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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, CaliforniaReprint Address: Jason Kroening, Department of Emergency Medicine, UC San Diego, 2751 Broadway, San Diego, CA 92102

, AbstractBackground: Although the overuse of antibi-

otics 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 computerdata-

base 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 antibi-

otic 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 inter-

val), antibiotics wereprescribed significantly more often in pa-

tients aged 50 years or older (1.7, 1.22.5) and in smokers (1.5,

1.02.2). Of patients without asthma, 346 (49.9%) were dis-

charged without a bronchodilator, and 631 (91.1%) were dis-

charged 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. 2012 Elsevier Inc.

, Keywordsacute bronchitis; antibiotics; bronchodila-

tors; emergency department; broad-spectrum antibiotics

INTRODUCTION

Epidemiological studies have shown that the majority

of cases of acute bronchitis are caused by viruses, with

bacterial pathogens accounting for 510% of acute

bronchitis in cases uncomplicated by underlying pulmo-

nary disease (15). 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 (57). 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 (6,812).

Current recommendations suggest that antibiotics

should not be prescribed for cases of uncomplicated

acute bronchitis (1315). In keeping with these recom-

mendations, one study demonstrated an almost 50%reduction in antibiotics prescribed for acute bronchitis in

adults from 19931999 (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

RECEIVED: 24 November 2010; FINAL SUBMISSION RECEIVED: 14 April 2011;ACCEPTED: 5 June 2011

1

The Journal of Emergency Medicine, Vol.-, No.-, pp. 17, 2012Copyright 2012 Elsevier Inc.

Printed in the USA. All rights reserved0736-4679/$ - see front matter

doi:10.1016/j.jemermed.2011.06.143
http://dx.doi.org/10.1016/j.jemermed.2011.06.143http://dx.doi.org/10.1016/j.jemermed.2011.06.143


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of breath, and a provider age$ 30 years independently

associated with provider prescribing (1618).

The purpose of this study is to characterize the

antibiotic and bronchodilator prescribing practices of

physicians at two EDs in the diagnosis of acute bronchi-

tis, and to identify factors that are, and are not, associated

with these practices.

MATERIALS AND METHODS

This is a retrospective study conducted via structured chart

data extraction of all patients presenting to the EDs of two

urban academic medical centers in San Diego, California

from January 1 through December 31, 2008 with a primary

diagnosis of acute bronchitis. This diagnosis was defined

by attending and resident physician entry of acute bronchi-

tis into the patients electronic medical chart on discharge

from the ED. All resident physician chart entry was subject

to required review by the attending physician on duty, and aseparate attending note was written. A total of 836 patients

fit this criterion, and were included in the study. Factors

such as patient age, gender, chief complaint, and medica-

tions prescribed during the visit were obtained from the

database. Additionally, the attending physician notes

were queried for information regarding duration of cough,

comorbid conditions, and social history (e.g., smoking, al-

cohol abuse, and drug use) as documented by the physician

at the time of the patient interview. Severity of substance

abuse was not reported. If no history of a comorbid condi-

tion (e.g., chronic obstructive pulmonary disease [COPD],

asthma, human immunodeficiency virus/acquired immunedeficiency syndrome[HIV/AIDS]) was noted in the history

of present illness or in nurses or physicians notes on past

medical history, it was assumed none existed. No patients

with a diagnosis of acute bronchitis during our specified

study timeframe were excluded from the study.

Institutional Review Board approval was obtained

through the University of California San Diegos Human

Subjects Protection Program.

Frequencies, percentages, means, and associated SDs

were used to describe the patient population. The rela-

tionship between patient factors and the frequency of

antibiotic prescribing was then analyzed using chi-squared analysis. p-Values < 0.05 were considered signif-

icant. Logistic regression was used to assess factors that

might be independently associated with prescribing anti-

biotics. Odds ratios (ORs), 95% confidence intervals

(CIs), and associated p-values are reported. Data were an-

alyzed with SPSS, version 17.0 (SPSS, Inc., Chicago, IL).

RESULTS

Of the 836 patients included in our study, 449 (53.7%)

were women, and 499 (59.7%) were under the age

of 50 years. Of the charts reviewed, 694 included

information on tobacco use, 447 on alcohol use, and

484 on illicit drug use: 282 (40.6%) were identified as

smokers on history, 87 (19.5%) reported alcohol use,

and 39 (8.0%) used recreational drugs. Asthma was the

most common comorbid condition (17.1%), with COPD

(10.8%) and diabetes mellitus (7.9%) being the secondand third most common, respectively. There were 56

(6.5%) patients recorded as having more than one comor-

bid condition. Table 1 provides patient demographics,

and vital signs are displayed in Figure 1.

There were 552 (66%) patients who reported 7 or

fewer days of cough, with only 50 (6%) reporting a cough

Table 1. Patient Characteristics (n = 836)

Characteristics n (%)

Gender

Female 449 (53.7)Male 386 (46.2)

Age (mean 6SD) 46.46 16.7< 50 years 499 (59.6)$ 50 years 337 (40.3)

SocialSmoker (n = 694) 282 (40.6)

Alcohol abuse (n = 447) 87 (19.5)Drug use (n = 484) 39 (8.0)

Comorbid conditionsCOPD 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 (mean6SD) 9.36 17.7

17 days 552 (66.0)>7 days 236 (28.3)Unknown 48 (5.7)

Chief complaintCough 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 treatmentsInhaled 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 = diabetesmellitus; HIV/AIDS = human immunodeficiency virus/acquiredimmune deficiency syndrome.

2 J. C. Kroening-Roche et al.


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of > 21 days duration before presentation. Of the charts

reviewed, 48 reported no information on the duration ofcough. Cough was the most common chief complaint

(60%), with shortness of breath being the next most com-

mon (15.9%). A variety of complaints made up portions

smaller than 1%, and was included in a category labeled

other, making up 10.8% of the total complaints.

Antibiotics were prescribed to 622 (74.0%) patients in

this study. Among patients with comorbid conditions, an-

tibiotics were prescribed to 81.1% with COPD, 76.2%

with asthma, 86.7% with HIV/AIDS or those taking im-

munosuppressive medication, and 77.3% with diabetes

mellitus. Antibiotics were prescribed to 74.1% of patients

for whom >1 comorbid condition was reported (Table 2).The three most common classes of antibiotics prescribed

were macrolides (50.0%), tetracyclines (15.0%), and qui-

nolones (6.7%). Of all the patients in the study, 480

(57.4%) received broad-spectrum antibiotics (defined as

a macrolide, quinolone, cephalosporin, or Augmentin

[GlaxoSmithKline, Brentford, Middlesex, UK]). In total,

broad-spectrum antibiotics made up 77.2% of all antibi-

otics prescribed (Figure 2).

Other treatments prescribed included inhaled bron-

chodilators in 400 (48%) patients, with 76 (9.1%) patients

receiving an aerosol spacer device. Of those patients

without asthma, 346 (49.9%) were discharged withouta bronchodilator, and 631 (91.1%) were discharged

without a spacer device. Again, in patients without

asthma, 289 (41.7%) were prescribed antibiotics but no

bronchodilator, compared to 124 (35.7%) who were

prescribed a bronchodilator but not antibiotics. Patients

with a historical finding of asthma were excluded from

these calculations because they were likely to have a bron-

chodilator and spacer at home.

Patients 50 years of age and older were found to be 1.7

times more likely to be prescribed antibiotics than those

under 50 years of age (95% CI 1.22.3, p = 0.002).

Furthermore, smokers were 1.5 times more likely to be

prescribed antibiotics than non-smokers (95% CI

1.02.2, p = 0.025), independent of age. No other statisti-

cally significant relationships were found relating theprescription of antibiotics to patient factors (Tables 35).

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 infec-

tion along with other illnesses such as non-specific upper

respiratory tract infection (URI), pharyngitis, and acute

bacterial sinusitis.

Many studies report that antibiotics are frequentlyprescribed for URIs despite evidence that they provide

little to no benefit to the patients (1618). Recent

studies, however, show that in cases of URI, antibiotic

Figure 1. Temperature data were not present in 11 patients,heart rate data in 15 patients, respiratory rate data in 14 pa-tients, and systolic blood pressure data in 10 patients.

Table 2. Comorbid Conditions and Antibiotic Prescribing

Patient FactorsCOPD

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.

Figure 2. Of patients prescribed antibiotics, macrolide anti-biotics were prescribed to 66%, tetracyclines to 19.9%,quinolones to 9%, and penicillin to 2.7%. Overall, broad-spectrum antibiotics were prescribed to 77.2% of patientsprescribed antibiotics.

Antibiotic Prescribing for Acute Bronchitis 3


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prescribing is declining overall, with < 10% of patients

receiving antibiotics in one ED study (16,1922). Never-

theless, 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 stud-

ies. 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 pre-scribing 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 signif-

icant 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

Table 3. Factors Affecting Antibiotic Prescribing

Factor Antibiotic n = 622 n (%) No Antibiotic n = 214 n (%) p Value

Gender 0.261Female 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 conditionsCOPD 0.159

No 549 (88.3) 197 (92.1)Yes 73 (11.7) 17 (7.9)

Asthma 0.674No 513 (82.5) 180 (84.1)Yes 109 (17.5) 34 (15.9)

HIV/AIDS, immunosuppressive medication 0.138No 596 (95.8) 210 (98.1)Yes 26 (4.2) 4 (1.9)

DM 0.660No 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 0.95617 days 412 (66.2) 140 (65.4)> 7 days 176 (28.3) 60 (28.0)Unknown 34 (5.5) 14 (6.5)

Vital signsTemperature 0.117

< 38.3 C (101F) 571 (93.3) 205 (96.2)$ 38.3 C (101F) 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

Antibioticn = 622 n (%)

No Antibioticn = 214 n (%) p Value

Smoking 0.025No 302 (48.6) 110 (51.4)Yes 226 (36.3) 56 (26.2)Not recorded 94 (15.1) 48 (22.4)

Alcohol abuse 0.543No 276 (44.4) 84 (39.3)Yes 64 (10.3) 23 (10.7)Not recorded 282 (45.3) 107 (50.0)

Drug use 0.145No 343 (55.1) 102 (47.7)Yes 34 (5.5) 5 (2.3)Not recorded 245 (39.4) 107 (48.6)



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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 beprescribed 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 ma-

jority was of the macrolide class (Figure 2). It is unclear

why broad-spectrum antibiotics are prescribed more fre-

quently 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 antimicro-

bial resistance (28). In addition, unnecessary antibiotic pre-

scribing is costly, time consuming, and associated with

allergic and adverse drug reactions. A variety of programshave been carried out in an effort to reduce antibiotic pre-

scribing 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 prescrib-

ing in acute bronchitis from 74% to 48% (32).

As described above, the promising efforts thathave been

made to decrease antibiotic prescribing are often time and

energy intensive. In addition, there remain strong expecta-

tions among patients who desire a quick fix. It then falls

on the emergency physician, often limited for time, to dis-

cussthe important ramifications of unnecessary antibiotics.

Responsibility sharing among ancillary staff should be con-

sidered in these instances where education is needed.

Furthermore, educational materials that may help alleviatepatient 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 re-

ducing symptom severity. Additionally, studies suggest

that bronchodilators may be helpful in patients with un-derlying pulmonary disease (3337). 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 (3844).

Limitations

Our study included all patients with a primary diagnosis of

acute bronchitisduring our specifiedtimeperiod. Although

this enabled a large study group, complete data were notavailable 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 wasperformed,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 cur-

rent antibiotic-prescribing state. It follows that we are

unable to definitively state a causal relationship between

the characteristics identified and greater antibiotic presc-

ribing. For instance, antibiotics are prescribed for a pleth-ora 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.

CONCLUSION

This study demonstrates that antibiotics are still over-

prescribed in the diagnosis of acute bronchitis in the

ED. Furthermore, broad-spectrum antibiotics are pre-

scribed in a surprisingly large proportion of cases.

Table 5. Use of Inhaled Bronchodilators and Spacers inPatients without Asthma

Patient Factors n (%)

Patients discharged withoutbronchodilator

346 (49.9)

Patients discharged without a spacer 631 (91.1)

Patients discharged witha bronchodilator but not spacer

294 (84.7)

Patients prescribed antibiotics and nobronchodilator

289 (41.7)

Patients prescribed a bronchodilator andno antibiotics

124 (35.7)



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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 re-

verse this disturbing trend. Additionally, our study sheds

new light on prescribing practices of inhaled bronchodi-

lators and spacers in acute 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 casesrepresent a considerable antibiotic burden among thepopulation.2. What does this study attempt to show?

This study sought to characterize the antibiotic andbronchodilator prescribing practices of physicians attwo academic EDs in the diagnosis of acute bronchitis,and to identify factors that may or may not be associatedwith 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 ageand older, and patients who smoke, are more likely tobe prescribed antibiotics. No other factors, however,were shown to increase antibiotic prescribing.4. How is patient care impacted?

Armed with this information, emergency physiciansmay commit to reducing microbial antibiotic resistanceby avoiding prescribing antibiotics, specifically broad-spectrum antibiotics, in the diagnosis of acute bronchitis.


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