bronchitis - apps.pharmacy.wisc.edu

BronchitisIntroduction to the Infectious Patient

Susanne Barnett, PharmD, BCPS

[email protected]

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.

http://www.cdc.gov/pertussis/clinical/treatment.html

Bronchitis Assessment Question #1

Nearly all children will have bronchiolitis by the age two, primarily caused by RSV.

A) True

B) False


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.


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


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


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

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

bronchitis - apps.pharmacy.wisc.edu

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