Advertisement

Clinical management decisions for adults with prolonged acute cough: Frequency and associated factors

Published:December 07, 2018DOI:https://doi.org/10.1016/j.ajem.2018.12.007

      Abstract

      Background

      Uncomplicated episodes of prolonged acute cough are usually viral and self-limited, but despite evidence and recommendations to the contrary, they are often treated with antibiotics.

      Methods

      Mixed cross-sectional and prospective observational study of adults 18 years or older presenting to two urgent care centers with a cough of 7 to 56 days as their chief complaint. Factors associated with cough duration and clinical decisions were analyzed by univariate and multivariate logistic regression.

      Results

      Of the 125 enrolled patients, 118 (94%) received an antibiotic, 97 (78%) a cough suppressant, 87 (70%) a systemic corticosteroid, and 39 (31%) a chest X-ray (CXR). Longer duration of cough was associated with the presence of self-reported wheezing or noises (adjusted odds ratio 6.29, 95% CI 1.36–29.16) while the presence of both wheezing and crackles on a clinician chest exam was associated with shorter duration (aOR 0.03, 95% CI 0.00–0.27). A clinician was more likely to order a CXR in patients with dyspnea (aOR 3.01, 95% CI 1.21–7.49), less likely to prescribe a systemic corticosteroid in patients with crackles (aOR 0.27, 95% CI 0.09–0.82), and more likely to prescribe a cough suppressant to older patients (1.04 per additional year of age, 95% CI 1.01–1.07).

      Conclusions

      Systemic corticosteroids and cough suppressants are being prescribed at high rates in patients with uncomplicated acute cough in the urgent care setting. Additional studies to determine if similar rates are seen in other urgent care centers, or in other contemporary ambulatory settings are warranted.

      Keywords

      To read this article in full you will need to make a payment
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to The American Journal of Emergency Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • CDC
        National Ambulatory Medical Care Survey: 2015 State and National Summary Tables CDC/National Center for Health Statistics.
        2015
        • Soler J.K.
        • Okkes I.
        • Oskam S.
        • Van Boven K.
        • Zivotic P.
        • Jevtic M.
        • et al.
        The interpretation of the reasons for encounter ‘cough’ and ‘sadness’ in four international family medicine populations.
        Inform Prim Care. 2012; 20: 25-39
        • Okkes I.M.
        • Oskam S.K.
        • Lamberts H.
        The probability of specific diagnoses for patients presenting with common symptoms to Dutch family physicians.
        J Fam Pract. 2002; 51: 31-36
        • van Vugt S.F.
        • Verheij T.J.
        • de Jong P.A.
        • Butler C.C.
        • Hood K.
        • Coenen S.
        • et al.
        Diagnosing pneumonia in patients with acute cough: clinical judgment compared to chest radiography.
        Eur Respir J. 2013; 42: 1076-1082
        • Ebell M.H.
        • Lundgren J.
        • Youngpairoj S.
        How long does a cough last? Comparing patients' expectations with data from a systematic review of the literature.
        Ann Fam Med. 2013; 11: 5-13
        • Ebell M.H.
        • Radke T.
        Antibiotic use for viral acute respiratory tract infections remains common.
        Am J Manag Care. 2015; 21: e567-e575
        • Suda K.J.
        • Hicks L.A.
        • Roberts R.M.
        • Hunkler R.J.
        • Danziger L.H.
        A national evaluation of antibiotic expenditures by healthcare setting in the United States, 2009.
        J Antimicrob Chemother. 2013; 68: 715-718
        • Fleming-Dutra K.E.
        • Hersh A.L.
        • Shapiro D.J.
        • Bartoces M.
        • Enns E.A.
        • File Jr., T.M.
        • et al.
        Prevalence of inappropriate antibiotic prescriptions among US ambulatory care visits, 2010–2011.
        JAMA. 2016; 315: 1864-1873
        • Barnett M.L.
        • Linder J.A.
        Antibiotic prescribing for adults with acute bronchitis in the United States, 1996–2010.
        JAMA. 2014; 311: 2020-2022
        • Lee G.C.
        • Reveles K.R.
        • Attridge R.T.
        • Lawson K.A.
        • Mansi I.A.
        • Lewis 2nd, J.S.
        • et al.
        Outpatient antibiotic prescribing in the United States: 2000 to 2010.
        BMC Med. 2014; 12: 96
        • Centre for Clinical Practice at N. National Institute for Health and Clinical Excellence: Guidance
        Respiratory tract infections-antibiotic prescribing: prescribing of antibiotics for self-limiting respiratory tract infections in adults and children in primary care.
        National Institute for Health and Clinical Excellence
        London
        Date: 2008
        • Irwin R.S.
        • Baumann M.H.
        • Bolser D.C.
        • Boulet L.P.
        • Braman S.S.
        • Brightling C.E.
        • et al.
        Diagnosis and management of cough executive summary: ACCP evidence-based clinical practice guidelines.
        Chest. 2006; 129: 1s-23s
        • Hay A.D.
        • Little P.
        • Harnden A.
        • Thompson M.
        • Wang K.
        • Kendrick D.
        • et al.
        Effect of oral prednisolone on symptom duration and severity in nonasthmatic adults with acute lower respiratory tract infection: a randomized clinical trial.
        JAMA. 2017; 318: 721-730
        • Holzinger F.
        • Beck S.
        • Dini L.
        • Stoter C.
        • Heintze C.
        The diagnosis and treatment of acute cough in adults.
        Dtsch Arztebl Int. 2014; 111: 356-363
        • Schroeder K.
        • Fahey T.
        Over-the-counter medications for acute cough in children and adults in ambulatory settings.
        Cochrane Database Syst Rev. 2004; (Cd001831)https://doi.org/10.1002/14651858.CD001831.pub2
        • Coster J.E.
        • Turner J.K.
        • Bradbury D.
        • Cantrell A.
        Why do people choose emergency and urgent care services? A rapid review utilizing a systematic literature search and narrative synthesis.
        Acad Emerg Med. 2017; 24: 1137-1149
        • Coenen S.
        • Michiels B.
        • Renard D.
        • Denekens J.
        • Van Royen P.
        Antibiotic prescribing for acute cough: the effect of perceived patient demand.
        Br J Gen Pract. 2006; 56: 183-190
        • Sirota M.
        • Round T.
        • Samaranayaka S.
        • Kostopoulou O.
        Expectations for antibiotics increase their prescribing: causal evidence about localized impact.
        Health Psychol. 2017; 36: 402-409
        • Welschen I.
        • Kuyvenhoven M.
        • Hoes A.
        • Verheij T.
        Antibiotics for acute respiratory tract symptoms: patients' expectations, GPs' management and patient satisfaction.
        Fam Pract. 2004; 21: 234-237
        • Macfarlane J.
        • Holmes W.
        • Macfarlane R.
        • Britten N.
        Influence of patients' expectations on antibiotic management of acute lower respiratory tract illness in general practice: questionnaire study.
        BMJ. 1997; 315: 1211-1214
        • Coenen S.
        • Francis N.
        • Kelly M.
        • Hood K.
        • Nuttall J.
        • Little P.
        • et al.
        Are patient views about antibiotics related to clinician perceptions, management and outcome? A multi-country study in outpatients with acute cough.
        PLoS One. 2013; 8e76691
        • Burnham K.
        Model selection and multimodel inference: a practical information-theoretic approach.
        2nd ed. Springer-Verlag New York, 2002
        • Burnham K.P.
        • Anderson D.R.
        Multimodel inference understanding AIC and BIC in model selection.
        Sociol Methods Res. 2004; 33: 261-304
        • Symonds M.R.E.
        • Moussalli A.
        A brief guide to model selection, multimodel inference and model averaging in behavioural ecology using Akaike's information criterion.
        Behav Ecol Sociobiol. 2011; 65: 13-21
        • Dale A.P.
        • Marchello C.
        • Ebell M.
        The accuracy of the overall clinical impression for the diagnosis of pharyngitis, sinusitis, and pneumonia: a meta-analysis.
        2018 ([Unpublished. Currently in peer review])
        • Marchello C.
        • Ebell M.
        • Dale A.P.
        • Harvill E.
        • Shen Y.
        • Whalen C.C.
        Signs and symptoms that rule out community-acquired pneumonia in outpatient adults: a systematic review and meta-analysis.
        J Am Board Fam Med. 2019; ([Accepted; in press])
        • Rowe B.H.
        • Spooner C.
        • Ducharme F.M.
        • Bretzlaff J.A.
        • Bota G.W.
        Early emergency department treatment of acute asthma with systemic corticosteroids.
        Cochrane Database Syst Rev. 2001; (Cd002178)https://doi.org/10.1002/14651858.CD002178
        • Stern A.
        • Skalsky K.
        • Avni T.
        • Carrara E.
        • Leibovici L.
        • Paul M.
        Corticosteroids for pneumonia.
        Cochrane Database Syst Rev. 2017; 12Cd007720
        • Waljee A.K.
        • Rogers M.A.
        • Lin P.
        • Singal A.G.
        • Stein J.D.
        • Marks R.M.
        • et al.
        Short term use of oral corticosteroids and related harms among adults in the United States: population based cohort study.
        BMJ. 2017; 357: j1415
        • Butler C.C.
        • Hood K.
        • Kelly M.J.
        • Goossens H.
        • Verheij T.
        • Little P.
        • et al.
        Treatment of acute cough/lower respiratory tract infection by antibiotic class and associated outcomes: a 13 European country observational study in primary care.
        J Antimicrob Chemother. 2010; 65: 2472-2478
        • Little P.
        • Rumsby K.
        • Kelly J.
        • Watson L.
        • Moore M.
        • Warner G.
        • et al.
        Information leaflet and antibiotic prescribing strategies for acute lower respiratory tract infection: a randomized controlled trial.
        JAMA. 2005; 293: 3029-3035