Which children with persistent cough should be regarded as persistent bacterial bronchitis?

We read with interest the article by Donnelly et al 1 on outcomes treated for persistent bacterial bronchitis. They reported on 81 children with persistent cough for a period of 1 month to 14 years with a retrospective chart review. The authors defined persistent bacterial bronchitis as a wet cough present for .1 month that resolved with appropriate antibiotic treatment. They concluded that persistent bacterial bronchitis is often misdiagnosed as asthma, and that the number of patients is increasing because of the reduction in prescribing of antibiotics in the community. Prolonged antibiotic prescription is an appropriate and safe treatment in children with persistent wet cough as advocated in this paper. Paediatricians reading the paper may think that all children with persistent wet cough lasting .1 month should be labelled first as persistent bacterial bronchitis and that antibiotics should be used for at least 6– 8 weeks to prevent progression to bronchiectasis in such children. There are a number of issues in this study on which we would like to comment. First, the authors defined persistent cough as a cough lasting .1 month, which means that patients with post-infectious cough might have been included in their analysis. However, this type of persistent cough may last .1 month but resolves progressively without any specific treatment. In fact, this was defined as ''period effect'' in reports defining and evaluating cough in children. 2 3 Second, almost 60% of their patients were symptomatic before 2 years of age and almost half also had wheezing and shortness of breath at referral for .1 year, which is very similar to a classic asthma history. These children were reported to be symptomatic despite anti-asthmatic treatment. However, the authors did not mention whether they had checked that these children had been treated effectively with asthma medications (ie, with an appropriate dose and for an appropriate duration). They also did not state whether they checked for problems with compliance with asthma treatment before they started to treat them with an antibiotic. Third, 11% of children diagnosed as having persistent bacterial bronchitis, which was expected to resolve with antibiotics, were still symptomatic at referral although they were on antibiotic treatment. In addition, almost half of the patients required at least 6 weeks of antibiotic treatment and 13% needed treatment for >3 months, which cannot be considered a minority. Most importantly, this approach may mislead general practitioners and paediatricians both to …