Wednesday, June 22, 2005
JAMA article & editorial:green sputum does not equal give antibiotics
A recent JAMA article from Great Britain concluded there is little to be gained from prescribing antibiotics for acute bronchitis. Their conclusion differs a bit from a meta-analysis by the Cochran group which concluded there may be modest benefit from antibiotics in this "entity". This study involved both children and adults and excluded patients with COPD or asthma and several other conditions including heart disease and was an open study, i.e. not double blinded, the patients knowing if they were taking antibiotics or not. The JAMA editorial takes a strong don't -use-antibiotics-for-acute bronchitis- stance but not only opponents of their use but also proponents can extract some data from the study supporting their position. Antibiotic use did seem to shorten the duration of "moderately bad symptoms" albeit by only one day on average-but that is an average- and fewer patients returned later presumably with the complaint of lingering cough. The 2004 Cochrane review suggested that for most patients antibiotics probably provide modest symptomatic relief. The authors of the current study in what sounds like typical British understatement say [their study]" suggest that the ...likely effects... are likely to be rather more modest than documented in the Cochrane review." The editorialist in his title says ".. do the right thing" by which he means forgo antibiotics in acute bronchitis in an otherwise healthy patient,the presumed decrease in the induction of community resistance organisms apparently playing a role in his analysis of what to do in management of acute bronchitis. However, the editorial does admit that there may be a small subset of patients who do benefit from antibiotics but we don't know how to determine who they are when we see them in the office. Maybe the best information we get from the article is that usually acute bronchits, counting cough duration, is about three weeks but not uncommonly 4 weeks in duration and even in Great Britain patients come back to the office when their cough does not "go away".