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

J Emerg Med. 2012;43(2):221-227.

Conclusion

This study demonstrates that antibiotics are still over-prescribed in the diagnosis of acute bronchitis in the ED. Furthermore, broad-spectrum antibiotics are prescribed in a surprisingly large proportion of cases. Although there is ample evidence directing providers to avoid antibiotics in cases of acute bronchitis, this practice continues. Further efforts and resources are needed to reverse this disturbing trend. Additionally, our study sheds new light on prescribing practices of inhaled bronchodilators and spacers in acute bronchitis.

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Table 1. Patient Characteristics (n = 836)
Characteristics	n (%)
Gender
Female	449 (53.7)
Male	386 (46.2)
Age (mean ± SD)	46.4 ± 16.7
< 50 years	499 (59.6)
≥ 50 years	337 (40.3)
Social
Smoker (n = 694)	282 (40.6)
Alcohol abuse (n = 447)	87 (19.5)
Drug use (n = 484)	39 (8.0)
Comorbid conditions
COPD	90 (10.8)
Asthma	143 (17.1)
DM	66 (7.9)
HIV/AIDS, immunosuppressive medication	30 (3.6)
> 1 Comorbidity	54 (6.5)
Duration of cough (mean ± SD)	9.3 ± 17.7
1–7 days	552 (66.0)
>7 days	236 (28.3)
Unknown	48 (5.7)
Chief complaint
Cough	426 (60.0)
Shortness of breath	133 (15.9)
Sinus pain	12 (1.4)
Fever	62 (7.4)
Chest pain	52 (6.2)
Sore throat	45 (5.4)
Weakness	16 (1.9)
Other	90 (10.8)
Prescribed antibiotics	622 (74.0)
Macrolide	416 (50.0)
Tetracycline	124 (15.0)
Quinolone	56 (6.7)
Penicillin	17 (2.0)
Sulfa	7 (0.84)
Augmentin	5 (0.6)
Cephalosporin	3 (0.36)
Other treatments
Inhaled bronchodilator	400 (48)
Aerosol spacer device	76 (9.1)
Dilators (oral)	22 (2.6)
Corticosteroids (oral)	88 (11.0)
Cough suppressant	276 (33.0)
Narcotics	140 (17.0)
Ibuprofen	54 (6.5)

COPD = chronic obstructive pulmonary disease; DM = diabetes mellitus; HIV/AIDS = human immunodeficiency virus/acquired immune deficiency syndrome.

Table 2. Comorbid Conditions and Antibiotic Prescribing
Patient Factors	COPD n = 90 n (%)	Asthma n = 143 n (%)	HIV/AIDS, Immunosuppression n = 30 n (%)	Diabetes Mellitus n = 66 n (%)	> 1 Comorbid Condition n = 54 n (%)	None Recorded 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.

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.

Table 4. Social History
	Antibiotic n = 622 n (%)	No Antibiotic n = 214 n (%)	p Value
Smoking			0.025
No	302 (48.6)	110 (51.4)
Yes	226 (36.3)	56 (26.2)
Not recorded	94 (15.1)	48 (22.4)
Alcohol abuse			0.543
No	276 (44.4)	84 (39.3)
Yes	64 (10.3)	23 (10.7)
Not recorded	282 (45.3)	107 (50.0)
Drug use			0.145
No	343 (55.1)	102 (47.7)
Yes	34 (5.5)	5 (2.3)
Not recorded	245 (39.4)	107 (48.6)

Table 5. Use of Inhaled Bronchodilators and Spacers in Patients without Asthma
Patient Factors	n (%)
Patients discharged without bronchodilator	346 (49.9)
Patients discharged without a spacer	631 (91.1)
Patients discharged with a bronchodilator but not spacer	294 (84.7)
Patients prescribed antibiotics and no bronchodilator	289 (41.7)
Patients prescribed a bronchodilator and no antibiotics	124 (35.7)

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