Review

The management of acute

bronchitis in children
Douglas M Fleming† & Alex J Elliot
†Birmingham Research Unit of the Royal College of General Practitioners, Lordswood House,
1. Introduction 54 Lordswood Road, Harborne, Birmingham B17 9DB, UK

2. Diagnosis
Acute bronchitis is one of the most common infections reported in children
3. Epidemiology under 5 years of age, and is a leading cause of hospitalisation. In general prac-
4. Pathogenesis tice, confusion surrounds the clinical diagnosis of acute bronchitis, especially
5. Disease management when distinguishing it from asthma. The microbiological causes are mostly
known, but the contribution of each is much less clear, and they are non-spe-
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6. Organism-specific treatment
cific in their clinical expression in individual cases. Viral pathogens, particularly
7. Disease prevention
respiratory syncytial virus and rhinoviruses are cited as the leading agents in
8. Expert opinion the development of serious episodes, but other pathogens may also be impor-
tant. This article covers a range of issues surrounding acute bronchitis, includ-
ing epidemiology and pathogenesis, as well as the management, prevention
and treatment of disease in children.

Keywords: acute bronchitis, children, cough, respiratory syncytial virus, rhinovirus, wheeze

Expert Opin. Pharmacother. (2007) 8(4):415-426

For personal use only.

1. Introduction

Acute bronchitis is one of the most common infections reported in children. In an

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analysis of routine consultation data reported in the general practice-based sentinel
surveillance scheme operating in England and Wales, known as the Weekly Returns
Service (WRS) of the Royal College of General Practitioners [1,101], 6.2% of children
(0 – 14 years of age) were reported with one or more episodes of acute bronchitis
during 2001 [2]. Altogether, 15.5% reported an acute respiratory infection. These
proportions are substantially less than those reported 10 years previously in a major
national morbidity survey in which similar methods were employed and many of
the same practices were involved [3].
This review considers children who are < 14 years of age, but does not discuss respi-
ratory infections in neonates or the management of problems that involve intensive care
management. The diagnostic term ‘acute bronchitis’ is imprecise, and is often loosely
applied to episodes of illness that involve a cough as the chief symptom. Mostly, it is
applied when children present with respiratory symptoms that have an acute onset. The
cough may be dry or productive, and although it is usual for the child to have an
elevated temperature, at least for part of the illness, it is not necessarily the case at the
time of consultation. Many children experience a comparatively minor illness, and
there are many who do not consult. Furthermore, several children consult late in the
course of the illness because of the persisting cough at a time when there are almost no
physical signs. In some cases, it can be particularly difficult to differentiate those with a
problem due to a slowly resolving infection from those with underlying asthma.
The Thoracic Society of Australia and New Zealand had attempted to classify
cough in children in order to rationalise management [4]. They emphasise the
important differences between the nature and causes of cough in children as
opposed to adults. Because the duration of cough is so important, children pre-
senting more than once in an episode will commonly move from one classification
category to the next.
The term acute bronchitis is vague in a pathological sense. Few pathogens that cause
respiratory infection limit their action to only one region of the respiratory tract [5].

10.1517/14656566.8.4.415 © 2007 Informa UK Ltd ISSN 1465-6566 415

 The management of acute bronchitis in children
For some, such as Bordetella pertussis, the overwhelming focus
on a particular region of the respiratory tract (in this case the
larynx) completely dominates issues surrounding management.
Other pathogens, for example respiratory syncytial virus (RSV),
are known to cause extensive damage to the lining of the entire
respiratory tract, although the clinical significance of damage to
the lower airways in infants considerably outweighs its
significance as a cause of upper airways infection.
The adjective ‘acute’ differentiates bronchitis from a
chronic condition, and in this context, implies a condition
from which complete recovery is to be expected, at least in the
majority of cases. However, it is not uncommon for children
to experience frequently recurring episodes of respiratory tract
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infection, and these call for special consideration. For practi-
cal purposes, chronic obstructive pulmonary disease (COPD)
is not a numerically important problem in children, although
the potential for recurring acute infections giving rise to irre-
versible damage must not be overlooked. RSV in particular
has long been incriminated as a determinant of asthma,
although the available evidence is conflicting [6-9]. This issue
was reviewed by Message and Johnston [10]: as compared with
controls, wheezing at ages 3 and 6, but not by 11 years, was
more likely in hospitalised children, because of RSV infection
in infancy. However, it is not clear whether the association is
For personal use only.
causal, or is found because of selection bias for hospitalisation.
In a comparison of the impact of influenza and RSV on respi-
ratory diagnoses made in primary care, exacerbations of
asthma occur during periods of RSV activity much more fre-
quently than in periods of influenza virus activity [11]. Our
understanding of the link between recurring viral infections
and long-term respiratory disease is limited by the quality of
virological investigation and the limited numbers of infected
children who are investigated. In epidemiological studies
undertaken during the last 15 years, there has been increasing
recognition of the role of respiratory viruses as a cause of
asthma exacerbations [12,13].
Despite these comments on the relative infrequency of
chronic respiratory disease in young children, it is essential to rec-
ognise those children presenting with recurring acute respiratory
infections who have pre-existing respiratory disease that has not
always been diagnosed prior to presentation. In this regard,
pre-existing lung diseases, such as cystic fibrosis, congenital cardi-
opulmonary malformations, situs inversus and tracheo-oesopha-
geal fistula must be considered when infants and preschool
children present. Prematurity presents its own set of problems,
and is particularly known to predispose children to serious infec-
tions caused by RSV [14]. Issues relating to the management of
premature infants are not considered in this paper.
2. Diagnosis
The diagnostic term ‘acute bronchitis’ is not used consistently,
which causes confusion when considering the results of research
on various aspects of this condition. There is first a distinction
between upper and lower respiratory disorder. The
416 Expert Opin. Pharmacother. (2007) 8(4)
International Classification of Diseases volume 9 (ICD9) classi-
fies acute bronchitis as an acute respiratory infection specifying
neither the lower nor the upper respiratory tract. In ICD9,
acute bronchitis is classified in the same three-digit category as
acute bronchiolitis, although these two conditions are more
clearly separated in ICD10. Acute bronchitis is specified sepa-
rately from COPD and from asthma, but general practitioners
often report the diagnosis ‘bronchitis not otherwise specified’
(ICD9 490), that is grouped together with COPD. It is unwise
to consider statistical data on exacerbations of asthma separately
from acute bronchitis. Most exacerbations of asthma in young
children occur as a result of viral respiratory infections [10].
Clinically, it is not always possible to distinguish an attack of
asthma from an infection labelled as acute bronchitis. Indeed, it
is common for a diagnosis of asthma to be made as a result of
apparently frequent attacks of acute bronchitis in which wheez-
ing is prominent. In the Oxford Textbook of Medicine, acute
bronchitis is classified as a lower respiratory tract infection,
an opinion that has been accepted for the purpose of this
article [15]. As a precaution, when considering published mate-
rial on respiratory infections that purport to distinguish upper
and lower respiratory tracts, it is important to be clear in which
category acute bronchitis is placed.
There is no satisfactory clinical distinction between asthma
and acute bronchitis when it first appears. Although the pres-
ence of wheeze, particularly if found consistently during epi-
sodes of respiratory infection, does provide a clue to the
likelihood of asthma, its absence does not deny this possibil-
ity. Wheeze may be present at the time of clinical assessment,
and may be a feature of the presenting history, but equally, it
may not be present at all. Persistent nocturnal cough is con-
sidered a hallmark symptom of asthma even though it is often
reported in the absence of wheeze.
A number of conditions cause airways obstruction at the
larynx, and it is important to recognise these promptly. Epi-
glottitis is a particularly dangerous condition because of the
rapidity with which patients deteriorate and may die. This is
usually caused by Haemophilus influenzae, and prompt treat-
ment in intensive care facilities is needed [16]. Other causes of
laryngospasm include croup (commonly associated with
parainfluenza infection) and whooping cough. In the latter
case, laryngeal stridor usually appears some days after onset. It
is particularly important to make this diagnosis in infants, as
the effects of recurring laryngeal stridor can be serious.
In hospital-based emergency rooms, oximetry and chest
X-rays assist in making management decisions. Assessment of
expiratory peak flow may also assist in older children, but with-
out a record of comparative readings from previous occasions,
the value of first time measurement in a child may be seriously
limited. Although the identification of the causative pathogen is
important both for surveillance and in cases in which the infec-
tion is persistent, this exercise is less useful in the acute phase of
the illness as most management decisions have to be made
promptly before the results of such tests are available. The
expansion of investigation using PCR techniques and near

patient tests may eventually lead to more widespread
investigations, even in the acute phase of the illness.
3. Epidemiology
The incidence of acute bronchitis has been recorded by gen-
eral practitioners reporting to the WRS for 35 years. During
this period, incidence in children 0 – 4 years of age has
remained relatively constant. There was a marked increase in
incidence that peaked in the early 1990s, since then, it has
been steadily falling. Annual incidence registered in children
0 – 4 years of age was ∼ 20 episodes per 100 population in
1995, and this fell to 12 per 100 in 2004 [101]. Systematic
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microbiological studies of children consulting with acute res-
piratory infections have found organisms in 50 – 90% of
cases, depending on the severity of illness, the type of patient
investigated and the method of investigation: viral pathogens
are always found more frequently than bacteria [17-21]. RSV is
the most common cause of acute lower respiratory tract infec-
tion in young children [22]. The annual seasonality of acute
bronchitis/bronchiolitis (the most common lower respiratory
tract infection) follows the same seasonal pattern as RSV
activity, monitored by laboratory reporting (Figure 1). Clinical
incidence data for the years 1999/2000 to 2003/2004 show
For personal use only.
that acute bronchitis in children aged 0 – 4 years peaks during
weeks 49 – 51; and the peak recorded in the elderly occurs
during weeks 1 and 2 (i.e., children peak in the weeks prior to
Christmas, and the elderly in the weeks following Christmas;
Figure 2). It is apparent that the traditional social mixing that
occurs during this holiday period provides the ideal opportu-
nity for the spread of infection from the younger to older gener-
ations. In young children, acute bronchitis and exacerbations of
asthma are reported more frequently in males than in females,
and boys are hospitalised more frequently [22-25]; this gender
difference is not present in adult cases [24]. This pattern has
not been explained adequately, but may reflect differences in
bronchial responsiveness to pathogens or differences in the
immune reactions between boys and girls triggered by viral
infections [25]. The difference is also seen in infant deaths due
to respiratory disease and, interestingly, is similar in sudden
infant death syndrome (SIDS; Figure 3).
Parainfluenza and rhinoviruses are other major causes of
acute respiratory infection in both children and adults. These
are more particularly associated with upper respiratory
illnesses, such as common cold and otitis media [26,27],
although they also sometimes cause more serious lower respi-
ratory illnesses. They are associated with asthma attacks and
wheezing [20,28], with bronchiolitis in young children [29,30],
and are a significant cause of deteriorating pulmonary
function in children with established respiratory disease [31].
There are also bacterial causes of acute bronchitis. Although
these may arise as complications of viral infection, they are
sometimes the primary causal agent. Bacteria are more often
identified in cases of recurrent infection. Esposito et al. studied
a group of 352 previously healthy children with recurrent
Expert Opin. Pharmacother. (2007) 8(4)
Fleming & Elliot
respiratory tract infections (8 or more episodes per year in chil-
dren < 3 years, and 6 or more episodes in older children), and
found causative pathogens in 199 cases, of which 58 were Myc-
oplasma pneumoniae and 16 were Chlamydia pneumoniae [5].
Interestingly, the symptoms in both instances embraced both
upper and lower respiratory tracts (although for M. pneumo-
niae, there was increased emphasis on the lower tract
symptoms). Wangroongsarb et al. identified 37 (27%)
C. pneumoniae infections in 135 children who were < 5 years
old, and who had a range of respiratory infections [32]. Bacterial
causes of persisting bronchitic symptoms in the elderly are more
common than in children, and a wider range of pathogens is
involved. Secondary bacterial infection is an uncommon com-
plication in RSV bronchiolitis in children [33,34]. The consistent
seasonal epidemics of acute bronchitis in children are more
consistent with a viral than bacterial cause.
4. Pathogenesis
Acute bronchitis arises as a result of damage to the epithelial
cellular lining of the respiratory tract, although some of the
symptoms associated with respiratory infection are attributa-
ble to cytokine response. Many viruses replicate in these cells,
but in doing so, they destroy them. Viral replication within
the cells of the respiratory tract is usually rapid, and from the
evidence of experimental infection, commonly peaks within
2 or 3 days for most diseases [35]. The natural course of the
disease involves replacement of the damaged epithelial lining.
The time taken will relate to the extent of the damage, which
is the function of the virulence of the virus and the host
response. Extensive damage to these cells results in sloughing
of the superficial epithelial cells, and creates a favourable envi-
ronment in which bacteria may subsequently multiply. In per-
sons with a healthy respiratory tract, bacterial complications
are unlikely, although they are not necessarily insignificant. In
persons with COPD, there are always many bacteria present
in the respiratory tract (predominantly H. influenzae, Morax-
ella catarrhalis and Streptococcus pneumoniae [36]), which
readily colonise the desquamating epithelium. Bacteria may
also be primary causes of acute bronchitis, although from sur-
veillance data in the WRS, seasonal trends in the diagnosis of
acute bronchitis in children particularly follow the identifica-
tion of RSV (Figure 2). At the outset, the pathogenic process
usually involves a considerable part of the respiratory tract.
Therefore, specimens taken from the nose or throat can be
used to investigate the causative organisms.
Viral pathogens including influenza, parainfluenza, rhino-
virus, adenovirus, coronavirus, metapneumovirus and boca-
virus are responsible for large numbers of childhood
respiratory infections, but diagnoses of acute bronchitis are
particularly likely during periods of RSV activity [11]. Most of
these viruses are present throughout the world, and when new
viruses are identified, there is rarely much delay before they
are found in other countries, as documented in recent years
with the human metapneumovirus [37-39] and human
417
 The management of acute bronchitis in children

A. 1400 1400

1200 1200

Laboratory reports
Rate per 100,000
1000 1000

800 800

600 600

400 400

200 200

0 0
40 42 44 46 48 50 52 02 04 06 08 10 12 14 16 18 20
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Week

B. 1000 1000

800 800

Laboratory reports
Rate per 100,000

600 600

400 400
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200 200

0 0
40 42 44 46 48 50 52 02 04 06 08 10 12 14 16 18 20

Week

Figure 1. Acute bronchitis and respiratory syncytial virus laboratory reports. Weekly incidence rates of acute bronchitis per
100,000 population in children aged 0 – 4 years are contrasted with laboratory reports of RSV submitted to the Health Protection Agency
Centre for Infections during winters A.1996/1997 and B. 2003/2004.

bocavirus [40-43]. The annual appearance and circulation of
each virus is entirely dependent on the pathogen in question
(Figure 4): RSV in particular is known for its constant season-
ality [44,45], whereas influenza can vary from season to season
in relation to the start and duration of seasonal epidemics [46].
The seasonality of the virus may, nevertheless, be specific to a
particular part of the world; influenza occurs as a winter epi-
demic in countries distant from the equator, but in equatorial
countries it is endemic rather than epidemic [47,48]. Most of
these disorders are spread by respiratory droplets, but some,
including RSV, are also preferentially spread by hand carriage
of contaminated secretions and fomites [49].
The consequence of infection in the bronchial lining is air-
ways restriction, which occurs as a result of mucosal oedema,
mucus plugging from excessive airway mucus gland secre-
tions and bronchospasm. The impact of this restriction of the
airways is greater where the lumen of the airways is small, as
in the cases of young children. The effect, particularly in
terms of oxygen interchange, relates to the extent to which
the bronchioles and alveoli are involved. Some organisms are
more likely to cause obstruction in the lower airways than
others: RSV is particularly (although not exclusively)
associated with bronchiolitis.
5. Disease management
The management of acute bronchitis is based primarily on the
assessment of impairment to airflow and oxygen transfer.
Examination of a patient therefore is directed towards the rec-
ognition of such impairment. Extreme signs of impairment
include tachypnoea, exhaustion, rib recession, difficulty in
breathing and, sometimes, dehydration. A high pulse-rate is
part of the response to an infection causing fever.
Dehydration, especially in very young children, is a
manifestation of severe disease. A recent increase in the availa-
bility of inexpensive equipment to assess oxygen saturation
suitable for use in primary care (pulse oximetry) presents an
opportunity to refine patient management [50].

418 Expert Opin. Pharmacother. (2007) 8(4)

 Fleming & Elliot

1200

1000

800
> 65 years
Rate per 100,000

0 – 4 years

600

400
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200

0
40 42 44 46 48 50 52 02 04 06 08 10 12 14 16 18 20 40 42 44 46 48 50 52 02 04 06 08 10 12 14 16 18 20
Week

1999/00 2000/01 2001/02 2002/03 2003/04

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Figure 2. Seasonality of acute bronchitis in the young and old. Weekly incidence rates of acute bronchitis per 100,000 of the
population are plotted for five winter seasons 1999/2000 to 2003/2004 in the 0 – 4 years and > 65 years age groups. The vertical dashed
line represents the Christmas/New Year period before which children peak, and after which the elderly peak.

1.0

Male
Rate per 1000 live births

0.8
Female

0.6

0.4

0.2

0
1995 1996 1997 1998 1999 2000 2001 2002 2003

Year
Figure 3. Sudden infant death syndrome. Rate of sudden infant death syndrome per 1000 live births are presented for the years
1995 – 2003 for males and females.
Data obtained from National Statistics Online [103].

Emergency measures appropriate to persons with
substantial airways impairment include the use of supple-
mental oxygen [51], bronchodilators by nebulised inhalation
(or intravenous administration) [52], intravenous steroids
when asthmatic broncho-constriction is considered likely
[53] and, in the most severely distressed, consideration of
mechanical ventilatory support [54,55]. The use of an
appropriate inhalant device and suitable mask should be
supervised. Hospital admission needs to be considered in
these cases, although in most cases, the decision can be
deferred for a short period to evaluate response. Subsequent
management of a hospitalised patient may involve admis-
sion to an intensive care facility, and management of these
cases is outside the scope of this review.

Expert Opin. Pharmacother. (2007) 8(4) 419

 The management of acute bronchitis in children
300
250
Laboratory reports
200
150
100
50
0 0
7 8
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Influenza A
Figure 4. Seasonality of respiratory viral pathogens. Average number of laboratory reports (made to the Health Protection Agency)
of common respiratory viruses in 4-week periods, centred over the mid-winter 4-week period (13) over the years 1993 – 2001.
RSV: Respiratory syncytial virus.
Regardless of the causative organism, children with acute
bronchitis are likely to require antipyretics (paracetamol pre-
ferred). Acute bronchitis is not a condition that causes pain
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and there is no good evidence to support the use of paraceta-
mol combined with an NSAID when used for antipyretic pur-
poses. Antitussive preparations should generally be avoided
because expectoration of respiratory secretions should not be
discouraged. However, children experiencing difficulties
expectorating because of viscid sputum may benefit from a
mucolytic agent [102]. These products have not been shown to
have demonstrable benefit in terms of accelerated patient
recovery, but persistent coughing can be distressing, and some
patients experience a benefit from them.
Bronchodilators, mainly belonging to the β2-agonist class,
have been used extensively for these disorders. They are avail-
able as orally-administered syrups, dose-metered inhalers
commonly used in association with spacer devices and neb-
ulised aerosols. Bronchodilators are important for children
who are asthmatic, but because it can be difficult to distin-
guish between underlying asthma and the symptoms of acute
bronchitis in the acute stage, it is often worth giving bron-
chodilators to children suffering from acute bronchitis. How-
ever, in the absence of evidence of airways obstruction, two
clinical trials in children (both using syrups) have not shown
any benefit [56]. Their use in acute bronchiolitis is also
unclear: some clinical trials have suggested short-term clinical
benefits, but these have not been reflected in measurements of
oxygen saturation [52]. The use of adrenaline for acute bron-
chiolitis has also been the subject of a Cochrane review, and
although the authors concluded against its use among hospital
in-patients, they felt there was some evidence of benefit for
use among out-patients [57]. The mechanism of delivery is
important, and in a systematic review of devices involving
metered-dosage with a valved holding chamber, advantages
420
900
Laboratory reports (RSV)
750
600
450
300
150
9 10 11 12 13 1 2 3 4 5 6
4-week period
Influenza B Rhinovirus
Parainfluenza virus RSV
were demonstrated over nebulised delivery in children wheez-
ing at presentation [58]. Some studies have shown additional
benefits by supplementing a β2-agonist with an antimus-
carinic inhaler in the treatment of asthma exacerbations [59,60];
there are no data relating to use in the absence of wheeze.
Corticosteroids are available as intravenous/muscular, oral
or inhaled preparations. They are used to suppress the inflam-
matory response in the cells of the airways thereby minimising
the intensity of the cellular reaction and consequent local
oedema, bronchospasm and airways obstruction. Their use is
established in asthma, both as part of a preventive manage-
ment programme, and in the management of acute episodes.
Their use in acute respiratory infections is less clear: they have
not been associated with benefit in acute bronchiolitis [61].
They have been helpful when given early to treat croup [62]. In
children aged 6 – 35 months presenting with viral lower respi-
ratory infection, a 3-day course of oral steroids reduced the
severity and duration of illness [63]. There is no basis for their
use in simple acute bronchitis, in which wheezing is not
evident on initial examination. However, uncertainties at
presentation (such as the confusion between acute bronchitis
and early asthma) often prompt a management programme
based on the possibility of acute asthma.
Treatments using Chinese herbal remedies [64],
Echinacea [65] and homeopathic regimens [66] have been
advocated to limit the symptoms of acute respiratory infec-
tions. Although some symptomatic benefits have been
reported both from the use of herbal remedies and from
treatment with Echinacea, their use remains controversial
and should not be encouraged because of inconsistencies in
different trials, and also because these products have not
been fully evaluated for safety [65]. Vitamin C supplements
are used by many adults to ward off colds, but there is no
evidence to support this belief [67,68].
Expert Opin. Pharmacother. (2007) 8(4)

6. Organism-specific treatment
Organism-specific management is desirable, although it is
not practicable at the outset. Microbiological investigation of
children with acute bronchitis is not common in general
practice, and apart from looking for RSV, virological investi-
gation is even less common. However, there are some clues in
the timing of the presentation. As referred to above, the tim-
ing of the RSV epidemic is predictable [44,45]: influenza
viruses tend to circulate for limited periods, and the presence
of a respiratory disease epidemic in a community increases
this probability [46]. An apparent attack of acute bronchitis
during the pollen season (early May and late June and July)
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should alert the consideration of underlying asthma. If at
presentation the child had already experienced symptoms for
≥ 4 days, and is still experiencing constitutional symptoms
such as fever, bacterial causes should be considered. Similarly
in patients experiencing particularly frequent respiratory
infections, there is increased likelihood of a bacterial cause [5].
Organism-specific treatments are available for illnesses
caused by influenza, RSV and bacteria.
Although acute bronchitis is not the classical presentation of
influenza, reports of acute bronchitis are substantially increased
during influenza active periods [11]. Antivirals are available for
For personal use only.
the prevention and treatment of influenza infections: there are
two classes of drugs, the adamantanes and neuraminidase
inhibitors (NIs). Adamantanes (amantadine and rimantadine)
have been available for several decades, but have recently
declined in importance compared with the NIs as they treat
only influenza A and are associated with rapid emergence of
viral resistance [69-71]. In older age groups, though not in chil-
dren, these drugs are associated with neurological and gastro-
intestinal side effects, however, rimantadine has been shown to
have a decreased incidence of adverse effects over aman-
tadine [72]. There are two NIs currently available for prophy-
laxis against and treatment for influenza A and B infections;
zanamivir (available by inhalation) and oseltamivir (available by
oral administration; in doses of 150 mg b.i.d. in adults and
10 mg/kg b.i.d. in a child). NIs have been shown to be effective
in shortening the course of influenzal illness and reducing the
complications [73-76], but only if medication is commenced
within 48 h of symptom onset. NIs have not been associated
with the emergence of resistant viral variants of clinical impor-
tance [77]. However, healthy children are not included as risk
groups to be targeted for treatment with NIs in the UK because
the potential benefits are not considered worthwhile [78]. This is
a subjective judgement, and is based on accumulated evidence
of influenza mainly over the last 10 years, during which time
there has not been a serious outbreak of influenza in western
Europe. This issue will certainly be revisited in the event of a
pandemic, or even in the case of a serious epidemic due to a
drifted variant of an existing strain. Oseltamivir is the only drug
licensed for use in children who are ≥ 1 year of age. These drugs
are also available for prophylaxis, but are not licensed for
prophylactic use in children [79].
Expert Opin. Pharmacother. (2007) 8(4)
Fleming & Elliot
Ribavirin has shown possible benefit in the treatment of
infections due to RSV [80]. However, the evidence is contro-
versial: meta-analyses of data have certainly not demon-
strated consistent benefit [81]. Palivizumab (a monoclonal
antibody) has been shown to protect against RSV infection
when given regularly during the RSV season, and to reduce
hospital admissions [82,83]. The ability to predict this is
useful, but this treatment is very expensive and is only rec-
ommended for use in children who are at particularly high
risk from RSV infection [84].
Drugs in the treatment of rhinovirus infection have been
well reviewed by Rotbart [85]. Preparations belonging to the
interferon group have been used experimentally for preven-
tion and treatment: reduced viral shedding and some diminu-
tion of symptoms have been observed, but the results have not
led to formal clinical trials in children. Amongst the
capsid-inhibiting compounds, plecanoril has shown most
promise, and has been the subject of several clinical trials in
adults with acute respiratory infections, mostly showing bene-
fits over placebo, particularly in relation to viral shedding and
earlier symptom relief [86]. These drugs have not yet come in
to the market as a treatment for common respiratory
infections in adults or in children.
For bacterial conditions, antibiotics are available, and when
a cough has persisted for 4 days and the patient is showing
systemic features or suggestive clinical signs on auscultation of
the chest or on X-ray, bacterial infection needs to be consid-
ered. Bacterial causes of acute bronchitis do not show the
same rapid and even dramatic onset of viral infections. Apart
from Bordatella pertussis, it is difficult to guess the causative
organism other than on the basis of probability from consoli-
dated knowledge obtained from aggregated laboratory data. A
7-day course of erythromycin has been shown to be beneficial
in pertussis infections, provided it is given within a week of
illness onset; it also reduces the infectious period and thus the
risk of spread [87]. There is a case for giving this antibiotic as
prophylaxis where a baby or unvaccinated child has been
exposed to pertussis [88]. Bacteria such as H. influenzae have
been isolated from persons with acute exacerbations of
chronic bronchitis in 22 – 58% of cases [36,89,90] and for these,
amoxicillin is the preferred first-line drug; COPD in children
is extremely rare.
M. pneumoniae infection is a significant cause of bacterial
infection in all age groups [5,91]. There is some evidence of a
3 – 4 year epidemic cycle [92,93] and thus, awareness of this
diagnosis can be heightened. The tetracycline group of drugs
is the treatment of choice for confirmed M. pneumoniae infec-
tion, although macroloides may also be used. Both drugs are
also effective against C. pneumoniae.
For management purposes, the critical decision concerning
the use of antibiotics needs to be taken at the initial presenta-
tion. As the available evidence strongly favours a viral cause,
patients with acute onset illness of < 2 days duration are
generally unlikely to benefit from antibiotics, and this is
borne out by randomised clinical trials in adults, but has not
421
 The management of acute bronchitis in children
been adequately investigated in children. There has been a
recent fashion to issue ‘a delayed prescription’ – a prescription
made available to patients only to be dispensed if there is
further deterioration [94,95]. Although this may achieve a bene-
fit in reducing the number of antibiotics consumed, there is
little evidence to support a therapeutic benefit from this
method of management. The presumption of bacterial aetio-
logy is a reasonable basis for management in circumstances in
which the patient remains constitutionally ill 4 days after
onset, and is not simply complaining of a persistent cough.
7. Disease prevention
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It is appropriate to consider ways in which the spread of
infection can be reduced. There are several environmental
factors associated with increasing risk of respiratory infec-
tions and of asthma exacerbations in children. Reducing the
exposure of children to tobacco smoke in the household
setting is perhaps the most readily achievable target. How-
ever, this should not detract from the need to reduce over-
crowding and the general effects of deprivation [96,97]. Many
viral pathogens are aerosol spread, and thus, air pollution
with high particulate content may favour certain types of
spread. For some other pathogens, spread by personal contact
For personal use only.
is frequent (RSV for example), and high standards of hygiene
(regular hand washing) are desirable [98]. The incidence of
acute bronchitis recorded in children just before Christmas,
and in the elderly just afterwards, suggests that close personal
contact with sick children should be minimised (Figure 2).
Palivizumab has already been mentioned in the context of
preventing infection due to RSV, but its use is confined to
premature children. Even in these cases, its value is limited. As
influenza can cause acute bronchitis, primary prevention of
influenza is likely to reduce the number of children with acute
respiratory infections, although in comparison with RSV, the
contribution of influenza to acute bronchitis is less [11]. In many
countries, primary annual vaccination against influenza is
encouraged in children at risk, particularly those with asthma.
In the US, vaccination of all children aged 6 – 59 months is
recommended [99]. Two doses of trivalent split virus vaccine are
recommended: live attenuated cold adapted vaccine may be an
alternative, especially as for some children nasal administration
may be preferred, and there is a suggestion from clinical trials
that the immune response following live attenuated cold
adapted vaccine is better than that following trivalent split
vaccine [100]. Effective immunisation of young children against
pertussis is particularly important if deaths from this condition
are to be prevented [87].
8. Expert opinion
8.1 Current knowledge
Acute bronchitis in children is very common. It is a confusing
diagnosis and is better viewed as a manifestation of acute
respiratory infection rather than as a distinct entity. The
422 Expert Opin. Pharmacother. (2007) 8(4)
potential for confusion with a new onset or exacerbation of
asthma is considerable, and management is sometimes driven
by this possibility. Acute bronchitis is almost always virologi-
cally determined, although secondary bacterial infection may
occur. Many viruses can cause acute bronchitis and other
related disorders, and there is often little distinction between
the clinical syndromes they cause. Among all of the potential
viral causes, RSV is probably the most important. Existing
knowledge of the contribution of several viruses towards the
burden of illness attributable to acute bronchitis in children is
limited as routine virological investigation of respiratory
illness is not practiced. Although such an investigational pol-
icy is unrealistic in terms of total care, it should nevertheless
be seen as a desirable target within sentinel practices dedicated
to the task. The contribution of rhinovirus in particular is
seriously underestimated.
In the initial assessment of cases, recognition of specific
clinical syndromes such as croup, epiglottitis and pertussis is
essential. However, immediate management depends mainly
on the existence and extent of airways obstruction, and this
assessment needs to be objectively made, if possible. Simple
devices to measure oxygen saturation will improve manage-
ment decisions. Vaccination against preventable causes is an
important element of treatment, but there are few organ-
ism-specific treatments available. Clinical trials in children
often pay insufficient attention to the route of administration.
For example, the role of β2-agonists is said to be doubtful on
the basis of existing evidence; however, this statement is
mainly based on research involving oral preparations. The
value of nebulised or inhaled formulations has not been
adequately tested. The significance of reduced viral shedding
in treated persons should not be underestimated. Reduced
potential for spreading infection may dramatically change the
burden of illness in the community.
8.2 Immediate future
An effective vaccine for general use against RSV infection is
needed, and it is hoped that this will materialise in the next
10 years. Equally, there is a need for an effective treatment;
NIs have been introduced for the treatment of influenza,
which is one cause of clinical acute bronchitis in children.
Given the stimulus of a pandemic threat, revised management
guidelines on the optimum use of NI antivirals are likely to
emerge in the next 3 years. There are some promising advances
in the development of antiviral drugs for rhinovirus infection.
Effective treatments for viral respiratory diseases will have
added benefits in decreasing the problems of otitis media.
8.3 Towards optimum management
The management of acute bronchitis will be advanced by a
better knowledge of the causative organisms. Background
predisposition to attacks is relatively insignificant, but until
we are clear about the cause, organism-specific treatments
will not be developed, and advances in treatment will not
be made. With this objective in mind, high quality
 Fleming & Elliot

virological investigation of many more cases is needed. The
greatly increased use of PCR technology will speed up this
process. Improved knowledge will stimulate vaccine and
therapeutic research.
Management decisions at the initial presentation for care
will always be critical, and the ready ability to distinguish an
acute asthmatic episode from an uncomplicated acute infec-
tion will enhance management decisions. The development of
simple tests to detect impaired oxygen transfer for use in
routine primary care and for routine monitoring of progress
during the illness will make for specific benefits in the
decision to hospitalise patients.
Expert Opin. Pharmacother. Downloaded from informahealthcare.com by RMIT University on 08/01/13
Finally, in the medical and clinical profession, we must
move away from the notion expressed in the catchphrase ‘it is
only a virus’. The total burden of illness due to common
respiratory infections in children should be seen as a challenge
to medicine, rather than an acceptance of the inevitable.
Disclosure
DM Fleming has received financial support from the pharma-
ceutical industry in matters relating to influenza prevention and
treatment. AJ Elliot is jointly funded by the Royal College of
General Practitioners and the Health Protection Agency.

Bibliography
Papers of special note have been highlighted as
either of interest (•) or of considerable interest
(••) to readers.
1. FLEMING DM: Weekly Returns Service of
the Royal College of General Practitioners.
Commun. Dis. Public Health (1999)
2(2):96-100.
For personal use only.
8. SIGURS N, GUSTAFSSON PM,
BJARNASON R et al.: Severe respiratory
syncytial virus bronchiolitis in infancy and
asthma and allergy at age 13. Am. J. Respir.
Crit. Care. Med. (2005) 171(2):137-141.
9. WELLIVER RC: RSV and chronic asthma.
Lancet (1995) 346(8978):789-790.
10. MESSAGE SD, JOHNSTON SL: Viruses
16. HEATH D, KAY JM: Respiratory System.
In Muir's Textbook of Pathology. Anderson
JR (Ed.) Edward Arnold, London (1980):
17. CHKHAIDZE I, MANJAVIDZE N,
NEMSADZE K: Serodiagnosis of acute
respiratory infections in children in
Georgia. Indian. J. Pediatr. (2006)
73(7):569-572.

2. FLEMING DM, CROSS KW,
BARLEY MA: Recent changes in the
prevalence of diseases presenting for health
care. Br. J. Gen. Pract. (2005)
55(517):589-595.
in asthma. Br. Med. Bull (2002) 61:29-43.
•• A comprehensive and valuable review of
the role of viruses in precipitating wheezy
episodes in infants and exacerbations of
asthma in older children.
18. HIJAZI Z, PACSA A, EISA S,
EL SHAZLI A, ABD EL-SALAM RA:
Laboratory diagnosis of acute lower
respiratory tract viral infections in children.
J. Trop. Pediatr. (1996) 42(5):276-280.

3. MCCORMICK A, FLEMING D, 11. FLEMING DM, PANNELL RS, 19. JACQUES J,

CHARLTON J: Morbidity Statistics from ELLIOT AJ, CROSS KW: Respiratory BOUSCAMBERT-DUCHAMP M,
General Practice. Fourth National Study 1991 illness associated with influenza and MORET H et al.: Association of respiratory
– 1992. (Ed.) HMSO, London (1995). respiratory syncytial virus infection. picornaviruses with acute bronchiolitis in
Arch. Dis. Child. (2005) 90(7):741-746. French infants. J. Clin. Virol. (2006)
4. CHANG AB, LANDAU LI,
12. FREYMUTH F, VABRET A, BROUARD J 35(4):463-466.
VAN ASPEREN PP et al.: Cough in
children: definitions and clinical evaluation. et al.: Detection of viral, Chlamydia 20. JARTTI T, LEHTINEN P, VUORINEN T
Med. J. Aust. (2006) 184(8):398-403. pneumoniae and Mycoplasma pneumoniae et al.: Respiratory picornaviruses and
infections in exacerbations of asthma in respiratory syncytial virus as causative agents
5. ESPOSITO S, BOSIS S, FAELLI N et al.:
children. J. Clin. Virol. (1999) of acute expiratory wheezing in children.
Role of atypical bacteria and azithromycin
13(3):131-139. Emerg. Infect. Dis. (2004) 10(6):1095-1101.
therapy for children with recurrent
13. PATTEMORE PK, JOHNSTON SL, • A study that examines the viral aetiology of
respiratory tract infections.
BARDIN PG: Viruses as precipitants of acute respiratory wheezing in hospitalised
Pediatr. Infect. Dis. J. (2005)
asthma symptoms. I. Epidemiology. children.
24(5):438-444.
Clin. Exp. Allergy (1992) 22(3):325-336. 21. NUMAZAKI K, CHIBA S, UMETSU M
6. COGSWELL JJ, HALLIDAY DF,
14. HOLMAN RC, SHAY DK, CURNS AT, et al.: Etiological agents of lower respiratory
ALEXANDER JR: Respiratory infections in
LINGAPPA JR, ANDERSON LJ: tract infections in Japanese children.
the first year of life in children at risk of
Risk factors for bronchiolitis-associated In Vivo (2004) 18(1):67-71.
developing atopy. BMJ (1982)
284(6321):1011-1013. deaths among infants in the United States. 22. SHAY DK, HOLMAN RC,
Pediatr. Infect. Dis. J. (2003) NEWMAN RD et al.:
7. SIGURS N, BJARNASON R,
22(6):483-490. Bronchiolitis-associated hospitalizations
SIGURBERGSSON F, KJELLMAN B,
15. QUIROGA LE, VERHEIJ TJM: Lower among US children, 1980-1996. JAMA
BJORKSTEN B: Asthma and
respiratory tract infections. In Oxford (1999) 282(15):1440-1446.
immunoglobulin E antibodies after
Textbook of Primary Medical Care. Jones R • A study that examined temporal trends in
respiratory syncytial virus bronchiolitis: a
et al. (Eds) Oxford University Press, Oxford bronchiolitis in children under 5 years, and
prospective cohort study with matched
(2004):675-677. estimated RSV-associated hospitalisations.
controls. Pediatrics (1995) 95(4):500-505.
23. CRIGHTON EJ, MAMDANI MM,
UPSHUR RE: A population based time

Expert Opin. Pharmacother. (2007) 8(4) 423

 The management of acute bronchitis in children
series analysis of asthma hospitalisations in
Ontario, Canada: 1988 to 2000.
BMC Health Serv. Res. (2001) 1(1):7.
24. MORRISON DS, MCLOONE P:
Changing patterns of hospital admission for
asthma, 1981-97. Thorax (2001)
56(9):687-690.
25. NAGAYAMA Y, TSUBAKI T,
NAKAYAMA S et al.: Gender analysis in
acute bronchiolitis due to respiratory
syncytial virus. Pediatr. Allergy Immunol.
(2006) 17(1):29-36.
26. MAKELA MJ, PUHAKKA T,
Expert Opin. Pharmacother. Downloaded from informahealthcare.com by RMIT University on 08/01/13
RUUSKANEN O et al.: Viruses and
bacteria in the etiology of the common cold.
J. Clin. Microbiol. (1998) 36(2):539-542.
27. PITKARANTA A, VIROLAINEN A,
JERO J, ARRUDA E, HAYDEN FG:
Detection of rhinovirus, respiratory
syncytial virus, and coronavirus infections
in acute otitis media by reverse transcriptase
polymerase chain reaction. Pediatrics (1998)
102(2 Pt 1):291-295.
28. NICHOLSON KG, KENT J,
IRELAND DC: Respiratory viruses and
For personal use only.
exacerbations of asthma in adults. BMJ
(1993) 307(6910):982-986.
29. HAYDEN FG: Rhinovirus and the lower
respiratory tract. Rev. Med. Virol. (2004)
14(1):17-31.
• A comprehensive review covering all areas
of infection and treatment of rhinovirus
infections in the respiratory tract.
30. SCHMIDT HJ, FINK RJ: Rhinovirus as a
lower respiratory tract pathogen in infants.
Pediatr. Infect. Dis. J. (1991)
10(9):700-702.
31. COLLINSON J, NICHOLSON KG,
CANCIO E et al.: Effects of upper
respiratory tract infections in patients with
cystic fibrosis. Thorax (1996)
51(11):1115-1122.
32. WANGROONGSARB P,
GEENKAJORN K,
PEKTKANCHANAPONG W et al.:
Chlamydophila pneumoniae infection among
young children with respiratory diseases in
Thailand. Jpn. J. Infect. Dis. (2003)
56(4):146-150.
33. DUTTWEILER L, NADAL D, FREY B:
Pulmonary and systemic bacterial
co-infections in severe RSV bronchiolitis.
Arch. Dis. Child. (2004) 89(12):1155-1157.
34. PURCELL K, FERGIE J: Concurrent
serious bacterial infections in 2396 infants
and children hospitalized with respiratory
syncytial virus lower respiratory tract
424
infections. Arch. Pediatr. Adolesc. Med.
(2002) 156(4):322-324.
35. GENTILE D, DOYLE W, WHITESIDE T
et al.: Increased interleukin-6 levels in nasal
lavage samples following experimental
influenza A virus infection. Clin. Diagn.
Lab. Immunol. (1998) 5(5):604-608.
36. BALL P, MAKE B: Acute exacerbations of
chronic bronchitis: an international
comparison. Chest (1998) 113(3
Suppl):199S-204S.
37. REGEV L, HINDIYEH M,
SHULMAN LM et al.: Characterization of
human metapneumovirus infections in
Israel. J. Clin. Microbiol. (2006)
44(4):1484-1489.
38. STOCKTON J, STEPHENSON I,
FLEMING D, ZAMBON M:
Human metapneumovirus as a cause of
community-acquired respiratory illness.
Emerg. Infect. Dis. (2002) 8(9):897-901.
39. VAN DEN HOOGEN BG, DE JONG JC,
GROEN J et al.: A newly discovered human
pneumovirus isolated from young children
with respiratory tract disease. Nat. Med.
(2001) 7(6):719-724.
40. ALLANDER T, TAMMI MT,
ERIKSSON M et al.: Cloning of a human
parvovirus by molecular screening of
respiratory tract samples. Proc. Natl. Acad.
Sci. USA (2005) 102(36):12891-12896.
41. ARNOLD JC, SINGH KK,
SPECTOR SA, SAWYER MH: Human
bocavirus: prevalence and clinical spectrum
at a children's hospital. Clin. Infect. Dis.
(2006) 43(3):283-288.
42. MA X, ENDO R, ISHIGURO N et al.:
Detection of human bocavirus in Japanese
children with lower respiratory tract
infections. J. Clin. Microbiol. (2006)
44(3):1132-1134.
43. WEISSBRICH B, NESKE F,
SCHUBERT J et al.: Frequent detection of
bocavirus DNA in German children with
respiratory tract infections. BMC Infect. Dis.
(2006) 6:109.
44. GODDARD NL, KYNCL J,
WATSON JM: Appropriateness of
thresholds currently used to describe
influenza activity in England. Commun. Dis.
Public Health (2003) 6(3):238-245.
45. TERLETSKAIA-LADWIG E,
ENDERS G, SCHALASTA G,
ENDERS M: Defining the timing of
respiratory syncytial virus (RSV) outbreaks:
an epidemiological study. BMC Infect. Dis.
(2005) 5(1):20.
Expert Opin. Pharmacother. (2007) 8(4)
46. FLEMING DM, ZAMBON M,
BARTELDS AI, DE JONG JC: The
duration and magnitude of influenza
epidemics: a study of surveillance data from
sentinel general practices in England, Wales
and the Netherlands. Eur. J. Epidemiol.
(1999) 15(5):467-473.
47. CHEW FT, DORAISINGHAM S,
LING AE, KUMARASINGHE G,
LEE BW: Seasonal trends of viral
respiratory tract infections in the tropics.
Epidemiol. Infec.t (1998) 121(1):121-128.
48. NICHOLSON KG: Human Influenza. In
Textbook of Influenza. Nicholson KG et al.
(Eds) Blackwell Sciences, Oxford
(1998):219-264.
49. HALL CB: Nosocomial respiratory
syncytial virus infections: the "Cold War"
has not ended. Clin. Infect. Dis. (2000)
31(2):590-596.
• Stressing the importance of RSV
nosocomial infections and barrier controls
by which these infections can be prevented.
50. INGRAM G, MUNRO N: The use (or
otherwise) of pulse oximetry in general
practice. Br. J. Gen. Pract. (2005)
55(516):501-502.
51. BAJAJ L, TURNER CG, BOTHNER J:
A randomized trial of home oxygen therapy
from the emergency department for acute
bronchiolitis. Pediatrics (2006)
117(3):633-640.
52. GADOMSKI AM, BHASALE AL:
Bronchodilators for bronchiolitis. Cochrane
Database Syst. Rev. (2006) 3:CD001266.
•• A meta-analysis assessing the effects of
bronchodilators on clinical outcomes in
infants with acute bronchitis.
53. LOWELL DI, LISTER G, VON KOSS H,
MCCARTHY P: Wheezing in infants: the
response to epinephrine. Pediatrics (1987)
79(6):939-945.
54. CHAN PW, GOH AY, LUM LC:
Respiratory failure requiring ventilation in
acute bronchiolitis. Med. J. Malaysia
(1999) 54(4):487-491.
55. LEBEL MH, GAUTHIER M,
LACROIX J, ROUSSEAU E,
BUITHIEU M: Respiratory failure and
mechanical ventilation in severe
bronchiolitis. Arch. Dis. Child.
(1989) 64(10):1431-1437.
56. SMUCNY J, FLYNN C, BECKER L,
GLAZIER R: β2-agonists for acute
bronchitis. Cochrane Database Syst. Rev.
(2004) 1:CD001726.
 Fleming & Elliot

•• A meta-analysis that assesses whether
β2-agonists improve the symptoms of acute
bronchitis in patients without underlying
pulmonary disease.
57. HARTLING L, WIEBE N, RUSSELL K,
PATEL H, KLASSEN TP: Epinephrine for
bronchiolitis. Cochrane Database Syst. Rev.
(2004)1:CD003123.
58. CASTRO-RODRIGUEZ JA,
RODRIGO GJ: β-agonists through
metered-dose inhaler with valved holding
chamber versus nebulizer for acute
exacerbation of wheezing or asthma in
children under 5 years of age: a systematic
Expert Opin. Pharmacother. Downloaded from informahealthcare.com by RMIT University on 08/01/13
syndromes. Cochrane Database Syst. Rev.
(2006) 3:CD001957.
67. DOUGLAS RM, HEMILA H,
D'SOUZA R, CHALKER EB, TREACY B:
Vitamin C for preventing and treating the
common cold. Cochrane Database Syst. Rev.
(2004) 4:CD000980.
68. HEMILA H, DOUGLAS RM:
Vitamin C and acute respiratory infections.
Int. J. Tuberc. Lung Dis. (1999)
3(9):756-761.
69. BRIGHT RA, MEDINA MJ, XU X et al.:
Incidence of adamantane resistance among
77. MONTO AS,
MCKIMM-BRESCHKIN JL,
MACKEN C et al.: Detection of influenza
viruses resistant to neuraminidase inhibitors
in global surveillance during the first 3 years
of their use. Antimicrob. Agents Chemother.
(2006) 50(7):2395-2402.
78. NATIONAL INSTITUTE FOR HEALTH
AND CLINICAL EXCELLENCE: Flu
treatment – zanamivir, amantadine and
oseltamivir: guidance. Publication refrence
TA05. London (2003).
79. NATIONAL INSTITUTE FOR HEALTH
AND CLINICAL EXCELLENCE: Flu

influenza A (H3N2) viruses isolated

review with meta-analysis. J. Pediatr. (2004)
145(2):172-177.
59. BROWNE GJ, TRIEU L,
VAN ASPEREN P: Randomized,
double-blind, placebo-controlled trial of
intravenous salbutamol and nebulized
ipratropium bromide in early management
of severe acute asthma in children
presenting to an emergency department.
Crit. Care Med. (2002) 30(2):448-453.
60. WATANASOMSIRI A,
For personal use only.
worldwide from 1994 to 2005: a cause for
concern. Lancet (2005)
366(9492):1175-1181.
70. BRIGHT RA, SHAY DK, SHU B,
COX NJ, KLIMOV AI: Adamantane
resistance among influenza A viruses
isolated early during the 2005-2006
influenza season in the United States.
JAMA (2006) 295(8):891-894.
71. SAITO R, LI D, SHIMOMURA C et al.:
An off-seasonal amantadine-resistant H3N2
prevention – amantadine and oseltamivir:
guidance. Publication refrence TA067.
London (2003).
80. SMITH DW, FRANKEL LR,
MATHERS LH et al.: A controlled trial of
aerosolized ribavirin in infants receiving
mechanical ventilation for severe respiratory
syncytial virus infection. N. Engl. J. Med.
(1991) 325(1):24-29.
81. VENTRE K, RANDOLPH A: Ribavirin
for respiratory syncytial virus infection of

PHIPATANAKUL W: Comparison of
nebulized ipratropium bromide with
salbutamol vs salbutamol alone in acute
72.
asthma exacerbation in children.
Ann. Allergy Asthma Immunol.
(2006) 96(5):701-706.
61. PATEL H, PLATT R, LOZANO JM,
WANG EE: Glucocorticoids for acute viral
73.
bronchiolitis in infants and young children.
Cochrane Database Syst. Rev. (2004)
3:CD004878.
62. RUSSELL K, WIEBE N, SAENZ A et al.:
Glucocorticoids for croup. Cochrane
Database Syst. Rev. (2004) 1:CD001955.
74.
63. CSONKA P, KAILA M, LAIPPALA P et al.:
Oral prednisolone in the acute management
of children age 6 to 35 months with viral
respiratory infection-induced lower airway
disease: a randomized, placebo-controlled
75.
trial. J. Pediatr. (2003) 143(6):725-730.
64. WU T, CHEN X, DUAN X et al.:
Chinese medicinal herbs for acute
bronchitis. Cochrane Database Syst. Rev.
(2005) 3:CD004560.
65. LINDE K, BARRETT B, WOLKART K,
BAUER R, MELCHART D: Echinacea for
76.
preventing and treating the common cold.
Cochrane Database Syst. Rev. (2006)
1:CD000530.
66. VICKERS AJ, SMITH C: Homoeopathic
Oscillococcinum for preventing and
treating influenza and influenza-like
influenza outbreak in Japan. Tohoku J. Exp.
Med. (2006) 210(1):21-27.
JEFFERSON T, DEMICHELI V, DI
PIETRANTONJ C, RIVETTI D:
Amantadine and rimantadine for influenza
A in adults. Cochrane Database Syst. Rev.
(2006) 2:CD001169.
HAYDEN FG, OSTERHAUS AD,
TREANOR JJ et al.: Efficacy and safety of
the neuraminidase inhibitor zanamivir in
the treatment of influenzavirus infections.
GG167 Influenza Study Group.
N. Engl. J. Med. (1997) 337(13):874-880.
WHITLEY RJ, HAYDEN FG,
REISINGER KS et al.: Oral oseltamivir
treatment of influenza in children.
Pediatr. Infect. Dis. J. (2001)
20(2):127-133.
MAKELA MJ, PAUKSENS K,
ROSTILA T et al.: Clinical efficacy and
safety of the orally inhaled neuraminidase
inhibitor zanamivir in the treatment of
influenza: a randomized, double-blind,
placebo-controlled European study.
J. Infect. (2000) 40(1):42-48.
NICHOLSON KG, AOKI FY,
OSTERHAUS AD et al.: Efficacy and
safety of oseltamivir in treatment of acute
influenza: a randomised controlled trial.
Neuraminidase Inhibitor Flu Treatment
Investigator Group. Lancet (2000)
355(9218):1845-1850.
the lower respiratory tract in infants and
young children. Cochrane Database Syst. Rev.
(2004) 4:CD000181.
82. THE IMPACT-RSV STUDY GROUP:
Palivizumab, a humanized respiratory
syncytial virus monoclonal antibody,
reduces hospitalization from respiratory
syncytial virus infection in high-risk infants.
Pediatrics (1998) 102(3 Pt 1):531-537.
83. FELTES TF, CABALKA AK,
MEISSNER HC et al.: Palivizumab
prophylaxis reduces hospitalization due to
respiratory syncytial virus in young children
with hemodynamically significant
congenital heart disease. J. Pediatr.
(2003) 143(4):532-540.
84. HANDFORTH J, SHARLAND M,
FRIEDLAND JS: Prevention of respiratory
syncytial virus infection in infants. BMJ
(2004) 328(7447):1026-1027.
85. ROTBART HA: Treatment of picornavirus
infections. Antiviral Res. (2002)
53(2):83-98.
•• Reports on the recent progress successes
reported towards the development of
antivirals for the treatment of picornavirus
infections.
86. HAYDEN FG, HERRINGTON DT,
COATS TL et al.: Efficacy and safety of oral
pleconaril for treatment of colds due to
picornaviruses in adults: results of 2
double-blind, randomized,

Expert Opin. Pharmacother. (2007) 8(4) 425

 The management of acute bronchitis in children
placebo-controlled trials. Clin. Infect. Dis.
(2003) 36(12):1523-1532.
87. CROWCROFT NS, PEBODY RG:
Recent developments in pertussis.
Lancet (2006) 367(9526):1926-1936.
88. TIWARI T, MURPHY TV, MORAN J:
Recommended antimicrobial agents for the
treatment and postexposure prophylaxis of
pertussis: 2005 CDC Guidelines. MMWR
Recomm. Rep. (2005) 54(RR-14):1-16.
89. ALVAREZ-SALA JL, KARDOS P,
MARTINEZ-BELTRAN J, CORONEL P,
AGUILAR L: Clinical and bacteriological
Expert Opin. Pharmacother. Downloaded from informahealthcare.com by RMIT University on 08/01/13
efficacy in treatment of acute exacerbations
of chronic bronchitis with
cefditoren-pivoxil versus cefuroxime-axetil.
Antimicrob. Agents Chemother. (2006)
50(5):1762-1767.
90. SETHI S, ANZUETO A, FARRELL DJ:
Antibiotic activity of telithromycin and
comparators against bacterial pathogens
isolated from 3,043 patients with acute
exacerbation of chronic bronchitis.
Ann. Clin. Microbiol. Antimicrob.
(2005) 4:5.
For personal use only.
91. GUTIERREZ F, MASIA M, MIRETE C
et al.: The influence of age and gender on
the population-based incidence of
community-acquired pneumonia caused by
different microbial pathogens. J. Infect.
(2006) 53(3):166-174.
92. PUBLIC HEALTH LABORATORY
SERVICE: Mycoplasma pneumoniae
surveillance. CDR Weekly (1991) 1(11):49.
93. PUBLIC HEALTH LABORATORY
SERVICE: Acute respiratory infections,
and influenza vaccine for 1999/2000.
CDR Weekly (1999) 9(10):87-90.
426
94. 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(464):200-205.
95. LITTLE P, RUMSBY K, KELLY J et al.:
Information leaflet and antibiotic
prescribing strategies for acute lower
respiratory tract infection: a randomized
controlled trial. JAMA (2005)
293(24):3029-3035.
96. GERGEN PJ, FOWLER JA,
MAURER KR, DAVIS WW,
OVERPECK MD: The burden of
environmental tobacco smoke exposure on
the respiratory health of children 2 months
through 5 years of age in the United States:
Third National Health and Nutrition
Examination Survey, 1988 to 1994.
Pediatrics (1998) 101(2):E8.
• A study that reinforces the need to reduce
the exposure of young children to tobacco
smoke.
97. LI JS, PEAT JK, XUAN W, BERRY G:
Meta-analysis on the association between
environmental tobacco smoke (ETS)
exposure and the prevalence of lower
respiratory tract infection in early
childhood. Pediatr. Pulmonol. (1999)
27(1):5-13.
98. CROWCROFT NS, CUTTS F,
ZAMBON MC: Respiratory syncytial
virus: an underestimated cause of
respiratory infection, with prospects for a
vaccine. Commun. Dis. Public Health (1999)
2(4):234-241.
99. SMITH NM, BRESEE JS, SHAY DK et al.:
Prevention and control of influenza:
Expert Opin. Pharmacother. (2007) 8(4)
recommendations of the Advisory
Committee on Immunization Practices
(ACIP). MMWR Recomm. Rep. (2006)
55(RR-10):1-42.
100. TREANOR JJ, KOTLOFF K, BETTS RF
et al.: Evaluation of trivalent, live,
cold-adapted (CAIV-T) and inactivated
(TIV) influenza vaccines in prevention of
virus infection and illness following
challenge of adults with wild-type influenza
A (H1N1), A (H3N2), and B viruses.
Vaccine (1999) 18(9-10):899-906.
Websites
101. http://www.rcgp.org.uk/bru
Royal College of General Practitioners.
Birmingham Research Unit. Accessed
22 Dec 2006.
102. http://www.clinicalevidence.com/ceweb/cond
itions/rda/1508/1508.jsp
BMJ clinical evidence.
103. http://www.statistics.gov.uk
National Statistics Online.
Affiliation
Douglas M Fleming†1 OBE, PhD, FRCGP,
FMedSci, FFPH & Alex J Elliot2 PhD, BSc
†Author for correspondence
1Director, Birmingham Research Unit of
the Royal College of General Practitioners,
Lordswood House, 54 Lordswood Road,
Harborne, Birmingham B17 9DB, UK
Tel: +44 (0)121 426 1125;
Fax: +44 (0)121 428 2084;
E-mail: dfleming@rcgpbhamresunit.nhs.uk
2Primary Care Scientist, Birmingham Research
Unit of the Royal College of General
Practitioners, Lordswood House, 54 Lordswood
Road, Harborne, Birmingham B17 9DB, UK