Clinical Trial Finds Decision-Support Strategy Can Reduce Antibiotic Overuse for Acute Bronchitis



 The percentage of adolescents and adults prescribed antibiotics for acute bronchitis decreased at intervention sites where printed and computer-assisted decision support was offered, according to a report of a clinical trial published Online First by JAMA Internal Medicine, a JAMA Network publication. The study is part of the journal’s Less is More series.1

The overuse of antibiotics for acute respiratory tract infections (ARIs) contributes to worsening trends in antibiotic-resistance. About 30 percent of office visits for colds and for nonspecific upper respiratory tract infections, along with up to 80 percent of all visits for bronchitis, are treated with antibiotics. Efforts have helped reduce antibiotic use for some ARIs, but it has remained a challenge to reduce antibiotic treatment for acute bronchitis, according to the authors.

Ralph Gonzales, M.D., M.S.P.H., of the University of California, San Francisco, and colleagues conducted a three-group cluster randomized study at 33 primary care practices in an integrated health care system in central Pennsylvania.

At 11 practices, the intervention was printed decision support (PDS) in which educational brochures were given by triage nurses to patients with cough illnesses as part of routine care and a poster displaying the clinical algorithm for distinguishing acute bronchitis vs. pneumonia was in all the examination rooms. At another 11 practices with a computer-assisted decision support (CDS) intervention, when triage nurses entered “cough” into the electronic health record (EHR) an alert would prompt the nurse to provide an educational brochure to the patient and the algorithm was programmed into the EHR. There also were 11 control sites.

The trial compared antibiotic prescription rates for uncomplicated acute bronchitis during the winter period (October 2009 through March 2010) following the intervention with the previous three winter periods. There were 9,808 visits for uncomplicated acute bronchitis during the baseline winter periods and 6,242 visits during the intervention winter period, according to the study.

“Compared with the baseline period, the percentage of adolescents and adults prescribed antibiotics for uncomplicated acute bronchitis during the intervention period decreased at the PDS intervention sites (from 80 percent to 68.3 percent) and CDS intervention sites (from 74 percent to 60.7 percent) but increased slightly at the control sites (from 72.5 percent to 74.3 percent),” according to the study results.

Differences for the intervention sites were statistically significant from the control sites but not between the PDS and CDS intervention sites, the results indicate.

“In this cluster randomized trial comparing the effectiveness of different implementation strategies for delivering clinical algorithm-based decision support for acute cough illness, we found that printed and computer-assisted approaches were equally effective at improving antibiotic treatment of uncomplicated acute bronchitis,” the study concludes. “In aggregate, these findings support the wider dissemination and use of this clinical algorithm to help reduce the overuse of antibiotics for acute bronchitis in primary care.”

In an invited commentary2, Jeffrey A. Linder, M.D., M.P.H., of Brigham and Women’s Hospital and Harvard Medical School, Boston, writes: “Despite the evidence, meta-analyses and performance measures, antibiotic prescribing for acute bronchitis in the United States remains at more than 70 percent.”

“However, some of the results by Gonzales and colleagues should give us pause. The antibiotic prescribing rate – an event that should never happen for these patients – in ‘successful’ intervention practices was still more than 60 percent,” Linder continues.

“We should address patients’ symptoms, but for antibiotics we need to tell our patients that ‘this medicine is more likely to hurt you than to help you,’” Linder concludes. “Success is not reducing the antibiotic prescribing rate by 10 percent; success is reducing the antibiotic prescribing rate to 10 percent.”


1. JAMA Intern Med. Published online January 14, 2013. doi:10.1001/jamainternmed.2013.1589

2. JAMA Intern Med. Published online January 14, 2013. doi:10.1001/jamainternmed.2013.1984.