Antimicrobial stewardship (AMS) remains an important topic in the role of pharmacy professionals in any practice environment and is becoming increasingly so for those in community practice settings. Pharmacy Connection welcomes contributors from the Antimicrobial Stewardship Program team at the Sinai Health System and University Health Network in Toronto to share their insights and perspectives.
This is the third in a series of articles about the role of community pharmacy professionals in AMS which reinforces important information for practitioners while providing practical tips and access to resources to support ongoing AMS efforts within our health system. In this issue, we’ll be focusing on acute bronchitis.
By Mark McIntyre, Pharm.D., ACPR
In Ontario, respiratory pathogens (such as respiratory syncytial virus, rhinovirus, adenovirus and influenza) circulate at their highest levels annually between November and April. Many parts of the health system experience an increase in the demand for patient care during respiratory pathogen season. Community pharmacists can play an important role assessing patients with a sore throat/pharyngitis, sinus infection/acute sinusitis or simple cough/uncomplicated bronchitis in a stable patient and conditions that may require further medical care.
Respiratory viruses cause more than 90% cases of acute bronchitis. The course of bronchitis typically begins with a non-specific upper respiratory tract infection (sore throat, runny nose, nasal congestion) with a cough. Cough may be productive (i.e. involve sputum production) and can last anywhere from 3 to 6 weeks (mean duration = 17.8 days).1 This bothersome and potentially persistent symptom leads to discomfort, lost days of school or work and concern about the potential for a more severe infection, such as pneumonia.
ASSESSMENT OF ACUTE BRONCHITIS
Bronchitis is an infection of the major airways leading to the lungs while pneumonia is an infection of the lungs themselves. There is no definitive test to diagnosis bronchitis, however, due to symptom overlap, the need to exclude pneumonia is paramount. While the “gold standard” diagnosis of pneumonia is by chest x-ray, the absence of certain clinical parameters may help exclude a diagnosis of pneumonia in younger, healthy patients.
In some cases, it may be helpful for community pharmacists to discuss with patients the following clinical signs which their primary care provider will use to assess the difference:
If all of the following signs/symptoms are absent, pneumonia is unlikely and x-ray unnecessary (adult, uncomplicated bronchitis):
- Tachycardia (Heart Rate > 100 bpm)
- Tachypnea (Respiratory Rate > 24 breath/minute)
- Temperature > 38oC
- Chest auscultation findings suggestive of pneumonia (on physical exam)
In patients older than 65 or those with chronic cardiovascular disease, respiratory disease, immunocompromise or other comorbidities, a more thorough assessment is required. These patients should be referred to the appropriate care provider.
Appropriate referral based on the patient’s presentation is vital. If you encounter a patient with moderate-severe respiratory symptoms (shortness of breath, tachypnea, accessory muscle use, difficulty speaking) or if you are uncertain of severity or comorbidity, refer them to the appropriate healthcare professional for diagnosis and further management. Persistent cough longer than 2-3 weeks, sputum tinged with blood, wheezing, chest pain or signs of systemic infection should also prompt referral to medical assessment. Sputum discolouration alone (white, yellow or green) does not indicate bacterial infection and is reflective of the body’s immune system response.
MANAGEMENT OF ACUTE BRONCHITIS
Antibiotics do not benefit uncomplicated acute bronchitis and should not be prescribed.3-5
Community pharmacists can support a physician’s decision not to prescribe an antibiotic in follow-up discussions with the patient and can encourage self-management of symptoms for viral infections when bronchitis is the likely cause.
Despite being the most common cause of acute healthcare contact, very little high quality evidence exists to guide symptomatic therapy.6 Setting expectations about the duration of symptoms and supportive care may be sufficient for many patients to reassure them that antibiotics provide no benefit and would only offer potential harms while treating uncomplicated bronchitis.9
Symptom Management of Acute Bronchitis
|Fever/pain||Acetaminophen or Ibuprofen||Be aware of risk for inadvertent acetaminophen co-ingestion with common cough and cold products and counsel patients accordingly|
|Cough||Dextromethorphan||Modest (17%) reduction in cough frequency6,7 Not to be used in children <12 years per Health Canada|
Health Canada recommends that children and youth not use cough and cold products that contain opioids - http://healthycanadians.gc.ca/recall-alert-rappel-avis/hc-sc/2019/69080a-eng.php
|Honey/Lemon||Limited data in adults, helpful in children 12 months to 18 years7,8|
*Randomized, controlled trial. Although commonly used and considered by many the optimal choice, little evidence of benefit and risk of harm preclude routine recommendations for codeine in the management of cough in children and adults.
Prescribers may also employ a delayed antibiotic approach to reduce patient anxiety and antimicrobial use.10 Pharmacists can support this by “logging” received medications with a “watch and wait” intention and following up with patients in 48-72 hours to reassess symptoms.
The pharmacist, in collaboration with the patient, should closely watch for worsening cough or other symptoms as the indication the antibiotic should be started. Note that bronchitis will take many days to weeks to improve dramatically and the intention should be to assess for worsening disease.
STEWARDSHIP OPPORTUNITIES FOR COMMUNITY PHARMACISTS
Despite decades of research and stewardship interventions, antibiotic prescribing for acute bronchitis is common and unnecessary. 11 It may be difficult to confirm the diagnosis, but a few strategies can assist in reducing the use of antibiotics in bronchitis treatment.
71% of patients presenting to primary care receive antibiotics for bronchitis. >90% of acute bronchitis is viral11
Proactive Strategies: Things to do before patients are ill with acute bronchitis
a. Review the role of viruses as a common cause of respiratory illness
b. Ensure patients understand antibiotics do not kill viruses when discussing cold and flu treatment
c. Focus on infection prevention by encouraging good hand hygiene practices such as washing hands and/or using hand sanitizers
a. Influenza: although influenza causes only a small portion of acute bronchitis, it is an opportunity to discuss the topics above and reduce the chance of influenza by providing annual influenza vaccination
Reactive Strategies - Things to do when patients present with symptoms of acute bronchitis:
- Assess severity and refer if necessary (see above)
- Educate and set expectations: Consider the term “chest cold” instead of bronchitis to align with etiology and expectations of disease
- Advise - discuss warning signs that should prompt medical assessment (see above)
- Support - empathize and review available options to ensure safe symptom management
- Follow up - consider calling patients in 2-3 days to reassess symptoms
- Antibiotic Prescriptions - If presenting with an antimicrobial, ensure the indication and follow-up with prescribers as necessary
- SHS and UHN ASP Adult Acute Bronchitis
- SHS and UHN Antimicrobial Stewardship
- Do Bugs Need Drugs, Cough
- Public Health Ontario, Respiratory Pathogen Bulletin
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2. Altiner A, Wilm S, Daubener W, et al. Sputum colour for diagnosis of a bacterial infection in patients with acute cough. Scand J Prim Health Care. 2009;27(2):70-73.
3. Llor C, Moragas A, Bayona C, et al. Efficacy of anti-inflammatory or antibiotic treatment in patients with non-complicated acute bronchitis and discoloured sputum: randomised placebo controlled trial. BMJ. 2013;347:f5762.
4. Smith SM, Fahey T, Smucny J, Becker LA. Antibiotics for acute bronchitis. Cochrane Database Syst Rev. 2014(3):CD000245.
5. Harris AM, Hicks LA, Qaseem A. Appropriate Antibiotic Use for Acute Respiratory Tract Infection in Adults: Advice for High-Value Care From the American College of Physicians and the Centers for Disease Control and Prevention. Annals of internal medicine. 2016;164(6):425-434.
6. Smith SM, Schroeder K, Fahey T. Over-the-counter (OTC) medications for acute cough in children and adults in community settings. Cochrane Database Syst Rev. 2014(11):CD001831.
7. Morice A, Kardos P. Comprehensive evidence-based review on European antitussives. BMJ Open Respir Res. 2016;3(1):e000137.
8. Oduwole O, Udoh EE, Oyo-Ita A, Meremikwu MM. Honey for acute cough in children. Cochrane Database Syst Rev. 2018;4:CD007094.
9. Anthierens S, Tonkin-Crine S, Cals JW, et al. Clinicians' views and experiences of interventions to enhance the quality of antibiotic prescribing for acute respiratory tract infections. J Gen Intern Med. 2015;30(4):408-416.
10. Little P, Moore M, Kelly J, et al. Delayed antibiotic prescribing strategies for respiratory tract infections in primary care: pragmatic, factorial, randomised controlled trial. BMJ. 2014;348:g1606.
11. Barnett ML, Linder JA. Antibiotic prescribing for adults with acute bronchitis in the United States, 1996-2010. JAMA. 2014;311(19):2020-2022.