to the editor: I read with interest the article “Acute Bronchitis” by Drs. Hueston and Mainous¹ in the March 15 issue of American Family Physician. I agree with the authors regarding the limited value of antibiotics in the treatment of this common condition. However, recommendations for the appropriate use of bronchodilator therapy were not clearly stated. Should one base treatment on history alone or on physical examination findings alone? Should peak flow measurements be less than 80 percent of the predicted measurement before treatment is started? How long should bronchodilator therapy be used to treat this condition? Clarification of these issues will help physicians to better care for their patients who have this common condition.

in reply: As Dr. Seehusen points out, antibiotics have not been shown to be beneficial in the treatment of acute bronchitis. Therefore, we do not recommend routine use of antibiotics in patients with acute bronchitis. While it would be convenient to have a “high-risk” profile for patients who are more likely to have a bacterial infection, as we pointed out in our article, there is no way to predict the rare patient who has a bacterial etiology for his or her bronchitis.

As far as treatment to prevent adult-onset asthma is concerned, antibiotics are not justified at this time. Currently, there is no good estimate of how often Chlamydia pneumoniae is the etiologic agent for acute bronchitis, nor is there conclusive proof that Chlamydia infection causes asthma or that early treatment of Chlamydia prevents the development of asthma. For patients with prolonged cough lasting a month or longer, treatment with antibiotics may be cost effective, especially when compared with an expensive evaluation for chronic cough.¹ Otherwise, antibiotics should be avoided since they are an unnecessary expense, can cause side effects and may increase resistance to antibiotics.

In response to Dr. Sharkness's questions, the use of bronchodilators, more specifically albuterol, is based on clinical suspicion of acute bronchitis. No aspect of the patient's history or physical findings (including wheezing) or findings on peak flow measurement indicates when albuterol will be most effective. Albuterol can be continued until symptoms are cleared; it should be noted, though, that in the two studies that examined the use of albuterol, 90 percent of patients had resolution of their cough after one week.^2,3