急性支气管炎与抗生素（英文ppt）areantibiotics of value in the treatment of

,Are antibiotics of Value in the treatment of Bronchitis?,Ashraf Mokhtar Madkour, Dr.med., MD, FCCP Pulmonary Medicine Department, Ain Shams University,Acute Bronchitis: Definition Overview & risk factors Causes & Diagnosis Pro & Con Antibiotics Antibiotics in acute complicated bronchitis Acute exacerbation of Chronic Bronchitis: Definition Causes Pro Antibiotics,Topics,Bronchial tree,Acute illness in patients without chronic lung disease. Symptoms including cough: productive Associated with other symptoms or clinical signs which suggest LRTI No alternative explanation e.g. sinusitis, asthma Normal chest radiograph Lasts for up to 3 weeks.,Acute Bronchitis: Definition,ERS LRTI guidelines: Eur Respir J 2005;26:1138-118 ACCP evidence-based guidelines on cough : Chest 2006;129:95S-103S,Generally follows an upper respiratory tract infection. Affects approximately 5% of adults annually. Higher incidence observed during the winter and fall than in the summer and spring. 9th most common illness among outpatients in USA. Average of 2-3 days work lost per episode.,Acute Bronchitis: An overview,Dust or other air pollution Fumes or vapors Tobacco smoke, including 2nd hand smoke Elderly, children and infants,Acute Bronchitis: Risks factors,Acute Bronchitis: Causes,90% of cases are non-bacterial. Viruses: Influenza Parainfleunza Respiratory Syncytial Virus Corona virus Adenovirus Rhinovirus Bacteria in rare cases Atypical bacteria B. pertussis Pollutants (air borne chemicals or irritants),Acute onset of symptoms Cold like symptoms (1st few days): Runny nose, sneezing & dry cough Mild URTI symptoms indistinguishable from those of acute bronchitis Cough: Deep, dry & painful Sputum production Shortness of breath Low-grade fever,Acute Bronchitis: Diagnosis,Wheezing Others: chilliness, malaise, body aches, soreness & constriction behind sternum Evaluation focus on excluding severe illness , particularly pneumonia Suspect pneumonia (fever 38C, tachypnea 24 breaths/min, tachycardia 100 beats/min, rales, egophony, fremitus) Chest X-ray signs of pneumonia, elderly, cough3 weeks,Acute Bronchitis: Diagnosis,Diagnostic Testing usually unnecessary expect Influenza outbreak in the community Suspected Pertussis: Contact with suspected pertussis or persistent cough Paroxysms of cough, whooping or post-tussive vomiting Nasopharyngeal swab or wash PCR is now standard,Acute Bronchitis: Diagnosis,1ry symptomatic The following might help: Smoking cessation, Good hydration. Analgesics/antipyretics. Antitussives might alleviate cough but will not reduce duration of illness. Bronchodilators Wheezing and shortness of breath with activity. Offer modest improvement of protracted cough. Inhaled or oral corticosteroids Brief trial (7 days) may be reasonable for troublesome cough ( 20 days).,Acute Bronchitis: Treatment,Pro: Antibiotics for Acute Bronchitis,Antibiotics for acute bronchitis,Antibiotic use & complication risk,Pneumonia after URTIs are more prevalent in those who did not receive antibiotics than those who receive antibiotics among those 64 y age.,RCT of Doxycycline vs placebo for actue bronchitis,RCT found that Doxycycline significantly reduced the number of people with cough & feeling ill at follow-up and also reduced the mean number of days of cough & feeling ill compared with placebo,Con: Antibiotics for Acute Bronchitis,Results of a randomized, double-blind trial comparing a 5-day course of azithromycin with vitamin C. No difference between 2 groups in: The health related quality of life at 7 days. The proportion of patients who returned to work, school or usual activities at home on day 3 or 7.,Uncomplicated Acute Bronchitis Azithromycin vs. vitamin C (Lancet 2002;359;1648-54),Resolution of Acute Bronchitis,Stott, BMJ 1976,Symptom severity scores over 28 days after presentation with acute cough/LRTI,The differences of symptom severity scores between those who were and were not prescribed antibiotics were not statistically significant.,Antibiotic prescribing for discoloured sputum in acute cough/LRTI ERJ,March, 2011,Sputum colour was not associated with recovery or benefit from antibiotic treatment.,Antibiotic prescribing for discoloured sputum in acute cough/LRTI ERJ,March, 2011,Analysis of 14 RCT trials involving over 1500 patients Comparing antibiotic therapy with placebo in acute bronchitis in patients without underlying pulmonary disease.,Cochrane review on Antibiotics for acute bronchitis Cochrane Database of Systematic Reviews: 2009 update Search: Central Register of Controlled trials (The Cochrane Library 2007, issue 4); MEDLINE (1966 to December 2007); and EMBASE (1974 to December 2007).,Fahey T, Smucny J, Becker L, Glazier R. Antibiotics for acute bronchitis. Cochrane Database of Systematic Reviews 2009, Issue 4. Art. No.: CD000245,Cochrane review on Antibiotics for acute bronchitis,Fahey T, Smucny J, Becker L, Glazier R. Antibiotics for acute bronchitis. Cochrane Database of Systematic Reviews 2009, Issue 4. Art. No.: CD000245,Antibiotic treatment is not justified in Acute bronchitis,Cochrane review on Antibiotics for acute bronchitis,Fahey T, Smucny J, Becker L, Glazier R. Antibiotics for acute bronchitis. Cochrane Database of Systematic Reviews 2009, Issue 4. Art. No.: CD000245,Antibiotic treatment is beneficial in Acute bronchitis,Conclusion: Antibiotics have only a modest effect on the duration of cough (by a fraction a day) compared with placebo. There were no significant differences regarding the presence of night cough, productive cough or activity limitations at follow up or in the mean duration of activity limitations.,Cochrane review on Antibiotics for acute bronchitis,Fahey T, Smucny J, Becker L, Glazier R. Antibiotics for acute bronchitis. Cochrane Database of Systematic Reviews 2004, Issue 4. Art. No.: CD000245,Conclusion: Non significantly increase in the adverse events attributed to antibiotics. Data on subsets of patients who may benefit more from treatment is lacking.,Cochrane review on Antibiotics for acute bronchitis,Fahey T, Smucny J, Becker L, Glazier R. Antibiotics for acute bronchitis. Cochrane Database of Systematic Reviews 2004, Issue 4. Art. No.: CD000245,If pertussis is suspected: Empiric antibiotic (Macrolides) may be initiated while obtaining a diagnostic test for confirmation. Antibiotic treatment decreases transmission, but has little effect on cough resolution if started after 10 days of illness.,Antibiotics in acute bronchitis:,American College of Physicians 2001: Antibiotic treatment is “not recommended, regardless of duration of cough.” American College of Chest Physicians 2006: Routine treatment with antibiotics is not justified. Centers for Disease Control and Prevention (CDC) Antibiotics only indicated in Pertussis.,Guidelines for uncomplicated acute bronchitis :,Antibiotics are recommended: Symptoms and signs suggesting pneumonia Those at high risk of serious complications because of pre-existing comorbidities (including patients with heart, lung, renal, liver, or neuromuscular disease, immunosuppression, or cystic fibrosis and young children who were born prematurely) Patients 65 years, if they had: Hospitalization in the past year. Diabetes mellitus. Congestive heart failure. On steroids.,Patients with acute bronchitis who are likely to be at risk of developing complications,BMJ 2008; 337:a437,Patients who have cough and sputum production on most days of the month for at least 3 months of the year during 2 consecutive years. Acute exacerbation of chronic bronchitis (AECB): “A sustained worsening of the patients condition, from stable state and beyond normal day to-day variations, that is acute in onset & necessitates a change in regular medication in a patient with underlying COPD”,Chronic bronchitis: Definition,50% of AECB is due to infectious etiology Mostly bacterial,AECB: Causes,Small, but statistically significant improvement due to antibiotic therapy in patients with AECB. This antibiotic-associated improvement may be clinically significant, especially in patients with low baseline flow rates (impaired lung functions),Antibiotics and AECB: when?,Purulent sputum Sensitivity 94% Specificity 77% Patients with purulent sputum benefits from antibiotic therapy.,For bacterial presence,GO