Evidence-Based Medicine for Student Health Services
Robert J. Flaherty, MD
Swingle Student Health Service
Montana State University
Bozeman, MT 59717

Acute Bronchitis
 

Etiology	Monitoring
Epidemiology	Prognosis
Diagnosis	Prevention
Treatment	Patient Education

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Etiology  Acute bronchitis is rarely caused by atypical bacteria such as C. pneumoniae and M. pneumoniae, and rarely caused by bacterial infections severe enough significantly to increase the level of C-reactive protein.  Caveats Age group studied: Age 16 y and over Type/size: Prospective study (113 patients) Population characteristics: General parctice population Diagnostic criteria: Coughing with or without expectorationk with ronchi or widespread crepitations on auscultation, and without any underlying lung disease or clinical signs of pneumonia Outcome measures: Serology for Chlamydia pneumoniae, Mycoplasma pneumoniae, respiratory tract viruses, level of C-reactive protein Citations Jonsson JS et al, Acute bronchitis in adults. How close do we come to its aetiology in general practice? Scand J Prim Health Care 1997 Sep;15(3):156-60 - From PubMed      Epidemiology  No evidence is cited.     Diagnosis  Of patients presenting with chronic cough, 92% had gastroesophageal reflux disease (GERD), postnasal drip syndrome, and/or asthma. Considering only patients with cough of at least 3 weeks duration who are non-smokers, are not receiving angiotensin-converting enzyme (ACE) inhibitors, and have normal or nearly normal and stable chest radiographs, 99.4% will have GERD, postnasal drip syndrome, and/or asthma. Only 39% had a single cause of cough. Caveats Age group studied: Mean age 53.1 years Type/size: Population study of 88 patients Population characteristics: Immunocompetent patients who were referred to a pulmonary outpatient clinic for evaluation of chronic cough, average duration of cough was 6.6 years, 27% were male Outcome measures: Relationship between the patient's symptoms and the final diagnosis or diagnoses Citations Diagnosis of chronic cough: Review of Mello CJ, Irwin RS, Curley FJ. Predictive values of the character, timing, and complications of chronic cough in diagnosing its cause. Arch Intern Med 1996; 156: 997-1003 - Reviewed by POEMS/JFP   Excellent diagnostic algorithm for chronic cough in: Lawler, WR, An Office Approach to the Diagnosis of Chronic Cough, Am Fam Phsysican, 58(9): 2015-2022       Treatment   Antibiotics  Doxycycline, erythromycin and trimethoprim/sulfamethoxazole appear to have, at best, a modest beneficial effect in the treatment of acute bronchitis, with a corresponding small risk of adverse effects. Antibiotic treated groups tended to be either no less likely or slightly less likely to report feeling unwell at a follow up visit, to show no improvement on physician assessment or to have abnormal lung findings, and had a more rapid return to work or usual activities. Antibiotic- treated patients reported significantly more adverse effects such as nausea, vomiting, headache, skin rash or vaginitis.  Caveats Age group studied: 8y-65+y Outcome measure: Symptom improvement and return to work The benefits of antibiotics may be overestimated in the Cochrane analysis, however, because of the tendency of published reports to include complete data on only the outcomes found to be statistically significant. CRD study slightly limited by the lack of information on the included patients, the quality of the included studies and absence of statistical differences in some studies may have been due to the small sample sizes. Citations Antibiotics for Acute Bronchitis - Reviewed by  Cochrane  Similarly: Treatment of acute bronchitis in adults without underlying lung disease - Reviewed by DARE  Similarly: MacKay DN, Treatment of acute bronchitis in adults without underlying lung disease, J Gen Intern Med 1996 Sep;11(9):557-562 - From PubMed  Similarly: Acute bronchitis: erythromycin vs placebo: Review of King DE et al,  Effectiveness of erythromycin in the treatment of acute bronchitis. J Fam Pract 1996;42:601-05 - Reviewed by POEMS/JFP Cefprozil, cefpodoxime proxetil, loracarbef, cefixime, and ceftibuten were compared to conventional antibiotic therapies (usually amoxicillin/clavulanate, cefaclor or cephalexin) for community acquired infections. Infections included acute otitis media, pharyngitis, sinusitis, bronchitis, pneumonia, urinary tract infection and skin and skin-structure infections. The newer agents appear to be as clinically effective as conventional therapies (but not more effective) for the treatment of common community-acquired infections. They may also have the potential to improve compliance due to their once/twice daily mode of administration.  Caveats Age group studied: Unknown Type/size: Analytical review of studies: acute otitis media: 19 studies, pharyngitis: 13 studies, sinusitis: 4 studies, bronchitis: 10 studies, pneumonia: 7 studies, urinary tract infection: 11 studies, skin and skin-structure infections: 4 studies. Most studies consisted of 30-50 patients in each arm Population: Unknown Outcome measure: Clinical response to therapy For some of these infections other studies show that there is no evidence that any antibiotic therapy is beneficial Citations Comparison of cefprozil, cefpodoxime, proxetil, loracarbef, cefixime, and ceftibuten - Reviewed by DARE  Under most circumstances, the most cost-effective strategy for treating acute bronchitis is to withhold antibiotics and treat only patients whose cough does not resolve.  Caveats Age group studied: N/A Type/size: Cost-effectiveness analysis Population characteristics: N/A Outcome measures: Cost per person in whom acute bronchitis was diagnosed Citations Hueston WJ, Antibiotics: neither cost effective nor 'cough' effective, J Fam Pract 1997 Mar;44(3):261-5 - From PubMed  Receiving a prescription for an antibiotic for a URI was not associated with increased patient satisfaction. Better to spend time explaining the nature of a particular illness and the physician's choice of treatment. Caveats Age group: Adults Type/size: RCT of 113 Outcome measure: Patient satisfaction Diagnostic criteria unclear Citations Antibiotic use and patient satisfaction: Review of Hamm RM et al, Antibiotics and respiratory infections: Are patients more satisfied when expectations are met? J Fam Pract 1996;43:56-62 - Reviewed by POEMS/JFP   Similarly: Mangione-Smith R et al, The relationship between perceived parental expectations and pediatrician antimicrobial prescribing behavior, Pediatrics 1999 Apr;103(4 Pt 1):711-8 - From PubMed  Similarly: Himmel W et al, Are patients more satisfied when they receive a prescription? The effect of patient expectations in general practice. Scand J Prim Health Care 1997 Sep;15(3):118-22 - From PubMed     Bronchodilators  There is a modest benefit from inhaled (preferred) or liquid albuterol, in terms of reduced duration of cough and a quicker return to work, particularly in patients with purulent secretions.  Caveats Age group studied: Adults Outcome measure: Symptom improvement and return to work Small number of studies and patients Citations Treatment of acute bronchitis in adults without underlying lung disease -Reviewed by DARE  Albuterol MDI in acute bronchitis: REview of Hueston W. Albuterol metered-dose inhaler in the treatment of acute bronchitis. J Fam Pract 1995; January - Reviewed by POEMS/JFP   Contrary view: Oral albuterol for acute cough: Review of Littenberg B, Wheeler M, Smith D. A randomized, controlled trial of oral albuterol in acute cough. J Fam Pract 1996; 42:49-53 - Reviewed by POEMS/JFP       Monitoring No evidence is cited.   Prognosis      Informational handouts which describe the purpose and natural history of coughs can lower the rate of return visits for lower respiratory tract symptoms.  Caveats Age group studied: Median age 45y Type/size: 1014 patients Population characteristics: Patients presenting to GPs' offices with a new cough with at least one of the following: sputum production, wheeze, or chest pain; 60% females, 31% smokers, 72% were given antibiotics Outcome measure: Rate at which patients with lower respiratory illness return for the same symptoms within one month Citations  Patient information leaflets for lower respiratory tract illness: Review of MacFarlane JT et al, Reducing reconsultations for acute lower respiratory tract illness with an information leaflet: a randomized controlled study of patients in primary care. Br J Gen Pract 1997; 47: 719-722 - Reviewed by POEMS/JFP       Prevention  No evidence is cited.     Patient Education The following patient education materials are consistent with the available evidence. Acute Bronchitis - From the American Academy of Family Physicians  Cough Self-care Flowchart - From the AAFP Antibiotics: When They Can and Can't Help - From the AAFP Careful Antibiotic Use - From Rensselaer Polytechnic Institute Student Health Center  Rev. 7/11/01

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