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Bronchitis in the ED: Analyzing Antibiotic Use

Bronchitis in the ED: Analyzing Antibiotic Use
Author Information (click to view)

Gary M. Vilke, MD, FACEP, FAAEM

Professor of Clinical Medicine
Director of Clinical Research, Department of Emergency Medicine
University of California, San Diego Medical Center

Gary M. Vilke, MD, FACEP, FAAEM, has indicated to Physician’s Weekly that he has no financial disclosures to report.

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Gary M. Vilke, MD, FACEP, FAAEM (click to view)

Gary M. Vilke, MD, FACEP, FAAEM

Professor of Clinical Medicine
Director of Clinical Research, Department of Emergency Medicine
University of California, San Diego Medical Center

Gary M. Vilke, MD, FACEP, FAAEM, has indicated to Physician’s Weekly that he has no financial disclosures to report.

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Although current guidelines recommend against the use of antibiotics in uncomplicated acute bronchitis, as most are viral in etiology, a recent analysis found that they are still grossly overprescribed.

Although antibiotics are often used in patients with common bacterial causes of acute bronchitis, current guidelines recommend against this practice, especially for cases of uncomplicated acute bronchitis, as most are viral in etiology. Fever, purulent sputum, shortness of breath, the presence of comorbid conditions, and a provider age of 30 or younger are factors that increase the likelihood of prescribing antibiotics for acute bronchitis. Better characterization of prescribing practices in the ED is needed in order to guide efforts to reduce the inappropriate use of antibiotics.

A Closer Look at Antibiotic Use

My colleagues and I had a study published in the Journal of Emergency Medicine that reviewed antibiotic and bronchodilator prescribing practices of emergency physicians at two EDs in patients with acute bronchitis. The investigation aimed to characterize key factors that were associated with antibiotic prescribing practices. Specifically, we looked at the frequency of antibiotic prescriptions, the class of antibiotic prescribed, and related factors, including age, gender, chief complaint, duration of cough, and comorbid conditions.

In our analysis, antibiotics were grossly overprescribed in acute bronchitis, with 74% of adults receiving these therapies. Of those who were prescribed these medications, most (about 77%) received broad-spectrum antibiotics. Prescribing practices for acute bronchitis did not decrease significantly from what has been shown in prior studies. Patients aged 50 and older and those who smoked were more likely to be prescribed antibiotics, but no other factors appeared to increase antibiotic prescribing practices. Among patients without asthma, nearly half were discharged without a bronchodilator, and more than 90% were discharged without a spacer device.

Impact on Patient Care for Acute Bronchitis

Although there is plenty of evidence indicating that emergency physicians need to avoid antibiotic use in most acute bronchitis cases, this practice continues. In light of our data, it’s clear that education on antibiotic prescribing for acute bronchitis and on the relationship between antibiotic use and antimicrobial resistance is necessary for emergency physicians. Unnecessary antibiotic prescribing is costly and time consuming and has been linked to allergic and adverse drug reactions. The many interventions used to reduce antibiotic prescribing practices, have had minimal success.

“Education on antibiotic prescribing for acute bronchitis and on the relationship between antibiotic use and antimicrobial resistance is necessary for emergency physicians.”

The efforts made to decrease inappropriate antibiotic prescribing practices are often time and energy intensive because there is no “quick fix” for patients. Prescribing a bronchodilator with a spacer is recommended therapy for acute bronchitis and can help improve symptoms as well as offer the patient an alternative “prescription” medication to treat their infection. Emergency physicians should discuss the ramifications of unnecessary antibiotics with their patients even when under significant time pressures. Sharing this patient education responsibility with other staff should be considered. Efforts to provide readily available educational materials in the ED may help alleviate patient concerns. By increasing educational resources in acute bronchitis, we may be able to reduce antibiotic prescribing practices and make greater steps to curbing the antimicrobial resistance problem.

Readings & Resources (click to view)

Kroening-Roche JC, Soroudi A, et al. Antibiotic and bronchodilator prescribing for acute bronchitis in the emergency department. J Emerg Med. 2012;43:221-227. Available at: http://www.jem-journal.com/article/S0736-4679(11)01400-4/abstract or at http://www.medscape.com/viewarticle/769190.

Ong S, Nakase J, Moran GJ, et al. Antibiotic use for emergency department patients with upper respiratory infections: prescribing practices, patient expectations, and patient satisfaction. Ann Emerg Med. 2007;50:213-220.

Stone S, Gonzales R, Maselli J. Antibiotic prescribing for patients with colds, upper respiratory tract infections, and bronchitis: a national study of hospital-based emergency departments. Ann Emerg Med. 2000;36:320-327.

Thorpe JM, Smith SR, Trygstad TK. Trends in emergency department antibiotic prescribing for acute respiratory tract infections. Pharmacotherapy. 2004;38:928-935.

Doyne EO, Alfaro MP, Siegel RM, et al. A randomized controlled trial to change antibiotic prescribing patterns in a community. Arch Pediatr Adolesc Med. 2004;158:577-583.

Rautakorpi U, Huikko S, Honkanen P, et al. The Antimicrobial Treatment Strategies (MIKSTRA) Program: a 5-year follow-up of infection-specific antibiotic use in primary health care and the effect of implementation of treatment guidelines. Clin Infect Dis. 2006;42: 1221-1230.

1 Comment

  1. Are we suggesting that cultures be taken and antibiotic sensitivity testing be performed on presumptive positive causitive microorganism and treat accordingly?

    Or do we continue to prescribe antibiotics emperically hoping to eliminate the causitive bug, reducing morbidity and mortality thereby minimizing the risk of a potential law suit for under-treatment, in spite of contributing to the over-use of antibiotics and increased antibiotic resistance?

    These are two difficult choices. Which way to turn?

    Reply

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