Antibiotics for acute bronchitis

Patterns and predictors of positive multiplex polymerase chain reaction respiratory panel among patients with acute respiratory infections in a single center in Lebanon

BACKGROUND

Infectious agents associated with community-acquired acute respiratory infections (ARIs) remain understudied in Lebanon. We aim to assess the microbiological profiles of ARIs by employing polymerase chain reaction (PCR) and identifying predictors of positive PCR results among patients admitted for ARI.

METHODS AND RESULTS

We conducted a retrospective single-center study at the American University of Beirut Medical Center, including all respiratory PCR panels performed on pediatric (< 18) and adult (≥ 18) patients presenting with an ARI from January 2015 to March 2018, prior to the onset of the COVID-19 pandemic. We aimed to identify the epidemiological patterns of ARIs and the factors associated with positive PCRs in both adult and pediatric patients. Among 281 respiratory PCRs, 168 (59.7%) were positive for at least one pathogen, with 54.1% positive PCR for viruses, 7.8% for bacteria species, and 3.9% with virus-bacteria codetection. Almost 60% of the patients received antibiotics prior to PCR testing. PCR panels yielded more positive results in pediatric patients than in adults (P = 0.005). Bacterial detection was more common in adults compared to pediatrics (P < 0.001). The most common organism recovered in the entire population was Human Rhinovirus (RhV) (18.5%). Patients with pleural effusion on chest CT were less likely to have a positive PCR (95% Cl: 0.22-0.99). On multivariate analysis, pediatric age group (P < 0.001), stem cell transplant (P = 0.006), fever (P = 0.03) and UTRI symptoms (P = 0.004) were all predictive of a positive viral PCR.

CONCLUSION

Understanding the local epidemiology of ARI is crucial for proper antimicrobial stewardship. The identification of factors associated with positive respiratory PCR enhances our understanding of clinical characteristics and potential predictors of viral detection in our population.

Levels and determinants of overprescribing of antibiotics in the public and private primary care sectors in South Africa

Although overprovision of antibiotics in primary care is a key driver of antibiotic resistance, little is known about its determinants in low-income and middle-income countries. Patient demand and financial incentives for providers are often held responsible for overprovision. Yet, inadequate provision exists in their absence and could be fuelled by quality of care issues and incorrect beliefs of providers regarding patients' expectations. We explored these issues in the private and public sector in South Africa, by conducting a cross-sectional study using standardised patients (SPs)-healthy individuals trained to portray a scripted clinical case to providers-presenting with symptoms of a viral respiratory infection in a sample of public and private sector clinics. We linked data from SP visits to rich survey data to compare the practices and their predictors in the two sectors. Unnecessary rates of antibiotics were similarly high in the public (78%) and private sector (67%), but private providers prescribed more antibiotics at higher risk of resistance development. In the private sector, overprescription of antibiotics diminished when consultations were more thorough, but increased for consultations scheduled later in the day, suggesting contrasting effects for provider effort and decision fatigue. We observed differences in beliefs that could be responsible for overprescription: in the public sector, a majority of providers (nurses) wrongly believed that antibiotics would help the patient recover more quickly. In the private sector, a majority of doctors thought patients would not come back if they did not receive antibiotics. Overall, this evidence suggests that different factors may be responsible for the high overprescribing rates of antibiotics in the public and private sectors. Tailored stewardship interventions are urgently needed that tackle providers' engrained habits and incorrect beliefs.

A combination of Tropaeolum majus herb and Armoracia rusticana root for the treatment of acute bronchitis

BACKGROUND

Tropaeolum majus herb (nasturtium) and Armoracia rusticana root (horseradish) produce three different isothiocyanates as secondary metabolites, which exert antibacterial, anti-inflammatory, and immune-modulatory functions in humans.

PURPOSE

Combined in the medicinal product ANGOCIN® Anti-Infekt N, the two natural components demonstrated promising effects against acute bronchitis.

STUDY DESIGN

A randomized, two-armed, placebo-controlled, double-blind, phase IV study revealed the healing fostering effect of the two herbal plant components METHODS: This study included 384 patients, with 195 in the treatment and 189 in the placebo group. The 'bronchitis severity score' (BSS) was utilized as primary endpoint. This score sums the ratings for five significant bronchitis symptoms, which are established at the patient's visits to the clinic.

RESULTS

Compared to placebo intake, the group of patients treated with the phytomedicine showed statistically significant accelerated healing of bronchitis symptoms after three days of treatment, with reductions in coughing, mucous production, and chest pain. This beneficial effect persisted for the entire duration of treatment until day ten.

CONCLUSION

In conclusion, a combination of Tropaeolum majus herb and Armoracia rusticana root promotes an elevated improvement of bronchitis symptomatology.

Clostridium difficile and other adverse events from overprescribed antibiotics for acute upper respiratory infection

BACKGROUND

Guidelines widely recommend avoiding antibiotics for many acute upper respiratory infections (aURIs) to avert adverse events in the absence of likely benefit. However, the extent of harm from these antibiotics remains a subject of debate and could inform patient-centered decision-making. Prior estimates finding a number needed to harm (NNH) between 8 and 10 rely on patient-reported adverse events of any severity. In this analysis, we sought to estimate adverse events by only measuring comparatively severe events that require subsequent clinical evaluation.

METHODS

We constructed a retrospective cohort, including 51 million patient encounters. Using logistic regression models, we determined the adjusted odds ratio (aOR) of clinically detectable adverse events following antibiotic use compared with events among unexposed individuals with aURIs. Our outcomes included candidiasis, diarrhea, Clostridium difficile infection (CDI), and a composite outcome.

FINDINGS

From our analysis, 62.4% of the population received antibiotics in an aURI encounter. Observed adverse events in the antibiotic-exposed group were 54,279 and 46,936 for diarrhea and candidiasis, respectively, yielding an aOR of 1.24 and 1.61, and an NNH of 3,126 and 1,975. Observed events of CDI in the exposed group were 30,133, and aORs of isolated CDI and combined adverse events were 1.07 and 1.30, resulting in an NNH of 17,695 and 1,150, respectively. Females were more likely to be diagnosed with any adverse event. Overall antibiotics were found to result in 5.7 additional cases of CDI per 100,000 outpatient prescriptions following an upper respiratory tract infection.

INTERPRETATION

Despite higher NNH than previous methods of analysis, we find substantial iatrogenic harm associated with prescribing antibiotics in aURIs.

Comparing GPs' antibiotic prescribing decisions to a clinical prediction rule: an online vignette study

BACKGROUND

The 'STARWAVe' clinical prediction rule (CPR) uses seven factors to guide risk assessment and antibiotic prescribing in children with cough (Short illness duration, Temperature, Age, Recession, Wheeze, Asthma, Vomiting).

AIM

To assess the influence of STARWAVe factors on GPs' unaided risk assessments and prescribing decisions.

DESIGN AND SETTING

Clinical vignettes administered to 188 UK GPs online.

METHOD

GPs were randomly assigned to view 32 (out of a possible 64) vignettes online depicting children with cough. The vignettes comprised the seven STARWAVe factors, which were varied systematically. For each vignette, GPs assessed risk of deterioration in one of two ways (sliding-scale versus risk-category selection) and indicated whether they would prescribe antibiotics. Finally, GPs saw an additional vignette, suggesting that the parent was concerned. Mixed-effects regressions were used to measure the influence of STARWAVe factors, risk-elicitation method, and parental concern on GPs' assessments and decisions.

RESULTS

Six STARWAVe risk factors correctly increased GPs' risk assessments (bssliding-scale≥0.66, odds ratios [ORs]category-selection≥1.75, Ps≤0.001), whereas one incorrectly reduced them (short illness duration: b sliding-scale -0.30, ORcategory-selection 0.80, P≤0.039). Conversely, one STARWAVe factor increased prescribing odds (temperature: OR 5.22, P<0.001), whereas the rest either reduced them (short illness duration, age, and recession: ORs≤0.70, Ps<0.001) or had no significant impact (wheeze, asthma, and vomiting: Ps≥0.065). Parental concern increased risk assessments (b sliding-scale 1.29, ORcategory-selection 2.82, P≤0.003) but not prescribing odds (P = 0.378).

CONCLUSION

GPs use some, but not all, STARWAVe factors when making unaided risk assessments and prescribing decisions. Such discrepancies must be considered when introducing CPRs to clinical practice.

User initiated symptom assessment with an electronic symptom checker. Study protocol for mixed-methods validation. (Preprint)

BACKGROUND

The national Omaolo digital social welfare and health care service of Finland provides a symptom checker, Omaolo, which is a medical device (based on Duodecim Clinical Decision Support EBMEDS software) with a CE marking (risk class IIa), manufactured by the government-owned DigiFinland Oy. Users of this service can perform their triage by using the questions in the symptom checker. By completing the symptom checker, the user receives a recommendation for action and a service assessment with appropriate guidance regarding their health problems on the basis of a selected specific symptom in the symptom checker. This allows users to be provided with appropriate health care services, regardless of time and place.

OBJECTIVE

This study describes the protocol for the mixed methods validation process of the symptom checker available in Omaolo digital services.

METHODS

This is a mixed methods study using quantitative and qualitative methods, which will be part of the clinical validation process that takes place in primary health care centers in Finland. Each organization provides a space where the study and the nurse triage can be done in order to include an unscreened target population of users. The primary health care units provide walk-in model services, where no prior phone call or contact is required. For the validation of the Omaolo symptom checker, case vignettes will be incorporated to supplement the triage accuracy of rare and acute cases that cannot be tested extensively in real-life settings. Vignettes are produced from a variety of clinical sources, and they test the symptom checker in different triage levels by using 1 standardized patient case example.

RESULTS

This study plan underwent an ethics review by the regional permission, which was requested from each organization participating in the research, and an ethics committee statement was requested and granted from Pirkanmaa hospital district's ethics committee, which is in accordance with the University of Tampere's regulations. Of 964 clinical user-filled symptom checker assessments, 877 cases were fully completed with a triage result, and therefore, they met the requirements for clinical validation studies. The goal for sufficient data has been reached for most of the chief symptoms. Data collection was completed in September 2019, and the first feasibility and patient experience results were published by the end of 2020. Case vignettes have been identified and are to be completed before further testing the symptom checker. The analysis and reporting are estimated to be finalized in 2024.

CONCLUSIONS

The primary goals of this multimethod electronic symptom checker study are to assess safety and to provide crucial information regarding the accuracy and usability of the Omaolo electronic symptom checker. To our knowledge, this will be the first study to include real-life clinical cases along with case vignettes.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/41423.

Antibiotic prescribing patterns for acute respiratory infections in a free clinic network: A pooled cross-sectional study

In the United States, overprescribing of antibiotics for viral respiratory infections and antimicrobial resistance continue to be public health concerns. To date, no literature has focused on antibiotic prescribing patterns from free clinics. To address this gap, we used patient-level data from a student-run free clinic network of four primary care clinics to assess factors associated with inappropriate antibiotic prescribing for viral respiratory infections. Treatment plans were deemed inappropriate if any type of antibiotic was prescribed. We used unpaired t-tests and chi-square tests to assess for differences in receiving an inappropriate antibiotic prescription by patient-level factors (i.e., age, race/ethnicity, sex, educational attainment, preferred language, insurance status). Of 298 visits, 22.5% did not meet treatment guidelines. No patient-level factors studied were associated with inappropriate antibiotic prescribing. Our findings suggest other factors, beyond patient-level, may be drivers of variation in antibiotic prescribing in free clinics.

Knowledge, Attitude and Practice of Family Physicians on Antimicrobial Therapy for Acute Respiratory Tract Infections - A Study from Istanbul, Turkey

Aim: We aimed to investigate the knowledge, attitude, practice of family physicians regarding an-timicrobial therapy in acute respiratory tract infections. Methods: After receiving the ethics committee approval, the data were collected by online questionnaire from a phone application with 304 physicians. Questions about socio-demographic features and knowledge, attitude, and practices on antibiotics use were asked. Using SPSS, we did the statistical analyses with appropriate procedures. Results: Among the participants, 127 (41.8%) were specialists, and 177 (58.2%) were gen-eral practitioners. The specialists gave correct answers about tonsillopharyngitis and bron-chiolitis significantly more often than the general practitioners did. The antibiotic choices for acute otitis media were not in compliance with the guidelines of the Centers for Disease Control, and between the groups, there was no significant difference in terms of initial antibiotic choice. The self-reported antibiotic prescription rate was 25%. In 10%, the most common perceived reason for inappropriate antibiotic prescription was pressure from patients. Conclusion: There remains considerable misuse of antibiotics by primary care physicians for acute respiratory tract infections. Education of physicians and patients regarding acute respiratory tract infections may be needed to lower the rate of inappropriate antibiotic pre-scriptions. Keywords: public health practice, practice patterns, primary healthcare

Evaluation of a multimodal intervention to promote rational antibiotic use in primary care

Background

Increasing antimicrobial resistance is a serious societal challenge affecting outpatient, inpatient and veterinary care. The German One-Health project, RAI (Rational use of Antibiotics via Information and Communication) addresses all three sectors. In the outpatient sector, General Practitioners (GPs) are the main prescribers of antibiotics and were therefore, targeted for this study. A multimodal intervention focusing on Acute Respiratory Tract infections (ARI) was designed and implemented. The aim of this study was to evaluate acceptance, rating and the self-reported impact of the intervention among GPs.

Methods

The intervention offered six tools: a GP training on rational antibiotic use, an app for self-monitoring, a leaflet and a set of posters (both for use as information materials in waiting rooms) and both digital and printed information prescriptions (material for ‘prescribing’ information instead of an antibiotic to the patient). The tools could be used according to individual preferences. The intervention was conducted between August 2016 and July 2017. Following the intervention, a three pages anonymous questionnaire was sent to all 271 participants. Items covered socio-demographic and professional background, use and judgement of the intervention tools (6 point Likert scale), impact of the intervention tools (4 point Likert scale).

Results

The response rate was 39% (n = 107). On average, respondents used 3.1 of the six available tools, with printed information prescriptions used most frequently (79%). Digital information prescriptions were used more frequently by men than by women (OR 2.8; 95% CI 1.16–7.24; p = 0.02). Eighty-seven percent of respondents stated that information prescriptions supported doctor-patient communication. In a comparison of the overall impression of the different intervention tools the GP training on rational antibiotic use was rated best (1.67 on a 6 point scale with 1 = highest, 6 = lowest) and most often noted as having had a “strong” or “very strong” impact on personal antibiotic prescribing behavior.

Conclusions

The multimodal intervention addressing education and communication was well accepted among GPs and could help in fostering rational use of antibiotics in primary care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13756-021-00908-9.

Effectiveness of interventions involving pharmacists on antibiotic prescribing by general practitioners: a systematic review and meta-analysis

BACKGROUND

The use of community antibiotic stewardship programmes (ASPs) is rising; however, their effectiveness when pharmacists are involved is uncertain.

OBJECTIVES

To assess the effectiveness of ASPs involving pharmacists at improving antibiotic prescribing by general practitioners (GPs).

METHODS

Medline, Embase, Emcare, PubMed, PsycINFO, Cochrane CENTRAL, CINAHL Plus and Web of Science databases were searched to February 2018. Randomized and non-randomized studies of ASPs involving pharmacists as interventionists to GPs were included. Primary outcomes were absolute changes in GPs' antibiotic prescribing rate (APR) and antibiotic prescribing adherence rate (APAR) according to recommendations/guidelines. Meta-analysis used random effects models.

RESULTS

Fifteen studies reporting 18 trials were included in the meta-analysis: 8 assessed the APR and 10 the APAR. APR reductions (OR 0.86, 95% CI 0.78-0.95, moderate-certainty evidence) and APAR improvements (OR 1.96, 95% CI 1.56-2.45, high-certainty evidence) were observed at 6 months median intervention follow-up. High-quality randomized trials reduced the APR (OR 0.92, 95% CI 0.90-0.94) and increased the APAR (OR 2.55, 95% CI 2.16-3.01). Interventions were successful in decreasing the APR (OR 0.93, 95% CI 0.90-0.95) and increasing the APAR (OR 1.72, 95% CI 1.04-2.84) when implemented by a pharmacist-GP team. Interventions involving pharmacist-infectious disease professional teams also decreased the APR (OR 0.81, 95% CI 0.66-1.0) and increased the APAR (OR 2.36, 95% CI 1.87-2.96). GP education plus prescribing feedback, and group meetings were effective in both outcomes, whereas GP education, academic detailing and workshop training were effective in APAR outcome. However, substantial heterogeneity was demonstrated.

CONCLUSIONS

ASPs involving pharmacists are effective in decreasing antibiotic prescribing and increasing guideline-adherent antibiotic prescribing by GPs.

Autonomy, power dynamics and antibiotic use in primary healthcare: A qualitative study

Antibiotic resistance is a global health concern. Although numerous strategies have tried to reduce inadequate antibiotic prescribing, antibiotics are still prescribed in 60% of acute lower respiratory tract infections (ALRTIs) cases in Catalonia (Spain). This study aims to explore service users' experiences of ALRTIs, the quality and access to healthcare services, and health education. Selective purposive sampling was carried out, based on a prior definition of participant characteristics. These were sex, age, ethnicity, date of the last ALRTI, number of ALRTIs in the last year, and treatments received. Participants with a previous diagnosis of ALRTIs were recruited from three primary health care centres in Barcelona and one in Tarragona. Twenty-nine interviews were conducted between April and June 2019. A content thematic analysis was performed. Three themes were identified: 1) risk perceptions and help-seeking; 2) treatment preferences and antibiotic use; and 3) relationship dynamics and communication with healthcare professionals. Accounts of service users' sense of autonomy towards their health and power dynamics within the healthcare system were apparent. Supporting service users to become reliable, subjective and agentic experts of their health and bodies could help them to voice their healthcare agendas. Power structures embedded within healthcare, political and economic institutions should be challenged so that healthcare services can be co-developed (with service users) and based on service users' autonomy and horizontal relationships. Special consideration should be paid to the intersection of social vulnerabilities. A concordance approach to prescribing could be key to improve the responsible use of antibiotics and to contribute to the prevention of AMR in primary healthcare. The marketisation of health, and the increased demands of private healthcare in Spain due to the financial pressures on public healthcare as a consequence of the financial crisis of 2008 and the COVID-19 pandemic, are a risk for promoting adequate antibiotic prescribing and use. Trial registration The ISAAC-CAT study has been registered in the NCT registry, ID: NCT03931577.

Effects of primary care C-reactive protein point-of-care testing on antibiotic prescribing by general practice staff: pragmatic randomised controlled trial, England, 2016 and 2017

Background

C-reactive protein (CRP) testing can be used as a point-of-care test (POCT) to guide antibiotic use for acute cough.

Aim

We wanted to determine feasibility and effect of introducing CRP POCT in general practices in an area with high antibiotic prescribing for patients with acute cough and to evaluate patients’ views of the test.

Methods

We used a McNulty–Zelen cluster pragmatic randomised controlled trial design in general practices in Northern England. Eight intervention practices accepted CRP testing and eight control practices maintained usual practice. Data collection included process evaluation, patient questionnaires, practice audit and antibiotic prescribing data.

Results

Eight practices with over 47,000 patient population undertook 268 CRP tests over 6 months: 78% of patients had a CRP < 20 mg/L, 20% CRP 20–100 mg/L and 2% CRP > 100 mg/L, where 90%, 22% and 100%, respectively, followed National Institute for Health and Care Excellence (NICE) antibiotic prescribing guidance. Patients reported that CRP testing was comfortable (88%), convenient (84%), useful (92%) and explained well (85%). Patients believed CRP POCT aided clinical diagnosis, provided quick results and reduced unnecessary antibiotic use. Intervention practices had an estimated 21% reduction (95% confidence interval: 0.46–1.35) in the odds of prescribing for cough compared with the controls, a non-significant but clinically relevant reduction.

Conclusions

In routine general practice, CRP POCT use was variable. Non-significant reductions in antibiotic prescribing may reflect small sample size due to non-use of tests. While CRP POCT may be useful, primary care staff need clearer CRP guidance and action planning according to NICE guidance.

Antibiotic use and prescription and its effects on Enterobacteriaceae in the gut in children with mild respiratory infections in Ho Chi Minh City, Vietnam. A prospective observational outpatient study

BACKGROUND AND OBJECTIVES

Treatment guidelines do not recommend antibiotic use for acute respiratory infections (ARI), except for streptococcal pharyngitis/tonsillitis and pneumonia. However, antibiotics are prescribed frequently for children with ARI, often in absence of evidence for bacterial infection. The objectives of this study were 1) to assess the appropriateness of antibiotic prescriptions for mild ARI in paediatric outpatients in relation to available guidelines and detected pathogens, 2) to assess antibiotic use on presentation using questionnaires and detection in urine 3) to assess the carriage rates and proportions of resistant intestinal Enterobacteriaceae before, during and after consultation.

MATERIALS AND METHODS

Patients were prospectively enrolled in Children's Hospital 1, Ho Chi Minh City, Vietnam and diagnoses, prescribed therapy and outcome were recorded on first visit and on follow-up after 7 days. Respiratory bacterial and viral pathogens were detected using molecular assays. Antibiotic use before presentation was assessed using questionnaires and urine HPLC. The impact of antibiotic usage on intestinal Enterobacteriaceae was assessed with semi-quantitative culture on agar with and without antibiotics on presentation and after 7 and 28 days.

RESULTS

A total of 563 patients were enrolled between February 2009 and February 2010. Antibiotics were prescribed for all except 2 of 563 patients. The majority were 2nd and 3rd generation oral cephalosporins and amoxicillin with or without clavulanic acid. Respiratory viruses were detected in respiratory specimens of 72.5% of patients. Antibiotic use was considered inappropriate in 90.1% and 67.5%, based on guidelines and detected pathogens, respectively. On presentation parents reported antibiotic use for 22% of patients, 41% of parents did not know and 37% denied antibiotic use. Among these three groups, six commonly used antibiotics were detected with HPLC in patients' urine in 49%, 40% and 14%, respectively. Temporary selection of 3rd generation cephalosporin resistant intestinal Enterobacteriaceae during antibiotic use was observed, with co-selection of resistance to aminoglycosides and fluoroquinolones.

CONCLUSIONS

We report overuse and overprescription of antibiotics for uncomplicated ARI with selection of resistant intestinal Enterobacteriaceae, posing a risk for community transmission and persistence in a setting of a highly granular healthcare system and unrestricted access to antibiotics through private pharmacies.

REGISTRATION

This study was registered at the International Standard Randomised Controlled Trials Number registry under number ISRCTN32862422: http://www.isrctn.com/ISRCTN32862422.

Antibiotic prescription for febrile outpatients: a health facility-based secondary data analysis for the Greater Accra region of Ghana

Background

Misguided prescription of antibiotics is an important contributor towards the emergence and spread of antibiotic resistance. The absence of effective interventions to control antibiotic use leads to increased consumption beyond the needed requirements. Antibiotic stewardship interventions must be appropriately targeted and assessed to enhance the controlled use of antibiotics. The objective of this study was to determine the factors associated with antibiotic prescription to febrile outpatients who seek care in health facilities within the Greater Accra region of Ghana.

Methods

Secondary data obtained from the medical records of 2519 febrile outpatients, consecutively sampled at the outpatient department of 6 health facilities in 3 municipalities during the baseline survey of a quasi-experiment in 2015 was used. The primary outcome was prescription of any antibiotic. Independent variables included patients’ demographics, symptoms, laboratory investigations (blood film microscopy, malaria rapid diagnostic test, full blood count, urine and stool routine examinations), diagnoses, and prescribers’ demographics. Crude and adjusted logistic regression analyses were used to determine the factors associated with antibiotic prescription.

Results

The prevalence of antibiotic prescription was 70.1% (95% CI: 67.7–72.4). Prescribers with more years of practice (> 5 years) were more likely to prescribe antibiotics compared to those with less than 3 years of practice (p <  0.001). Integrated Management of Neonatal and Childhood Illnesses (IMNCI) training was associated with a 2.3 (95% CI: 1.54, 3.53, p <  0.001) fold odds of antibiotic prescribing. Patients aged 5 years or more were 60% less likely to receive antibiotics compared with those under 5 years (AOR = 0.40, 95% CI: 0.32, 0.51; p <  0.001). Patients referred for laboratory investigations were 29% less likely to be prescribed antibiotics than those not referred. The presence of cough as a presenting symptom was associated with a 3.5 (95% CI: 2.54, 4.92) fold odds of antibiotic prescription.

Conclusion

Prescription of antibiotics to febrile outpatients was high. Promoting laboratory testing can potentially reduce irrational antibiotic prescription. Prescribing antibiotics for children under five and the prescribing practices of prescribers with longer years of practice should be targeted with interventions to reduce high use of antibiotics.

[Acute and chronic cough-What is new?]

The most frequent cause of acute cough (lasting up to 3 weeks) or subacute cough (3-8 weeks) is a viral infection, which is mostly a self-limiting disease in otherwise healthy persons. Some herbal compounds, the antitussive dextromethorphan and ambroxol are effective for symptom relief. Antibiotics are ineffective and should not be used due to resistance development. If after appropriate diagnostic procedures the cause of chronic cough, i.e. cough lasting more than 8 weeks, cannot be attributed to a well-established respiratory disease, it meets the definition of a disease in its own right, chronic idiopathic (unexplained) cough (CIH). This is caused by hypersensitivity of the cough reflex. Thus, even weak low threshold stimuli, e.g. changing temperature, extensive speaking and odors can trigger the cough reflex. In the case of nonresponse to guideline-conform treatment the definition of chronic refractory cough is met.

Point-of-Care C-Reactive Protein Testing to Reduce Antibiotic Prescribing for Respiratory Tract Infections in Primary Care: Systematic Review and Meta-Analysis of Randomised Controlled Trials

C-reactive protein (CRP) point-of-care testing (POCT) is increasingly being promoted to reduce diagnostic uncertainty and enhance antibiotic stewardship. In primary care, respiratory tract infections (RTIs) are the most common reason for inappropriate antibiotic prescribing, which is a major driver for antibiotic resistance. We systematically reviewed the available evidence on the impact of CRP-POCT on antibiotic prescribing for RTIs in primary care. Thirteen moderate to high-quality studies comprising 9844 participants met our inclusion criteria. Meta-analyses showed that CRP-POCT significantly reduced immediate antibiotic prescribing at the index consultation compared with usual care (RR 0.79, 95%CI 0.70 to 0.90, p = 0.0003, I² = 76%) but not during 28-day (n = 7) follow-up. The immediate effect was sustained at 12 months (n = 1). In children, CRP-POCT reduced antibiotic prescribing when CRP (cut-off) guidance was provided (n = 2). Meta-analyses showed significantly higher rates of re-consultation within 30 days (n = 8, 1 significant). Clinical recovery, resolution of symptoms, and hospital admissions were not significantly different between CRP-POCT and usual care. CRP-POCT can reduce immediate antibiotic prescribing for RTIs in primary care (number needed to (NNT) for benefit = 8) at the expense of increased re-consultations (NNT for harm = 27). The increase in re-consultations and longer-term effects of CRP-POCT need further evaluation. Overall, the benefits of CRP-POCT outweigh the potential harms (NNTnet = 11).

Risk assessment and antibiotic prescribing decisions in children presenting to UK primary care with cough: a vignette study

OBJECTIVES

The validated 'STARWAVe' (Short illness duration, Temperature, Age, Recession, Wheeze, Asthma, Vomiting) clinical prediction rule (CPR) uses seven variables to guide risk assessment and antimicrobial stewardship in children presenting with cough. We aimed to compare general practitioners' (GPs) risk assessments and prescribing decisions to those of STARWAVe and assess the influence of the CPR's clinical variables.

SETTING

Primary care.

PARTICIPANTS

252 GPs, currently practising in the UK.

DESIGN

GPs were randomly assigned to view four (of a possible eight) clinical vignettes online. Each vignette depicted a child presenting with cough, who was described in terms of the seven STARWAVe variables. Systematically, we manipulated patient age (20 months vs 5 years), illness duration (3 vs 6 days), vomiting (present vs absent) and wheeze (present vs absent), holding the remaining STARWAVe variables constant.

OUTCOME MEASURES

Per vignette, GPs assessed risk of hospitalisation and indicated whether they would prescribe antibiotics or not.

RESULTS

GPs overestimated risk of hospitalisation in 9% of vignette presentations (88/1008) and underestimated it in 46% (459/1008). Despite underestimating risk, they overprescribed: 78% of prescriptions were unnecessary relative to GPs' own risk assessments (121/156), while 83% were unnecessary relative to STARWAVe risk assessments (130/156). All four of the manipulated variables influenced risk assessments, but only three influenced prescribing decisions: a shorter illness duration reduced prescribing odds (OR 0.14, 95% CI 0.08 to 0.27, p<0.001), while vomiting and wheeze increased them (OR_vomit 2.17, 95% CI 1.32 to 3.57, p=0.002; OR_wheeze 8.98, 95% CI 4.99 to 16.15, p<0.001).

CONCLUSIONS

Relative to STARWAVe, GPs underestimated risk of hospitalisation, overprescribed and appeared to misinterpret illness duration (prescribing for longer rather than shorter illnesses). It is important to ascertain discrepancies between CPRs and current clinical practice. This has implications for the integration of CPRs into the electronic health record and the provision of intelligible explanations to decision-makers.

Unnecessary antibiotic prescribing in a Canadian primary care setting: a descriptive analysis using routinely collected electronic medical record data

BACKGROUND

Unnecessary antibiotic use in the community in Canada is not well defined. Our objective was to quantify unnecessary antibiotic prescribing in a Canadian primary care setting.

METHODS

We performed a descriptive analysis in Ontario from April 2011 to March 2016 using the Electronic Medical Records Primary Care database linked to other health administrative data sets at ICES. We determined antibiotic prescribing rates (per 100 patient-physician encounters) for 23 common conditions and estimated rates of unnecessary prescribing using predefined expected prescribing rates, both stratified by condition and patient age group.

RESULTS

The study included 341 physicians, 204 313 patients and 499 570 encounters. The rate of unnecessary antibiotic prescribing for included conditions was 15.4% overall and was 17.6% for those less than 2 years of age, 18.6% for those aged 2-18, 14.5% for those aged 19-64 and 13.0% for those aged 65 or more. The highest unnecessary prescribing rates were observed for acute bronchitis (52.6%), acute sinusitis (48.4%) and acute otitis media (39.3%). The common cold, acute bronchitis, acute sinusitis and miscellaneous nonbacterial infections were responsible for 80% of the unnecessary antibiotic prescriptions. Of all antibiotics prescribed, 12.0% were for conditions for which they are never indicated, and 12.3% for conditions for which they are rarely indicated. In children, 25% of antibiotics were for conditions for which they are never indicated (e.g., common cold).

INTERPRETATION

Antibiotics were prescribed unnecessarily for 15.4% of included encounters in a Canadian primary care setting. Almost one-quarter of antibiotics were prescribed for conditions for which they are rarely or never indicated. These findings should guide safe reductions in the use of antibiotics for the common cold, bronchitis and sinusitis.

Assessment of the 4-week repeated-dose oral toxicity and genotoxicity of GHX02

Herbal medicines are widely utilized for disease prevention and health promotion. GHX02 consists of mixtures including Gwaruin (Trichosanthes kirilowii), Haengin (Prunus armeniaca), Hwangryeon (Coptis japonica) and Hwangkeum (Scutellaria baicalensis). It has been purported to have therapeutic effectiveness in cases of severe bronchitis. Non‐clinical safety testing comprised a single‐dose oral toxicity study and a 28‐day repeated‐dose oral toxicity study with a 14‐day recovery period, and genotoxicity was assessed by a bacterial reverse mutation test, in vitro chromosomal aberration test, in vivo mouse bone marrow micronucleus test and single cell gel electrophoresis assay (comet assay). In the single‐dose oral toxicity study, the approximate lethal dosage is estimated to be higher than 5000 mg/kg in rats. Thus, the dosage levels were set at 0, 1250, 2500 and 5000 mg/kg/day in the 28‐day repeated‐dose oral toxicity study, and 10 male rats and 10 female rats/dose were administered GHX02. No clinical signs of toxicological significance were recorded in any animal during the dosing and the observation period in the single‐dose study. The no‐observed‐adverse‐effect level of GHX02 was 5000 mg/kg/day when administered orally for 28 days to male and female Sprague‐Dawley rats. Despite increases in the frequencies of cells with numerical chromosomal aberration in the in vitro test, the increases were not considered relevant to the in vivo genetic risk. Except for the increase of in vitro numerical chromosomal aberration, clear negative results were obtained from other genetic toxicity studies.

GHX02 consists of mixtures including Gwaruin, Haengin, Hwangryeon and Hwangkeum. This study aimed to evaluate the 4‐week repeated‐dose oral toxicity and genotoxicity of GHX02. GHX02 exhibits no general toxic and genotoxic effects and the no‐observed‐adverse‐effect level of GHX02 could be established in 5000 mg/kg/day in both male and female Sprague‐Dawley rats.

Rapid Molecular Tests for Influenza, Respiratory Syncytial Virus, and Other Respiratory Viruses: A Systematic Review of Diagnostic Accuracy and Clinical Impact Studies

We systematically reviewed available evidence from Embase, Medline, and the Cochrane Library on diagnostic accuracy and clinical impact of commercially available rapid (results <3 hours) molecular diagnostics for respiratory viruses as compared to conventional molecular tests. Quality of included studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies criteria for diagnostic test accuracy (DTA) studies, and the Cochrane Risk of Bias Assessment and Risk of Bias in Nonrandomized Studies of Interventions criteria for randomized and observational impact studies, respectively. Sixty-three DTA reports (56 studies) were meta-analyzed with a pooled sensitivity of 90.9% (95% confidence interval [CI], 88.7%-93.1%) and specificity of 96.1% (95% CI, 94.2%-97.9%) for the detection of either influenza virus (n = 29), respiratory syncytial virus (RSV) (n = 1), influenza virus and RSV (n = 19), or a viral panel including influenza virus and RSV (n = 14). The 15 included impact studies (5 randomized) were very heterogeneous and results were therefore inconclusive. However, we suggest that implementation of rapid diagnostics in hospital care settings should be considered.

Defining the appropriateness and inappropriateness of antibiotic prescribing in primary care

Objectives

To assess the appropriateness of prescribing systemic antibiotics for different clinical conditions in primary care, and to quantify 'ideal' antibiotic prescribing proportions in conditions for which antibiotic treatment is sometimes but not always indicated.

Methods

Prescribing guidelines were consulted to define the appropriateness of antibiotic therapy for the conditions that resulted in antibiotic prescriptions between 2013 and 2015 in The Health Improvement Network (THIN) primary care database. The opinions of subject experts were then formally elicited to quantify ideal antibiotic prescribing proportions for 10 common conditions.

Results

Of the antibiotic prescriptions in THIN, 52.5% were for conditions that could be assessed using prescribing guidelines. Among these, the vast majority of prescriptions (91.4%) were for conditions where antibiotic appropriateness is conditional on patient-specific indicators. Experts estimated low ideal prescribing proportions in acute, non-comorbid presentations of many of these conditions, such as cough (10% of patients), rhinosinusitis (11%), bronchitis (13%) and sore throat (13%). Conversely, antibiotics were believed to be appropriate in 75% of non-pregnant women with non-recurrent urinary tract infection. In impetigo and acute exacerbation of chronic obstructive pulmonary disease, experts clustered into distinct groups that believed in either high or low prescribing.

Conclusions

In English primary care, most antibiotics are prescribed for conditions that only sometimes require antibiotic treatment, depending on patient-specific indicators. Experts estimated low ideal prescribing proportions in many of these conditions. Incomplete prescribing guidelines and disagreement about prescribing in some conditions highlight further research needs.

Predictors of Adverse Outcomes in Uncomplicated Lower Respiratory Tract Infections

PURPOSE

Presentation with acute lower respiratory tract infection (LRTI) in primary care is common. The aim of this study was to help clinicians treat patients presenting with LRTI in primary care by identifying those at risk of serious adverse outcomes (death, admission, late-onset pneumonia).

METHODS

In a prospective cohort study of patients presenting with LRTI symptoms, patient characteristics and clinical findings were recorded and adverse events identified over 30 days by chart review. Multivariable logistic regression analyses identified predictors of adverse outcomes.

RESULTS

Participants were recruited from 522 UK practices in 2009-2013. The analysis was restricted to the 28,846 adult patients not referred immediately to the hospital. Serious adverse outcomes occurred in 325/28,846 (1.1%). Eight factors were independently predictive; these characterized symptom severity (absence of coryza, fever, chest pain, and clinician-assessed severity), patient vulnerability (age >65 years, comorbidity), and physiological impact (oxygen saturation <95%, low blood pressure). In aggregate, the 8 features had moderate predictive value (area under the receiver operating characteristic curve 0.71, 95% CI, 0.68-0.74); the 4% of patients with ≥5 features had an approximately 1 in 17 (5.7%) risk of serious adverse outcomes, the 35% with 3 or 4 features had an intermediate risk (1 in 50, 2.0%), and the 61% with ≤2 features had a low (1 in 200, 0.5%) risk.

CONCLUSIONS

In routine practice most patients presenting with LRTI in primary care can be identified as at intermediate or low risk of serious outcome.

The Spectrum of Non-asthmatic Airway Diseases Contributing to Cough in the Adult

PURPOSE OF REVIEW

Cough becomes a pathologic reflex when the airways are inflamed and overwhelmed with excessive mucus. The goal of this review is to discuss acute and chronic cough syndromes caused by non-asthmatic airway diseases.

RECENT FINDINGS

Acute cough syndrome is short-lived and self-limited. Acute bronchitis and diffuse acute infectious bronchiolitis (DAIB) are examples. The former is usually caused by a viral illness; the latter by Mycoplasma pneumoniae, influenza, and Haemophilus influenzae. Causes of chronic cough in the adult include chronic bronchitis, non-infectious bronchiolitis, and non-cystic fibrosis bronchiectasis.

SUMMARY

Supportive measures are recommended for acute bronchitis and antibiotic use is discouraged. Antibiotics may be needed for DAIB. Smoking cessation and bronchodilators can control cough in chronic bronchitis. Therapeutic approaches for non-infectious bronchiolitis depend on the varied etiology. The hallmark of bronchiectasis is a chronic infection of the airways, and antibiotics, mucus clearance measures, and bronchodilators are all supportive.

Perceptions in the community about the use of antibiotics without a prescription: Exploring ideas behind this practice

Objective:

The use of antibiotics without prescription is common in Colombia as well as in other developing countries. The objective of this study is to explore the attitudes and motivations associated with the use of antibiotics without prescription.

Methods:

Focus group sessions were held with residents of Bogotá. Different socioeconomic groups were approached to identify possible differences of opinion. A semi-structured interview guide was used to guide the discussion, with thematic analysis used to identify central themes.

Results:

In total, 21 people, aged between 25 and 50 years participated in four focus groups. The results suggest that the use of antibiotics without prescription is common practice. The main reasons included barriers to access to prescribed medications due to limited health insurance. Even those with adequate access to health insurance report being willing to use a treatment without a prescription if they have confidence in its effectiveness. The relationship with the physician is important, but pharmacy storekeepers are also highly trusted. While some participants understood that antibiotics can cure infections but cause serious adverse events, several misconceptions about antibiotics therapy were identified. These included a lack of knowledge of resistance transmissibility among communities.

Conclusions:

The results have implications for interventions aimed at reducing inappropriate use of antibiotics, highlighting i) how lack of access to timely care creates an incentive to self-prescribe, ii) the key role that pharmacy storekeepers play in the Colombian healthcare system and the need to include them in interventions, and iii) the misconceptions about inappropriate use of medications that need to be addressed by educational programs. These findings provide insights to other countries where antibiotics misuse is also a problem.

Antibiotic Prescribing for Acute Respiratory Tract Infections 12 Months After Communication and CRP Training: A Randomized Trial

PURPOSE

C-reactive-protein (CRP) is useful for diagnosis of lower respiratory tract infections (RTIs). A large international trial documented that Internet-based training in CRP point-of-care testing, in enhanced communication skills, or both reduced antibiotic prescribing at 3 months, with risk ratios (RRs) of 0.68, 0.53, 0.38, respectively. We report the longer-term impact in this trial.

METHODS

A total of 246 general practices in 6 countries were cluster-randomized to usual care, Internet-based training on CRP point-of-care testing, Internet-based training on enhanced communication skills and interactive booklet, or both interventions combined. The main outcome was antibiotic prescribing for RTIs after 12 months.

RESULTS

Of 228 practices providing 3-month data, 74% provided 12-month data, with no demonstrable attrition bias. Between 3 months and 12 months, prescribing for RTIs decreased with usual care (from 58% to 51%), but increased with CRP training (from 35% to 43%) and with both interventions combined (from 32% to 45%); at 12 months, the adjusted RRs compared with usual care were 0.75 (95% CI, 0.51-1.00) and 0.70 (95% CI, 0.49-0.93), respectively. Between 3 months and 12 months, the reduction in prescribing with communication training was maintained (41% and 40%, with an RR at 12 months of 0.70 [95% CI, 0.49-0.94]). Although materials were provided for free, clinicians seldom used booklets and rarely used CRP point-of-care testing. Communication training, but not CRP training, remained efficacious for reducing prescribing for lower RTIs (RR = 0.7195% CI, 0.45-0.99, and RR = 0.76; 95% CI, 0.47-1.06, respectively), whereas both remained efficacious for reducing prescribing for upper RTIs (RR = 0.60; 95% CI, 0.37-0.94, and RR = 0.58; 95% CI, 0.36-0.92, respectively).

CONCLUSIONS

Internet-based training in enhanced communication skills remains effective in the longer term for reducing antibiotic prescribing. The early improvement seen with CRP training wanes, and this training becomes ineffective for lower RTIs, the only current indication for using CRP testing.

The effect of malaria rapid diagnostic tests results on antimicrobial prescription practices of health care workers in Burkina Faso

BACKGROUND

Malaria rapid diagnostic tests (RDT) are widely used in endemic areas in order to comply with the recommendation that malaria treatment should only be given after the clinical diagnosis has been confirmed by RDT or microscopy. However, the overestimation of malaria infection with the use of PfHRP2 based RDT, makes the management of febrile illnesses more challenging. This study aimed to assess the effect of the use of malaria RDT on antimicrobial prescription practices.

METHODS

A prospective study was conducted among febrile children under-5 years of age attending four health facilities and the referral hospital in the Nanoro Health District (Burkina Faso). To assess the effect of malaria RDT testing on the prescriptions of antimicrobials in febrile children, the initial diagnosis and antimicrobial prescriptions following a malaria RDT testing were recorded. The necessity of these prescriptions was subsequently checked by assessing the actual cause of fever by expert malaria microscopy and a microbiology analysis of blood, urine, stool and nasopharynx swabs that were collected from febrile cases to determine the actual cause of the fever episode.

RESULTS

Malaria was diagnosed by nurses, who are the primary health care providers, with a malaria RDT in 72.7% (798/1098) of febrile children, but only 53.7% (589/1097) cases could be confirmed by expert microscopy. Health care workers were likely to prescribe antimalarials to malaria positive RDT compared to malaria negative RDT (RR = 7.74, p = 0.00001). Malaria negative RDT result had a significant influence on the antibiotic prescriptions (RR = 3.57, p = 0.0001). The risk of prescribing antimicrobials was higher in health facility level compared to referral hospital. By cross-checking of laboratory findings to antimicrobial prescriptions, an important part of children with positive bacterial infection have received antibiotic prescriptions although the majority without any infection have also received antibiotics.

CONCLUSION

Despite the good attitude of health care workers to adhere to diagnostic test results, antimalarials and antibiotics remain inappropriate prescribed to febrile children. The low specificity of malaria RDT used could be an important cause of these practices.

An analysis of reporting quality of prospective studies examining community antibiotic use and resistance

Background

Antibiotic resistance is a global problem, but the relationship between antibiotic use and resistance development and decay is not well understood. This knowledge is best provided by prospective studies, but to be useful they must be both conducted and reported well. Little is known about the reporting quality of these studies. This study aimed to assess the quality of reporting in prospective studies that investigated antibiotic resistance following antibiotic exposure in community-based individuals.

Methods

The quality of reporting of prospective studies (17 randomised trials, eight cohort studies) identified in a systematic review of the relationship between antibiotic use and resistance were assessed independently by two researchers using checklists (one for trials, one for cohort studies) developed from existing reporting guidelines for these designs and this field.

Results

The mean percentage (SD, minimum-maximum) of mandatory items that were adequately described by the included studies was 59% for trials (14%, 36–84%) and 52% for cohort studies (17%, 13–70%). Most studies adequately described the study background and rationale, the type, combination, and duration of the antibiotic intervention, and the sampling procedures followed to isolate resistant bacteria. Most studies did not report the incident numbers of resistant and susceptible isolates analysed at each time point. Blinding and sample size calculation was inadequately reported in almost half of the trials and all cohort studies.

Conclusions

The quality of reporting in prospective studies investigating the association between antibiotic exposure in the community and isolation of resistance isolates is variable. Some details were missing in more than half of the studies, which precludes a complete risk of bias assessment and accurate interpretation and synthesis of results.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-3040-6) contains supplementary material, which is available to authorized users.

Amoxicillin is associated with a lower risk of further antibiotic prescriptions for lower respiratory tract infections in primary care - A database analysis spanning over 30 years

Antibiotic prescriptions for lower respiratory tract infections occur commonly in primary care but there is uncertainty about the most effective initial treatment strategy. Both increasing antimicrobial resistance and awareness of preventable harm from medicines make resolving this uncertainty a priority. Pragmatic, real-life epidemiological investigations are needed to inform future interventional studies. In this cross-sectional database study we analysed antibiotic prescriptions for non-pneumonic, lower respiratory tract infections (LRTI) in primary care as captured in the Optimum Care Database from 1984 to 2017. The primary outcome was a second antibiotic prescription for a LRTI code within 14 days of index prescription, the secondary outcome further antibiotic prescription for any indication. Only individuals without chronic respiratory diseases were included. We conducted univariable analysis to identify factors associated with repeat prescriptions and generate hypotheses for forthcoming projects. We analysed 367,188 index prescriptions for LRTI. Amoxicillin was the commonest used index drug (65.1%). In 6% a second antibiotic course coded for a further LRTI was prescribed (11.2% without this coding restriction). Further antibiotic prescriptions for LRTI were significantly associated with older age, previous smoking, seven day index courses and not using amoxicillin initially. The largest effect size was seen when amoxicillin was not used as index drug (odds ratio (OR) 1.15, p < 0.001). This would support current prescribing practice for amoxicillin as index drug in those without respiratory disease. Prospective studies are needed to explore the observed differences.

Shared decision making and antibiotic benefit-harm conversations: an observational study of consultations between general practitioners and patients with acute respiratory infections

Background

Little research has examined whether shared decision making (SDM) occurs in consultations for acute respiratory infections (ARIs), including what, and how, antibiotic benefits and harms are discussed. We aimed to analyse the extent and nature of SDM in consultations between GPs and patients with ARIs, and explore communication with and without the use of patient decision aids.

Methods

This was an observational study in Australian general practices, nested within a cluster randomised trial of decision aids (for acute otitis media [AOM], sore throat, acute bronchitis) designed for general practitioners (GPs) to use with patients, compared with usual care (no decision aids). Audio-recordings of consultations of a convenience sample of consenting patients seeing a GP for an ARI were independently analysed by two raters using the OPTION-12 (observing patient involvement in decision making) scale (maximum score of 100) and 5 items (about communicating evidence) from the Assessing Communication about Evidence and Patient Preferences (ACEPP) tool (maximum score of 5). Patients also self-completed a questionnaire post-consultation that contained items from CollaboRATE-5 (perceptions of involvement in the decision-making process), a decisional conflict scale, and a decision self-efficacy scale. Descriptive statistics were calculated for each measure.

Results

Thirty-six consultations, involving 13 GPs, were recorded (20 for bronchitis, 10 sore throat, 6 AOM). The mean (SD) total OPTION-12 score was 29.4 (12.5; range 4–54), with item 12 (need to review decision) the highest (mean = 3) and item 10 (eliciting patients’ preferred level of decision-making involvement) the lowest (mean = 0.1). The mean (SD) total ACEPP score was 2 (1.6), with the item about discussing benefits scoring highest. In consultations where a decision aid was used (15, 42%), compared to the 21 usual care consultations, mean observer-assessed SDM scores (OPTION-12, ACEPP scores) were higher and antibiotic harms mentioned in all (compared to only 1) consultations. Patients generally reported high decision involvement and self-efficacy, and low decisional conflict.

Conclusions

The extent of observer-assessed SDM between GPs and patients with ARIs was generally low. Balanced discussion of antibiotic benefits and harms occurred more often when decision aids were used.

Electronic supplementary material

The online version of this article (10.1186/s12875-018-0854-y) contains supplementary material, which is available to authorized users.

Resistance decay in individuals after antibiotic exposure in primary care: a systematic review and meta-analysis

BACKGROUND

Antibiotic resistance is an urgent global problem, but reversibility is poorly understood. We examined the development and decay of bacterial resistance in community patients after antibiotic use.

METHODS

This was a systematic review and meta-analysis. PubMed, EMBASE and CENTRAL (from inception to May 2017) were searched, with forward and backward citation searches of the identified studies. We contacted authors whose data were unclear, and of abstract-only reports, for further information. We considered controlled or times-series studies of patients in the community who were given antibiotics and where the subsequent prevalence of resistant bacteria was measured. Two authors extracted risk of bias and data. The meta-analysis used a fixed-effects model.

RESULTS

Of 24,492 articles screened, five controlled and 20 time-series studies (total 16,353 children and 1461 adults) were eligible. Resistance in Streptococcus pneumoniae initially increased fourfold after penicillin-class antibiotic exposure [odds ratio (OR) 4.2, 95% confidence interval (CI) 3.5-5.4], but this fell after 1 month (OR 1.7, 95% CI 1.3-2.1). After cephalosporin-class antibiotics, resistance increased (OR 2.2, 95%CI 1.7-2.9); and fell to (OR 1.6, 95% CI 1.2-2.3) at 1 month. After macrolide-class antibiotics, resistance increased (OR 3.8, 95% CI 1.9-7.6) and persisted for 1 month (OR 5.2, 95% CI 2.6-10.3) and 3 months (OR 8.1, 95% CI 4.6-14.2, from controlled studies and OR 2.3, 95% CI 0.6-9.4, from time-series studies). Resistance in Haemophilus influenzae after penicillins was not significantly increased (OR 1.3, 95% CI 0.9-1.9) initially but was at 1 month (OR 3.4, 95% CI 1.5-7.6), falling after 3 months (OR 1.0, 95% CI 0.5-2.2). Data were sparse for cephalosporins and macrolides. Resistance in Enterobacter increased post-exposure (OR 3.2, 95% CI 0.9-10.8, from controlled studies and OR 7.1, 95% CI 4.2-12, from time-series studies], but was lower after 1 month (OR 1.8, 95% CI 0.9-3.6).

CONCLUSIONS

Resistance generally increased soon after antibiotic use. For some antibiotic classes and bacteria, it partially diminished after 1 and 3 months, but longer-term data are lacking and urgently needed.

TRIAL REGISTRATION

PROSPERO CRD42015025499 .

General Practitioners' Views on the Acceptability and Applicability of Using Quality Indicators as an Intervention to Reduce Unnecessary Prescription of Antibiotics in Four South American Countries

As part of the quality improvement program &ldquo;Health Alliance for Prudent Prescribing, Yield And Use of anti-microbial Drugs In the Treatment of respiratory tract infections&rdquo; (HAPPY AUDIT) South America, we planned to implement an intervention based on the use of quality indicators as a means to influence General Practitioners&rsquo; (GPs) prescribing decision. Knowledge on the acceptability and applicability of an intervention is crucial to decide whether the intervention is suitable and will achieve the expected outcomes. This study explores GPs&rsquo; views about the acceptability and applicability of using quality indicators as an intervention to influence their prescribing decision in patients with suspected Respiratory Tract Infections (RTIs) across four countries in South-America. In March 2015, GPs that were participating in HAPPY AUDIT South America were invited to participate in focus groups. A discussion guide covering the domains acceptability and applicability was used. Data was analyzed through systematic text condensation with an inductive approach. 171 GPs were invited and 48% participated. Acceptability ranged from totally acceptable to slightly acceptable. This spectrum of GPs views on acceptability was influenced by themes concerning applicability. In conclusion, there is a positive attitude towards the use of quality indicators. Nonetheless, applicability challenges have to be taken into consideration and solved if we are to achieve a large effect with the implementation of this intervention.

Preparing Parents to Make An Informed Choice About Antibiotic Use for Common Acute Respiratory Infections in Children: A Randomised Trial of Brief Decision Aids in a Hypothetical Scenario

BACKGROUND

Childhood acute respiratory infections (ARIs) are one of the most common reasons for primary care consultations and for receiving an antibiotic. Public awareness of antibiotic benefit and harms for these conditions is low. To facilitate informed decision making, ideally in collaboration with their doctor, parents need clear communication about benefits and harms. Decision aids may be able to facilitate this process.

OBJECTIVE

The aim of this study was to evaluate the effectiveness of three decision aids about antibiotic use for common ARIs in children.

METHODS

Adult parents of children aged 1-16 years (n = 120) were recruited from community settings and then randomised using a computer-generated randomisation sequence to receive a decision aid (n = 60) or fact sheet (n = 60). Allocation was concealed and used sealed and opaque sequentially numbered envelopes. Participants self-completed questionnaires at baseline and immediately post-intervention. The primary outcome was informed choice (conceptual and numerical knowledge; attitudes towards, and intention to use, antibiotics for a future ARI). Secondary outcomes were decisional conflict, decisional self-efficacy, and material acceptability.

RESULTS

After reading the information, significantly more intervention group participants made an informed choice [57%] compared with control group participants [29%] [difference 28, 95% confidence interval (CI) 11-45%, p < 0.01], and had higher total knowledge [mean difference (MD) 2.8, 95% CI 2.2-3.5, p < 0.01], conceptual knowledge (MD 0.7, 95% CI 0.4-1.1, p < 0.01) and numerical knowledge (MD 2.1, 95% CI 1.6-2.5, p < 0.01). Between-group differences in attitudes or intention to use antibiotics were not significant. Most intervention group participants found the information understandable and liked the aids' format and features.

CONCLUSION

The decision aids prepared parents to make an informed choice about antibiotic use more than fact sheets, in a hypothetical situation. Their effect within a consultation needs to be evaluated. Clinical Trials Registration Number: ACTRN12615000843550.

Can pay-for-performance to primary care providers stimulate appropriate use of antibiotics?

Antibiotic resistance is a major threat to public health worldwide. As the healthcare sector's use of antibiotics is an important contributor to the development of resistance, it is crucial that physicians only prescribe antibiotics when needed and that they choose narrow-spectrum antibiotics, which act on fewer bacteria types, when possible. Inappropriate use of antibiotics is nonetheless widespread, not least for respiratory tract infections (RTI), a common reason for antibiotics prescriptions. We examine if pay-for-performance (P4P) presents a way to influence primary care physicians' choice of antibiotics. During 2006-2013, 8 Swedish healthcare authorities adopted P4P to make physicians select narrow-spectrum antibiotics more often in the treatment of children with RTI. Exploiting register data on all purchases of RTI antibiotics in a difference-in-differences analysis, we find that P4P significantly increased the share of narrow-spectrum antibiotics. There are no signs that physicians gamed the system by issuing more prescriptions overall.

Decreasing Inappropriate Use of Antibiotics in Primary Care in Four Countries in South America-Cluster Randomized Controlled Trial

High antibiotic prescribing and antimicrobial resistance in patients attending primary care have been reported in South America. Very few interventions targeting general practitioners (GPs) to decrease inappropriate antibiotic prescribing have been investigated in this region. This study assessed the effectiveness of online feedback on reducing antibiotic prescribing in patients with suspected respiratory tract infections (RTIs) attending primary care. The aim was to reduce antibiotic prescribing in patients with acute bronchitis and acute otitis media. Both are RTIs for which antibiotics have a very limited effect. A cluster randomized two-arm control trial was implemented. Healthcare centres from Bolivia, Argentina, Paraguay and Uruguay participating in the quality improvement program HAPPY AUDIT were randomly allocated to either intervention or control group. During ten consecutive weeks, GPs in the intervention group received evidence-based online feedback on the management of suspected RTIs. In patients with acute bronchitis, the intervention reduced the antibiotic prescribing rate from 71.6% to 56% (control group from 61.2% to 52%). In patients with acute otitis media, the intervention reduced the antibiotic prescribing from 94.8% to 86.2% (no change in the control group). In all RTIs, the intervention reduced antibiotic prescribing rate from 37.4% to 28.1% (control group from 29% to 27.2%). Online evidence-based feedback is effective for reducing antibiotic prescribing in patients with RTIs attending primary care in South America.

Adverse Effects of Amoxicillin for Acute Lower Respiratory Tract Infection in Primary Care: Secondary and Subgroup Analysis of a Randomised Clinical Trial

A European placebo-controlled trial of antibiotic treatment for lower respiratory tract infection (LRTI) conducted in 16 primary care practices networks recruited participants between November 2007 and April 2010, and found adverse events (AEs) occurred more often in patients prescribed amoxicillin compared to placebo. This secondary analysis explores the causal relationship and estimates specific AEs (diarrhoea, nausea, rash) due to amoxicillin treatment for LRTI, and if any subgroup is at increased risk of any or a specific AE. A total of 2061 patients were randomly assigned to amoxicillin (1038) and placebo (1023); 595 (28%) were 60 and older. A significantly higher proportion of any AEs (diarrhoea or nausea or rash) (OR = 1.31, 95% CI 1.05–1.64, number needed to harm (NNH) = 24) and of diarrhoea (OR 1.43 95% CI 1.08–1.90, NNH = 29) was reported in the amoxicillin group during the first week after randomisation. Subgroup analysis showed rash was significantly more often reported in males prescribed amoxicillin (interaction term 3.72 95% CI 1.22–11.36; OR of amoxicillin in males 2.79 (95% CI 1.08–7.22). No other subgroup at higher risk was identified. Although the study was not powered for subgroup analysis, this analysis suggests that most patients are likely to be equally harmed when prescribed antibiotics.

Community-Acquired Pneumonia in Adults

BACKGROUND

The clinical spectrum of community-acquired pneumonia ranges from infections that can be treated on an outpatient basis, with 1% mortality, to those that present as medical emergencies, with a mortality above 40%.

METHODS

This article is based on pertinent publications and current guidelines retrieved by a selective search of the literature.

RESULTS

The radiological demonstration of an infiltrate is required for the differentiation of pneumonia from acute bronchitis regardless of whether the patient is seen in the outpatient setting or in the emergency room. For risk prediction, it is recommended that the CRB-65 criteria, unstable comorbidities, and oxygenation should be taken into account. Amoxicillin is the drug of choice for mild pneumonia; it should be given in combination with clavulanic acid if there are any comorbid illnesses. The main clinical concerns in the emergency room are the identification of acute organ dysfunction and the management of sepsis. Intravenous beta-lactam antibiotics should be given initially, in combination with a macrolide if acute organ dysfunction is present. The treatment should be continued for 5-7 days. Cardiovascular complications worsen the patient's prognosis and should be meticulously watched for. Structured followup care includes the follow-up of comorbid conditions and the initiation of recommended preventive measures such as antipneumococcal and anti-influenza vaccination, the avoidance of drugs that increase the risk, smoking cessation, and treatment of dysphagia, if present.

CONCLUSION

Major considerations include appropriate risk stratification and the implementation of a management strategy adapted to the degree of severity of the disease, along with the establishment of structured follow-up care and secondary prevention, especially for patients with comorbidities.

Spicae aetheroleum in uncomplicated acute bronchitis: a double-blind, randomised clinical trial

Background

The trial aimed to evaluate the efficacy and safety of Spicae aetheroleum (Spicae ae.), a phytomedicine obtained by steam distillation of the flowering tops of Lavandula latifolia, as compared to placebo in adult patients with acute bronchitis.

Methods

Patients with uncomplicated acute bronchitis (bronchitis severity score [BSS] ≥ 5 score points) were randomly assigned to treatment with Spicae ae. or placebo in a double-blind, parallel-group design. No additional treatment was admitted. The primary objective was the mean difference of a defined total BSS of 25% between the Spicae ae. and the placebo group after 7 days of full medication dose. Secondary endpoints included the BSS at day 10, additional signs and symptoms of bronchitis, quality of life (QoL) and safety.

Results

The mean decrease in BSS at day 7 and day 10 was significant with 4.79 vs. 3.20 (p < 0.005 for a 25% difference) and 6.47 vs. 4.32 (p < 0.009 for a 25% difference) score points respectively in the Spicae ae. (n = 119) vs. placebo group (n = 110). Accordingly, most additional signs and symptoms of acute bronchitis as well as the patients’ QoL improved significantly with Spicae ae. as compared to placebo. In all, 258 patients were eligible for safety analysis. The treatment with Spicae ae. was well tolerated; no serious adverse events occurred.

Conclusion

The defined objectives both for the primary and secondary endpoints have been met. The results of this study provide evidence that Spicae ae. is well tolerated, effective and superior to placebo in the symptomatic treatment of uncomplicated acute bronchitis in adult patients.

Predictors of pneumonia in lower respiratory tract infections: 3C prospective cough complication cohort study

The aim was to aid diagnosis of pneumonia in those presenting with lower respiratory tract symptoms in routine primary care.

A cohort of 28 883 adult patients with acute cough attributed to lower respiratory tract infections (LRTIs) was recruited from 5222 UK practices in 2009–13. Symptoms, signs and treatment were recorded at presentation and subsequent events followed-up for 30 days by chart review. The predictive value of patient characteristics, presenting symptoms and clinical findings for the diagnosis of pneumonia in the first 7 days was established.

Of the 720 out of 28 883 (2.5.%) radiographed within 1 week of the index consultation, 115 (16.0%; 0.40% of 28 883) were assigned a definite or probable pneumonia diagnosis. The significant independent predictors of radiograph-confirmed pneumonia were temperature >37.8°C (RR 2.6; 95% CI 1.5–4.8), crackles on auscultation (RR 1.8; 1.1–3.0), oxygen saturation <95% (RR 1.7; 1.0–3.1) and pulse >100·min^–1 (RR 1.9; 1.1–3.2). Most patients with pneumonia (99/115, 86.1%) exhibited at least one of these four clinical signs; the positive predictive value of having at least one of these signs was 20.2% (95% CI 17.3–23.1).

In routine practice, radiograph-confirmed pneumonia as a short-term complication of LRTI is very uncommon (one in 270). Pulse oximetry may aid the diagnosis of pneumonia in this setting.

Pulse oximetry probably has a role in the diagnosis of pneumonia in the communityhttp://ow.ly/QpWc30fVM2j

Antibiotic Prescribing for Uncomplicated Acute Bronchitis Is Highest in Younger Adults

Reducing inappropriate antibiotic prescribing is currently a global health priority. Current guidelines recommend against antibiotic treatment for acute uncomplicated bronchitis. We studied antibiotic prescribing patterns for uncomplicated acute bronchitis and identified predictors of inappropriate antibiotic prescribing. We used the Epic Clarity database (electronic medical record system) to identify all adult patients with acute bronchitis in family medicine clinics from 2011 to 2016. We excluded factors that could justify antibiotic use, such as suspected pneumonia, COPD or immunocompromising conditions. Of the 3616 visits for uncomplicated acute bronchitis, 2244 (62.1%) resulted in antibiotic treatment. The rates of antibiotic prescribing were similar across the years, p value for trend = 0.07. Antibiotics were most frequently prescribed in the age group of 18–39 years (66.9%), followed by the age group of 65 years and above (59.0%), and the age group of 40–64 years (58.7%), p value < 0.001. Macrolides were significantly more likely to be prescribed for younger adults, while fluoroquinolones were more likely to be prescribed for patients 65 years or older. Duration of antibiotic use was significantly longer in older adults. Sex and race were not associated with antibiotic prescribing. Our findings highlight the urgent need to reduce inappropriate antibiotic use for uncomplicated acute bronchitis, particularly in younger adults.

Clinician-targeted interventions to influence antibiotic prescribing behaviour for acute respiratory infections in primary care: an overview of systematic reviews

BACKGROUND

Antibiotic resistance is a worldwide health threat. Interventions that reduce antibiotic prescribing by clinicians are expected to reduce antibiotic resistance. Disparate interventions to change antibiotic prescribing behaviour for acute respiratory infections (ARIs) have been trialled and meta-analysed, but not yet synthesised in an overview. This overview synthesises evidence from systematic reviews, rather than individual trials.

OBJECTIVES

To systematically review the existing evidence from systematic reviews on the effects of interventions aimed at influencing clinician antibiotic prescribing behaviour for ARIs in primary care.

METHODS

We searched the Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects (DARE), MEDLINE, Embase, CINAHL, PsycINFO, and Science Citation Index to June 2016. We also searched the reference lists of all included reviews. We ran a pre-publication search in May 2017 and placed additional studies in 'awaiting classification'.We included both Cochrane and non-Cochrane reviews of randomised controlled trials evaluating the effect of any clinician-focussed intervention on antibiotic prescribing behaviour in primary care. Two overview authors independently extracted data and assessed the methodological quality of included reviews using the ROBIS tool, with disagreements reached by consensus or by discussion with a third overview author. We used the GRADE system to assess the quality of evidence in included reviews. The results are presented as a narrative overview.

MAIN RESULTS

We included eight reviews in this overview: five Cochrane Reviews (33 included trials) and three non-Cochrane reviews (11 included trials). Three reviews (all Cochrane Reviews) scored low risk across all the ROBIS domains in Phase 2 and low risk of bias overall. The remaining five reviews scored high risk on Domain 4 of Phase 2 because the 'Risk of bias' assessment had not been specifically considered and discussed in the review Results and Conclusions. The trials included in the reviews varied in both size and risk of bias. Interventions were compared to usual care.Moderate-quality evidence indicated that C-reactive protein (CRP) point-of-care testing (risk ratio (RR) 0.78, 95% confidence interval (CI) 0.66 to 0.92, 3284 participants, 6 trials), shared decision making (odds ratio (OR) 0.44, 95% CI 0.26 to 0.75, 3274 participants, 3 trials; RR 0.64, 95% CI 0.49 to 0.84, 4623 participants, 2 trials; risk difference -18.44, 95% CI -27.24 to -9.65, 481,807 participants, 4 trials), and procalcitonin-guided management (adjusted OR 0.10, 95% CI 0.07 to 0.14, 1008 participants, 2 trials) probably reduce antibiotic prescribing in general practice. We found moderate-quality evidence that procalcitonin-guided management probably reduces antibiotic prescribing in emergency departments (adjusted OR 0.34, 95% CI 0.28 to 0.43, 2605 participants, 7 trials). The overall effect of these interventions was small (few achieving greater than 50% reduction in antibiotic prescribing, most about a quarter or less), but likely to be clinically important.Compared to usual care, shared decision making probably makes little or no difference to reconsultation for the same illness (RR 0.87, 95% CI 0.74 to 1.03, 1860 participants, 4 trials, moderate-quality evidence), and may make little or no difference to patient satisfaction (RR 0.86, 95% CI 0.57 to 1.30, 1110 participants, 2 trials, low-quality evidence). Similarly, CRP testing probably has little or no effect on patient satisfaction (RR 0.79, 95% CI 0.57 to 1.08, 689 participants, 2 trials, moderate-quality evidence) or reconsultation (RR 1.08, 95% CI 0.93 to 1.27, 5132 participants, 4 trials, moderate-quality evidence). Procalcitonin-guided management probably results in little or no difference in treatment failure in general practice compared to normal care (adjusted OR 0.95, 95% CI 0.73 to 1.24, 1008 participants, 2 trials, moderate-quality evidence), however it probably reduces treatment failure in the emergency department compared to usual care (adjusted OR 0.76, 95% CI 0.61 to 0.95, 2605 participants, 7 trials, moderate-quality evidence).The quality of evidence for interventions focused on clinician educational materials and decision support in reducing antibiotic prescribing in general practice was either low or very low (no pooled result reported) and trial results were highly heterogeneous, therefore we were unable draw conclusions about the effects of these interventions. The use of rapid viral diagnostics in emergency departments may have little or no effect on antibiotic prescribing (RR 0.86, 95% CI 0.61 to 1.22, 891 participants, 3 trials, low-quality evidence) and may result in little to no difference in reconsultation (RR 0.86, 95% CI 0.59 to 1.25, 200 participants, 1 trial, low-quality evidence).None of the trials in the included reviews reported on management costs for the treatment of an ARI or any associated complications.

AUTHORS' CONCLUSIONS

We found evidence that CRP testing, shared decision making, and procalcitonin-guided management reduce antibiotic prescribing for patients with ARIs in primary care. These interventions may therefore reduce overall antibiotic consumption and consequently antibiotic resistance. There do not appear to be negative effects of these interventions on the outcomes of patient satisfaction and reconsultation, although there was limited measurement of these outcomes in the trials. This should be rectified in future trials.We could gather no information about the costs of management, and this along with the paucity of measurements meant that it was difficult to weigh the benefits and costs of implementing these interventions in practice.Most of this research was undertaken in high-income countries, and it may not generalise to other settings. The quality of evidence for the interventions of educational materials and tools for patients and clinicians was either low or very low, which prevented us from drawing any conclusions. High-quality trials are needed to further investigate these interventions.

Delayed antibiotic prescriptions for respiratory infections

BACKGROUND

Concerns exist regarding antibiotic prescribing for respiratory tract infections (RTIs) owing to adverse reactions, cost, and antibacterial resistance. One proposed strategy to reduce antibiotic prescribing is to provide prescriptions, but to advise delay in antibiotic use with the expectation that symptoms will resolve first. This is an update of a Cochrane Review originally published in 2007, and updated in 2010 and 2013.

OBJECTIVES

To evaluate the effects on clinical outcomes, antibiotic use, antibiotic resistance, and patient satisfaction of advising a delayed prescription of antibiotics in respiratory tract infections.

SEARCH METHODS

For this 2017 update we searched the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, Issue 4, 2017), which includes the Cochrane Acute Respiratory Infection Group's Specialised Register; Ovid MEDLINE (2013 to 25 May 2017); Ovid Embase (2013 to 2017 Week 21); EBSCO CINAHL Plus (1984 to 25 May 2017); Web of Science (2013 to 25 May 2017); WHO International Clinical Trials Registry Platform (1 September 2017); and ClinicalTrials.gov (1 September 2017).

SELECTION CRITERIA

Randomised controlled trials involving participants of all ages defined as having an RTI, where delayed antibiotics were compared to immediate antibiotics or no antibiotics. We defined a delayed antibiotic as advice to delay the filling of an antibiotic prescription by at least 48 hours. We considered all RTIs regardless of whether antibiotics were recommended or not.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodological procedures. Three review authors independently extracted and collated data. We assessed the risk of bias of all included trials. We contacted trial authors to obtain missing information.

MAIN RESULTS

For this 2017 update we added one new trial involving 405 participants with uncomplicated acute respiratory infection. Overall, this review included 11 studies with a total of 3555 participants. These 11 studies involved acute respiratory infections including acute otitis media (three studies), streptococcal pharyngitis (three studies), cough (two studies), sore throat (one study), common cold (one study), and a variety of RTIs (one study). Five studies involved only children, two only adults, and four included both adults and children. Six studies were conducted in a primary care setting, three in paediatric clinics, and two in emergency departments.Studies were well reported, and appeared to be of moderate quality. Randomisation was not adequately described in two trials. Four trials blinded the outcomes assessor, and three included blinding of participants and doctors. We conducted meta-analysis for antibiotic use and patient satisfaction.We found no differences among delayed, immediate, and no prescribed antibiotics for clinical outcomes in the three studies that recruited participants with cough. For the outcome of fever with sore throat, three of the five studies favoured immediate antibiotics, and two found no difference. For the outcome of pain related to sore throat, two studies favoured immediate antibiotics, and three found no difference. One study compared delayed antibiotics with no antibiotic for sore throat, and found no difference in clinical outcomes.Three studies included participants with acute otitis media. Of the two studies with an immediate antibiotic arm, one study found no difference for fever, and the other study favoured immediate antibiotics for pain and malaise severity on Day 3. One study including participants with acute otitis media compared delayed antibiotics with no antibiotics and found no difference for pain and fever on Day 3.Two studies recruited participants with common cold. Neither study found differences for clinical outcomes between delayed and immediate antibiotic groups. One study favoured delayed antibiotics over no antibiotics for pain, fever, and cough duration (moderate quality evidence for all clinical outcomes - GRADE assessment).There were either no differences for adverse effects or results favoured delayed antibiotics over immediate antibiotics (low quality evidence - to GRADE assessment) with no significant differences in complication rates. Delayed antibiotics resulted in a significant reduction in antibiotic use compared to immediate antibiotics prescription (odds ratio (OR) 0.04, 95% confidence interval (CI) 0.03 to 0.05). However, a delayed antibiotic was more likely to result in reported antibiotic use than no antibiotics (OR 2.55, 95% CI 1.59 to 4.08) (moderate quality evidence - GRADE assessment).Patient satisfaction favoured delayed over no antibiotics (OR 1.49, 95% CI 1.08 to 2.06). There was no significant difference in patient satisfaction between delayed antibiotics and immediate antibiotics (OR 0.65, 95% CI 0.39 to 1.10) (moderate quality evidence - GRADE assessment).None of the included studies evaluated antibiotic resistance.

AUTHORS' CONCLUSIONS

For many clinical outcomes, there were no differences between prescribing strategies. Symptoms for acute otitis media and sore throat were modestly improved by immediate antibiotics compared with delayed antibiotics. There were no differences in complication rates. Delaying prescribing did not result in significantly different levels of patient satisfaction compared with immediate provision of antibiotics (86% versus 91%) (moderate quality evidence). However, delay was favoured over no antibiotics (87% versus 82%). Delayed antibiotics achieved lower rates of antibiotic use compared to immediate antibiotics (31% versus 93%) (moderate quality evidence). The strategy of no antibiotics further reduced antibiotic use compared to delaying prescription for antibiotics (14% versus 28%). Delayed antibiotics for people with acute respiratory infection reduced antibiotic use compared to immediate antibiotics, but was not shown to be different to no antibiotics in terms of symptom control and disease complications. Where clinicians feel it is safe not to prescribe antibiotics immediately for people with respiratory infections, no antibiotics with advice to return if symptoms do not resolve is likely to result in the least antibiotic use while maintaining similar patient satisfaction and clinical outcomes to delaying prescription of antibiotics. Where clinicians are not confident in using a no antibiotic strategy, a delayed antibiotics strategy may be an acceptable compromise in place of immediate prescribing to significantly reduce unnecessary antibiotic use for RTIs, and thereby reduce antibiotic resistance, while maintaining patient safety and satisfaction levels.Editorial note: As a living systematic review, this review is continually updated, incorporating relevant new evidence as it becomes available. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review.

Patient Willingness to Have Tests to Guide Antibiotic Use for Respiratory Tract Infections: From the WWAMI Region Practice and Research Network (WPRN)

INTRODUCTION

The majority of consultations for acute respiratory tract infections (RTIs) lead to prescriptions for antibiotics, which have limited clinical benefit. We explored patients' willingness to have blood tests as part of the diagnostic work-up for RTIs, and patient knowledge about antibiotics.

METHODS

Patients at 6 family medicine clinics were surveyed. Regression modeling was used to determine independent predictors of willingness to have venous and point-of-care (POC) blood tests, and knowledge of the value of antibiotics for RTIs.

RESULTS

Data were collected from 737 respondents (response rate 83.8%), of whom 65.7% were women, 60.1% were white, and 25.1% were current smokers; patients' mean age was 46.9 years. Sex (female), race (white), and a preference to avoid antibiotics were independent predictors of greater level of antibiotic knowledge. A total of 63.1% were willing to have a venous draw and 79% a POC blood test, to help guide antibiotic decision-making. Non-American Indian/Alaskan Native race, current smoking, and greater knowledge of antibiotics were independent predictors of willingness to have a POC test.

CONCLUSION

A large majority of patients seemed willing to have POC tests to facilitate antibiotic prescribing decisions for RTIs. Poor knowledge about antibiotics suggests better education regarding antibiotic use might influence patient attitudes towards use of antibiotics for RTIs.

Antibiotics for acute bronchitis

BACKGROUND

The benefits and risks of antibiotics for acute bronchitis remain unclear despite it being one of the most common illnesses seen in primary care.

OBJECTIVES

To assess the effects of antibiotics in improving outcomes and to assess adverse effects of antibiotic therapy for people with a clinical diagnosis of acute bronchitis.

SEARCH METHODS

We searched CENTRAL 2016, Issue 11 (accessed 13 January 2017), MEDLINE (1966 to January week 1, 2017), Embase (1974 to 13 January 2017), and LILACS (1982 to 13 January 2017). We searched the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) and ClinicalTrials.gov on 5 April 2017.

SELECTION CRITERIA

Randomised controlled trials comparing any antibiotic therapy with placebo or no treatment in acute bronchitis or acute productive cough, in people without underlying pulmonary disease.

DATA COLLECTION AND ANALYSIS

At least two review authors extracted data and assessed trial quality.

MAIN RESULTS

We did not identify any new trials for inclusion in this 2017 update. We included 17 trials with 5099 participants in the primary analysis. The quality of trials was generally good. At follow-up there was no difference in participants described as being clinically improved between the antibiotic and placebo groups (11 studies with 3841 participants, risk ratio (RR) 1.07, 95% confidence interval (CI) 0.99 to 1.15). Participants given antibiotics were less likely to have a cough (4 studies with 275 participants, RR 0.64, 95% CI 0.49 to 0.85; number needed to treat for an additional beneficial outcome (NNTB) 6) and a night cough (4 studies with 538 participants, RR 0.67, 95% CI 0.54 to 0.83; NNTB 7). Participants given antibiotics had a shorter mean cough duration (7 studies with 2776 participants, mean difference (MD) -0.46 days, 95% CI -0.87 to -0.04). The differences in presence of a productive cough at follow-up and MD of productive cough did not reach statistical significance.Antibiotic-treated participants were more likely to be improved according to clinician's global assessment (6 studies with 891 participants, RR 0.61, 95% CI 0.48 to 0.79; NNTB 11) and were less likely to have an abnormal lung exam (5 studies with 613 participants, RR 0.54, 95% CI 0.41 to 0.70; NNTB 6). Antibiotic-treated participants also had a reduction in days feeling ill (5 studies with 809 participants, MD -0.64 days, 95% CI -1.16 to -0.13) and days with impaired activity (6 studies with 767 participants, MD -0.49 days, 95% CI -0.94 to -0.04). The differences in proportions with activity limitations at follow-up did not reach statistical significance. There was a significant trend towards an increase in adverse effects in the antibiotic group (12 studies with 3496 participants, RR 1.20, 95% CI 1.05 to 1.36; NNT for an additional harmful outcome 24).

AUTHORS' CONCLUSIONS

There is limited evidence of clinical benefit to support the use of antibiotics in acute bronchitis. Antibiotics may have a modest beneficial effect in some patients such as frail, elderly people with multimorbidity who may not have been included in trials to date. However, the magnitude of this benefit needs to be considered in the broader context of potential side effects, medicalisation for a self limiting condition, increased resistance to respiratory pathogens, and cost of antibiotic treatment.

[Recommendations for the use of rapid diagnosis techniques in respiratory infections in primary care]

Respiratory tract infections rank first as causes of adult and paediatric infectious morbidity in primary care in Spain. These infections are usually self-limiting and are mainly caused by viruses. However, a high percentage of unnecessary antibiotic prescription is reported. Point-of-care tests are biomedical tests, which can be used near the patient, without interference of a laboratory. The use of these tests, many of which have been recently developed, is rapidly increasing in general practice. Notwithstanding, we must mull over whether they always contribute to an effective and high-quality diagnostic process by primary care clinicians. We present a set of criteria that can be used by clinicians and discuss the pros and cons of the instruments available for the management of respiratory tract infections and how to use them appropriately.

The STOP-AB trial protocol: efficacy and safety of discontinuing patient antibiotic treatment when physicians no longer consider it necessary

INTRODUCTION

Since 2011, the Spanish Society of Family Medicine has recommended general practitioners (GPs) to ask their patients to stop taking antibiotics when they suspect a viral infection. However, this practice is seldom used because uncertainty about diagnosis, and fear of consequences of discontinuing antibiotic therapy, as well as perceived pressure to continue prescribing antibiotics and potential conflict with patients are more of a concern for GPs than antibiotic resistance. The main objective of this study is to determine whether discontinuation of antibiotic therapy when a GP no longer considers it necessary has any impact on the number of days with severe symptoms.

METHODS AND ANALYSIS

This is a multicentre, open-label, randomised controlled clinical trial. The study was conducted in 10 primary care centres in Spain. We included patients from 18 to 75 years of age with uncomplicated acute respiratory tract infections-acute rhinosinusitis, acute sore throat, influenza or acute bronchitis-who had previously taken any dose of antibiotic for <3 days, which physicians no longer considered necessary. The patients were randomly assigned to the usual strategy of continuing antibiotic treatment or to discontinuing antibiotic therapy. A sample size of 240 patients per group was calculated on the basis of a reduction of 1 day in the duration of severe symptoms being a clinically relevant outcome. The primary outcome was the duration of severe symptoms, that is, symptoms scored 5 or 6 by means of validated symptom diaries. Secondary outcomes included antibiotics taken, adverse events, patient satisfaction and complications within the first 3 months.

ETHICS AND DISSEMINATION

The study was approved by the Ethical Board of Fundació Jordi Gol i Gurina (reference number: 16/093). The findings of this trial will bedisseminated through research conferences and peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT02900820; pre-results.