SEPTEMBER 2017 DRUG ANTIBIOTICS

ACUTE BRONCHITIS

This optimal usage guide is mainly intended for primary care health professionnals. It is provided for information purposes only and should not replace the clinician’s judgement. The recommendations were developed using a systematic approach and are supported by the scientific literature and the knowledge and experience of Quebec clinicians and experts. For more details, go to inesss.qc.ca.

GENERAL INFORMATIONS IMPORTANT CONSIDERATIONS

„„Most cases of acute bronchitis (>90 %) are of viral origin. ACUTE BRONCHITIS „„The symptoms of acute bronchitis generally resolve on their own. „„Antibiotic therapy is generally not recommended in healthy individuals with acute bronchitis. „„The increase in antimicrobial resistance is directly linked to the prescribed amount of antibiotics.

MAIN PATHOGENS THAT CAN CAUSE ACUTE BRONCHITIS

•• Adenovirus •• Coronavirus •• Enterovirus •• Influenza Mostly of viral origin : •• Human metapneumovirus •• Parainfluenza •• Rhinovirus •• Respiratory syncytial virus

•• Bordetella pertussis In the rare cases of bacterial infection : •• Chlamydophila pneumoniae •• Mycoplasma pneumoniae

PREVENTIVE MEASURES

„„Regular hand hygiene and respiratory etiquette. „„Vaccination ••Annual influenza vaccination Vaccination or booster (>10 years) for whooping cough. For further details consult the Quebec •• Stay up to date at inesss.qc.ca Immunization Protocol. Stay up to date at inesss.qc.ca ACUTE BRONCHITIS RADIOGRAPHY MICROBIOLOGICAL INVESTIGATIONS SUPPORTIVE TREATMENTS SYMPTOMS „ „ „ „ „ „ „ „ „ „ TREATMENT PRINCIPLES DIAGNOSIS „ „ „ „ „ „ „ „ „ „ Antitussives Analgesics/antipyretics Acute bronchitis generally resolves onitsown within4weeks. failure).or congestive heart A radiograph isnotrecommended. Consider ordering aradiograph (e.g., ifanotherillnessissuspected pneumonia ordered. or if the patient has flu-like infection), symptoms,or B.be agent may pertussis tests for identifying the infectious Identifying theinfectiousagent isnotrecommended. epidemiological contexts (e.g., Incertain ariskofinfluenza Auscultation ofthelungsisgenerally normal. However, thepatientmayhave rhonchiorwheezing. illness (e.g., pneumonia). Fever ismostlyabsent, however thepatient may beinasubfebrile state. Fever ofanother suggests thepossibility acute exacerbation ofCOPD. disease(COPD),individuals withchronic obstructive pulmonary theymayrequire treatment. Consultguide on the Purulent orcoloured sputaare infectionindicator notareliable inhealthy bacterial individuals, whereas in A repetitive cough cancausechestpain. although itcanlastfor upto 6weeks. Cough withorwithoutsputumisthemainsymptom ofacute bronchitis andgenerally lasts2to 3weeks, exposure, patient to notvaccinated B. againstwhooping cough pertussis orneedsabooster. Whooping-like coughcock’s (barking, crow), cough lasting>3weeks, vomiting (causedby coughing), : applies factors following the one than more if Consider infection a B. pertussis • • • • • • bed, they should be limited to once-daily use (e.g.,bed, limited theyshouldbe to once-daily atnight)foralimited time. prescribedbe to patientswithasevere statusorsleep. cough theirfunctional affecting However, whenprescri- scientific data,risk of adverse andbecauseofthehigh effects. However,good-quality thesenarcotics can The useofthesenarcotics isgenerally evidence notrecommended or becauseofthelackefficacy Codeine, morphine, normethadone, hydrocodone : modest efficacy. Chlophedianol’s against seems coughhasnotbeenestablished, tobe butthe efficacy tendency toward Chlophedianol DM seemsto have amodestbeneficialeffect on cough frequency. Dextromethorphan (DM) : :

„„Expectorants Because there are no good-quality scientific data, the routine use of an expectorant (guaifenesin) cannot be recommended. It may, however, be useful in patients with a productive cough, although its effectiveness can vary from none to modest. „„Bronchodilators The use of a short-acting beta-2-agonist is generally not recommended. However, it seems that a reduction in cough duration is observed in patients with respiratory function limitations (e.g., wheezing). „„Corticosteroids (inhaled or oral) Because of a lack of good-quality scientific data, the use of corticosteroids (inhaled or oral) in acute bronchitis in the absence of asthma cannot be recommended.

ANTIBIOTIC THERAPY

Antibiotics have very modest efficacy in the treatment of acute bronchitis. ACUTE BRONCHITIS When antibiotic therapy is compared to treatment with placebo, the following are observed : • A statistically significant, but clinically very modest, mean reduction of : - 0.5 days in cough duration - 0.5 days of lost activity • A statistically significant increase of 20 % in adverse effects.

Antibiotic therapy is generally not recommended in healthy individuals with acute bronchitis.

„„An antibiotic can be prescribed in a patient with significant comorbidities, a persistent cough (> 3 weeks) or advanced age (≥ 75 years), based on clinical judgement and bearing in mind the risk of adverse effects and drug interactions.

Recommended Antibiotic Dosage Duration

Clarithromycin 500 mg PO BID 5 days Clarithromycin XL 1000 mg PO daily 5 days 500 mg PO daily on day 1, then Azithromycin1 5 days 250 mg PO daily from days 2 to 5 Doxycycline 100 mg PO BID 7 days 1. Vanderkooi and colleagues found a significantly lower risk of emerging macrolide resistance with the use of clarithromycin than with that of azithromycin.

„„If B. pertussis infection is suspected (see box on p. 2), a macrolide should be prescribed to quickly limit the spread of the infection. Whooping cough is a notifiable disease and must be reported to the public health department in your area.

Recommended

Stay up to date at inesss.qc.ca Antibiotic Dosage Duration

Clarithromycin 500 mg PO BID 7 days Clarithromycin XL 1000 mg PO daily 7 days 500 mg PO daily on day 1, then Azithromycin1 5 days 250 mg PO daily from days 2 to 5 Trimethoprim- 160/800 mg PO BID 7 days sulfamethoxazole 1. Vanderkooi and colleagues found a significantly lower risk of emerging macrolide resistance with the use of clarithromycin than with that of azithromycin. Stay up to date at inesss.qc.ca ACUTE BRONCHITIS the source ismentioned. for non-commercial useispermitted on condition that Any reproduction ofthisdocument inwholeorpart „ „ „ „ MAIN REFERENCES CRITERIA FORREFERRINGTHEPATIENT TOASPECIALIST FOLLOW-UP „ „ „ „ Please note that otherreferences have beenconsulted. Vanderkooi O.G., Low D.E., Powis Green K., J.E., A.Predicting McGeer antimicrobial resistance ininvasive pneumococcal infections. Dis2005;40(9):1288-97. ClinInfect Smith S.M.,Fahey T., Smucny J., Becker. L.A.,2014b. Antibiotics for acute bronchitis. The Cochrane database ofsystematic reviews, (3),p.CD000245. of systematic reviews, (11). Smith, S.M., Schroeder, & Fahey, K. T., (OTC) 2014a. Over-the-counter medications for acute cough in children settings. and adults in community The Cochrane database of physicians andthecenters for diseasecontrol andprevention. Medicine, Annals ofInternal 164(6),pp.425–434. Harris, A.M.,Hicks, L.A.&Qaseem,A.,2016.Appropriate antibiotic usefor infectioninadults:Advice acute respiratorytract for high-value care from college theAmerican Becker, for L.A.etal.,2015.Beta2-agonists acute cough oraclinicaldiagnosis ofacute bronchitis. The Cochrane database ofsystematic reviews, (9). Refer thepatient to aspecialistif: thecough persistsbeyond If 3weeks orifthepatient’s condition worsens, doareevaluation. provide treatment suited to thepatient’s condition. presence ofdyspnea, abnormallungauscultation,smoker) consult the guideonacute exacerbation ofCOPD to an acute exacerbation disease (COPD)If of undiagnosed chronic pulmonary obstructive is suspected, (e.g., the guideoncommunity-acquired pneumoniato provide treatment suited to thepatient’s condition. (e.g., pneumoniaissuspected If presence of fever, abnormal lung auscultation) order aradiograph andconsult • • • • • • (e.g., fibrosis). asthma,allergy orpulmonary Another causethat could from explain chronic posterior rhinorrhea cough issuspected, apart The patient hasmore than3episodesofacute bronchitis inthepastyear. been attempted. The cough persistsbeyond 6weeks andifat leastonetherapy appropriate for thepatient’s symptoms has