THE MANAGEMENT OF ACUTE BRONCHITIS

JOHN G. BARTLETT, MD
CHIEF, DIVISION OF INFECTIOUS DISEASES
PROFESSOR OF MEDICINE
THE JOHNS HOPKINS UNIVERSITY SCHOOL OF MEDICINE
TRANSCRIPT
Lecture 4 of 6 from the Symposium Optimal Management of Infections of
the Upper and Lower Respiratory Tract
Webcast on WML.com starting April 30, 2001
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John Bartlett, MD: I am John Bartlett from John
Hopkins University and I am going to be talking
about acute bronchitis, my discussion will not deal
with chronic obstructive lung disease with
exacerbations; Mike Niederman has that charge. I
am not going to be talking about sinusitis, which is
frequently associated with bronchitis, because that
topic has been covered. I am going to dwell on
acute bronchitis, which is a topic that is usually not
remembered in these types of symposiums, but it
turns out to be one of the most common clinical
scenarios that a clinician sees.
First of all, let me mention an arbitrary definition,
which is acute respiratory tract infection in which
cough is a prominent feature. It becomes acute if it
less than three weeks in duration, usually it much
briefer in duration than that. The frequency is
obviously very high. It says on the slide on the
basis of one of these large epidemiologic reviews,
5% per year for adults, but I expect everybody in
the audience has had acute bronchitis within the
last five years, so it is certainly more common than
it is stated there.
In terms of the etiology, the study that is cited
showed a distribution in which upper respiratory
tract infections, primarily the common cold, was
found in 70%, asthma in 6%, and pneumonia in
5%. In terms of the etiology when an infectious
disease is responsible, the major pathogens are
viruses and the most common are influenza,
parainfluenza, and respiratory syncytial virus,
although other viral agents of acute respiratory
infections could also cause acute bronchitis. About
5-10% are caused by bacteria that are potentially
treatable including Mycoplasma pneumoniae,
Chlamydia pneumoniae, and Bordetella pertussis or
whoopingcough.
The major role of the physician in dealing with a
patient who has the acute cough syndrome is to
make sure they do not have pneumonia. We
usually take a history and do physical exam and
sometimes have inappropriate confidence in our
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ability to diagnose pneumonia on the basis of
clinical observations. The study shows that we are
good, but we are not real good. The sensitivity and
specificity are 60-80%. The real way to make a
diagnosis of pneumonia, yes or no, is on the basis
of a chest X-ray, and there are some guidance
about when to get a chest X-ray because you
obviously do not want to be getting a chest X-ray
on everybody that has an acute cough. So, the
recommendations are to get a chest X-ray if there
is an abnormality in vital signs. The signs are
shown on the slide. If you hear rales or fremitus or
egophony, then that would also be an appropriate
scenario in which to get an X-ray, or if a patient has
a chronic cough, but that is a different disease an
that is not what I am talking about. Now those
guidelines are generally good, but they are verified
on the basis primarily of young adults and patients
who are immunocompetent in patients without
chronic lung disease. So, in the elderly patient, you
have to be careful because they may not have
abnormalities of vital signs, they may not have
some of the other findings that are characteristic of
pneumonia, and pneumonia on the elderly patient
can be a serious disease despite a deceptively well-
looking person. So, those are important exceptions
to be aware of.
Now, is the X-ray ever falsely negative? The
answer is yes, because there is never a never in
medicine, but there are, as far as I know, four
situations in which various clinicians have called
attention to the possibility that an X-ray would not
show an infiltrate, when in fact there should have
been one there. In other words, there is an
alveolar process which is not expressed and
something we can see on a chest X-ray, and the
ones that are usually cited is very early in the
course of pneumonia, which I think probably does
occur but it is varnishing rare. Neutropenia, but we
are really not talking about the neutropenic host.
Patients who have severe dehydration, which is
something I have never bought as a concept, but
people always talk about on the ward. I never
bought it as a concept because it never made sense
to me. It never made sense that you could get so
dehydrated that you were unable to muster an
inflammatory reaction. So that, if I see a patient
that might have cellulitis on the arm, I would never
say well hydrate that patient up and it will turn red
and be puffy because now they are hydrated, yet
we seem to say that about the lung, and the dog
experiments have certainly not verified the fact that
there is any difference in a pulmonary infiltrate, yes
or no, in a dog that is dehydrated or bone dry, if
you will excuse the pun. The final exception is one
that probably is very real and that is Pneumocystis
carinii pneumonia, and at this point in history of
medicine that is a disease we have to be eminently
aware of and probably somewhere between 20 and
30% of patients with AIDS, who have Pneumocystis
carinii pneumonia, that is well verified will have a
negative chest X-ray. So, just be leery of that. You
will probably be able to tell on the basis of a CBC,
on the basis of history, basis of some other
information that will lead you down that pathway.
Now, in terms of the microbial diagnosis, we have
already heard about influenza and the diagnostic
utility of the rapid test, what my understanding is
that a good clinician dealing with a patient who is
seen in the midst of an influenza epidemic who has
fever and has typical symptoms, that diagnostic
probability is about as good in sensitivity and
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specificity as a rapid test. In terms of other
etiologic agents, I am not sure we will need to know
if a patient has parainfluenza or respiratory
syncytial virus when they are outpatients. I think
for epidemiologic tracking purposes we would like to
know that information, and we do collect that at
Hopkins on patients who are admitted, but we do
not collect it in our outpatient clinics. We do not
think we need it. With regard to bacteria in
general, the patient with acute bronchitis is not a
candidate for a sputum Gram stain and culture,
despite the fact we are fond of that for community
acquired pneumonia and so forth. We would not
say that that was an appropriate test in a patient
with chronic bronchitis. If anything, that is
probably going to be somewhat deceptive. So,
even if the sputum is really tenacious, really green,
really looks infected, that makes the probability of
a treatable diagnosis no more likely than if that it is
caused by parainfluenza, for example.
Now, in terms of the treatment, I have suggested
some things on the slide that would be appropriate
for patients who have chest problems associated
with the acute cough syndrome, specifically
bronchodilator, which in therapeutic trials in
patients with acute bronchitis has seemed to work,
and then there may be a role for some antitussive
agents. With regard to antibiotics, the major thing
that we need to do is to dissuade our colleagues,
dissuade our patients from the, what seems to be,
an uncontrollable urge to treat patients with
antibiotics for acute bronchitis. Some of this is
patient information, in other words, patients often
expect antibiotics when they have cough,
especially, if it is cough productive of sputum, and
one of the things that has been found in the studies
of acute bronchitis is that if you ask the average
doctor, if you should treat acute bronchitis with an
antibiotic, yes/no, most will say yes. If you ask a
patient that they expect to be treated with an
antibiotic, if they have acute bronchitis, the answer
is yes, most of the time. However, if you rephrase
the question and say, Do you expect to be treated
with an antibiotic if you have a chest cold? both
the doctor and the patient say no. So, one of the
ploys that some have suggested is to stop calling it
acute bronchitis and start calling it a common
cold.
Now, some other recommendations that have been
made, and I am summarizing here in the review in
the New England Journal on management of the
acute cough, and this addresses some of the other
issues of the companion or the underlying disease
such as the common cold, sinusitis, or allergic
rhinitis, which are really the major causes of acute
bronchitis when due to infectious disease. For the
common cold, the recommendation on the basis of
therapeutic trials done some time ago but
nevertheless showed good results, was for a first
generation antihistamine, a sedating antihistamine
combined with a nasal decongestant and I went
through the pharmacopoeia to find out how many of
those there are in the over-the-counter listing and it
turned out that, in the book I looked in, there were
246 different preparations that offered that
combination of drugs. Sinusitis, we have already
heard about that. For allergic rhinitis, this is a
situation in which the second-generation or non-
sedating antihistamines are probably more likely to
be effective.
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In terms of antibiotics, why do we feel so strongly
about antibiotics? The part of the reason is because
this is an area in which there are an awful lot of
mistakes made. This may be one of the most over-
treated diseases there is in medicine, certainly
common diseases with regard to antibiotics,
antibiotics abuse and the problems now associated
with consequences of that mainly being antibiotic
resistance. So, there is a great deal of energy now
placed on just weaning physicians and patients from
the use of antibiotics for patients who have acute
bronchitis. Now, we have scientific basis to be so
strong in that recommendation, and what I have
summarized on the slide are the studies that have
been reviewed by people who are students of
studies and therefore feel that they are conclusive
studies in terms of having the proper design. There
are nine, and none of them were able to show a
distinct benefit with antibiotic therapy. There are
three meta-analyses and all three concluded that
there was no distinct benefit with antibiotics. In
1998, the FDA withdrew acute bronchitis as grounds
for clinical trials for which antibiotics would be
approved since antibiotics were not thought to a
play role.
Now, are there are any exception to that? We come
on pretty strong in terms of what we said. Well,
Mycoplasma and Chlamydia are conditions that can
cause acute bronchitis and are certainly treatable,
and we are not going to able to diagnose those.
The average clinician does not have a way to
diagnose Mycoplasma or Chlamydia infections, but I
think so far we have to say that those who have
studied these diseases have concluded that for the
patient that simply has acute bronchitis, the
evidence that they improve or benefit from the
antibiotic therapy is not persuasive. A pertussis is
an exception, but the way we are going to able to
make the diagnosis or suspect the diagnosis of
pertussis is not so much for the acute cough unless
it is associated with an outbreak or typical clinical
symptoms, that is posttussive vomiting or the
whoop. I think by and large we will suspect
whooping cough when the patient has cough that is
persistent for two to three weeks. Influenza is
another exception, and we heard about that in
terms of the therapeutic agents that are available
for treatment of influenza.
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Now, with regard to antibiotic prescribing, there is a
great study, which I want to review by Ralph
Gonzales, but before getting into that let me just
mention what is on the slide and that is a recent
review from emergency rooms from a national
database to verify simply the abuse of antibiotics
for acute bronchitis, and what they found in this
national survey with over 2000 patients that were
seen with acute bronchitis is that 40% of the
physicians had prescribed antibiotics for their
condition.
Now, the study that I was mentioning by Ralph
Gonzales was done in Denver and this was done
within the big HMO Kaiser in Denver, and he divided
the patients into three groups. Each had at least
30,000 members in a group. One group got patient
education and physician education. Patient
education amounted to fliers, educational material,
things you stick on your refrigerator that tell you
the antibiotics and their problems and so forth. The
patient education amounted to a 30-minute
lecture. So, in one group both the physicians and
patients got that message. The second one was for
physicians only and the third group was for
controls, and
these are the results which are promising, perhaps
not as good what you would like, but what they
show was that you really needed to educate both
the physician and the patient about the issue that I
am talking about, in order to have a distinct impact
on the antibiotic prescribing practices. Note that in
this population the rate of antibiotic prescriptions
for patients with acute bronchitis was between 70%
and 80%, so somewhat higher than some of the
numbers that I have been quoting.
Now, all of this applies to the patient with acute
cough syndrome. When the cough persists for
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three weeks or more, then we have to start thinking
about some other possibilities. One is pertussis,
and that may be one of the most important. Ten to
twenty percent of the patients that have acute
cough syndrome and have persistent cough for two
to three weeks turn out to have pertussis, which is
something that we should be treating and be aware
of. Other causes are common infections that we
have talked about before, Chlamydia, pneumoniae
and Mycoplasma can persist. It does not happen
often but it sometimes happens, and then there are
other mycobacterial or fungal infections that could
cause more chronic disease. Another consideration
is cough variant asthma. The patient could have
chronic lung disease, could have the postnasal drip
syndrome, might have GERD or might have ACE
inhibitor; these are all things that would go into the
differential of a patient who has a cough that
persists for two to three weeks.
Cough variant asthma is probably worth saying
something a little bit more about because of its
frequency. This is a condition in which the cough
usually last for two to three weeks. There is usually
lack of wheezing and is often worse at night, worse
with cold exposure and worse with exercise, and
the diagnosis is made with pulmonary function
tests, which will show improvement with
bronchodilator therapy.
Pertussis, I have talked about, is an important
diagnosis to recognize for the reasons that were
mentioned and accounts for about 10-20% of
patients, at least in some studies, where the cough
has persisted for two to three weeks. It is often
atypical in presentation because of partial immunity
by the host. The diagnostic tests are vast, in terms
of what is out there, but none of them are very
sensitive, so you have the serologic tests, you have
the DFA stain, you have a PCR technique and you
have culture. All of them are specific when positive,
but none of them are terribly sensitive. So, it is a
tough diagnosis to make in a laboratory. The
treatment of choice is a macrolide, usually
erythromycin or possibly sulfatrimethoprim and the
major reason to treat it to prevent transmission
because once they have gone out that far, why you
do not really do much in terms of all altering the
symptoms.
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With regard to the chronic cough evaluation,
pertussis is a diagnosis that should be suspected on
the basis of symptoms, laboratory data, and
epidemiology as I have already talked about. For
the patient that has the persistent cough, you are
going to want to get a chest X-ray in that setting,
not in the acute setting necessarily, according to
guidance that I gave before. For asthma,
pulmonary function test and then a bronchodilator.
I put on the slide an esophageal study, but actually
most of us are simply going to get a typical history
and treat empirically and measure esophageal pH
only in those who do not respond. For the
postnasal drip syndrome, those are patients who
need to be evaluated for sinusitis.
Finally, Ill finish with a case, which I think
illustrates some of the problems that are likely to
be encountered in a patient that has, what you
might call, acute bronchitis or acute cough
syndrome. So, this is a young medical student who
has cough, fever, mucoid sputum, three days in
duration, the epidemiologic information that you
always need to get. It is September. It is
Baltimore. He has no pets. He has not been
anyplace, and he was previously well. He has a
temperature of 100 and he has clear lungs. The
test is that I have asked about; I did not ask for
treatment. I have already revealed my bias about
treatment.
Does he need a chest X-ray? Does he need a
sputum Gram stain and culture, and does he need a
CBC? I think all of these questions are tough.
I am not sure there is an easy answer to any of
these. Chest X-ray, by the base of what I told you
before, he should have a chest X-ray. He has
abnormal vital signs. He has a temperature of
100. I would have to say that a lot of people are
going to conclude that this person probably has a
viral respiratory tract infection and does need to be
treated or could simply be treated with
erythromycin with possibility or probability that they
have Mycoplasma infection or doxycycline, seven
sets of pills; a lot cheaper than an X-ray. However,
the rules are that this patient ought to have a chest
X-ray. Sputum Gram stains and culture are a little
bit easier; he should not have that. It is not going
to help at all. CBC is kind of arbitrary, but if you
really thought he had Mycoplasma, why that might
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help. So, that is my case and that concludes my
remarks.
Jack Gwaltney, MD: John, there are a group of
patients, and I think you mentioned them, they are
previously healthy adults, they have an acute
respiratory infection, they get a cough, they get
over most of their other symptoms and then they
continue to cough and they often come in about the
second or the third week. They are no longer
producing sputum. They cannot sleep. They are
miserable. In my experience, most of them will get
over the cough and another week or two if you do
not do anything. These patients have been a
problem, as far as I am concerned, and one of the
things you mentioned was the use of a beta-
agonist, albuterol, and the other thing I have heard
mentioned as being useful in these patients is
steroid. Could you comment on those two things?
Dr. Bartlett: Yeah, I can comment on them, but I
am not sure I am the right person to answer the
question. I think if the patient continues to have
problems, that is probably a patient you would want
to get a chest X-ray on just to make sure that they
do not really have something in their lung that you
have to know about. That may be the most
important thing in terms of a diagnosis. In order to
deal with the cough, major complaint, I think
probably the best thing to do is to get pulmonary
function tests and then measure response to a
bronchodilator and if they have a response then
teach them how to use an inhaler with albuterol or
something like that, beta-agonist of some sort. I
also think you probably have to entertain the
possibility that they have pertussis. I think most
physicians are aware of the symptoms that
specifically suggest pertussis. But, I think most of
us are hamstrung by laboratory tests that are not
very helpful for pertussis and really have to have
high clinical index of suspicion in order to know the
person is likely to have that on the base of the
etiology and clinical symptoms with or without the
laboratory. With regards to steroids, I do not have
any experience with steroids. I have usually done
what I mentioned, which is the albuterol therapy,
but I expect that for that patient population a bolus
of steroids would work well as well. I think maybe
somebody in Pulmonary Medicine like Mike
Niederman, might need to make other comments
on the things I have said.
Michael Niederman, MD: I think you have described
a very common clinical scenario and I think that
what distinguishes that patient from the typical
acute bronchitis is, as you have said, they have
gotten over that productive sputum stage of the
disease and it is a predominantly nonproductive
cough. It is worse at night; it is worse with cold air
and exercise and in my experience that is often a
bronchospastic equivalent. Many of those patients,
when you do spirometry, will have abnormalities,
particularly in their mid flow rates, and I think that
is a fairly good clue that they have small airway
obstruction. A lot of those patients do not do that
well with inhaled bronchodilators. They get some
relief but part of the problem is that they have a lot
of ongoing inflammation, and the other part of
problem is that they are so bronchospastic just the
deposition of the inhaler makes them cough even
more, and so we are often forced in that situation
to treat them with, as Dr. Bartlett said, a tapering
course of corticosteroids, typically something like 40
mg of prednisone for two or three days, tapering
down by 10 mg every two or three days and at the
same time starting an inhaled steroid to kick in as
the systemic steroid is tapered. Usually, when they
get to that point, they are sick for a total of
probably six or eight weeks, so we end up giving
them a month course of inhaled steroids and then
try to stop it and see whether or not we can get
by. The other common thing to remember is all the
other causes of cough. A lot of the patients develop
this as a post-infectious bronchospasm. They can
have postnasal drip, also post-infectious, and they
may need an inhaled nasal steroid or antihistamine
and we seem to see a lot of patients with reflux and
so one of the points that has been made is a lot of
these cough syndromes are not just one
explanation, but I do think that post-infectious
cough is dry and is often a bronchospasmic cough
that needs to be treated, just for relief of
symptoms. As you have said, the patients will get
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better anyway, but may be a miserable couple of
weeks until they get better.
Frederick Hayden, MD : John, I want to return
your case, if I could, because you emphasize the
importance of chest X-ray in the differential
diagnosis. Now, if I were to change the season,
lets say January, given influenza circulation during
that period of time, then this scenario is remarkably
common where someone comes in with two to three
days of low grade fever and cough. Are you
advocating those people need a chest X-ray? Dr.
Bartlett: No. I am glad you pointed it out, because
I should have said it during the talk. One of the
exceptions to getting the X-ray in patients who
have cough with vital sign abnormality is when the
clinical suspicion is influenza, because we do not
necessarily want to get a chest X-ray on everybody
with influenza, and since they usually have fever,
they are going to qualify for a chest X-ray. We
know they have influenza and probably do not need
an X-ray as the great majority.
Ilana Newman, MD : Is there any need to lower
your threshold for the use of antibiotics in a
previously healthy patient with a heavy smoker, for
example? Dr. Bartlett: Well, I think not; however,
I think most of those cases are going to be viral
infections. I do not think the patient that has
chronic lung disease who has acute bronchitis with
negative chest X-ray is likely to have a bacterial
infection. Now, if it is an exacerbation of chronic
bronchitis, then that is a different issue, and I think
the evidence that antibiotics work is kind of
marginal, but the standard of the care is that they
are going to get antibiotics, but Mike Niederman is
going to talk about that, so I do not need to discuss
it now. If they have enough symptoms then they
are going to wind up qualifying for an antibiotic.
Dr. Niederman: There are smokers that do not
have chronic bronchitis and those that do, and I
think the definition of chronic bronchitis is not just a
history of smoking, it is chronic recurrent cough,
sputum production three months of the year for two
consecutive years. If the patient fits that definition,
then they fall into the chronic bronchitis category,
and all of those patients do not need antibiotics
either. Patients that need antibiotics in that
category are patients who have at least two to
three cardinal symptoms, has been identified in
clinical trials, and is predicting a response to
antibiotics, which is increased dyspnea, increased
sputum volume and increased sputum purulence.
So, it is a very selective group. I would agree
smoking alone would not be enough to make me
give an antibiotic if there was not a history
compatible with chronic bronchitis.
Alan Bisno, MD : In a patient with chronic cough,
and I have happened to see a fair number of these
in primary care clinic, once I stopped their ACE
inhibitors and ruled out that they do not have GERD
and they are coughing for few weeks and it is a dry
cough with no production, their lungs are clear, but
I will get a chest X-ray at that point anyway to
make sure I am not missing something else. If that
is all negative, at that point do I go to treatment for
pertussis since, as you pointed out, the modalities
for making a timely diagnosis of pertussis are
usually not good in a primary care clinic. Are there
any answers to when you would treat for pertussis
in the case like that when you seem to have
excluded other things? Dr. Bartlett: First of all, I
am glad you mentioned the ACE inhibitor. I think I
implied, but I am not sure I said anything about it,
but that is something that we often overlook or
forget. The issue of the pertussis is really a tough
one and I think a lot of us are going to wind up
saying that after cough that does not seem to
respond to other measures, persists for that
duration of time, that we are going to wind up
giving a macrolide, either because it is pertussis,
possibly, or because it might be pertussis but it also
might be Chlamydia pneumonia or Mycoplasma,
which do tend to hang on. I think it is far more
likely that they have cough variant asthma or post-
nasal drip. I think there are some other things that
are perhaps higher on the priority list in terms of
diagnostic probabilities to explain that, but if those
things do not fit, then I think pertussis has to be a
diagnostic consideration.
Dr. Bisno: One thing I have found is by the time
you stop the ACE inhibitor or put him on a receptor
inhibitor to see if they respond to GERD therapy,
send them for the pulmonary function test and all
that, eventually the cough is probably gone away
anyway. Dr. Bartlett: There was a recent review of
pertussis in state of Massachusetts and they wound
up saying that the great majority of patients had
either posttussive vomiting or had whooping, but I
had an uncomfortable feeling about the report. It
was a large number of cases, 91 cases, but I had an
uncomfortable feeling about the report because
those are specifically the kinds of patients who
would have had diagnostic studies done and I
expect there are a lot more that had pertussis that
they did not know about.
Dr. Gwaltney: John, since we know and have
learned in recent years that in a country like the
United states where the children are immunized
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that the impact of the disease is in adults, that is
pertussis. Is this enough of a problem to immunize
or re-immunize adults? Dr. Bartlett: Who that is
tough! Dr. Hayden: There are actually studies going
on right now with the cellular vaccines in the adult
population, largely sponsored by the National
Institute of Health, so it will be interesting to see
how those trials turn out because it will give us
further information really about the actual attack
rates in the placebo recipients as well as the value
of effects. Dr. Bartlett: But, you know, it has been
very hard to get adults to accept vaccinations for
things that are really common, and pertussis may
be so uncommon that that may not be where we
want to put our energy if it is a vaccine strategy.
Dr. Hayden: I think it will be interesting to see what
the evidence says when it comes out of these trials
and that is the importance of having the placebo to
really gain the knowledge about incidents. Dr.
Bartlett: But I mean, just in this room, how many
people have seen a case of pertussis in the last
year? Dr. Gwaltney: Clinical pertussis. Medical
panelist : Let me say I have not recognized a case
of the pertussis in the last year.
Dr. Niederman: I think it is interesting that we are
getting into almost a paradoxical situation where
you are absolutely right, we have to be careful with
using antibiotics and yet this looming threat of
pertussis may mean that we will pull the trigger and
give antibiotics anyway after a time. Then the
other thing that I worry about is the data showing
that patients with negative chest radiographs who
might fit the acute bronchitis syndrome when they
have had CT scans and sometimes have infiltrates,
and maybe those patients need to get antibiotic
therapy, thought it is not clear just because CT scan
shows an infiltrate and the X-ray is negative that
you have a pneumonia that needs to be treated, but
I guess my question would be would you relent a
little bit on the use of antibiotics in a patient with
the negative chest radiograph and focal physical
findings? Dr. Bartlett:: I was trying to make it real
clean. What you are referring to is a publication in
which there were spiral CTs done of patients who
had signs and symptoms of pneumonia and had
negative chest X-ray but had positive viral CTs. I
always interpreted that as giving you information
that you did not want or need in the sense that
there are all those bronchitis studies, which
probably included a heck of a lot of patients, who
would have had positive spiral CTs, and they did not
seem the benefit from antibiotics. So, I assume
that that was defining a population that really did
not need antibiotics. It may be that we go in that
direction, but you know it is interesting. After that
paper came out, it said one-third of people that had
negative chest-rays had positive spiral CTs.
Nobody that I know of, has really picked up on that
and said we ought to be doing CT scans. Dr.
Niederman: I dont think anybody wants to do a CT
scan for acute bronchitis, but I think that you are
right. It raises the question, are these pneumonias
that need treatment? I guess the way I have
interpreted it is I do not know if they need
treatment but I am more willing to treat somebody
who has a negative X-ray and focal physical
findings because I worry it could be the situation
you described of an early pneumonia that just has
not yet shown up on X-ray, but if they have clear
cut physical findings, maybe they should be treated
with antibiotics. Thank you very much.

The Management of Acute Bronchitis
John G. Bartlett, MD
Page 12 of 12
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John G. Bartlett, MD
Chief, Division of Infectious Diseases
Professor of Medicine
The Johns Hopkins University School of Medicine
John G Bartlett, M.D. is Professor of Medicine and Chief of the Division of Infectious Diseases at John Hopkins
University School of Medicine. He received his undergraduate degree at Dartmouth in 1959 and his medical
degree at Upstate Medical Center in Syracuse in 1963. Training in internal medicine was done at the Brigham
Hospital in Boston and the University of Alabama, he then received his fellowship training in infectious diseases at
UCLA. In 1970, he joined the faculty of UCLA, and then joined the faculty of Tufts University School of
Medicine where he served as Associate Chief of Staff for Research at the Boston VA Hospital. In 1980, he moved
to Hopkins to assume his current position. Dr. Bartlett has worked in several areas of research, all related to his
specialty in infectious diseases. Major research interests and publications have dealt with anaerobic infections,
pathogenic mechanisms of Bacteroides fragilis, anaerobic pulmonary infections, and Clostridium difficile-
associated colitis. Since moving to Hopkins in 1980, his major interests, and have been HIV/AIDS and, most
recently, managed care of patients with HIV infection.