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Acute Cough Illness (Acute Bronchitis): Physician Information Sheet (Adults)

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Acute bronchitis is an acute respiratory infection with a normal chest radiograph that is manifested by cough with or without phlegm production that lasts for up to 3 weeks (Chest 2006;129:95S-103S).

Principles apply to the appropriate treatment of cough illness lasting less than 3 weeks in otherwise healthy adults.

Refer to acute cough illness as a “chest cold” to reduce patient expectation for antibiotics (Am J Med 2000;108-83).

Background

  • Greater than 90% of cases of acute cough illness are non-bacterial.
    • Viral etiologies include influenza, parainfluenza, RSV, and adenovirus.
    • Bacterial agents include Bordatella pertussis, Mycoplasma pneumoniae, and Chlamydophila pneumoniae.
  • The presence of purulent sputum is not predictive of bacterial infection.
    • 95% of patients with purulent sputum do not have pneumonia (J Chron Di 1984; 37:215).

Diagnosis

  • Evaluation should focus on excluding severe illness, particularly pneumonia.

Clinical Assessment for Pneumonia

  • Pneumonia is unlikely if all of the following findings are absent (JAMA 1997;278:1440).

    Sign Abnormal Finding
    Fever ≥38°C
    Tachypnea ≥24 breaths/min
    Tachycardia ≥100 beats/min
    Evidence of consolidation
    on chest exam
    rales, egophony, fremitus
  • Consider chest radiograph for patients with any of these findings or cough lasting >3 weeks.

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Treatment

  • Empiric antibiotic treatment is not indicated for acute bronchitis.
    • Meta-analyses of randomized, controlledtrials all concluded that routine antibiotic treatment is not justified (BMJ 1998;316:906; Chest 2006;129:95S-103S).
  • If influenza therapy is considered, it should be initiated within 48 hours of symptom onset for clinical benefit.
    • During the 2005-06 Flu recommends that neither amantadine nor rimantadine be used for treatment or prevention of influenza A infections because of high levels of resistance (MMWR 2006 Jan 20;55(2):44-6).
    • Neuramidase inhibitors such as oseltamivir or zanamivir have activity against influenza A and B viruses.
    • Antiviral therapy reduces symptom duration by approximately 1 day.
      http://www.cdc.gov/flu/ professionals/treatment/
  • If pertussis is suspected, empiric therapy may be initiated while obtaining a diagnostic test for confirmation.
    • Antibiotic treatment decreases transmission but has little effect on symptom resolution.
  • Over-the-counter cough suppressants have limited efficacy in relief of cough due to acute bronchitis (Chest 2006; 129:95S-103S).

Tips to Reduce Antibiotic Use

  • Tell patients that antibiotic use increases the risk of an antibiotic resistant infection.
  • Identify and validate patient concerns.
  • Recommend specific symptomatic therapy.
  • Spend time answering questions and offer a contingency plan if symptoms worsen.
  • Provide patient education materials on antibiotic resistance.
  • REMEMBER: Effective communication is more important than an antibiotic for patient satisfaction.
  • See www.cdc.gov/drugresistance/community or contact your local health department for more information and patient education materials.

Key Reference

Cooper RJ et al. Principles of appropriate antibiotic use for acute pharyngitis in adults: Background. Annals of Internal Medicine 2001;134(6):509-17.

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