The Journal of Emergency Medicine, Vol. -, No. -, pp. 1–7, 2012Copyright � 2012 Elsevier Inc.

Printed in the USA. All rights reserved0736-4679/$ - see front matter

doi:10.1016/j.jemermed.2011.06.143

RECEIVED: 24 NACCEPTED: 5 Jun

OriginalContributions

ANTIBIOTIC AND BRONCHODILATOR PRESCRIBING FOR ACUTE BRONCHITISIN 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

, Abstract—Background: Although the overuse of antibi-otics and underuse of bronchodilators for treatment of acutebronchitis is well known, few studies have analyzed thesetrends in the emergency department (ED). Study Objectives:To characterize the antibiotic and bronchodilator prescribingpractices of physicians at two academic EDs in the diagnosis ofacute bronchitis, and to identify factors that may or may notbe associatedwith these practices.Methods: A computer data-base was searched retrospectively for all patients with an EDdischarge diagnosis of acute bronchitis, and analyzed, lookingat the frequency of antibiotic prescriptions, the class of antibi-otic prescribed, and several other related factors includingage, gender, chief complaint, duration of cough, and comorbidconditions. Results: During the study period, there were 836cases 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% confidence inter-val), antibiotics were prescribed significantlymore often in pa-tients aged 50 years or older (1.7, 1.2–2.5) and in smokers (1.5,1.0–2.2). Of patients without asthma, 346 (49.9%) were dis-charged without a bronchodilator, and 631 (91.1%) were dis-charged without a spacer device. Conclusion: Antibiotics areover-prescribed in the ED for acute bronchitis, with broad-spectrum antibiotics making up the majority of the antibioticsprescribed. Age$ 50 years and smoking are associated withhigher antibiotic prescribing rates. � 2012 Elsevier Inc.

, Keywords—acute bronchitis; antibiotics; bronchodila-tors; emergency department; broad-spectrum antibiotics

ovember 2010; FINAL SUBMISSION RECEIVED: 14 Ae 2011

1

INTRODUCTION

Epidemiological studies have shown that the majorityof cases of acute bronchitis are caused by viruses, withbacterial pathogens accounting for 5–10% of acutebronchitis in cases uncomplicated by underlying pulmo-nary disease (1–5). In adults with otherwise healthylungs, the most common bacterial causes of acutebronchitis are Mycoplasma pneumoniae, Chlamydiapneumoniae, and Bordetella pertussis (4,6). Of these,antibiotic therapy is recommended only for treatment ofsuspected pertussis (Centers for Disease Control andPrevention guidelines), and it is believed that pertussisis the causative agent in only 1% of cases of acutebronchitis (5–7). In fact, multiple studies demonstrateno benefit from antibacterial use in the treatment ofacute bronchitis, with one citing the superiority ofalbuterol to antibiotics (6,8–12).

Current recommendations suggest that antibioticsshould not be prescribed for cases of uncomplicatedacute bronchitis (13–15). In keeping with these recom-mendations, one study demonstrated an almost 50%reduction in antibiotics prescribed for acute bronchitis inadults from 1993–1999 (16). Many studies since then,however, do not report a similar reduction. Recent studiessuggest that antibiotics are prescribed between 57% and97% of the time for acute bronchitis in the emergencydepartment (ED), with fever, purulent sputum, shortness

pril 2011;

Table 1. Patient Characteristics (n = 836)

Characteristics n (%)

GenderFemale 449 (53.7)Male 386 (46.2)

Age (mean6 SD) 46.46 16.7< 50 years 499 (59.6)$ 50 years 337 (40.3)

SocialSmoker (n = 694) 282 (40.6)Alcohol abuse (n = 447) 87 (19.5)Drug use (n = 484) 39 (8.0)

Comorbid conditionsCOPD 90 (10.8)Asthma 143 (17.1)DM 66 (7.9)HIV/AIDS, immunosuppressive medication 30 (3.6)> 1 Comorbidity 54 (6.5)

Duration of cough (mean6 SD) 9.36 17.71–7 days 552 (66.0)>7 days 236 (28.3)Unknown 48 (5.7)

Chief complaintCough 426 (60.0)Shortness of breath 133 (15.9)Sinus pain 12 (1.4)Fever 62 (7.4)Chest pain 52 (6.2)Sore throat 45 (5.4)Weakness 16 (1.9)Other 90 (10.8)

Prescribed antibiotics 622 (74.0)Macrolide 416 (50.0)Tetracycline 124 (15.0)Quinolone 56 (6.7)Penicillin 17 (2.0)Sulfa 7 (0.84)Augmentin 5 (0.6)Cephalosporin 3 (0.36)

Other treatmentsInhaled bronchodilator 400 (48)Aerosol spacer device 76 (9.1)Dilators (oral) 22 (2.6)Corticosteroids (oral) 88 (11.0)Cough suppressant 276 (33.0)Narcotics 140 (17.0)Ibuprofen 54 (6.5)

COPD= chronic obstructive pulmonary disease; DM= diabetesmellitus; HIV/AIDS = human immunodeficiency virus/acquiredimmune deficiency syndrome.

2 J. C. Kroening-Roche et al.

of breath, and a provider age$ 30 years independentlyassociated with provider prescribing (16–18).

The purpose of this study is to characterize theantibiotic and bronchodilator prescribing practices ofphysicians at two EDs in the diagnosis of acute bronchi-tis, and to identify factors that are, and are not, associatedwith these practices.

MATERIALS AND METHODS

This is a retrospective study conducted via structured chartdata extraction of all patients presenting to the EDs of twourban academic medical centers in San Diego, Californiafrom January 1 through December 31, 2008with a primarydiagnosis of acute bronchitis. This diagnosis was definedby attending and resident physician entry of acute bronchi-tis into the patient’s electronic medical chart on dischargefrom the ED. All resident physician chart entry was subjectto required review by the attending physician on duty, and aseparate attending note was written. A total of 836 patientsfit this criterion, and were included in the study. Factorssuch as patient age, gender, chief complaint, and medica-tions prescribed during the visit were obtained from thedatabase. Additionally, the attending physician noteswere queried for information regarding duration of cough,comorbid conditions, and social history (e.g., smoking, al-cohol abuse, and drug use) as documented by the physicianat the time of the patient interview. Severity of substanceabuse was not reported. If no history of a comorbid condi-tion (e.g., chronic obstructive pulmonary disease [COPD],asthma, human immunodeficiency virus/acquired immunedeficiency syndrome [HIV/AIDS])was noted in the historyof present illness or in nurses’ or physicians’ notes on pastmedical history, it was assumed none existed. No patientswith a diagnosis of acute bronchitis during our specifiedstudy timeframe were excluded from the study.

Institutional Review Board approval was obtainedthrough the University of California San Diego’s HumanSubject’s Protection Program.

Frequencies, percentages, means, and associated SDswere used to describe the patient population. The rela-tionship between patient factors and the frequency ofantibiotic prescribing was then analyzed using chi-squared analysis. p-Values < 0.05 were considered signif-icant. Logistic regression was used to assess factors thatmight be independently associated with prescribing anti-biotics. Odds ratios (ORs), 95% confidence intervals(CIs), and associated p-values are reported. Data were an-alyzed 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 includedinformation on tobacco use, 447 on alcohol use, and484 on illicit drug use: 282 (40.6%) were identified assmokers on history, 87 (19.5%) reported alcohol use,and 39 (8.0%) used recreational drugs. Asthma was themost common comorbid condition (17.1%), with COPD(10.8%) and diabetes mellitus (7.9%) being the secondand third most common, respectively. There were 56(6.5%) patients recorded as having more than one comor-bid condition. Table 1 provides patient demographics,and vital signs are displayed in Figure 1.

There were 552 (66%) patients who reported 7 orfewer days of cough, with only 50 (6%) reporting a cough

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

Figure 2. Of patients prescribed antibiotics, macrolide anti-biotics were prescribed to 66%, tetracyclines to 19.9%,quinolones to 9%, and penicillin to 2.7%. Overall, broad-spectrum antibiotics were prescribed to 77.2% of patientsprescribed antibiotics.

Antibiotic Prescribing for Acute Bronchitis 3

of > 21 days duration before presentation. Of the chartsreviewed, 48 reported no information on the duration ofcough. Cough was the most common chief complaint(60%), with shortness of breath being the next most com-mon (15.9%). A variety of complaints made up portionssmaller 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 inthis study. Among patients with comorbid conditions, an-tibiotics were prescribed to 81.1% with COPD, 76.2%with asthma, 86.7% with HIV/AIDS or those taking im-munosuppressive medication, and 77.3% with diabetesmellitus. Antibiotics were prescribed to 74.1% of patientsfor whom >1 comorbid condition was reported (Table 2).The three most common classes of antibiotics prescribedwere macrolides (50.0%), tetracyclines (15.0%), and qui-nolones (6.7%). Of all the patients in the study, 480(57.4%) received broad-spectrum antibiotics (defined asa macrolide, quinolone, cephalosporin, or Augmentin[GlaxoSmithKline, Brentford, Middlesex, UK]). In total,broad-spectrum antibiotics made up 77.2% of all antibi-otics prescribed (Figure 2).

Other treatments prescribed included inhaled bron-chodilators in 400 (48%) patients, with 76 (9.1%) patientsreceiving an aerosol spacer device. Of those patientswithout asthma, 346 (49.9%) were discharged withouta bronchodilator, and 631 (91.1%) were dischargedwithout a spacer device. Again, in patients withoutasthma, 289 (41.7%) were prescribed antibiotics but no

Table 2. Comorbid Conditions and Antibiotic Prescribing

Patient FactorsCOPD

n = 90 n (%)Asthma

n = 143 n (%)

HIV/AIDS,Immunosuppression

n = 30 n (%)

Antibiotic 73 (81.1) 109 (76.2) 26 (86.7)No antibiotic 17 (18.9) 34 (23.8) 4 (13.3)

COPD = chronic obstructive pulmonary disease; HIV/AIDS = human im

bronchodilator, compared to 124 (35.7%) who wereprescribed a bronchodilator but not antibiotics. Patientswith a historical finding of asthma were excluded fromthese calculations because theywere likely to have a bron-chodilator and spacer at home.

Patients 50 years of age and older were found to be 1.7times more likely to be prescribed antibiotics than thoseunder 50 years of age (95% CI 1.2–2.3, p = 0.002).Furthermore, smokers were 1.5 times more likely to beprescribed antibiotics than non-smokers (95% CI1.0–2.2, p = 0.025), independent of age. No other statisti-cally significant relationships were found relating theprescription of antibiotics to patient factors (Tables 3–5).

DISCUSSION

Acute bronchitis is a self-limited inflammatory disorderof the upper airways that affects approximately 5% ofpeople in the United States each year (13). It is includedunder the broader heading of acute respiratory tract infec-tion along with other illnesses such as non-specific upperrespiratory tract infection (URI), pharyngitis, and acutebacterial sinusitis.

Many studies report that antibiotics are frequentlyprescribed for URIs despite evidence that they providelittle to no benefit to the patients (16–18). Recentstudies, however, show that in cases of URI, antibiotic

Diabetes Mellitusn = 66 n (%)

> 1 Comorbid Conditionn = 54 n (%)

None Recordedn = 562 n (%)

51 (77.3) 40 (74.1) 406 (72.2)15 (22.7) 14 (25.9) 156 (27.8)

munodeficiency virus/acquired immune deficiency syndrome.

Table 3. Factors Affecting Antibiotic Prescribing

Factor Antibiotic n = 622 n (%) No Antibiotic n = 214 n (%) p Value

Gender 0.261Female 341 (54.9) 108 (50.5)Male 280 (45.1) 106 (49.5)

Age 0.002< 50 years 352 (56.6) 147 (68.7)$ 50 years 270 (43.4) 67 (31.3)

Comorbid conditionsCOPD 0.159

No 549 (88.3) 197 (92.1)Yes 73 (11.7) 17 (7.9)

Asthma 0.674No 513 (82.5) 180 (84.1)Yes 109 (17.5) 34 (15.9)

HIV/AIDS, immunosuppressive medication 0.138No 596 (95.8) 210 (98.1)Yes 26 (4.2) 4 (1.9)

DM 0.660No 571 (91.8) 199 (93.0)Yes 51 (8.2) 15 (7.0)

More than one comorbidity 0.954No 582 (93.6) 200 (93.5)Yes 40 (6.4) 14 (6.5)

Duration of cough 0.9561–7 days 412 (66.2) 140 (65.4)> 7 days 176 (28.3) 60 (28.0)Unknown 34 (5.5) 14 (6.5)

Vital signsTemperature 0.117

< 38.3 �C (101�F) 571 (93.3) 205 (96.2)$ 38.3 �C (101�F) 41 (6.7) 8 (3.8)

Heart rate 0.220# 100 beats/min 473 (77.3) 170 (81.3)> 100 beats/min 139 (22.7) 39 (18.7)

Respiratory rate 0.913# 20 breaths/min 566 (92.0) 191 (92.3)> 20 breaths/min 49 (8.0) 16 (7.7)

Systolic blood pressure 0.837< 140 mm Hg 421 (68.2) 141 (67.5)$ 140 mm Hg 196 (31.8) 68 (32.5)

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

4 J. C. Kroening-Roche et al.

prescribing is declining overall, with < 10% of patientsreceiving antibiotics in one ED study (16,19–22). Never-theless, this decrease is not present in the treatment ofacute bronchitis.

Table 4. Social History

Antibioticn = 622 n (%)

No Antibioticn = 214 n (%) p Value

Smoking 0.025No 302 (48.6) 110 (51.4)Yes 226 (36.3) 56 (26.2)Not recorded 94 (15.1) 48 (22.4)

Alcohol abuse 0.543No 276 (44.4) 84 (39.3)Yes 64 (10.3) 23 (10.7)Not recorded 282 (45.3) 107 (50.0)

Drug use 0.145No 343 (55.1) 102 (47.7)Yes 34 (5.5) 5 (2.3)Not recorded 245 (39.4) 107 (48.6)

Our data suggest that antibiotic prescribing for acutebronchitis has not significantly decreased from prior stud-ies. Antibiotics were prescribed to 74% of patients in ourstudy. Patients with underlying COPD were prescribedantibiotics over 81% of the time. Onewould expect, givenevidence that antibiotics improve outcomes in acuteCOPD exacerbations, that this difference in antibiotic pre-scribingwould be larger (23). Other than age and smokingstatus, no specific factors were associated with a greaterlikelihood of antibiotic prescribing by the physician. Priorstudies suggest important factors to be the presence offever, more than one comorbid condition, and shortnessof breath. We did not find these relationships to be signif-icant in our sample. Furthermore, neither length of illness,underlying pulmonary disease, or vital sign abnormalitieswas associated with greater antibiotic prescribing.

A common misconception among practitioners is thatantibiotics provide benefit to smokers with acute

Table 5. Use of Inhaled Bronchodilators and Spacers inPatients without Asthma

Patient Factors n (%)

Patients discharged withoutbronchodilator

346 (49.9)

Patients discharged without a spacer 631 (91.1)Patients discharged with

a bronchodilator but not spacer294 (84.7)

Patients prescribed antibiotics and nobronchodilator

289 (41.7)

Patients prescribed a bronchodilator andno antibiotics

124 (35.7)

Antibiotic Prescribing for Acute Bronchitis 5

bronchitis. One ED study shows that smokers are 4.3times more likely to be prescribed antibiotics than non-smokers (24). A review article of 109 studies looking atthe effectiveness of antibiotics in smokers with acutebronchitis, however, reports that antibiotics are no moreeffective in this population than in non-smokers (25).Our study also found that smokers are more likely to beprescribed antibiotics at a rate 1.5 times greater thanthat of non-smokers. This shows an improvement fromprior reports, but it continues to suggest that physiciansdo not fully understand the relationship between smokingand antibiotic usage for this diagnosis.

Several more studies show a disturbing trend towardincreasing use of broad-spectrum antibiotics (22,26).One study of acute bronchitis in the elderly reportedthat antibiotics were prescribed in 83% of patients, andone-half of the antibiotics prescribed were broad-spectrum (27). Our study demonstrates an even moretroubling trend toward broad-spectrum antibiotic use.More than 75% of patients who received antibioticswere prescribed a broad-spectrum type, and the vast ma-jority was of the macrolide class (Figure 2). It is unclearwhy broad-spectrum antibiotics are prescribed more fre-quently than narrow-spectrum.

It is clear from our study that further education ofphysicians is needed regarding antibiotic prescribing incases of acute bronchitis, as it is well known that a positiverelationship exists between antibiotic usage and antimicro-bial resistance (28). In addition, unnecessary antibiotic pre-scribing is costly, time consuming, and associated withallergic and adverse drug reactions. A variety of programshave been carried out in an effort to reduce antibiotic pre-scribing practices, but have had minimal success (29,30).One such study records a modest success: decreasingantibiotic use from 75% to 60% in cases of acutebronchitis; however, the use of broad-spectrum antibioticsincreased from 24% to 48% during the same period (31).Another study utilized household- and office-based patienteducation, and describes a decrease in antibiotic prescrib-ing in acute bronchitis from 74% to 48% (32).

Asdescribed above, the promising efforts that have beenmade to decrease antibiotic prescribing are often time and

energy intensive. In addition, there remain strong expecta-tions among patients who desire a ‘‘quick fix.’’ It then fallson the emergency physician, often limited for time, to dis-cuss the important ramifications of unnecessary antibiotics.Responsibility sharing among ancillary staff shouldbe con-sidered in these instances where education is needed.Furthermore, educational materials that may help alleviatepatient concerns are rarely readily available in the ED. Ourstudy demonstrates an increasing need for resources in thearea of physician and patient education to reduce antibioticprescribing, with an emphasis on broad-spectrum, in aneffort to combat antimicrobial resistance.

In addition to these antibiotic-related findings, ourstudy also found that 50% of patients were not prescribeda bronchodilator. Although data recommending the use ofbronchodilators in acute bronchitis are scarce, there iswidespread anecdotal evidence that they are helpful in re-ducing symptom severity. Additionally, studies suggestthat bronchodilators may be helpful in patients with un-derlying pulmonary disease (33–37). In our study,aerosol spacer devices were prescribed in only 15.3% ofpatients who were prescribed a bronchodilator, despiteevidence that these devices improve bioavailability inthe lungs, especially in those who may not be educatedon the proper use of metered-dose inhalers (38–44).

Limitations

Our study included all patients with a primary diagnosis ofacute bronchitis duringour specified time period.Althoughthis enabled a large study group, complete data were notavailable for every patient for the variables studied. Thislimited the power in several areas, namely, those relatingto social history. As this was a retrospective study, theaccuracy of the data set must be questioned. In our study,no formal teachingwas performed, nor a consensus presentregarding how to diagnose acute bronchitis, allowing forpossible misrepresentation of our primary outcome.

This retrospective study is limited to describing the cur-rent antibiotic-prescribing state. It follows that we areunable to definitively state a causal relationship betweenthe characteristics identified and greater antibiotic presc-ribing. For instance, antibiotics are prescribed for a pleth-ora of diagnoses that may not be reflected in our data.Similarly, in a retrospective study it is difficult to controlfor bias and confounders, although efforts were made inthis regard.

CONCLUSION

This study demonstrates that antibiotics are still over-prescribed in the diagnosis of acute bronchitis in theED. Furthermore, broad-spectrum antibiotics are pre-scribed in a surprisingly large proportion of cases.

6 J. C. Kroening-Roche et al.

Although there is ample evidence directing providers toavoid antibiotics in cases of acute bronchitis, this practicecontinues. Further efforts and resources are needed to re-verse this disturbing trend. Additionally, our study shedsnew light on prescribing practices of inhaled bronchodi-lators and spacers in acute bronchitis.

REFERENCES

1. Gonzales R, SandeM.What will it take to stop physicians from pre-scribing antibiotics in acute bronchitis? Lancet 1995;345:665–6.

2. Gonzales R, Steiner JF, SandeMA. Antibiotic prescribing for adultswith colds, upper respiratory tract infections, and bronchitis byambulatory care physicians. JAMA 1997;278:901–4.

3. Gonzales R, Steiner JF, Lum A, et al. Decreasing antibiotic use inambulatory practice: impact of a multidimensional interventionon the treatment of uncomplicated acute bronchitis in adults.JAMA 1999;281:1512–9.

4. Snow V, Mottur-Pilson C, Gonzales R. Principles of appropriateantibiotic use for treatment of acute bronchitis in adults. Ann InternMed 2001;134:518–20.

5. Gonzales R, Bartlett JG, Besser RE, et al. Principles of appropriateantibiotic use for treatment of uncomplicated acute bronchitis:background. Ann Intern Med 2001;134:521–9.

6. MacKay DN. Treatment of acute bronchitis in adults without under-lying lung disease. J Gen Intern Med 1996;11:557–62.

7. Nennig ME, Shinefield HR, Edwards KM, et al. Prevalence and in-cidence of adult pertussis in an urban population. JAMA 1996;275:1672–4.

8. Orr PH, Scherer K, MacDonald A, et al. Randomized placebo-controlled trials of antibiotic for acute bronchitis: a critical reviewof the literature. J Fam Pract 1993;36:507–12.

9. Evans AT, Husain S, Durairaj L, et al. Azithromycin for acute bron-chitis: a randomised, double-blind, controlled trial. Lancet 2002;359:1648–54.

10. Little P, Rumsby K, Kelly J, et al. Information leaflet and antibioticprescribing strategies for acute lower respiratory tract infection:a randomized controlled trial. JAMA 2005;293:3029–35.

11. Fahey T, Stocks N, Thomas T. Quantitative systematic review ofrandomized controlled trials comparing antibiotic with placebofor acute cough in adults. BMJ 1998;316:906–10.

12. Bent S, Saint S, Vittinghoff E, et al. Antibiotics in acute bronchitis:a meta-analysis. Am J Med 1999;107:62–7.

13. Wenzel RP, Fowler AA 3rd. Clinical practice. Acute bronchitis.N Engl J Med 2006;355:2125–30.

14. Wong DM, Blumberg DA, Lowe LG. Guidelines for the use of an-tibiotics in acute upper respiratory tract infections. Am Fam Physi-cian 2006;74:956–66.

15. Braman SS. Chronic cough due to acute bronchitis: ACCP evidence-based clinical practice guidelines. Chest 2006;129:95S–103.

16. Aspinall SL, Good CB, Metlay JP, et al. Antibiotic prescribing forpresumed nonbacterial acute respiratory tract infections. Am JEmerg Med 2009;27:544–51.

17. Thorpe JM, Smith SR, Trygstad TK. Trends in emergency depart-ment antibiotic prescribing for acute respiratory tract infections.Pharmacotherapy 2004;38:928–35.

18. Del Mar CB, Glaszious PP, Spinks AB. Antibiotics for sore throat.Cochrane Database Syst Rev 2006;4:CD000023.

19. Mainous AG 3rd, HuestonWJ, Davis MP, et al. Trends in antimicro-bial prescribing for bronchitis and upper respiratory infectionsamong adults and children. Am J Public Health 2003;93:1910–4.

20. Ong S, Nakase J, Moran GJ, et al. Antibiotic use for emergencydepartment patients with upper respiratory infections: prescribingpractices, patient expectations, and patient satisfaction. Ann EmergMed 2007;50:213–20.

21. Ashworth M, Latinovic R, Charlton J, et al. Why has antibiotic pre-scribing for respiratory illness declined in primary care? A longitu-

dinal study using the General Practice Research Database. J PublicHealth Med 2004;26:268–74.

22. Steinman MA, Landefeld CS, Gonzales R. Predictors of broad-spectrum antibiotic prescribing for acute respiratory tract infectionsin adult primary care. JAMA 2003;289:719–25.

23. Ram FS, Rodriguez-Roisin R, Granados-Navarrete A, et al.Antibiotics for exacerbations of chronic obstructive pulmonarydisease. Cochrane Database Syst Rev 2006;19:CD004403.

24. Stone S, Gonzales R, Maselli J. Antibiotic prescribing for patientswith colds, upper respiratory tract infections, and bronchitis:a national study of hospital-based emergency departments. AnnEmerg Med 2000;36:320–7.

25. Linder JA, Sim I. Antibiotic treatment of acute bronchitis insmokers-a systematic review. J Gen Intern Med 2002;17:230–4.

26. Roumie CL, Halasa NB, Grijalva CG. Trends in antibiotic prescrib-ing for adults in the United States—1995 to 2002. J Gen Intern Med2005;20:697–702.

27. Steinman MA, Sauaia A, Maselli JH. Office evaluation and treat-ment of elderly patients with acute bronchitis. J Am Geriatr Soc2004;52:875–9.

28. Steinke D, Davey P. Association between antibiotic resistance andcommunity prescribing: a critical review of bias and confoundingin published studies. Clin Infect Dis 2001;33:S193–205.

29. Doyne EO, Alfaro MP, Siegel RM, et al. A randomized controlledtrial to change antibiotic prescribing patterns in a community.Arch Pediatr Adolesc Med 2004;158:577–83.

30. Rautakorpi U, Huikko S, Honkanen P, et al. The AntimicrobialTreatment Strategies (MIKSTRA) Program: a 5-year follow-up ofinfection-specific antibiotic use in primary health care and the effectof implementation of treatment guidelines. Clin Infect Dis 2006;42:1221–30.

31. Steinman MA, Gonzales R, Linder JA, et al. Changing use of anti-biotics in community-based outpatient practice, 1991–1999. AnnIntern Med 2003;138:525–33.

32. Gonzales R, Steiner JF, Lum A. Decreasing antibiotic use in ambu-latory practice-impact of a multidimensional intervention on thetreatment of uncomplicated acute bronchitis in adults. JAMA1999;281:1512–9.

33. Hueston WJ. A comparison of albuterol and erythromycin for thetreatment of acute bronchitis. J Fam Pract 1991;33:476–80.

34. Hueston WJ. Albuterol delivered by metered-dose inhaler to treatacute bronchitis. J Fam Pract 1994;39:437–40.

35. Melbye H, Aasebo U, Straume B. Symptomatic effect of inhaled fe-noterol in acute bronchitis; a placebo-controlled double-blind study.Fam Pract 1991;8:216–22.

36. Littenberg B, Wheeler M, Smith DS. A randomized controlled trialof oral albuterol in acute cough. J Fam Pract 1996;42:49–53.

37. Smucny JJ, Flynn CA, Becker LA, et al. Are beta2-agonists effec-tive treatment for acute bronchitis or acute cough in patients withoutunderlying pulmonary disease? A systematic review. J Fam Pract2001;50:945–51.

38. Nair A, Clearie K, Menzies D, et al. A novel breath-actuated inte-grated vortex spacer device increases relative lung bioavailabilityof fluticasone/salmeterol in combination. Pulm Pharmacol Ther2009;22:305–10.

39. Lavorini F, Fontana GA. Targeting drugs to the airways: the role ofspacer devices. Expert Opin Drug Deliv 2009;6:91–102.

40. Nair A, Menzies D, Hopkinson P, et al. In vivo comparison of therelative systemic bioavailability of fluticasone propionate fromthree anti-static spacers and a metered dose inhaler. Br J Clin Phar-macol 2009;67:191–8.

41. Mazhar SH, Chrystyn H. Salbutamol relative lung and systemic bio-availability of large and small spacers. J Pharm Pharmacol 2008;60:1609–13.

42. Newman SP. Spacer devices for metered dose inhalers. Clin Phar-macokinet 2004;43:349–60.

43. Kelly HW. New beta 2-adrenergic agonist aerosols. Clin Pharm1985;4:393–403.

44. Konig P. Spacer devices used with metered-dose inhalers. Break-through or gimmick? Chest 1985;2:276–84.

Antibiotic Prescribing for Acute Bronchitis 7

ARTICLE SUMMARY

1. Why is this topic important?Acute bronchitis affects 5% of Americans annually.

Antibiotics prescribed in the majority of these casesrepresent a considerable antibiotic burden among thepopulation.2. What does this study attempt to show?

This study sought to characterize the antibiotic andbronchodilator prescribing practices of physicians attwo academic EDs in the diagnosis of acute bronchitis,and to identify factors that may or may not be associatedwith these practices.3. What are the key findings?

This study shows that antibiotics are grossly over-prescribed in acute bronchitis, with age and smoking re-lated to increased prescribing. Patients 50 years of ageand older, and patients who smoke, are more likely tobe prescribed antibiotics. No other factors, however,were shown to increase antibiotic prescribing.4. How is patient care impacted?

Armed with this information, emergency physiciansmay commit to reducing microbial antibiotic resistanceby avoiding prescribing antibiotics, specifically broad-spectrum antibiotics, in the diagnosis of acute bronchitis.