Antibiotic prescribing for acute bronchitis: how low can we go?

By the time I graduated from medical school in 1975, I had learned that most respiratory tract infections in otherwise healthy children and adults were caused by viruses, such as parainfiuenza, influenza, adenovirus, and respiratory syncytial virus. This learning was reinforced during my family practice residency training in Charleston, Se. I was taught that the challenge of primary care practice is to distinguish the many patients with benign, selflimited respiratory tract infections from those patients who are more seriously ill with bacterial pneumonia and who need an antibiotic to recover more quickly and more certainly. Anned with this scientific knowledge, I marched valiantly into practice, determined to base my prescribing on good science. It was only in rural practice that I clearly recall regularly confronting syndromes called "acute bronchitis" and "sinusitis," for which patients seemed to expect an antibiotic and for which their previous physicians had prescribed one. "I get this bronchitis every fall. Dr. Smith gives me a shot of penicillin and I'm fine 2 days later." With modest success I was able to talk patients out of this approach, but I more frequently failed than succeeded, though many were willing to take my prescription for pills as an acceptable alternative to the shot in the buttock. A quarter-century later I am still fighting the good battle of appropriate antibiotic use for respiratory tract infections. After a 25-year cold war, however, the battle is heating up! The Centers for Disease Control and Prevention has entered the fray, urging us and our patients to use antibiotics sparingly and wisely for acute respiratory tract infections. 1 Family physicians have been named as a major contributor to the problem of bacterial resistance, and the reasons we participate in the problem have been thoroughly described. In the words