Principles of appropriate antibiotic use for treatment of uncomplicated acute bronchitis: background

Impact of Antibiotics Used for Acute Aspiration Bronchitis on the Prevention of Pneumonia

BACKGROUNDS

It remains unclear if antibiotics should be used for the treatment of acute aspiration bronchitis to prevent the development of pneumonia. This study aimed to assess the associations between the use of antibiotics and the development of pneumonia among patients with acute aspiration bronchitis.

METHODS

We retrospectively reviewed consecutive patients with acute aspiration bronchitis aged ≥75 years. Acute aspiration bronchitis was defined as a condition with aspiration risk, high fever (body temperature, ≥37.5 °C), respiratory symptoms, and the absence of evidence of pneumonia.

RESULTS

There was no significant difference in the incidence of pneumonia between patients treated with and without antibiotics for acute aspiration bronchitis (6/44, 14% vs. 31/143, 22%; p = 0.242). Lower estimated glomerular filtration rate (adjusted odds ratio, 0.956; 95% confidence interval, 0.920-0.993) was significantly associated with the development of pneumonia.

CONCLUSIONS

Antibiotic administration should not be routinely recommended to prevent pneumonia following acute aspiration bronchitis, and patients with decreased renal function should be closely monitored. A randomized controlled trial is necessary to validate these results.

Guidelines on Implementing Antimicrobial Stewardship Programs in Korea

These guidelines were developed as a part of the 2021 Academic R&D Service Project of the Korea Disease Control and Prevention Agency in response to requests from healthcare professionals in clinical practice for guidance on developing antimicrobial stewardship programs (ASPs). These guidelines were developed by means of a systematic literature review and a summary of recent literature, in which evidence-based intervention methods were used to address key questions about the appropriate use of antimicrobial agents and ASP expansion. These guidelines also provide evidence of the effectiveness of ASPs and describe intervention methods applicable in Korea.

Prescription of antibacterial agents for acute upper respiratory tract infections in Beijing, 2010-2012

Purpose

The purpose of this study was to describe the prescription of antibacterial agents for acute upper respiratory tract infections (URIs) in Beijing.

Methods

A total of 8,588,699 outpatient cases in tertiary hospitals with acute upper respiratory tract infections (URIs) were selected from the Beijing Medical Claim Data for Employees (BMCDE) from Oct 2010 to Sep 2012. Second-generation cephalosporins, third-generation cephalosporins, fourth-generation cephalosporins, fluoroquinolones, macrolides (except for erythromycin), combinations of penicillins (including β-lactamase inhibitors), and streptomycins were classified as broad-spectrum antibacterial agents. The rates for antibiotic prescriptions and broad-spectrum antibiotic use were calculated in all cases as well as in various URI diagnosis subgroups and age (18–44, 45–64, and ≥65 years) subgroups. The most frequently prescribed antibiotic classes were identified by calculating the proportions of the different agents in all prescribed antibiotic agents.

Results

Overall, the rate of antibiotic prescription is 39.0 %, and cases diagnosed with acute tonsillitis, sinusitis, and epiglottitis have the highest prescription rate (73.6 %), followed by acute laryngitis and bronchitis (52.3 %), acute pharyngitis (40.1 %), and acute nasopharyngitis (37.2 %). Broad-spectrum agents were chosen in 82.4 % of the cases that were prescribed antibiotics, ranging from 81.9 % of cases with naspharyngitis to 87.1 % of the cases with tonsillitis, sinusitis, and epiglottitis. Second-generation cephalosporins, macrolides, fluoroquinolones, third-generation cephalosporins, and combinations of penicillins were most frequently prescribed, accounting for more than 80 % of all prescribed antibacterials.

Conclusions

Antibacterial drug prescription for outpatients with acute URIs is common in tertiary hospitals in Beijing, and the prescribed antibacterials are usually broad-spectrum agents.

Electronic supplementary material

The online version of this article (doi:10.1007/s00228-015-1997-6) contains supplementary material, which is available to authorized users.

The Value of Macrolide-Based Regimens for Community-Acquired Pneumonia

Macrolide antimicrobials are commonly prescribed, specifically for the treatment of respiratory tract infections. Although still effective, the development of widespread macrolide resistance has limited their use. Aside from their antimicrobial effects, macrolides are also known to possess immune-modulatory properties which may confer a survival benefit in both acute and chronic inflammatory states. This review discusses the efficacy, potential mechanisms, and adverse effects of macrolide therapy specifically in community-acquired pneumonia in outpatients, hospitalized ward patients, and those requiring intensive care unit admission. Challenges for ongoing research in this field are discussed and treatment recommendations offered.

Fever and the rational use of antimicrobials in the emergency department

Any patient presenting to the emergency department (ED) with fever triggers consideration of the administration of an antimicrobial. Empiric antimicrobial therapy has become a cornerstone of treatment. Frequently, the decision to initiate empiric treatment needs to be made before the definitive diagnosis is known. In such cases, an organized approach is helpful. This article aims to provide a systems-based approach to prescribing antimicrobials to patients presenting to the ED with fever, while understanding the risk associated with overutilization. An understanding of the key considerations is needed to ensure that decisions are made well and appropriate treatment begins promptly.

Visit complexity, diagnostic uncertainty, and antibiotic prescribing for acute cough in primary care: a retrospective study

BACKGROUND

Guidelines and performance measures recommend avoiding antibiotics for acute cough/acute bronchitis and presume visits are straightforward with simple diagnostic decision-making. We evaluated clinician-assigned diagnoses, diagnostic uncertainty, and antibiotic prescribing for acute cough visits in primary care.

METHODS

We conducted a retrospective analysis of acute cough visits - cough lasting ≤21 days in adults 18-64 years old without chronic lung disease - in a primary care practice from March 2011 through June 2012.

RESULTS

Of 56,301 visits, 962 (2%) were for acute cough. Clinicians diagnosed patients with 1, 2, or ≥ 3 cough-related diagnoses in 54%, 35%, and 11% of visits, respectively. The most common principal diagnoses were upper respiratory infection (46%), sinusitis (10%), acute bronchitis (9%), and pneumonia (8%). Clinicians prescribed antibiotics in 22% of all visits: 65% of visits with antibiotic-appropriate diagnoses and 4% of visits with non-antibiotic-appropriate diagnoses. Clinicians expressed diagnostic uncertainty in 16% of all visits: 43% of visits with antibiotic-appropriate diagnoses and 5% of visits with non-antibiotic-appropriate diagnoses. Clinicians expressed uncertainty more often when prescribing antibiotics than when not prescribing antibiotics (30% vs. 12%; p < 0.001). As the number of visit diagnoses increased from 1 to 2 to ≥ 3, clinicians were more likely to express diagnostic uncertainty (5%, 25%, 40%, respectively; p < 0.001) and prescribe antibiotics (16%, 25%, 41%, respectively; p < 0.001).

CONCLUSIONS

Acute cough may be more complex and have more diagnostic uncertainty than guidelines and performance measures presume. Efforts to reduce antibiotic prescribing for acute cough should address diagnostic complexity and uncertainty that clinicians face.

Amoxicillin for acute lower-respiratory-tract infection in primary care when pneumonia is not suspected: a 12-country, randomised, placebo-controlled trial

BACKGROUND

Lower-respiratory-tract infection is one of the most common acute illnesses managed in primary care. Few placebo-controlled studies of antibiotics have been done, and overall effectiveness (particularly in subgroups such as older people) is debated. We aimed to compare the benefits and harms of amoxicillin for acute lower-respiratory-tract infection with those of placebo both overall and in patients aged 60 years or older.

METHODS

Patients older than 18 years with acute lower-respiratory-tract infections (cough of ≤28 days' duration) in whom pneumonia was not suspected were randomly assigned (1:1) to either amoxicillin (1 g three times daily for 7 days) or placebo by computer-generated random numbers. Our primary outcome was duration of symptoms rated "moderately bad" or worse. Secondary outcomes were symptom severity in days 2-4 and new or worsening symptoms. Investigators and patients were masked to treatment allocation. This trial is registered with EudraCT (2007-001586-15), UKCRN Portfolio (ID 4175), ISRCTN (52261229), and FWO (G.0274.08N).

FINDINGS

1038 patients were assigned to the amoxicillin group and 1023 to the placebo group. Neither duration of symptoms rated "moderately bad" or worse (hazard ratio 1.06, 95% CI 0.96-1.18; p=0.229) nor mean symptom severity (1.69 with placebo vs 1.62 with amoxicillin; difference -0.07 [95% CI -0.15 to 0.007]; p=0.074) differed significantly between groups. New or worsening symptoms were significantly less common in the amoxicillin group than in the placebo group (162 [15.9%] of 1021 patients vs 194 [19.3%] of 1006; p=0.043; number needed to treat 30). Cases of nausea, rash, or diarrhoea were significantly more common in the amoxicillin group than in the placebo group (number needed to harm 21, 95% CI 11-174; p=0.025), and one case of anaphylaxis was noted with amoxicillin. Two patients in the placebo group and one in the amoxicillin group needed to be admitted to hospital; no study-related deaths were noted. We noted no evidence of selective benefit in patients aged 60 years or older (n=595).

INTERPRETATION

When pneumonia is not suspected clinically, amoxicillin provides little benefit for acute lower-respiratory-tract infection in primary care both overall and in patients aged 60 years or more, and causes slight harms.

FUNDING

European Commission Framework Programme 6, UK National Institute for Health Research, Barcelona Ciberde Enfermedades Respiratorias, and Research Foundation Flanders.

Antimicrobial, Antiviral and Immunomodulatory Activity Studies of Pelargonium sidoides (EPs® 7630) in the Context of Health Promotion

Pelargonium species contribute significantly to the health care of a large population in the Southern African region, as part of a long-standing medical system intimately linked to traditional healing practices. Most notably, extracts of the roots of P. sidoides have commonly been applied for the treatment of dysentery and diarrhoea but only occasionally for respiratory complaints. Clinical trials have shown that a modern aqueous-ethanolic formulation of P. sidoides extracts (EPs^® 7630) is an efficacious treatment for disorders of the respiratory tract, for example bronchitis and sinusitis. It should be noted that EPs^® 7630 is the most widely investigated extract and therefore is the focus of this review. In order to provide a rationale for its therapeutic activity extracts have been evaluated for antibacterial activity and for their effects on non-specific immune functions. Only moderate direct antibacterial capabilities against a spectrum of bacteria, including Mycobacteria strains, have been noted. In contrast, a large body of in vitro studies has provided convincing evidence for an anti-infective principle associated with activation of the non-specific immune system. Interestingly, significant inhibition of interaction between bacteria and host cells, a key to the pathogenesis of respiratory tract infections, has emerged from recent studies. In addition, antiviral effects have been demonstrated, including inhibition of the replication of respiratory viruses and the enzymes haemagglutinin and neuraminidase. Besides, an increase of cilliary beat frequency of respiratory cells may contribute to the beneficial effects of P. sidoides extracts. This example provides a compelling argument for continuing the exploration of Nature and traditional medical systems as a source of therapeutically useful herbal medicines.

Access to a polymerase chain reaction assay method targeting 13 respiratory viruses can reduce antibiotics: a randomised, controlled trial

BACKGROUND

Viral respiratory infections are common worldwide and range from completely benign disease to life-threatening illness. Symptoms can be unspecific, and an etiologic diagnosis is rarely established because of a lack of suitable diagnostic tools. Improper use of antibiotics is common in this setting, which is detrimental in light of the development of bacterial resistance. It has been suggested that the use of diagnostic tests could reduce antibiotic prescription rates. The objective of this study was to evaluate whether access to a multiplex polymerase chain reaction (PCR) assay panel for etiologic diagnosis of acute respiratory tract infections (ARTIs) would have an impact on antibiotic prescription rate in primary care clinical settings.

METHODS

Adult patients with symptoms of ARTI were prospectively included. Nasopharyngeal and throat swabs were analysed by using a multiplex real-time PCR method targeting thirteen viruses and two bacteria. Patients were recruited at 12 outpatient units from October 2006 through April 2009, and samples were collected on the day of inclusion (initial visit) and after 10 days (follow-up visit). Patients were randomised in an open-label treatment protocol to receive a rapid or delayed result (on the following day or after eight to twelve days). The primary outcome measure was the antibiotic prescription rate at the initial visit, and the secondary outcome was the total antibiotic prescription rate during the study period.

RESULTS

A total sample of 447 patients was randomised. Forty-one were excluded, leaving 406 patients for analysis. In the group of patients randomised for a rapid result, 4.5% (9 of 202) of patients received antibiotics at the initial visit, compared to 12.3% (25 of 204) (P = 0.005) of patients in the delayed result group. At follow-up, there was no significant difference between the groups: 13.9% (28 of 202) in the rapid result group and 17.2% (35 of 204) in the delayed result group (P = 0.359), respectively.

CONCLUSIONS

Access to a rapid method for etiologic diagnosis of ARTIs may reduce antibiotic prescription rates at the initial visit in an outpatient setting. To sustain this effect, however, it seems necessary to better define how to follow and manage the patient according to the result of the test, which warrants further investigation.

Antibiotic prescribing for acute respiratory infection and subsequent outpatient and hospital utilization in veterans with spinal cord injury and disorder

OBJECTIVE

To assess the association between antibiotic prescribing for acute respiratory infection (ARI) and subsequent health-care utilization in veterans with spinal cord injury and disorder (SCI/D).

DESIGN

Retrospective cohort of veterans with SCI/D.

SETTING

Veterans Affairs medical facilities that provide outpatient care.

PATIENTS

Veterans with SCI/D with a diagnosis of acute bronchitis or upper respiratory infection during an outpatient visit between fiscal year 2006 and 2007 that did not result in same-day hospitalization.

INDEPENDENT VARIABLE

Receipt of a new antibiotic prescription occurring within 3 days before or after an ARI visit.

MAIN OUTCOME MEASURE

Subsequent outpatient visit or hospitalization within 30 days of the index ARI visit.

RESULTS

A total of 1277 patients were identified with ARI; 53.2% were prescribed an antibiotic. An outpatient clinic visit within 30 days of the index ARI visit occurred in 47.0% of patients. Receipt of an antibiotic prescription was not associated with a subsequent outpatient visit. However, in those with certain chronic respiratory conditions (cough, shortness of breath, bronchitis not specified as acute or chronic, and allergic rhinitis), those prescribed antibiotics were less likely to return for an outpatient visit than those not prescribed antibiotics (adjusted relative risk =0.77, 95% confidence interval = 0.61-0.97); no association was observed in those patients without these conditions. A total of 7.9% of patients were hospitalized within 30 days and did not differ by prescribing group. The 30-day mortality rate was 0.6%.

CONCLUSIONS

Certain chronic respiratory conditions in veterans with SCI/D may be risk factors for increased health-care utilization and potentially poor outcomes if a patient is not treated with antibiotics for ARI. However, in those without these conditions, those with ARI who were prescribed antibiotics have similar utilization to those not prescribed antibiotics. These data suggest that in the absence of chronic respiratory conditions, antibiotic use for ARI can be curbed in this population that is at high risk for respiratory complications.

Guideline for low-cost antimicrobial use in the outpatient setting

In an effort to increase appropriate prescribing of low-cost antimicrobials in the outpatient setting, an evidence-based guideline was created to identify situations when low-cost medications can be used. A literature search identified relevant clinical trials describing the efficacy of antimicrobials used in the outpatient setting. These were analyzed to identify low-cost medications defined as $15 or less. The information was put into guideline format that includes the level of evidence for recommending the drug and information about cost. Sixteen common infections and their treatments were included in the guideline. The efficacy data were similar for the low-cost and higher-cost antimicrobials for all infections included. We created a low-cost antimicrobial guideline for common infections treated in the outpatient setting. The treatment options have similar efficacy to higher cost medications. This guideline will serve as an information source for providers to help them rapidly determine the low-cost treatments for common infections. In addition, it can serve as a template for the development of similar guidelines in other therapeutic classes. These guidelines should be customized before implementation at other health care organizations, with consideration of local resistance patterns, drug availability and patient factors. The effect of guideline implementation on future prescribing habits and providers' opinions about availability of cost information and subsequent conversations with patients and prescribers of medications deserves further study.

Treatment of acute bronchitis with a liquid herbal drug preparation from Pelargonium sidoides (EPs 7630): a randomised, double-blind, placebo-controlled, multicentre study

OBJECTIVE

The objective of this study was to examine the efficacy and safety of a herbal drug preparation from the roots of Pelargonium sidoides (EPs 7630) in the treatment of acute bronchitis in adults outside the very restricted indication for an antibiotic therapy.

RESEARCH DESIGN AND METHODS

This was a randomised, double-blind, placebo-controlled, multicentre study with 217 patients aged between 18 and 66 years with acute bronchitis. One hundred and eight patients were given 30 drops of EPs 7630-solution three times daily and 109 patients 30 drops of placebo three times daily for a period of 7 days.

MAIN OUTCOME MEASURES

Individual change in bronchitis symptom score (BSS) over 7 days, individual symptoms, patient satisfaction and adverse events.

RESULTS

After 7 days of treatment, the BSS decreased by 7.6 +/- 2.2 points in the EPs 7630 group and by 5.3 +/- 3.2 points in the placebo group. The 95% confidence interval for the difference between the effects was calculated as 1.6-3.1, showing highly significant superiority for the EPs 7630 treatment (p < 0.0001). There were also marked improvements in the individual symptoms, which are the components of BSS - cough, chest pain on coughing, sputum, rales/rhonchi and dyspnoea - in the treatment group, relative to placebo. Patient satisfaction was very good. Only minor and transitory adverse events were recorded. No serious adverse events occurred during the trial.

CONCLUSION

EPs 7630-solution is a well tolerated and effective treatment for acute bronchitis in adults outside the very restricted indication for an antibiotic therapy.

Treatment of acute bronchitis in adults with a pelargonium sidoides preparation (EPs 7630): a randomized, double-blind, placebo-controlled trial

BACKGROUND

Acute bronchitis is a widespread medical problem, and, although predominantly caused by viruses, antibiotics are still prescribed unnecessarily. Therefore, it is of utmost importance to evaluate the use of alternative treatments for acute bronchitis.

OBJECTIVE

To evaluate the efficacy and safety of a Pelargonium sidoides preparation (EPs 7630 is a registered trademark of Dr. Willmar Schwabe GmbH & Co. KG, Karlsruhe, Germany) compared with placebo in patients with acute bronchitis.

DESIGN

Randomized, double-blind, placebo-controlled trial using a design with planned interim analyses.

SETTING

Six outpatient clinics.

PATIENTS

One hundred twenty-four adults with acute bronchitis present </=48 hours, Bronchitis Severity Score (BSS) >/=five points, and informed consent.

INTERVENTION

EPs 7630 or placebo (30 drops three times daily) for seven days.

MEASUREMENTS

The primary outcome criterion was the change of BSS on day seven.

RESULTS

The decrease of BSS from baseline to day seven was 7.2 +/- 3.1 points with EPs 7630 (n = 64) and 4.9 +/- 2.7 points with placebo (n = 60). The 95% confidence interval for the difference of effects between the two treatment groups (EPs 7630 minus placebo) was calculated as (1.21, 3.56) showing a significant improvement of EPs 7630 compared with placebo on day seven (P < .0001). For each of the five individual symptoms, rates of complete recovery were considerably higher in the EPs 7630 group. Within the first four days, onset of treatment effect was recognized in 68.8% of patients in the EPs 7630 group compared with 33.3% of patients in the placebo group (P < .0001). Health-related quality of life improved more in patients treated with EPs 7630 compared with placebo-treated patients. Adverse events occurred in 25 of 124 patients (EPs 7630: 15/64 patients, placebo: 10/60 patients). All adverse events were assessed as nonserious.

CONCLUSIONS

EPs 7630 was superior in efficacy compared with placebo in the treatment of adults with acute bronchitis. It may therefore offer an effective alternative for acute bronchitis unless antibiotics are clearly indicated.

Chronic Cough Due to Tuberculosis and Other Infections

BACKGROUND

Although tuberculosis (TB) and other lung infections are common throughout the developing world, they are not among the most common causes of chronic cough.

METHODS

Articles were selected from a MEDLINE search from 1966 through 2003 (using medical subject heading words "cough," "tuberculosis," and "lung infection"), and World Health Organization and Centers for Disease Control and Prevention web sites.

RESULTS

Because of the contagious nature of TB and its potential for devastating morbidity and mortality for individual patients and society, TB should be considered early on in the workup of patients with chronic cough when the likelihood of active TB is high. On a worldwide basis, many cases of chronic cough are caused by infection including TB, and endemic fungi and parasites are important causes of cough in specific geographic regions. The convergence of the AIDS epidemic with the high prevalence of TB in the developing world has fueled the marked increase in cases of TB. Persons who live and work in facilities like prisons and nursing homes are also susceptible to tuberculous infection, and they spread it to others. Infection with endemic fungi and parasites should be considered in patients with chronic cough who live, or have lived, in these areas.

CONCLUSION

Patients with unexplained chronic cough who have resided in areas having endemic infection with TB, fungi, or parasites should undergo diagnostic evaluation for these pathogens when more common causes of cough have been ruled out.

Antibiotic prescribing for children with nasopharyngitis (common colds), upper respiratory infections, and bronchitis who have health-professional parents

OBJECTIVE

Antibiotic resistance might be reduced if patients could be better informed regarding the lack of benefits of antibiotics for children with viral infections and avoid antibiotic prescriptions in these circumstances. This study investigated whether children having health professionals as parents, a group whose parents are expected to have more medical knowledge and expertise, are less likely than other children to receive antibiotics for nasopharyngitis (common colds), upper respiratory tract infections (URIs), and acute bronchitis.

METHODS

Retrospective analyses were conducted by using National Health Insurance data for children of physicians, nurses, pharmacists, and non-health personnel, who had visited hospital outpatient departments or physician clinics for common colds, URIs, and acute bronchitis in Taiwan in 2000. A total of 53733 episodes of care for common colds, URIs, and acute bronchitis in a nationally representative sample of children (aged < or =18 years) living in nonremote areas were analyzed.

RESULTS

The study found that, after adjusting for characteristics of the children (demographic, socioeconomic, and health status) and the treating physicians (demographic, practice style, and setting), children with a physician (odds ratio [OR]: 0.50; 95% confidence interval [CI]: 0.36-0.68) or a pharmacist (OR: 0.69; 95% CI: 0.52-0.91) as a parent were significantly less likely than other children to receive antibiotic prescriptions. The likelihood of receiving an antibiotic for the children of nurses (OR: 0.91; 95% CI: 0.77-1.09) was similar to that for children in the comparison group.

CONCLUSIONS

This finding supports our hypothesis that better parental education does help to reduce the frequency of injudicious antibiotic prescribing. Medical knowledge alone, however, may not fully reduce the overuse of antibiotics. Physician-parents, the expected medically savvy parents, can serve as a benchmark for the improvement potentially achievable in Taiwan through a combination of educational, regulatory, communication, and policy efforts targeted at more appropriate antibiotic prescribing in ambulatory settings.

Interventions to improve treatment of respiratory infections in ambulatory managed-care patients

OBJECTIVE

To review the literature on managed-care initiatives to improve antimicrobial use in respiratory tract infections (RTIs) and examine whether efforts were successful in decreasing antibiotic prescribing when an antibiotic was not indicated or in increasing the frequency with which a preferred antimicrobial agent was chosen when an antibiotic was appropriate.

DATA SOURCES

A computerized search of Ovid MEDLINE was conducted for research articles published between 1966 and September 2004 using a key word search of MeSH subject headings and titles. Search terms included managed care or health maintenance organization and antibacterial agents or antibiotic or antimicrobial.

STUDY SELECTION AND DATA EXTRACTION

Studies evaluating initiatives in ambulatory managed-care environments and the effects of managed care on treatment of RTIs were chosen. Articles addressing both population and individual level tools were included.

DATA SYNTHESIS

Initiatives have been attempted in a variety of managed-care models. In some studies, multidimensional educational interventions were effective in decreasing antimicrobial prescribing rates for RTIs. However, in other studies, no decrease in antimicrobial prescribing after implementation of an evidence-based guideline or initiation of an educational intervention was observed. In one successful study, patient satisfaction was similar between groups. Each study had limitations in design or generalizability. Several studies had strengths, including using randomized groups or offering multidimensional educational efforts.

CONCLUSIONS

Randomized prospective studies of interventions to improve antimicrobial prescribing for RTIs in managed care have been variably successful. Because the topic is one of ongoing importance, it will continue to be an area of research.