bronchitis and antibiotics vs ibuprofen

recent online article in BMJ finding lack of efficacy of antibiotics or ibuprofen on acute bronchitis with discolored sputum (see bronchitis and antibiotics bmj 2013 in dropbox, or BMJ 2013;347:f5762 doi: 10.1136/bmj.f5762). 416 adults aged 18-70 in primary care centers in spain with sx of respiratory tract infection of less than 1 week, cough predominant with discolored sputum, and at least one other sx suggesting lower resp tract infection (dyspnea, wheezing, chest discomfort or pain). chest xray not required to r/o pneumonia -- the dx of acute bronchitis was a clinical one. randomized to ibuprofen 600 TID, amox/clavulanic acid 500/125 TID, or placebo for 10 days.  patients reported sx in diary. overall, 40% of patients were smokers, 10% had diabetes, 8% with fever, >50% had increased CRP with 25% quite high CRP (>21). results

    --median # days from the initial presentation of frequent cough slightly decreased with ibuprofen (9 days) vs those on abx (11 days) or placebo (11 days), not statistically different
    --no diff in probability of cough resolution
    --adverse effects common with abx (12%), vs ibuprofen (5%) or placebo (3%).

so, not a lot to do for patients with acute bronchitis. (note: this does not apply to patients with copd and exacerbation with change in color of their sputum). cochrane reviews do not show benefit from b-agonists or anti-tussives. it is pretty clear that providers do prescribe antibiotics a lot for acute bronchitis (>60% of the time), and even more so if there is discolored sputum (3.2 times as likely as in patients without discolored sputum). would have been better in this study if they evaluated utility of antibiotics or ibuprofen in patient subgroups (eg, smokers, or diabetics, or those with higher CRP), but overall this article provides further impetus to avoid prescribing antibiotics, with their adverse effects on the patients and on society overall from resistant bacteria.

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