Mythbusting, Pulmonary

Being Color Blind to Bronchitis.

An October 2013 BMJ study compared patients aged 18-70 without underlying lung disease or immunosuppression, with an acute cough of less than one weeks duration. Cough with “discolored” sputum was a requirement of all patients, and they required at least one other symptom of lower respiratory tract infection (dyspnea, wheezing, chest pain or chest discomfort). Patients were excluded if they had previously used NSAIDs or antibiotics within the last 2 weeks, greater than 7 days of cough, allergies to NSAIDs or Augmentin, or had pneumonia on chest film. The three arms were as follows for ten days:

Ibuprofen 600mg TID (136 patients)
Augmentin 500-125 TID (137 patients)
Placebo TID (143 patients)

Patients had follow up at 2-4 days, 11-13 days, and again at 30 days if symptoms were not resolved by the second visit. Patients kept a diary of disease severity, daytime cough, night time cough, limitations of ADLs, and fever. There was essentially no difference in the number of days with cough, regardless of treatment, and 12 % of Augmentin patients having an adverse drug reaction, compared to 3% of placebo and 5% of ibuprofen. The authors point out a previous Cochrane review found antibiotics to have a slight advantage over placebo in controlling cough, but that review came from a total of 275 patients – more than a hundred fewer than this trial. The authors are also quick to point out that COPDers have been shown to benefit from antibiotic treatment with a change in sputum color.

The next time a patient states, “but I’m coughing up green stuff,” you’ll have the evidence in hand to either refute the prescription request, or give a risk benefit discussion about the 400% increased rate of side effects from antibiotics over placebo in this setting (12% vs 3%).

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PMID: 24097128

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