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

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

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

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

Background

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

Diagnosis

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

Clinical Assessment for Pneumonia

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

  Sign	Abnormal Finding
  Fever	≥38°C
  Tachypnea	≥24 breaths/min
  Tachycardia	≥100 beats/min
  Evidence of consolidation on chest exam	rales, egophony, fremitus

• Consider chest radiograph for patients with any of these findings or cough lasting >3 weeks.

Treatment

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

Tips to Reduce Antibiotic Use

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

Key Reference

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