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

. Printed in the USA. All rights reserved 0736-4679/$ - see front matter

doi:10.1016/j.jemermed.2011.06.143

Original Contributions

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

, AbstractBackground: Although the overuse of antibiotics 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 computer database 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 antibiotic 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% condence interval), antibiotics were prescribed signicantly more often in patients 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 discharged without a bronchodilator, and 631 (91.1%) were discharged without a spacer device. Conclusion: Antibiotics are over-prescribed in the ED for acute bronchitis, with broadspectrum 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; bronchodilators; 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 pulmonary 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 benet 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 recommendations, 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
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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 bronchitis, 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 dened by attending and resident physician entry of acute bronchitis 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 a separate attending note was written. A total of 836 patients t this criterion, and were included in the study. Factors such as patient age, gender, chief complaint, and medications 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, alcohol 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 condition (e.g., chronic obstructive pulmonary disease [COPD], asthma, human immunodeciency virus/acquired immune deciency 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 specied 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 relationship between patient factors and the frequency of antibiotic prescribing was then analyzed using chisquared analysis. p-Values < 0.05 were considered significant. Logistic regression was used to assess factors that might be independently associated with prescribing antibiotics. Odds ratios (ORs), 95% condence intervals (CIs), and associated p-values are reported. Data were analyzed 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 identied 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 second and third most common, respectively. There were 56 (6.5%) patients recorded as having more than one comorbid 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 Gender Female Male Age (mean 6 SD) < 50 years $ 50 years Social Smoker (n = 694) Alcohol abuse (n = 447) Drug use (n = 484) Comorbid conditions COPD Asthma DM HIV/AIDS, immunosuppressive medication > 1 Comorbidity Duration of cough (mean 6 SD) 17 days >7 days Unknown Chief complaint Cough Shortness of breath Sinus pain Fever Chest pain Sore throat Weakness Other Prescribed antibiotics Macrolide Tetracycline Quinolone Penicillin Sulfa Augmentin Cephalosporin Other treatments Inhaled bronchodilator Aerosol spacer device Dilators (oral) Corticosteroids (oral) Cough suppressant Narcotics Ibuprofen n (%) 449 (53.7) 386 (46.2) 46.4 6 16.7 499 (59.6) 337 (40.3) 282 (40.6) 87 (19.5) 39 (8.0) 90 (10.8) 143 (17.1) 66 (7.9) 30 (3.6) 54 (6.5) 9.3 6 17.7 552 (66.0) 236 (28.3) 48 (5.7) 426 (60.0) 133 (15.9) 12 (1.4) 62 (7.4) 52 (6.2) 45 (5.4) 16 (1.9) 90 (10.8) 622 (74.0) 416 (50.0) 124 (15.0) 56 (6.7) 17 (2.0) 7 (0.84) 5 (0.6) 3 (0.36) 400 (48) 76 (9.1) 22 (2.6) 88 (11.0) 276 (33.0) 140 (17.0) 54 (6.5)

COPD = chronic obstructive pulmonary disease; DM = diabetes mellitus; HIV/AIDS = human immunodeciency virus/acquired immune deciency syndrome.

Antibiotic Prescribing for Acute Bronchitis

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

of > 21 days duration before presentation. Of the charts reviewed, 48 reported no information on the duration of cough. Cough was the most common chief complaint (60%), with shortness of breath being the next most common (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, antibiotics were prescribed to 81.1% with COPD, 76.2% with asthma, 86.7% with HIV/AIDS or those taking immunosuppressive 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 quinolones (6.7%). Of all the patients in the study, 480 (57.4%) received broad-spectrum antibiotics (dened as a macrolide, quinolone, cephalosporin, or Augmentin [GlaxoSmithKline, Brentford, Middlesex, UK]). In total, broad-spectrum antibiotics made up 77.2% of all antibiotics prescribed (Figure 2). Other treatments prescribed included inhaled bronchodilators in 400 (48%) patients, with 76 (9.1%) patients receiving an aerosol spacer device. Of those patients without asthma, 346 (49.9%) were discharged without a bronchodilator, and 631 (91.1%) were discharged without a spacer device. Again, in patients without asthma, 289 (41.7%) were prescribed antibiotics but no
Table 2. Comorbid Conditions and Antibiotic Prescribing COPD n = 90 n (%) 73 (81.1) 17 (18.9) Asthma n = 143 n (%) 109 (76.2) 34 (23.8) HIV/AIDS, Immunosuppression n = 30 n (%) 26 (86.7) 4 (13.3)

Figure 2. Of patients prescribed antibiotics, macrolide antibiotics were prescribed to 66%, tetracyclines to 19.9%, quinolones to 9%, and penicillin to 2.7%. Overall, broadspectrum antibiotics were prescribed to 77.2% of patients prescribed antibiotics.

bronchodilator, compared to 124 (35.7%) who were prescribed a bronchodilator but not antibiotics. Patients with a historical nding of asthma were excluded from these calculations because they were likely to have a bronchodilator 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 statistically signicant relationships were found relating the prescription of antibiotics to patient factors (Tables 35). DISCUSSION Acute bronchitis is a self-limited inammatory 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 infection along with other illnesses such as non-specic upper respiratory tract infection (URI), pharyngitis, and acute bacterial sinusitis. Many studies report that antibiotics are frequently prescribed for URIs despite evidence that they provide little to no benet to the patients (1618). Recent studies, however, show that in cases of URI, antibiotic

Patient Factors Antibiotic No antibiotic

Diabetes Mellitus n = 66 n (%) 51 (77.3) 15 (22.7)

> 1 Comorbid Condition n = 54 n (%) 40 (74.1) 14 (25.9)

None Recorded n = 562 n (%) 406 (72.2) 156 (27.8)

COPD = chronic obstructive pulmonary disease; HIV/AIDS = human immunodeciency virus/acquired immune deciency syndrome.

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Table 3. Factors Affecting Antibiotic Prescribing Factor Gender Female Male Age < 50 years $ 50 years Comorbid conditions COPD No Yes Asthma No Yes HIV/AIDS, immunosuppressive medication No Yes DM No Yes More than one comorbidity No Yes Duration of cough 17 days > 7 days Unknown Vital signs Temperature < 38.3  C (101 F) $ 38.3  C (101 F) Heart rate # 100 beats/min > 100 beats/min Respiratory rate # 20 breaths/min > 20 breaths/min Systolic blood pressure < 140 mm Hg $ 140 mm Hg Antibiotic n = 622 n (%) 341 (54.9) 280 (45.1) 352 (56.6) 270 (43.4) 549 (88.3) 73 (11.7) 513 (82.5) 109 (17.5) 596 (95.8) 26 (4.2) 571 (91.8) 51 (8.2) 582 (93.6) 40 (6.4) 412 (66.2) 176 (28.3) 34 (5.5) 571 (93.3) 41 (6.7) 473 (77.3) 139 (22.7) 566 (92.0) 49 (8.0) 421 (68.2) 196 (31.8)

J. C. Kroening-Roche et al.

No Antibiotic n = 214 n (%) 108 (50.5) 106 (49.5)

p Value 0.261 0.002

147 (68.7) 67 (31.3) 0.159 197 (92.1) 17 (7.9) 0.674 180 (84.1) 34 (15.9) 0.138 210 (98.1) 4 (1.9) 0.660 199 (93.0) 15 (7.0) 0.954 200 (93.5) 14 (6.5) 0.956 140 (65.4) 60 (28.0) 14 (6.5) 0.117 205 (96.2) 8 (3.8) 0.220 170 (81.3) 39 (18.7) 0.913 191 (92.3) 16 (7.7) 0.837 141 (67.5) 68 (32.5)

COPD = chronic obstructive pulmonary disease; HIV/AIDS = human immunodeciency virus/acquired immune deciency syndrome; DM = diabetes mellitus.

prescribing is declining overall, with < 10% of patients receiving antibiotics in one ED study (16,1922). Nevertheless, this decrease is not present in the treatment of acute bronchitis.
Table 4. Social History Antibiotic n = 622 n (%) Smoking No Yes Not recorded Alcohol abuse No Yes Not recorded Drug use No Yes Not recorded 302 (48.6) 226 (36.3) 94 (15.1) 276 (44.4) 64 (10.3) 282 (45.3) 343 (55.1) 34 (5.5) 245 (39.4) No Antibiotic n = 214 n (%) 110 (51.4) 56 (26.2) 48 (22.4) 0.543 84 (39.3) 23 (10.7) 107 (50.0) 0.145 102 (47.7) 5 (2.3) 107 (48.6) p Value 0.025

Our data suggest that antibiotic prescribing for acute bronchitis has not signicantly decreased from prior studies. 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 prescribing would be larger (23). Other than age and smoking status, no specic 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 nd these relationships to be significant 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 benet to smokers with acute

Antibiotic Prescribing for Acute Bronchitis

Table 5. Use of Inhaled Bronchodilators and Spacers in Patients without Asthma Patient Factors Patients discharged without bronchodilator Patients discharged without a spacer Patients discharged with a bronchodilator but not spacer Patients prescribed antibiotics and no bronchodilator Patients prescribed a bronchodilator and no antibiotics n (%) 346 (49.9) 631 (91.1) 294 (84.7) 289 (41.7) 124 (35.7)

bronchitis. One ED study shows that smokers are 4.3 times more likely to be prescribed antibiotics than nonsmokers (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 be prescribed 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 broadspectrum (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 majority was of the macrolide class (Figure 2). It is unclear why broad-spectrum antibiotics are prescribed more frequently 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 antimicrobial resistance (28). In addition, unnecessary antibiotic prescribing is costly, time consuming, and associated with allergic and adverse drug reactions. A variety of programs have been carried out in an effort to reduce antibiotic prescribing 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 ofce-based patient education, and describes a decrease in antibiotic prescribing in acute bronchitis from 74% to 48% (32). As described above, the promising efforts that have been made to decrease antibiotic prescribing are often time and

energy intensive. In addition, there remain strong expectations among patients who desire a quick x. It then falls on the emergency physician, often limited for time, to discuss the important ramications of unnecessary antibiotics. Responsibility sharing among ancillary staff should be considered in these instances where education is needed. Furthermore, educational materials that may help alleviate patient 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 ndings, 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 reducing symptom severity. Additionally, studies suggest that bronchodilators may be helpful in patients with underlying 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 bronchitis during our specied time period. Although this enabled a large study group, complete data were not available 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 was performed, 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 current antibiotic-prescribing state. It follows that we are unable to denitively state a causal relationship between the characteristics identied and greater antibiotic prescribing. For instance, antibiotics are prescribed for a plethora of diagnoses that may not be reected in our data. Similarly, in a retrospective study it is difcult to control for bias and confounders, although efforts were made in this regard. CONCLUSION This study demonstrates that antibiotics are still overprescribed in the diagnosis of acute bronchitis in the ED. Furthermore, broad-spectrum antibiotics are prescribed in a surprisingly large proportion of cases.

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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 reverse this disturbing trend. Additionally, our study sheds new light on prescribing practices of inhaled bronchodilators and spacers in acute bronchitis. REFERENCES
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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 cases represent a considerable antibiotic burden among the population. 2. What does this study attempt to show? This study sought 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. 3. What are the key ndings? This study shows that antibiotics are grossly overprescribed in acute bronchitis, with age and smoking related to increased prescribing. Patients 50 years of age and older, and patients who smoke, are more likely to be prescribed antibiotics. No other factors, however, were shown to increase antibiotic prescribing. 4. How is patient care impacted? Armed with this information, emergency physicians may commit to reducing microbial antibiotic resistance by avoiding prescribing antibiotics, specically broadspectrum antibiotics, in the diagnosis of acute bronchitis.