A comparison of albuterol and erythromycin for the treatment of acute bronchitis

Journal of Family Practice, Nov, 1991 by William J. Hueston

Acute bronchitis is one of the most common illnesses seen in ambulatory practice, [1-3] yet there is no clear effective treatment. Despite the opinion that acute bronchitis is a viral-mediated disease [4-6] and that antibiotics are not indicated for this disorder, [7-8] antibiotics are frequently prescribed for patients with acute bronchitis. [9,10] This may be based on observations that Mycoplasma may be recovered from patients with acute bronchitis. [11-14] However, other than two studies that showed a marginal benefit from erythromycin [15,16] and another study showing a small benefit of sulfamethoxazole with trimethoprim, [17] no antibiotic has been shown to be useful in treating acute bronchitis.

Other observations have shown that pulmonary function testing in patients with acute bronchitis resembles that of patients with acute asthma [18,19] and that patients with previous acute bronchitis are more likely to develop asthma in the future. [20] These reports suggest that acute bronchitis may respond to medications that are useful in treating acute reversible airway obstruction. In order to study this hypothesis, the effectiveness of an oral bronchodilator, albuterol, was tested in healty adult patients who presented with an acute productive cough in the absence of pneumonia. Since over 90% of physicians use antibiotics for the treatment of acute bronchitis, [9,10] albuterol was compared with erythromycin, a commonly used antibiotic and one that has been demonstrated to have some small effect on the symptoms of acute bronchitis. [15,16]

Methods

This study was conducted between September 1, 1989, and April 1, 1991, at three rural primary care centers and a suburban family practice residency program in northeastern Kentucky. Patients between the ages of 18 and 65 years who presented to their physician with a productive cough of less than 30 days' duration were considered for entry into the study. Patients were excluded for any of the following conditions: pregnancy, a history of chronic obstructive pulmonary disease or asthma, a history of cardiac disease, or any allergy to erythromycin or albuterol. In addition, patients with clinical or radiographic evidence of pneumonia or who had a history of pneumonia in the past 6 months, or a temperature over 39.5 degrees C, or who had taken antibiotics in the 14 days prior to the study were excluded from the study.

In order to compare albuterol with erythromycin in a double-blinded fashion, the liquid form of both medications was used. After informed consent, patients in the study were given a number-coded bottle that was tinted to prevent the physician from seeing the color of the contents and which contained either liquid albuterol in a concentration of 25 mg/5 mL or erythromycin ethylsuccinate at 400 mg/5 mL. Instructions on the bottle directed the patient to take one teaspoonful of medication every 6 hours for the next 7 days. Attached to the medication bottle was a patient symptom diary, which the patient was instructed to complete for each day of the study. The diary asked if the patient's cough had improved that day, if the patient had been kept awake by the cought, if the patient felt well enought to return to work, and if the patient had resumed normal activities by that day. In addition, patients were asked to rate their general feeling of well-being on a 5-point Likert scale and to indicate if they had taken any additional medications that day or had experienced any side effects from the study medication.

Following 7 days of medication, patients returned to their primary health care provider. The patient was reexamined, and the unused portion of medication and the symptoms diary were returned. Participating medical providers submitted to the principal investigator the patient symptoms diary and volume of unused medication along with preprinted number-coded forms containing the initial and follow-up patient history and physical examination findings.

Discrete data were analyzed using chi-square analysis with the Mantel-Haenszel correction or two-tailed Fisher's exact test in cases of comparisons with small cell sizes. Two-tailed t tests were used for continuous data. Statistical significance was defined as P < .05.

Results

Forty-five patients were eligible for the study. Three patients declined to participate: two declined because they coult not return in 7 days, and the third initially agreed and then changed his mind before signing the consent form. Of the 42 remaining patients, 22 began taking erythromycin and 20 began taking albuterol. Two patients in each group were withdrawn from the study because of medication side effects, and three patients (two in the erythromycin group and one in the albuterol

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group) failed to follow up after their 7-day course of treatment. Thirty-five patients completed the study, but one patient in the erythromycin group was excluded after completing the medication because she had a cough lasting more than 30 days and therefore did not meet the study entry criteria. Thus, data were analyzed for 34 patients, 17 in the albuterol group and 17 in the erythromycin group.