Reducing Use of Antibiotics to Treat Acute Bronchitis

Citing an overuse of antibiotics for acute respiratory tract infections (ARIs) as a contributor to worsening trends in patterns of antibiotic resistance among community-acquired pathogens, researchers recently conducted a study to compare the effect of 2 decision support strategies on antibiotic treatment of uncomplicated acute bronchitis [JAMA Intern Med. 2013;173(4):267-273].

According to the researchers, approximately 30% of visits to a physician’s office for the common cold and nonspecific upper respiratory tract infections, and up to 80% of all visits for bronchitis, are treated with antibiotics in the United States each year. Whereas antibiotic prescribing for ARIs among children has declined, antibiotic prescribing for bronchitis diagnosed in children has not changed.

On a national level, antibiotic prescribing for bronchitis seems to be “worsening,” the researchers noted. Among health plans participating in the National Committee for Quality Assurance’s Healthcare Effectiveness Data and Information Set, the measure of the mean percentage of adult visits for uncomplicated acute bronchitis with antibiotic treatment were 71.3%, 74.6%, 75.4%, and 76.0% for 2006 through 2009, respectively.

The researchers conducted a 3-arm cluster randomized trial among 33 primary care practices belonging to an integrated healthcare system in central Pennsylvania. The 3 arms were: (1) 11 printed decision support (PDS) intervention sites that received decision support for acute cough illness through a print-based strategy; (2) 11 computer-assisted decision support (CDS) intervention sites that received decision support through an electronic medical record-based strategy; and (3) 11 practices that served as the control arm. The 2 intervention sites also received clinician education and feedback on prescribing practices.

The main outcome measure was antibiotic prescription rates for uncomplicated acute bronchitis in the winter period (October 1, 2009, through March 31, 2010) following introduction of the intervention versus the previous 3 winter periods in the intent-to-treat analysis.

There were 9808 incident visits for uncomplicated acute bronchitis during the baseline winter periods and 6242 incident visits during the intervention winter period. The number of visits and proportion of ARIs diagnosed as uncomplicated acute bronchitis remained stable across study sites between the baseline and intervention periods.

At the PDS sites, the percentage of adolescents and adults prescribed antibiotics for uncomplicated acute bronchitis during the intervention period decreased compared with the baseline period (from 80.0% to 68.3%). The percentages also decreased at the CDS sites compared with the baseline period (from 74.0% to 60.7%). At the control sites, the percentage increased slightly (from 72.5% to 74.3%).

Following controls for patient temperature, respiratory rate, smoking status, clinician type, clinician specialty, and clustering of observations by clinician and by practice site, the differences for the intervention sites were statistically significant from the control sites.

In summary, the researchers said, “Implementation of a decision support strategy for acute bronchitis can help reduce the overuse of antibiotics in primary care settings. The effect of printed versus computer-assisted decision support strategies for providing decision support was equivalent.”