Objectives
Recognize differences between bronchiolitis, acute bronchitis, and an acute exacerbation of chronic bronchitis (AECB)
Identify most common pathogens causing bronchiolitis, acute bronchitis, and AECB
Identify patients with an AECB that would benefit from appropriate antibiotic therapy for patients with an AECB
Recommend first-line antibiotic regimen for patients w/ AECB
Evidence-Based Resources
Global Initiative for Chronic Obstructive Lung Disease (GOLD) – 2018 Report. Chapter 5: Management of Exacerbations. Pages 98-113.
Definitions
All: Inflammatory condition of the tracheobronchial tree
Bronchiolitis: small elements (bronchioles)
Bronchitis (acute or chronic): large elements (mucous membranes of the bronchi)
Image accessed 4/3/14 at: http://www.ivy-rose.co.uk/HumanBody/Respiratory/Respiratory_Tracheobronchial_Tree.php
Bronchiolitis Primarily affects young children (75-90% caused by
respiratory syncytial virus (RSV)) Self-limiting w/ outpatient management (abx not
recommended) Antipyretic, hydration recommended Complication: dehydration Infants w/ underlying pulmonary or
cardiovascular dz Prophylaxis w/ RSV immune globulin or palvizumab
Prodrome (2-8d): irritability, restlessness, mild fever
Duration of illness: 3-7 days
Presentation: coughing (V, N, D possible)
Blackford gM, Glover ML, Reed MD. DiPiro 9th ed. Chptr 85.
Acute Bronchitis
5% of adult U.S. population annually (winter/fall common)
>90% viral etiology (Influenza A and B, parainfluenza, RSV, rhinovirus); often self-limiting w/ hydration and antipyretics Bacterial: Mycoplasma and Chlamydophila pneumoniae, and
Bordetella pertussis
Presentation: persistent cough >5d, sputum production (purulent), bronchospasms (’d FEV1), fever uncommon
Supportive care: beta-2 agonist, antitussive agents
Wenzel RP, Fowler AA. N Engl J Med. 2006;355:2125-30.; Snow V, Mottur-Pilson C, Gonzales R. Ann Intern Med. 2001; 134:518.; Blackford gM, Glover ML, Reed MD. DiPiro 9th ed. Chptr 85.; Cappelletty D. Infect Dis Clin Pract. 1998;7:S287-93.; Balter MS, et al. Can Respir J. 2003;10:248-58.
Acute Bronchitis: Pertussis (Whooping Cough)
Bordetella pertussis 10-20% of patient w/ persistent cough >2-3 weeks
Antibiotic of benefit if begun early (>7d) Given >7d to limit spread
Macrolide Azithromycin, clarithromycin, erythromycin (+ GI adverse
effects) (alternative: TMP/SMZ)
Snow V, Mottur-Pilson C, Gonzales R. Ann Intern Med. 2001; 134:518.http://www.cdc.gov/pertussis/clinical/treatment.html. Accessed 4/21/2012.
Bronchitis Assessment Question #1
Nearly all children will have bronchiolitis by the age two, primarily caused by RSV.
A) True
B) False
Bronchitis Assessment Question #1
Nearly all children will have bronchiolitis by the age two, primarily caused by RSV.
A) True
B) False
Bronchitis Assessment Question #2
Which of the following bacterial species is the cause of the Whooping Cough?
A. Bordetella pertussis
B. Chlamydophila pneumoniae
C. Mycoplasma pneumoniae
D. Staphylococcus aureus
Bronchitis Assessment Question #2
Which of the following bacterial species is the cause of the Whooping Cough?
A. Bordetella pertussis
B. Chlamydophila pneumoniae
C. Mycoplasma pneumoniae
D. Staphylococcus aureus
Chronic Bronchitis Defined Definition
Mucus producing excessive cough On most days of the week For at least 3 consecutive months For 2 consecutive years or more
Sudden clinical deterioration of patient w/ chronic bronchitis = Acute Exacerbation of Chronic Bronchitis (AECB)
Contributing factors: cigarette smoking, occupational dusts, fumes, environmental pollution, bacterial infection
Blackford gM, Glover ML, Reed MD. DiPiro 9th ed. Chptr 85.Balter M, Grossman RF. Int J Antimicrob Agents. 1997: 9:83-93.
Epidemiology
10-25% of adult population >40 years of age
AECB mortality rate ~4% If admitted to ICU ~24% After discharge from ICU – 1-year mortality rate ~46%
Causative Pathogens
Sputum is often colonized – sputum culture not generally useful
Bacterial etiology ~30-50% of AECB
Most likely bacteria dependent on lung function FEV1 >50%: S. pneumoniae (~47%), H. Influenzae/M. catarhallis (~22%),
Enterobacteriaceae and Pseudomonas spp (~30%) FEV1 35-50%: S. pneumoniae (~28%), H. Influenzae/M. catarhallis (~33%),
Enterobacteriaceae and Pseudomonas spp (~40%) FEV1 <35%: S. pneumoniae (~22%), H. Influenzae/M. catarhallis (~13%),
Enterobacteriaceae and Pseudomonas spp (~63%)
Exacerbations are often caused by acquisition of a new strain of bacteria
Albertson TE et al. J Am Geriatr Soc. 2010;58:570-79.; Sethi S. American Thoracic Society. 2004; 1:109
Determination of Antimicrobial Benefit
Indication of infection (incr’d HR or RR, incr’d wheezing or cough, or a fever)
Severe AECB (3 cardinal symptoms): (Treatment recommended) Increased dyspnea Increased sputum volume Increased sputum purulence
Moderate AECB: 2 cardinal symptoms (Treatment recommended)
Mild AECB: 1 cardinal symptom (resolution often self-limiting)
Anthonisen NR, et al. Ann Intern Med. 1987;106:196-204.Adams SG, Anzueto A. Seminars in Resp Inf. 2000;15.
AECB Treatment
Simple chronic bronchitis: 2 cardinal symptoms w/ FEV1>50% Doxycycline, trimethoprim-sulfamethoxazole, or a
cephalosporin (etc.)
Complicated chronic bronchitis w/ FEV1 35-50% or with risk factors for resistance (cardiac dz, use of home O2, chronic po steroid use, abx use in last 3 months) Moxifloxacin, levofloxacin, amoxicllin/clavulanate
Suppurative chronic bronchitis w/ FEV1 <35% Tailor to pathogen (consider Pseudomonal coverage)
Balter MS, et al. Can Respir J. 2003;10:248-58.
Duration of Therapy
Data provides little guidance
5-7 days recommended Shorter course associated with fewer adverse effects and no
difference in treatment success
Falagas ME, et al. J Antimicrob Chemother. 2008;62;442-50.Mesna J, Trilla A. Clin Microbiol Indwxr 2006;12(suppl 3):42-54.
Bronchitis Assessment Question #3
JT is a 82 yo male with h/o of COPD and chronic bronchitis. He presents with increased difficulty breathing, and increased volume of sputum production. Spirometry reveals FEV1 60% of predicted. ALL: Amoxicillin (hives) PMH: Hyperlipidemia, type II diabetes; no recent
hospitalizations or antibiotics
Should an antibiotic be prescribed for JT?A) YesB) No
Bronchitis Assessment Question #3
JT is a 82 yo male with h/o of COPD and chronic bronchitis. He presents with increased difficulty breathing, and volume of sputum production. Spirometry reveals FEV1 60% of baseline. ALL: Amoxicillin (hives) PMH: Hyperlipidemia, type II diabetes; no recent
hospitalizations or antibiotics
Should an antibiotic be prescribed for JT?A) YesB) No
Bronchitis Assessment Question #4
Which of the following antibiotics would be the best choice for JT’s exacerbation of chronic bronchitis?A) Amoxicillin/clavulanateB) AzithromycinC) DoxycyclineD) Ciprofloxacin
Bronchitis Assessment Question #4
Which of the following antibiotics would be the best choice for JT’s exacerbation of chronic bronchitis?A) Amoxicillin/clavulanateB) AzithromycinC) DoxycyclineD) Ciprofloxacin
Supportive Care
Bronchodilators Short-acting β2-agonists: first line Anticholinergics: initiate after β2-agonist is maxed out
Systemic steroids x 2 weeks – if patient requires hospitalization
Not recommended Mucolytics Methylxanthine bronchodilators
Snow V, et al. Chest. 2001;119:1185-1189.
Role of the Pharmacist
Counseling pearls If prescribed antibiotics
Take for duration of prescription (5-7 days) Encourage vaccinations
Influenza Pneumococcal
Encourage/support tobacco cessation Survival advantage Reduces the rate of FEV1 decline Coughing stops in up to 77% of patients
Balter MS, et al. Can Respir J. 2003;10:248-58.
Role of the Pharmacist (cont’d)
Encourage patient (or parent) to seek further care if: Temperature >100.4°F A fever or cough with thick or bloody mucus Shortness of breath of trouble breathing Symptoms that last > 3 weeks
http://www.cdc.gov/getsmart/antibiotic-use/URI/bronchitis.html
Key Points
Bronchiolitis and acute bronchitis are often caused by a viral etiology and are self-limiting
AECBs are characterized by lung function and cardinal symptoms (increased dyspnea, sputum volume, and purulence) Patients with signs of infection and 2 or more cardinal signs
are candidates for antimicrobial therapy Most common bacteria include: S. pneumoniae, H.
Influenzae, M. Catarrhalis, and Enterobacteriaceae species including Pseudomonas