Happy Monday, and welcome to Medical Mondays! This topic was actually fairly unplanned and will be less “technical” today, but we’re gonna go with it because…I think it’s what I’ve been trying to battle out for the past several weeks!
As some of you might know, I’ve had a pretty terrible cough since the end of my peds rotation. Initially, I thought it was a parting gift of RSV from one of the kids or that my body was doing a protest on psych, but it’s been lasting way too long for that. ._. (It’s actually past the norm even for acute bronchitis, but there really isn’t much else in my differential.)
On the plus side, I’m not coughing up blood, and I’m not really coughing to the point of retching throughout the night, so…at least there’s that?! I’d like to believe I’m on the mend, although I’d really love it if I could recover before my voice gets ruined forever. I miss being able to sing, and I’m worried that my patients think I’m contagious and/or dying, but enough about me, let’s talk about…
Cough is the most common symptom that brings a patient to the primary care physician’s office, and acute bronchitis tends to be the diagnosis. Symptoms usually last 2-3 weeks.
The most common infectious etiologies of acute bronchitis are listed below:
- Influenza A + B
- Parainfluenza virus
- Respiratory syncytial virus
- Bordetella pertussis
- Chlamydia pneumonia
- Mycoplasma pneumonia
Please note that all but the last three in that are viruses. Viruses are responsible for over 90% of acute bronchitis infections, so antibiotics are generally not indicated for the treatment of bronchitis, unless pertussis is suspected, or if the patient is at increased risk of developing pneumonia.
Despite the fact that 90% of bronchitis infections are caused by viruses, ~2/3 patients are treated with antibiotics.
(Warning: This is where I get on one of my soapboxes.)
I’ve seen this happen in many a clinic/hospital and each time, I’ve asked my preceptors about antibiotic resistance, and whether or not the antibiotic is really necessary if the cause is usually viral.
The answer I always get is…no, the antibiotic is not necessary, and “once upon a time, they were young and stupid” and tried to explain that the antibiotic wouldn’t help because it was a viral infection…but patients have come to expect that prescription, so complaints increase, patient satisfaction rates decrease, and they get reprimanded by the hospital for said decrease in satisfaction rates.
My family med preceptor went with the delayed “pocket” prescription/”wait-and-see” prescription, where she’d put an order in and ask her patients to fill the prescription only if they felt that they really needed it after a couple days (if it was a URI) or a couple weeks (if it was likely to be acute bronchitis).
Because I am still
young and stupid idealistic in my ways, and for the greater good of us all, however, I’d like to share the following:
- Symptom duration for acute bronchitis tends to be about 3 weeks.
- Antibiotics do not significantly reduce the duration of symptoms, and may cause adverse effects + lead to antibiotic resistance.
- Antibiotics are used to treat bacteria, not viruses.
Depending on the severity, symptomatic treatment options include:
- Antitussives (e.g. dextromethorphan, codeine, hydrocodone) in patients > 6yo
- Beta-agonist inhalers in patients with wheezing
- High-dose episodic inhaled corticosteroids
- Echinacea or pelargonium (few studies have shown a modest positive effect)
- Dark honey in children
- Routine use of antibiotics
- Expectorants (commonly used/suggested by physicians, although they’ve been shown to be ineffective)
- Beta-agonist inhalers in patients without wheezing
- Antitussives in children < 6yo