Category: Federal Forum Posters
Purpose: Acute bronchitis and unspecified upper respiratory tract infections (URI-NOS) are primarily caused by viruses and generally do not require antibiotic therapy. Acute bronchitis can be caused by bacterial pathogens such as pertussis, but less than 10% of cases identify a bacterial etiology. Therefore, antibiotics are only recommended for patients with acute bronchitis in cases of suspected or confirmed pertussis exposure, and the primary recommended treatment is symptomatic therapy. This analysis reports documented symptoms, and the frequency of treatment with antibiotic and symptomatic medications for outpatients diagnosed with acute bronchitis or URI-NOS in 28 Veterans Affairs (VA) facilities.
Methods: A sub-cohort of patients who were identified from a Veterans Affairs Center for Medication Safety (VAMedSAFE) retrospective medication use evaluation (MUE) of acute respiratory tract infections were evaluated. Patients with an outpatient visit associated with an International Classification of Diseases 10th Clinical Modification (ICD-10 CM) code for acute bronchitis, or URI-NOS which occurred between October 1, 2015 and March 30, 2016 through the VA’s corporate data warehouse (CDW) were identified. CDW data extracted included patient demographics, patient diagnosis, and medications dispensed during the encounter. Chart documentation of symptoms and recommended symptomatic therapies were obtained by manual chart review. Patients with chronic respiratory or immunocompromising comorbidities were excluded. Patient symptoms on presentation, antibiotics prescribed, and symptomatic therapy prescribed or recommended were tabulated. Symptomatic therapies were categorized based on similar mechanisms of actions. Antibiotics prescribed between 2 days prior and 3 days after the ARI visit and symptomatic therapy that was either prescribed or recommended for external purchase were attributed to the visit. Findings are summarized with percentages, descriptive and non-parametric statistics as indicated.
Results: A total of 2630 patient visits were identified: acute bronchitis (n=1155), URI-NOS (n=1475). The most common documented symptoms for bronchitis and URI-NOS included cough (96% versus 83%, p<0.01), fever (28% versus 26%, p=0.16), and sore throat (27% versus 41%, p<0.01). Fewer patients with bronchitis had facial pain or pressure (7% versus 14%, p<0.01), nasal discharge (21% versus 36%, p<0.01), or myalgia (18% versus 22%, p<0.01), but more patients with bronchitis had wheezing (25% versus 9%, p<0.01). For patients with acute bronchitis, 7 (<1%) had documented concern for pertussis exposure, and 0/7 (0%) patients tested positive for pertussis. Antibiotics were prescribed in 86% and 37% of bronchitis and URI-NOS cases respectively of which 59% were treated with azithromycin. Bronchitis and URI-NOS patients had a symptomatic therapy recommended in 11% and 20% of visits (p<0.01) and prescribed in 94% and 86% of visits, respectively (P<0.01). The most commonly prescribed or recommended symptomatic therapies for bronchitis and URI-NOS included cough suppressants (48% versus 43%, p=0.01) and expectorants (39% versus 34%, p<0.01). Patients with bronchitis were more likely to receive a beta-agonist inhaler (30% versus 10%, p<0.01), while patients with URI-NOS were more likely to receive an analgesic (10% versus 21%, p<0.01).
Conclusion: Symptomatic therapy was prescribed or recommended to most patients with acute bronchitis or URI-NOS. These therapies were frequently given in addition to antibiotics rather than instead of antibiotics. While the overwhelming majority of patients presented with cough, less than half received cough suppressants and less than one third received expectorants, yet most were prescribed antibiotics. Further information of outcomes associated with the presence or lack of antibiotic and/or symptomatic therapy prescriptions are required to reinforce symptomatic therapy’s ability to placate the perceived patient demand for antibiotics while improving quality of life.
Benjamin Pontefract– Infectious Disease Fellow, Boise VA Medical Center, Boise, ID