Acute Bronchitis PDF

Acute Bronchitis SCOTT KINKADE, MD, MSPH, and NATALIE A. LONG, MD University of Missouri School of Medicine, Columbia, Missouri Cough is the most common illness-related reason for ambulatory care visits in the United States. Acute bronchitis is a clinical diagnosis characterized by cough due to acu...

Acute Bronchitis SCOTT KINKADE, MD, MSPH, and NATALIE A. LONG, MD University of Missouri School of Medicine, Columbia, Missouri Cough is the most common illness-related reason for ambulatory care visits in the United States. Acute bronchitis is a clinical diagnosis characterized by cough due to acute inflammation of the trachea and large airways without evidence of pneumonia. Pneumonia should be suspected in patients with tachypnea, tachycardia, dyspnea, or lung findings suggestive of pneumonia, and radiography is warranted. Pertussis should be suspected in patients with cough persisting for more than two weeks that is accompanied by symptoms such as paroxysmal cough, whooping cough, and post-tussive emesis, or recent pertussis exposure. The cough associated with acute bronchitis typically lasts about two to three weeks, and this should be emphasized with patients. Acute bronchitis is usually caused by viruses, and antibiotics are not indicated in patients without chronic lung disease. Antibiotics have been shown to provide only minimal benefit, reducing the cough or illness by about half a day, and have adverse effects, including allergic reac- tions, nausea and vomiting, and Clostridium difficile infection. Evaluation and treatment of bronchitis include ruling out secondary causes for cough, such as pneumonia; educating patients about the natural course of the disease; and recommending symptomatic treatment and avoidance of unnecessary antibiotic use. Strategies to reduce inappropri- ate antibiotic use include delayed prescriptions, patient education, and calling the infection a chest cold. (Am Fam Physician. 2016;94(7):560-565. Copyright © 2016 American Academy of Family Physicians.) C CME This clinical content ough is the most common illness- evidence of B. pertussis infection.7,8 Dur- conforms to AAFP criteria related reason for ambulatory care ing outbreaks, pertussis detection is more for continuing medical education (CME). See visits, accounting for 2.7 million likely in children and those with prolonged CME Quiz Questions on outpatient visits and more than coughs.6,9 Antibiotics can eradicate B. per- page 542. 4 million emergency department visits annu- tussis from the nasopharynx. They do not Author disclosure: No rel- ally.1 Acute bronchitis is a clinical diagnosis seem to shorten the course of illness unless evant financial affiliations. characterized by acute cough, with or with- given in the first one to two weeks.10 Isolated Patient information: out sputum production, and signs of lower outbreaks of pertussis occur throughout the ▲ A handout on this topic, respiratory tract infection in the absence United States, and increased testing of adults written by the authors of of chronic lung disease, such as chronic and children should be considered during this article, is available obstructive pulmonary disease, or an identi- these periods. at http://www.aafp.org/ afp/2016/1001/p560-s1. fiable cause, such as pneumonia or sinusitis.2 html. Diagnosis Etiology MEDICAL HISTORY Acute bronchitis is most often caused by a Cough is the predominant and defining viral infection.3,4 The most commonly identi- symptom of acute bronchitis. The primary fied viruses are rhinovirus, enterovirus, influ- diagnostic consideration in patients with enza A and B, parainfluenza, coronavirus, suspected acute bronchitis is ruling out more human metapneumovirus, and respiratory serious causes of cough, such as asthma, syncytial virus.3 Bacteria are detected in 1% exacerbation of chronic obstructive pulmo- to 10% of cases of acute bronchitis.3-5 Atypi- nary disease, heart failure, or pneumonia. cal bacteria, such as Mycoplasma pneumoniae, The diagnoses that have the most overlap Chlamydophila pneumoniae, and Bordetella with acute bronchitis are upper respiratory pertussis, are rare causes of acute bronchitis. tract infections and pneumonia. Whereas In a study of sputum samples of adults with acute bronchitis and the common cold are acute cough for more than five days, M. pneu- self-limited illnesses that do not require moniae was isolated in less than 1% of cases antibiotic treatment, the standard therapy and C. pneumoniae was not identified.6 for pneumonia is antibiotics. Approximately 10% of patients presenting Besides cough, other signs and symp- with a cough lasting at least two weeks have toms of acute bronchitis include sputum 560 American Downloaded Family from the Physician American www.aafp.org/afp Family Physician website at www.aafp.org/afp. Copyright © 2016 American AcademyVolume of Family94, NumberFor7 theOctober Physicians. 1, 2016 private, noncom- ◆ mercial use of one individual user of the website. All other rights reserved. Contact [email protected] for copyright questions and/or permission requests.  Acute Bronchitis SORT: KEY RECOMMENDATIONS FOR PRACTICE Evidence Clinical recommendation rating References Avoid prescribing antibiotics for uncomplicated acute bronchitis. A 27, 41 Over-the-counter cough medications containing antihistamines and antitussives should not be C 30 used in children younger than four years because of the high potential for harm. Consider using dextromethorphan, guaifenesin, or honey to manage acute bronchitis symptoms. B 30, 34, 38 Avoid using beta2 agonists for the routine treatment of acute bronchitis unless wheezing is B 35 present. Employ strategies to reduce antibiotic use, such as asking patients to call for or pick up an A 42, 43 antibiotic or to hold an antibiotic prescription for a set amount of time. A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort. production, dyspnea, nasal congestion, headache, and results of a prospective trial, which found that patients fever.4,11,12 The first few days of an acute bronchitis infec- who had a cough for at least five days had a median of tion may be indistinguishable from the common cold. 18 days of coughing.16 Patients may have substernal or chest wall pain when PHYSICAL EXAMINATION coughing. Fever is not a typical finding after the first few days, and presence of a fever greater than 100°F (37.8°C) On physical examination, patients with acute bronchi- should prompt consideration of influenza or pneumo- tis may be mildly ill-appearing, and fever is present in nia. Production of sputum, even purulent, is common about one-third of patients.4,11 Lung auscultation may and does not correlate with bacterial infection.13,14 reveal wheezes, as well as rhonchi that typically improve Because the cough associated with bronchitis is so with coughing. It is important to rule out pneumonia. bothersome and slow to resolve, patients often seek High fever; moderate to severe ill-appearance; hypoxia; treatment. Patients and clinicians may underestimate and signs of lung consolidation, such as decreased breath the time required to fully recover from acute bronchi- sounds, bronchial breath sounds, crackles, egophony, tis.15 The duration of acute bronchitis–related cough is and increased tactile fremitus, are concerning for pneu- typically two to three weeks, with a pooled estimate of monia. Pneumonia is unlikely in nonfrail older adults 18 days in one systematic review.15 This corresponds to who have normal vital signs and normal lung examina- tion findings.17-20 DIAGNOSTIC TESTING BEST PRACTICES IN INFECTIOUS DISEASE: RECOMMENDATIONS FROM THE CHOOSING WISELY CAMPAIGN Laboratory testing is usually not indicated in the evaluation of acute bronchitis. Leuko- Recommendation Sponsoring organization cytosis is present in about 20% of patients; Cough and cold medicines should not be American Academy of significant leukocytosis is more likely with prescribed or recommended for respiratory Pediatrics a bacterial infection than with bronchi- illnesses in children younger than four years. tis.21 Although rapid testing is available for Antibiotics should not be used for apparent American Academy of some respiratory pathogens, it is usually not viral upper respiratory tract illnesses (sinusitis, Pediatrics necessary in the typical ambulatory care pharyngitis, bronchitis). patient.22 Testing for influenza and pertus- Avoid prescribing antibiotics for upper Infectious Diseases respiratory tract infections. Society of America sis may be considered when the suspicion is high and treatment would impact the course Source: For more information on the Choosing Wisely Campaign, see http://www. of the illness. choosingwisely.org. For supporting citations and to search Choosing Wisely recom- Biomarkers may assist in identifying mendations relevant to primary care, see http://www.aafp.org/afp/recommendations/ search.htm. patients who might benefit from antibiot- ics. Studies using C-reactive protein levels to October 1, 2016 ◆ Volume 94, Number 7 www.aafp.org/afp American Family Physician 561 Acute Bronchitis guide antibiotic use in patients with respiratory tract All major guidelines on bronchitis, including those from infections are inconclusive,23 although an elevated the American College of Chest Physicians, recommend C-reactive protein level was associated with an increased against using antibiotics for acute bronchitis unless the likelihood of pneumonia in a large primary care trial.24 A patient has a known pertussis infection.2,22 The American clinical decision rule for pneumonia was developed and Academy of Pediatrics recommends that antibiotics not prospectively validated by Swiss researchers, who found be used for apparent viral respiratory illnesses, includ- that pneumonia could be ruled out in patients with a ing sinusitis, pharyngitis, and bronchitis.28 Despite these C-reactive protein level of less than 50 mcg per mL and recommendations, antibiotics are often prescribed for no dyspnea or daily fever.25 Procalcitonin testing may acute bronchitis.29 be useful in the differentiation of pneumonia and acute OVER-THE-COUNTER MEDICATIONS bronchitis, but it is not widely available in clinical set- tings.26 A large primary care trial of patients with lower Over-the-counter medications are often recommended respiratory tract infections found that procalcitonin as first-line treatment for acute cough. However, a testing added no benefit to a model that included signs, Cochrane review on over-the-counter medications for symptoms, and C-reactive protein levels.24 acute cough in the community setting showed a paucity of good data; existing trials are of low quality and report INDICATIONS FOR CHEST RADIOGRAPHY conflicting results.30 In patients with symptoms of acute bronchitis, imag- A randomized controlled trial showed that compared ing is primarily used to rule out pneumonia. Evidence- with placebo, there was no benefit from ibuprofen in based guidelines from the American College of Chest decreasing severity or duration of cough in patients with Physicians state that imaging is not needed in patients acute bronchitis.31 Another randomized controlled trial with acute bronchitis symptoms who have normal vital comparing ibuprofen, acetaminophen, and steam inha- signs and normal lung examination findings.22 Patients lation found that those with a lower respiratory tract with pneumonia typically have tachypnea, tachycardia, infection or age younger than 16 years had a modest or dyspnea.12 An exception to this rule is patients older reduction in symptom severity when taking ibuprofen than 75 years, who may present with more subtle signs of over acetaminophen, although the ibuprofen group was pneumonia and are less likely to have fever or tachycar- more likely to seek care again for new or nonresolving dia.19 Table 1 includes indications for chest radiography symptoms.32 in patients with symptoms of acute bronchitis.22 Antihistamines are often used in combination with decongestants in the treatment of acute cough. Two tri- Management als of antihistamines alone showed no benefit compared Supportive care and symptom management are the with placebo in relieving cough symptoms. Combina- mainstay of treatment for acute bronchitis. The role of tion decongestant/antihistamines are more likely to antibiotics is limited. Since 2005, the National Commit- have adverse effects with no to modest improvement in tee for Quality Assurance has recommended avoidance cough symptom scores.30 In 2008, The U.S. Food and of antibiotic prescribing for acute bronchitis as a Health- Drug Administration warned against the use of over- care Effectiveness Data and Information Set Measure.27 the-counter cough medications containing antihista- mines and antitussives in young children because of the high risk for harm, and these medications are no longer Table 1. Indications for Chest Radiography labeled for use in children younger than four years. They in Adult Patients with Symptoms of Acute are continuing to investigate the safety of these medica- Bronchitis tions in children up to 11 years of age.30,33 Dyspnea, bloody sputum, or rusty sputum color ANTITUSSIVES Pulse > 100 beats per minute Antitussives work by reducing the cough reflex and can Respiratory rate > 24 breaths per minute be divided into central opioids and peripherally acting Oral body temperature > 100°F (37.8°C) agents. Codeine is a centrally acting, weak opioid that sup- Focal consolidation, egophony, or fremitus on chest examination presses cough. Two studies show no benefit from codeine in decreasing cough symptoms,30 and the American Col- Information from reference 22. lege of Chest Physicians does not recommend its use in the treatment of upper respiratory tract infections.22 562 American Family Physician www.aafp.org/afp Volume 94, Number 7 ◆ October 1, 2016  Acute Bronchitis Dextromethorphan is a nonopioid, synthetic deriva- obstructive pulmonary disease. Because there is lim- tive of morphine that works centrally to decrease cough. ited supportive evidence, the use of such medications Three placebo-controlled trials show that dextrometh- should be weighed against the risk of adverse effects, orphan, 30 mg, decreased the cough count by 19% to including tremor, shakiness, and nervousness.35 36% (P <.05) compared with placebo, which is equiva- HERBAL AND OTHER PREPARATIONS lent to eight to 10 fewer coughing bouts per 30 minutes.30 Benzonatate is a peripherally acting antitussive that is Alternative medications are commonly used in the treat- thought to suppress cough via anesthesia of the respira- ment of acute bronchitis. Pelargonium sidoides has some tory stretch receptors. One small study comparing ben- reported modest effectiveness in the treatment of acute zonatate, guaifenesin, and placebo showed significant bronchitis, but the quality of evidence is considered improvement with the combination of benzonatate and low, and the studies were all done by the manufacturer guaifenesin, but not with either agent alone.34 in Ukraine and Russia.36 There are insufficient data to recommend for or against the use of Chinese medicinal EXPECTORANTS herbs for the treatment of acute bronchitis, and there are Guaifenesin is a commonly used expectorant. It is safety concerns.37 thought to stimulate respiratory tract secretions, thereby A Cochrane review of honey for acute cough in chil- increasing respiratory fluid volumes and decreas- dren included two small trials comparing honey with ing mucus viscosity, and it may also have antitussive dextromethorphan, diphenhydramine (Benadryl), and properties. no treatment.38 Honey was found to be better than no A Cochrane review including three trials of guai- treatment in decreasing the frequency and severity of fenesin vs. placebo showed some benefit.30 In one trial, cough, decreasing bothersome cough, and improving patients reported that guaifenesin decreased cough fre- quality of sleep. Given the warnings against the use of quency and intensity by 75% at 72 hours compared with antitussives in young children, honey is a reasonable 31% in the placebo group (number needed to treat = 2). alternative for the relief of acute cough in children older A second trial showed decreased cough frequency (100% than one year.38 of the guaifenesin group vs. 94% of the placebo group; ANTIBIOTICS P =.5) and improved cough severity (100% of the guai- fenesin group vs. 91% of the placebo group; P =.2) at 36 At least 90% of acute bronchitis episodes are viral, yet hours, and reduced sputum thickness (96% of the guai- antibiotics are commonly prescribed. Unnecessary fenesin group vs. 54% of the placebo group; P =.001). antibiotic prescriptions result in adverse effects and A third trial using an extended-release formulation of contribute to rising health care costs and antimicro- guaifenesin showed improved symptom severity at day 4 bial resistance. A recent study of antibiotic prescribing but no difference at day 7.30 trends from 1996 to 2010 found that antibiotics were pre- scribed in 71% of visits for acute bronchitis and that the BETA 2 AGONISTS rate of prescribing increased during the study period.29 Many patients with acute bronchitis have bronchial Although clinicians are more likely to prescribe antibiot- hyperreactivity, leading to impaired airflow in a mecha- ics in patients with purulent sputum, a prospective obser- nism similar to asthma. A 2015 Cochrane review does not vational study showed no difference in outcomes when support the routine use of beta2 agonists for acute cough.35 antibiotics were prescribed to patients with green or yel- Two trials included children and found no benefit from low sputum, indicating that this is not a useful indicator albuterol in decreasing daily cough scores, daily propor- of bacterial infection.39 Smokers are also more likely to tion of cough, or median duration of cough, although receive antibiotic prescriptions, with some populations both studies excluded children who were wheezing at of smokers being prescribed antibiotics more than 90% the time of evaluation or had signs of bronchial obstruc- of the time despite no difference in outcomes.40 tion. The studies of adults had mixed results, but the A Cochrane review suggests there is no net benefit findings suggest that beta2 agonists should be avoided to using antibiotics for acute bronchitis in otherwise if there is no underlying history of lung disease or evi- healthy individuals.41 Although antibiotics decreased dence of wheeze or airway obstruction. However, beta2 cough duration by 0.46 days, decreased ill days by 0.64 agonists may have some benefit in certain adults, espe- days, and decreased limited activity by 0.49 days, there cially those with wheezing at the time of evaluation who was no difference in clinical improvement at follow-up. do not have a previous diagnosis of asthma or chronic The most common adverse effects reported were nausea, October 1, 2016 ◆ Volume 94, Number 7 www.aafp.org/afp American Family Physician 563 Acute Bronchitis personal interest, discusses the expected course of the Table 2. Strategies to Reduce Antibiotic Use illness, and explains the treatment plan.45 Calling the for Acute Bronchitis infection a chest cold44 and educating the patient about the expected duration of illness (two to three weeks)15 Use delayed prescription strategies, such as asking patients are also helpful. Table 2 includes strategies for reducing to call for or pick up an antibiotic or to hold an antibiotic antibiotic prescriptions for acute bronchitis.29,42,43 prescription for a set amount of time Data Sources: The PubMed database was searched in Clinical Queries Address patient concerns in a compassionate manner using the term acute bronchitis. Systematic reviews were searched Discuss the expected course of illness and cough duration and narrowed by etiology, diagnosis, therapy, prognosis, and clinical (two to three weeks) prediction guidelines. The Agency for Healthcare Research and Quality, Explain that antibiotics do not significantly shorten illness National Guideline Clearinghouse, National Quality Measures Clearing- duration and are associated with adverse effects and house, and Essential Evidence Plus were also searched. Search date: antibiotic resistance January 2015. Discuss the treatment plan, including the use of NOTE:This review updates a previous article on this topic by Albert,46 nonantibiotic medications to control symptoms Knutson and Braun,47 and Hueston and Mainous.48 Describe the infection as a viral illness or chest cold Information from references 29, 42, and 43. The Authors SCOTT KINKADE, MD, MSPH, is an associate professor in the Department of Family and Community Medicine at the University of Missouri School of Medicine in Columbia. diarrhea, headache, skin rash, and vaginitis with a NATALIE A. LONG, MD, is an assistant professor in the Department of number needed to harm of 5. Given minimal symptom Family and Community Medicine at the University of Missouri School of improvement in an otherwise self-limited condition, Medicine. increased rate of adverse effects, and potential for anti- Address correspondence to Scott Kinkade, MD, MSPH, University of biotic resistance, it is wise to limit the use of antibiot- Missouri, MA303 Medical Sciences Bldg., DC032.00, Columbia, MO ics in the general population; further study in frail older 65212 (e-mail: [email protected]). Reprints are not avail- persons and individuals with multiple comorbidities is able from the authors. needed.41 If pertussis is confirmed or suspected because of a persistent cough accompanied by symptoms of REFERENCES paroxysmal cough, whooping cough, and post-tussive 1. National Hospital Ambulatory Medical Care Survey: 2011 outpatient depart- emesis, or recent pertussis exposure, treatment with a ment summary tables. http://www.cdc.gov/nchs/data/ahcd/nhamcs_ outpatient/2011_opd_web_tables.pdf. Accessed March 28, 2015. macrolide is recommended.10 2. Woodhead M, Blasi F, Ewig S, et al.; Joint Taskforce of the European Respiratory Society and European Society for Clinical Microbiology STRATEGIES TO REDUCE INAPPROPRIATE ANTIBIOTIC USE and Infectious Diseases. Guidelines for the management of adult Delayed prescribing, in which the patient is given an anti- lower respiratory tract infections—full version. Clin Microbiol Infect. 2011;17(suppl 6):E1-E59. biotic prescription at the visit but told not to fill it unless 3. Clark TW, Medina MJ, Batham S, Curran MD, Parmar S, Nicholson KG. symptoms continue beyond a predetermined time, sig- Adults hospitalised with acute respiratory illness rarely have detectable nificantly decreases antibiotic use.42 A Cochrane review bacteria in the absence of COPD or pneumonia; viral infection predomi- showed no difference in clinical outcomes between nates in a large prospective UK sample. J Infect. 2014;69(5):507-515. patients with acute bronchitis who were treated imme- 4. Gencay M, Roth M, Christ-Crain M, Mueller B, Tamm M, Stolz D. Single and multiple viral infections in lower respiratory tract infection. Respira- diately with antibiotics and those with delayed or no tion. 2010;80(6):560-567. antibiotic treatment. In addition, patients reported com- 5. Macfarlane J, Holmes W, Gard P, et al. Prospective study of the inci- parable satisfaction when given immediate vs. delayed dence, aetiology and outcome of adult lower respiratory tract illness in antibiotics (92% vs. 87%).43 the community. Thorax. 2001;56(2):109-114. 6. Wadowsky RM, Castilla EA, Laus S, et al. Evaluation of Chlamydia pneu- Patients who present with the expectation that they moniae and Mycoplasma pneumoniae as etiologic agents of persistent will receive an antibiotic are more likely to receive one, cough in adolescents and adults. J Clin Microbiol. 2002;40(2):637-640. even if the clinician thinks the prescription is unneces- 7. Philipson K, Goodyear-Smith F, Grant CC, Chong A, Turner N, Stewart sary.44 In fact, the strongest predictor for an antibiotic J. When is acute persistent cough in school-age children and adults whooping cough? Br J Gen Pract. 2013;63(613):e573-e579. prescription is the clinician’s perception of patient desire 8. Riffelmann M, Littmann M, Hülsse C, O’Brien J, Wirsing von König CH. Per- for antibiotics.45 However, patients want symptom relief tussis [in German]. Dtsch Med Wochenschr. 2006;131(50):2829-2834. and will often accept leaving without an antibiotic pre- 9. Cornia PB, Hersh AL, Lipsky et al. Does this coughing adolescent or scription if the clinician addresses their concerns, shows adult patient have pertussis? JAMA. 2010;304(8):890-896. 564 American Family Physician www.aafp.org/afp Volume 94, Number 7 ◆ October 1, 2016  Acute Bronchitis 10. Altunaiji S, Kukuruzovic R, Curtis N, Massie J. Antibiotics for whooping 28. American Academy of Pediatrics. Five things physicians and patients cough (pertussis). Cochrane Database Syst Rev. 2007;(3):CD004404. should question. http://www.choosingwisely.org/wp-content/uploads/ 11. Verheij T, Hermans J, Kaptein A, Mulder J. Acute bronchitis: course 2015/02/AAP-Choosing-Wisely-List.pdf. Accessed September 15, 2015. of symptoms and restrictions in patients’ daily activities. Scand J Prim 29. Barnett ML, Linder JA. Antibiotic prescribing for adults with acute bron- Health Care. 1995;13(1):8-12. chitis in the United States, 1996-2010. JAMA. 2014;311(19):2020-2022. 12. van Vugt SF, Verheij TJ, de Jong PA, et al.; GRACE Project Group. Diag- 30. Smith SM, Schroeder K, Fahey T. Over-the-counter (OTC) medications nosing pneumonia in patients with acute cough: clinical judgment com- for acute cough in children and adults in community settings. Cochrane pared to chest radiography. Eur Respir J. 2013;42(4):1076-1082. Database Syst Rev. 2014;(11):CD001831. 13. Altiner A, Wilm S, Däubener W, et al. Sputum colour for diagnosis of 31. Llor C, Moragas A, Bayona C, et al. Efficacy of anti-inflammatory or a bacterial infection in patients with acute cough. Scand J Prim Health antibiotic treatment in patients with non-complicated acute bronchi- Care. 2009;27(2):70-73. tis and discoloured sputum: randomised placebo controlled trial. BMJ. 14. Steurer J, Held U, Spaar A, et al. A decision aid to rule out pneumo- 2013;347:f5762. nia and reduce unnecessary prescriptions of antibiotics in primary care 32. Little P, Moore M, Kelly J, et al.; PIPS Investigators. Ibuprofen, para- patients with cough and fever. BMC Med. 2011;9:56. cetamol, and steam for patients with respiratory tract infections in pri- 15. Ebell MH, Lundgren J, Youngpairoj S. How long does a cough last? mary care. BMJ. 2013;347:f6041. Comparing patients’ expectations with data from a systematic review 33. Briars LA. The latest update on over-the-counter cough and cold product of the literature. Ann Fam Med. 2013;11(1):5-13. use in children. J Pediatr Pharmacol Ther. 2009;14(3):127-131. 16. Ward JI, Cherry JD, Chang SJ, et al.; APERT Study Group. Efficacy of an 34. Dicpinigaitis PV, Gayle YE, Solomon G, Gilbert RD. Inhibition of cough- acellular pertussis vaccine among adolescents and adults. N Engl J Med. reflex sensitivity by benzonatate and guaifenesin in acute viral cough. 2005;353(15):1555-1563. Respir Med. 2009;103(6):902-906. 17. Ebell MH. Predicting pneumonia in adults with respiratory illness. Am 35. Becker LA, Hom J, Villasis-Keever M, van der Wouden JC. Beta2agonists Fam Physician. 2007;76(4):560-562. for acute cough or a clinical diagnosis of acute bronchitis. Cochrane 18. Wootton DG, Feldman C. The diagnosis of pneumonia requires a chest Database Syst Rev. 2015;(9):CD001726. radiograph (x-ray) – yes, no or sometimes? Pneumonia. 2014;5:1-7. 36. Timmer A, Günther J, Motschall E, Rücker G, Antes G, Kern WV. Pelar- 19. Metlay JP, Schulz R, Li YH, et al. Influence of age on symptoms at pre- gonium sidoides extract for treating acute respiratory tract infections. sentation in patients with community-acquired pneumonia. Arch Intern Cochrane Database Syst Rev. 2013;(10):CD006323. Med. 1997;157(13):1453-1459. 37. Jiang L, Li K, Wu T. Chinese medicinal herbs for acute bronchitis. 20. Evertsen J, Baumgardner DJ, Regnery A, Banerjee I. Diagnosis and man- Cochrane Database Syst Rev. 2012;(2):CD004560. agement of pneumonia and bronchitis in outpatient primary care prac- 38. Oduwole O, Meremikwu MM, Oyo-Ita A, Udoh EE. Honey for acute tices. Prim Care Respir J. 2010;19(3):237-241. cough in children. Cochrane Database Syst Rev. 2014;(12):CD007094. 21. Holm A, Nexoe J, Bistrup LA, et al. Aetiology and prediction of pneu- 39. Butler CC, Kelly MJ, Hood K, et al. Antibiotic prescribing for discoloured monia in lower respiratory tract infection in primary care. Br J Gen Pract. sputum in acute cough/lower respiratory tract infection. Eur Respir J. 2007;57(540):547-554. 2011;38(1):119-125. 22. Braman SS. Chronic cough due to acute bronchitis: ACCP evidence- 40. Oeffinger KC, Snell LM, Foster BM, Panico KG, Archer RK. Treatment of based clinical practice guidelines. Chest. 2006;129(1 suppl):95S-103S. acute bronchitis in adults. J Fam Pract. 1998;46(6):469-475. 23. Aabenhus R, Jensen JU, Jørgensen KJ, Hróbjartsson A, Bjerrum L. Bio- 41. Smith SM, Fahey T, Smucny J, Becker LA. Antibiotics for acute bronchi- markers as point-of-care tests to guide prescription of antibiotics in tis. Cochrane Database Syst Rev. 2014;(3):CD000245. patients with acute respiratory infections in primary care. Cochrane 42. Little P, Moore M, Kelly J, et al. Delayed antibiotic prescribing strategies Database Syst Rev. 2014;(11):CD010130. for respiratory tract infections in primary care. BMJ. 2014;348:g1606. 24. van Vugt SF, Broekhuizen BD, Lammens C, et al.; GRACE Consortium. 43. Spurling GK, Del Mar CB, Dooley L, et al. Delayed antibiotics for respira- Use of serum C reactive protein and procalcitonin concentrations tory infections. Cochrane Database Syst Rev. 2013; (4):CD004417. in addition to symptoms and signs to predict pneumonia in patients 44. Phillips TG, Hickner J. Calling acute bronchitis a chest cold may improve presenting to primary care with acute cough: diagnostic study. BMJ. patient satisfaction with appropriate antibiotic use. J Am Board Fam 2013;346:f2450. Pract. 2005;18(6):459-463. 25. Held U, Steurer-Stey C, Huber F, Dallafior S, Steurer J. Diagnostic aid to 45. Hirschmann JV. Antibiotics for common respiratory tract infections in rule out pneumonia in adults with cough and feeling of fever. A valida- adults. Arch Intern Med. 2002;162(3):256-264. tion study in the primary care setting. BMC Infect Dis. 2012;12:355. 46. Albert RH. Diagnosis and treatment of acute bronchitis. Am Fam Physi- 26. Albrich WC, Dusemund F, Bucher B, et al.; ProREAL Study Team. Effec- cian. 2010; 82(11):1345-1350. tiveness and safety of procalcitonin-guided antibiotic therapy in lower respiratory tract infections in “real life”: an international, multicenter 47. Knutson D, Braun C. Diagnosis and management of acute bronchitis. poststudy survey (ProREAL) [published correction appears in Arch Intern Am Fam Physician. 2002;65(10):2039-2044. Med. 2014;174(6):1011]. Arch Intern Med. 2012;172(9):715-722. 48. Hueston WJ, Mainous AG 3rd. Acute bronchitis. Am Fam Physician. 27. National Committee for Quality Assurance. 2015 Healthcare Effec- 1998;57(6):1270-1276. tiveness Data and Information Set Measures. http://www.ncqa.org/ Portals/0/HEDISQM/Hedis2015/List_of_HEDIS_2015_Measures.pdf. Accessed March 10, 2015. 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