In Practice

Acute Bronchitis
Bjorn Buhagiar
Abstract
Acute bronchitis is a common respiratory tract infection usually caused by viruses and encountered often by family doctors. Diagnosis is usually made on clinical symptoms, as findings on physical examination are usually limited and investigations give non-specific results. Numerous studies have shown that antimicrobial agents are useless in acute bronchitis, and have a negligible effect on symptoms. The use of other medications such as 2-agonists and cough suppressants has also been questioned and these medications are usually reserved for patients suffering from chronic lung conditions. Delayed prescription has been considered as a means of reducing antibiotic overprescribing in respiratory tract infections, however, the effect of such measures on antibiotic use and resolution of symptoms is questionable, as are studies on the patients satisfaction with delayed prescribing. Patients knowledge on respiratory tract infections and their treatment must also be considered, as it has been shown that family practitioners should be aware of the patients expectations when they attend with a respiratory tract infection.

Introduction
Acute bronchitis is a self-limited inflammation of the large airways of the lungs. It affects approximately 5% of adults annually, with a higher incidence observed during winter and autumn rather than in summer and spring.1,2 Acute bronchitis represents almost 20% of respiratory tract infections with an incidence of around 29 episodes per thousand person years.3 In children, 5% of visits to the family doctor are for acute bronchitis, representing around 12% of visits for respiratory tract infections.4,5 On the other hand, in adults, acute bronchitis comprises 23% of respiratory tract infections encountered by family doctors.6

A typical clinical scenario

A 34 year-old male presented with a three day history of increasing cough, progressing from a dry one, to one producing yellowish sputum. He also complained of night-time lowgrade fever which was relieved with paracetamol. The patient confirmed mild shortness of breath on exertion but denied chest pain. He did not suffer from asthma and had quit smoking ten years previously. On examination, the patient was afebrile and auscultation of the chest disclosed faint wheezing on expiration.

Aetiology
Viruses are the most common cause of acute bronchitis: the main culprits being influenza A and B viruses, parainfluenza virus, respiratory syncytial virus, coronavirus, adenovirus and rhinovirus.7 Bacterial species commonly implicated in community-acquired pneumonias are also isolated from the sputum in a minority of patients suffering from acute bronchitis.1 These include Streptococcus pneumoniae , Haemophilus influenzae and Moraxella catharralis.8 However, the role of these species in the disease remains unclear as bronchial biopsies have not shown bacterial invasion. In some cases, atypical bacteria such as Bordetella pertussis, Chlamydia pneumoniae and Mycoplasma pneumoniae may be implicated.1

Keywords
Acute bronchitis, antimicrobials, delayed prescriptions, patient expectations

Clinical presentation
Bjorn Buhagiar MD Department of Primary Health Care, Floriana Email: bjornbuh@maltanet.net

Management of acute bronchitis in the community is very much dependent on comprehensive history taking and a high index of suspicion.

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Signs and symptoms

During the first few days of the infection, the symptoms of acute bronchitis cannot be distinguished from those of a mild upper respiratory tract infection. However, in the case of acute bronchitis the cough persists for more than 5 days, usually for 10 to 20 days, although occasionally it may last for 4 or more weeks. This cough is usually dry but some patients may report the production of sputum. Fever, fatigue and malaise may feature together with the cough and more severe symptoms include shortness of breath, wheezing and chest pains. Infections by adenoviridae might also cause gastrointestinal symptoms.9 Examination in patients with acute bronchitis is usually normal however in severe cases, there may be a rise in temperature and signs of respiratory distress. Chest examination can reveal decreased intensity of breath sounds, wheezing, rhonchi and prolonged expiration.9

culture for bacteria is infrequently done at community level, since the results of such procedure take time, and as previously highlighted, do not have a particularly relevant role in the management of the patients condition. Clinical symptoms that indicate the presence of a bacterial infection would be production of greenish sputum and the presence of high fever. If antibiotic treatment is deemed necessary, the medications of choice are co-amoxiclav, and clarithromycin in patients allergic to penicillin.8 Other treatment A few randomised controlled trials have studied the effect of 2-agonists administered orally or by aerosol for cough associated with acute bronchitis. All these trials have involved a small number of patients and produced mixed results. Most trials involved patients without preexisting lung disease and showed that daily cough scores and the likelihood of persistent cough after seven days did not differ significantly between the active treatment and placebo groups.13-15 However, in one trial, a subgroup of patients with evidence of airflow limitation had significantly lower scores for symptoms on day two after treatment with 2-agonists.13 A recent Cochrane Review of five trials involving 418 adults showed that even among patients with airflow obstruction, the potential benefit of 2-agonists is not well supported and should be balanced against the adverse effects of treatment.16 Although there are multiple clinical trial data on the use of mucolytics and oral steroids in chronic bronchitis, there is no data that supports the use of these agents in the treatment of acute bronchitis. Guidelines According to the 2001 guidelines of the American College of Physicians for the treatment of uncomplicated acute bronchitis, antibiotic treatment is not recommended, regardless of the duration of cough.17 According to the 2006 guidelines of the American College of Chest Physicians (ACCP), routine treatment with antibiotics for treating acute bronchitis is not justified. They also suggest that antitussive agents are only occasionally useful and that there is no routine role for inhaled bronchodilators or mucolytic agents. However, these guidelines note that subgroups of patients with chronic airflow obstruction at baseline or wheezing at the onset of illness may benefit from beta2-agonists. These guidelines have been criticised on the grounds that many of the recommendations were based more on opinion rather than on evidence. Delayed prescriptions Delayed prescription is when the family doctor prescribes a medicine and advises the patient to take medication after a number of days, only if certain signs or symptoms persist or develop. This can potentially address both the patients expectation of an antibiotic prescription and the practitioners clinical uncertainty, while minimising actual antibiotic consumption.

Investigations
Diagnosis of acute bronchitis is usually made from the clinical history and by exclusion of the presence of pneumonia. Most family doctors rely on the presence of a persistent dry or productive cough. A chest X-ray can reveal hyperinflation whilst a full blood count would feature a raised white blood cell count. A sputum sample may disclose increased neutrophils and a culture may grow an organism, when the cause is bacterial.

Treatment
Antimicrobial therapy Antibiotics are not recommended in most cases of acute bronchitis. Systematic analyses of clinical trials have suggested that antimicrobial agents may reduce the duration of symptoms only slightly. A quantitative systemic review showed that resolution of cough was not affected by antibiotic treatment and neither was there any significant clinical improvement. The side-effects of antibiotics were predictably more common in the antibiotic groups than in the placebo groups.9 A meta-analysis of eight trials showed that the use of antibiotics in acute bronchitis reduced the duration of cough and sputum production by one and a half days. The results were statistically significant, however, one can argue that the risk of side-effects and the societal cost of increasing antibiotic resistance need to be taken into consideration when interpreting such findings.10 Results of a randomised, double-blind trial comparing patients suffering with acute bronchitis treated with azithromycin with those treated with vitamin C showed no difference between the groups in the health-related quality of life at seven days or in the proportion of patients who returned to work, school or usual activities at home on day three or seven.11 A Cochrane review of nine randomised, controlled trials of antibiotic agents showed a significant but minor reduction in the duration of cough. There was a non-significant reduction in the number of days of feeling ill and a non-significant increase in adverse events attributed to antibiotics.12 Antibiotics are indicated for acute bronchitis when bacteria are cultivated from sputum cultures. Admittedly, sputum

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Antibiotic overprescribing The use of delayed prescription to reduce antibiotic overprescribing in acute bronchitis and other respiratory tract infections has been considered in several studies. The first evidence of benefit from delayed prescribing using a randomised controlled trial came from a 1997 study involving patients complaining of a sore throat. This showed that 99% of the immediate prescriptions were consumed whilst only 31% of delayed prescriptions were consumed without apparent serious harm.19 Other studies showed that delayed prescriptions resulted in reduced antibiotic prescription also in patients with otitis media, in those with cough, and in patients with common cold.20-23 Three of these studies reported an increase in signs and symptoms in patients who received a delayed prescription19,20,22, one study reported a decrease in symptoms23 whilst the other study did not report anything on symptoms.21 Satisfaction with the consultation and beliefs on delayed prescription Little is known about patients response to delayed prescribing, or the decision-taking processes that they employ in choosing whether to take their medication. The satisfaction of the patient with delayed prescribing was also studied in the studies mentioned above. Two of the randomised trials showed a significant decrease in satisfaction with the consultation when delayed antibiotics were given.20,22 Two studies reported good patient satisfaction but this was not statistically significant.19,23 Moreover, two of the studies showed that patients were less convinced that delayed prescriptions were more effective than immediate prescription.19,21 In contrast, in a study on patients responses to delayed prescription it was found that around half of the patients that were prescribed a delayed antibiotic for a respiratory tract infection, actually took the medication. Eighty-seven percent of these people reported that they were confident taking the decision whether to take the prescribed antibiotic, and more than 90% would have chosen a delayed prescription again.24 Patients expectations Not all patients are aware that most respiratory tract infections, including acute bronchitis, are caused by viruses and many patients have misconceptions on the use of antibiotics for such infections.25-27 In fact, many patients would expect an antibiotic for their infection, though less would request a prescription. Many of such patients would base their satisfaction on the prescription of the antibiotic.26 The situation with children is different, in that parents are being increasingly concerned about the excessive amount of antibiotics their children were being prescribed.28 The association between receiving antibiotics and information/reassurance on the one hand, and patients satisfaction on the other, among patients with acute respiratory tract symptoms has also been studied. It was found that 90% of patients expected reassurance or information and most of these

patients received it. Half of the patients expected an antibiotic and more than 70% of these received one. They also reported that receiving information or reassurance was more strongly associated with patient satisfaction rather than being prescribed an antibiotic.29

Conclusion
The patient presented in this clinical scenario was not prescribed any antibiotics as there were no clinical features suggestive of bacterial aetiology. Instead, the patients expectations from the consultation were explored. He stated that he had decided to consult a doctor as he was worried that he might be getting a bad infection. It was subsequently explained that the bronchitis was probably being caused by a virus and the natural course of the infection was discussed. He was reassured that no antibiotics were required but paracetamol was prescribed to relieve symptoms. He was also prescribed a short-acting bronchodilator for a brief period to relieve the shortness of breath. An opportunity was taken to discuss the issue of smoking with the patient. Instead of offering a delayed prescription, the patient was advised to attend again if symptoms were to deteriorate or if the cough would persist for more than three weeks.

References

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11. Evans AT, Husain S, Durairaj L, Sadowski LS, Charles-Damte M, Wang Y. Azithromycin for acute bronchitis: a randomized doubleblind, controlled trial. Lancet. 2002;359:1648-54. 12. Smucny J, Fahey T, Becker L, Glazier R. Antibiotics for acute bronchitis. Cochrane Database Syst Rev. 2004,4:CD000245. 13. Melbey H, Aasebo U, Straume B. Symptomatic effect of inhaled fenoterol in acute bronchitis: a placebo controlled double-blind study. Fam Pract. 1991;8:216-22. 14. Hueston WJ. Albuterol delivered by metered-dose inhaler to treat acute bronchitis. J Fam Pract. 1994;39:437-40. 15. Littenberg B, Wheeler M, Smith DS. A randomised controlled trial of oral albuterol in acute cough. J Fam Pract. 1996;42:49-53. 16. Smucny J, Flynn C, Becker L, Glazier R. Beta2-agonist for acute bronchitis. Cochrane Database Syst Rev. 2004;1:CD001726. 17. Gonzales R, Bartlett JG, Besser RE, Cooper RJ, Hickner JM, Hoffman JR et al. American Academy of Family Physicians; American College of Physicians-American Society of Internal Medicine; Centers for Disease Control; Infectious Diseases Society of America. Principles of appropriate antibiotic use for treatment of uncomplicated acute bronchitis: background. Ann Intern Med. 2001;134:521-9. 18. Braman SS. Chronic cough due to acute bronchitis: ACCP evidence-based clinical practice guidelines. Chest. 2006;129 (Suppl):95-103. 19. Little P, Williamson I, Warner G, Gould C, Gantley M, Kinmonth AL. Open randomised trial of prescribing strategies in managing sore throat. BMJ. 1997; 314:722-7. 20. Dowell J, Pitkethly M, Bain J, Martin S. A randomised controlled trial of delayed antibiotic prescribing as a strategy for managing uncomplicated respiratory tract infection in primary care. Br J Gen Pract. 2001;51:200-5.

21. Cates C. An evidence-based approach to reducing antibiotic use in children with acute otitis media: controlled before and after study. BMJ. 1999;318:715-6. 22. Little P, Gould C, Williamson I, Moore M, Warner G, Dunleavey J. Pragmatic randomized controlled trial of two prescribing strategies for childhood acute otitis media. BMJ. 2001; 322:336-42. 23. Arroll B, Kenealy T, Kerse N. Do delayed prescriptions reduce the use of antibiotics for the common cold? A single-blind controlled trial. J Fam Pract. 2002;51:324-8. 24. Edwards M, Dennison J, Sedgwick P. Patients responses to delayed antibiotic prescription for acute upper respiratory tract infections. British Journal of General Practice. 2003;53:845-50. 25. Collett C, Pappas DE, Evans BA, Hayden GF. Parental knowledge about common respiratory infections and antibiotic therapy in children. Southern Medical Journal. 1999; 92:971-6. 26. Macfarlene J, Holmes W, Macfarlene R, Britten N. Influence of patients expectations on antibiotic management of acute lower respiratory tract illness in general practice: questionnaire study. BMJ. 1997;315:1211-4. 27. Wilson AA, Crane LA, Barrett PH, Gonzales R. Public beliefs and use of antibiotics for acute respiratory illness. J Gen Inter Med. 1999;14:658-62. 28. Palmer DA, Bauchner H. Parents and physicians views on antibiotics. Pediatrics. 1997;99:e6. 29. Welschen I, Kuyvenhoven M, Hoes A, Verheij T. Antibiotics for acute respiratory tract symptoms: patients expectations, GPs management and patient satisfaction. Family Practice. 2004;21:2347.

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