, and the vast majority was of the macrolide class (Figure 2). It is unclear why broad-spectrum antibiotics are prescribed more frequently than narrow-spectrum.

It is clear from our study that further education of physicians is needed regarding antibiotic prescribing in cases of acute bronchitis, as it is well known that a positive relationship exists between antibiotic usage and antimicrobial resistance.[28] In addition, unnecessary antibiotic prescribing is costly, time consuming, and associated with allergic and adverse drug reactions. A variety of programs have been carried out in an effort to reduce antibiotic prescribing practices, but have had minimal success.[29,30] One such study records a modest success: decreasing antibiotic use from 75% to 60% in cases of acute bronchitis; however, the use of broad-spectrum antibiotics increased from 24% to 48% during the same period.[31] Another study utilized household- and office-based patient education, and describes a decrease in antibiotic prescribing in acute bronchitis from 74% to 48%.[32]

As described above, the promising efforts that have been made to decrease antibiotic prescribing are often time and energy intensive. In addition, there remain strong expectations among patients who desire a "quick fix." It then falls on the emergency physician, often limited for time, to discuss the important ramifications of unnecessary antibiotics. Responsibility sharing among ancillary staff should be considered in these instances where education is needed. Furthermore, educational materials that may help alleviate patient concerns are rarely readily available in the ED. Our study demonstrates an increasing need for resources in the area of physician and patient education to reduce antibiotic prescribing, with an emphasis on broad-spectrum, in an effort to combat antimicrobial resistance.

In addition to these antibiotic-related findings, our study also found that 50% of patients were not prescribed a bronchodilator. Although data recommending the use of bronchodilators in acute bronchitis are scarce, there is widespread anecdotal evidence that they are helpful in reducing symptom severity. Additionally, studies suggest that bronchodilators may be helpful in patients with underlying pulmonary disease.[33–37] In our study, aerosol spacer devices were prescribed in only 15.3% of patients who were prescribed a bronchodilator, despite evidence that these devices improve bioavailability in the lungs, especially in those who may not be educated on the proper use of metered-dose inhalers.[38–44]

Limitations

Our study included all patients with a primary diagnosis of acute bronchitis during our specified time period. Although this enabled a large study group, complete data were not available for every patient for the variables studied. This limited the power in several areas, namely, those relating to social history. As this was a retrospective study, the accuracy of the data set must be questioned. In our study, no formal teaching was performed, nor a consensus present regarding how to diagnose acute bronchitis, allowing for possible misrepresentation of our primary outcome.

This retrospective study is limited to describing the current antibiotic-prescribing state. It follows that we are unable to definitively state a causal relationship between the characteristics identified and greater antibiotic prescribing. For instance, antibiotics are prescribed for a plethora of diagnoses that may not be reflected in our data. Similarly, in a retrospective study it is difficult to control for bias and confounders, although efforts were made in this regard.

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