Back-up antibiotic prescriptions could reduce unnecessary antibiotic use in rhinosinusitis

Health service utilization following symptomatic respiratory tract infections and influencing factors among urban and rural residents in Anhui, China

Aim:

This study seeks to identify healthcare utilization patterns following symptomatic respiratory tract infections (RTIs) and the variables that may influence these patterns.

Background:

RTIs are responsible for the bulk of the primary healthcare burden worldwide. Yet, the use of health services for RTIs displays great discrepancies between populations. This research examines the influence of social demographics, economic factors, and accessibility on healthcare utilization following RTIs.

Methods:

Structured interviews were administered by trained physicians at the households of informants selected by cluster randomization. Descriptive and multivariate binary logistic regression analysis was performed to assess healthcare utilization and associated independent variables.

Findings:

A total of 60 678 informants completed the interviews. Of the 2.9% informants exhibiting upper RTIs, 69.5–73.9% sought clinical care. Healthcare utilization rates for common cold, influenza, nine acute upper RTIs, and overall RTIs demonstrate statistically significant associations with the variables of age, type of residence, employment, medical insurance, annual food expenditure, distance to medical facilities, and others. The odds ratios for healthcare utilization rates varied substantially, ranging from 0.026 to 9.364. More than 69% of informants with RTIs sought clinical interventions. These findings signify a marked issue with the large amount of healthcare for self-limited RTIs.

Medical management of acute upper respiratory infections in an urban primary care out-of-hours facility: cross-sectional study of patient presentations and expectations

OBJECTIVES

The purpose of this study was to examine the expectations of patients attending an urban primary care out-of-hours (OOH) facility with acute upper respiratory tract infection (acute URTI) regarding clinical examination, symptom management, information on their condition, reassurance, antibiotic treatment and other possible options including referral.

DESIGN

Cross-sectional design.

SETTING

One urban primary care OOH facility located in the midwest of Ireland.

PARTICIPANTS

457 patients filled out a questionnaire while waiting in the OOH facility; 22 surveys were excluded as the patients did not present with symptoms of acute URTI resulting in 435 patients' data being included in this study. There were 59.5% female participants and 40.5% male participants.

RESULTS

435 patients with acute URTI symptoms participated in the survey, representing 25.4% of those attending the single branch where the survey was conducted (n=1715). Of the study participants, 43% were aged under 6 years and 60% were women. The most common presenting symptoms were cough (72%), throat ache (46%) and common cold (26%). The most common expectations were for further examination (53%), reassurance (51%), information (49%) and medication for cough (47%), with 34% expecting an antibiotic.

CONCLUSIONS

Only one in three patients attending this primary care OOH facility with acute URTI symptoms had an expectation of antibiotics, with most seeking further assessment, information and reassurance. Recognition of such expectations may be important considerations for clinicians when deciding on management options for patients with acute URTI.

Over prescribing of antibiotics for acute respiratory tract infections; a qualitative study to explore Irish general practitioners' perspectives

BACKGROUND

Anti-microbial resistance (AMR) is a global threat to public health and antibiotics are often unnecessarily prescribed for acute respiratory tract infections (ARTIs) in general practice. We aimed to investigate why general practitioners (GPs) continue to prescribe antibiotics for ARTIs despite increasing knowledge of their poor efficacy and worsening antimicrobial resistance.

METHODS

We used an explorative qualitative study design. Thirteen GPs were recruited through purposive sampling to represent urban and rural settings and years of experience. They were based in general practices within the Mid-West of Ireland. GPs took part in semi-structured interviews that were digitally audio recorded and transcribed.

RESULTS

Three main themes and three subthemes were identified. Themes include (1) non-comprehensive guidelines; how guideline adherence can be difficult, (2) GPs under pressure; pressures to prescribe from patients and perceived patient expectations and (3) Unnecessary prescribing; how to address it and the potential of public interventions to reduce it.

CONCLUSIONS

GPs acknowledge their failure to implement guidelines because they feel they are less usable in clinical situations. GPs felt pressurised to prescribe, especially for fee-paying patients and in out of hours settings (OOH), suggesting the need for interventions that target the public's perceptions of antibiotics. GPs behaviours surrounding prescribing antibiotics need to change in order to reduce AMR and change patients' expectations.

Antibiotic use for acute respiratory tract infections (ARTI) in primary care; what factors affect prescribing and why is it important? A narrative review

BACKGROUND

Antimicrobial resistance is an emerging global threat to health and is associated with increased consumption of antibiotics. Seventy-four per cent of antibiotic prescribing takes place in primary care. Much of this is for inappropriate treatment of acute respiratory tract infections.

AIMS

To review the published literature pertaining to antibiotic prescribing in order to identify and understand the factors that affect primary care providers' prescribing decisions.

METHODS

Six online databases were searched for relevant paper using agreed criteria. One hundred ninety-five papers were retrieved, and 139 were included in this review.

RESULTS

Primary care providers are highly influenced to prescribe by patient expectation for antibiotics, clinical uncertainty and workload induced time pressures. Strategies proven to reduce such inappropriate prescribing include appropriately aimed multifaceted educational interventions for primary care providers, mass media educational campaigns aimed at healthcare professionals and the public, use of good communication skills in the consultation, use of delayed prescriptions especially when accompanied by written information, point of care testing and, probably, longer less pressurised consultations. Delayed prescriptions also facilitate focused personalised patient education.

CONCLUSION

There is an emerging consensus in the literature regarding strategies proven to reduce antibiotic consumption for acute respiratory tract infections. The widespread adoption of these strategies in primary care is imperative.

Amoxicillin for acute rhinosinusitis: a randomized controlled trial

CONTEXT

Evidence to support antibiotic treatment for acute rhinosinusitis is limited, yet antibiotics are commonly used.

OBJECTIVE

To determine the incremental effect of amoxicillin treatment over symptomatic treatments for adults with clinically diagnosed acute rhinosinusitis.

DESIGN, SETTING, AND PARTICIPANTS

A randomized, placebo-controlled trial of adults with uncomplicated, acute rhinosinusitis were recruited from 10 community practices in Missouri between November 1, 2006, and May 1, 2009.

INTERVENTIONS

Ten-day course of either amoxicillin (1500 mg/d) or placebo administered in 3 doses per day. All patients received a 5- to 7-day supply of symptomatic treatments for pain, fever, cough, and nasal congestion to use as needed.

MAIN OUTCOME MEASURES

The primary outcome was improvement in disease-specific quality of life after 3 to 4 days of treatment assessed with the Sinonasal Outcome Test-16 (minimally important difference of 0.5 units on a 0-3 scale). Secondary outcomes included the patient's retrospective assessment of change in sinus symptoms and functional status, recurrence or relapse, and satisfaction with and adverse effects of treatment. Outcomes were assessed by telephone interview at days 3, 7, 10, and 28.

RESULTS

A total of 166 adults (36% male; 78% with white race) were randomized to amoxicillin (n = 85) or placebo (n = 81); 92% concurrently used 1 or more symptomatic treatments (94% for amoxicillin group vs 90% for control group; P = .34). The mean change in Sinonasal Outcome Test-16 scores was not significantly different between groups on day 3 (decrease of 0.59 in the amoxicillin group and 0.54 in the control group; mean difference between groups of 0.03 [95% CI, -0.12 to 0.19]) and on day 10 (mean difference between groups of 0.01 [95% CI, -0.13 to 0.15]), but differed at day 7 favoring amoxicillin (mean difference between groups of 0.19 [95% CI, 0.024 to 0.35]). There was no statistically significant difference in reported symptom improvement at day 3 (37% for amoxicillin group vs 34% for control group; P = .67) or at day 10 (78% vs 80%, respectively; P = .71), whereas at day 7 more participants treated with amoxicillin reported symptom improvement (74% vs 56%, respectively; P = .02). No between-group differences were found for any other secondary outcomes. No serious adverse events occurred.

CONCLUSION

Among patients with acute rhinosinusitis, a 10-day course of amoxicillin compared with placebo did not reduce symptoms at day 3 of treatment.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00377403.

Delayed prescribing for upper respiratory tract infections: a qualitative study of GPs' views and experiences

BACKGROUND

Delayed prescribing has been promoted as a strategy that meets patients' expectations and helps to avoid unnecessary use of antibiotics in upper respiratory tract infections.

AIM

To explore GPs' views on and experiences with delayed prescribing in patients with acute upper respiratory tract infections.

DESIGN OF STUDY

Qualitative study involving focus groups. Setting Norwegian general practice.

METHOD

Qualitative analysis of data collected from five focus groups comprising 33 GPs who took part in a quality-improvement programme of antibiotic prescribing.

RESULTS

The views of GPs differed on the usefulness of delayed prescribing. GPs who endorsed the strategy emphasised shared decision making and the creation of opportunities for educating patients, whereas GPs who were negative applied the strategy mainly when being pressed to prescribe. Mild and mainly harmless conditions of a possible bacterial origin, such as acute sinusitis and acute otitis, were considered most suitable for delayed prescribing. A key argument for issuing a wait-and-see prescription was that it helped patients avoid seeking after-hours care. For issuing a wait-and-see prescription, the GPs required that the patient was 'knowledgeable', able to understand the indications for antibiotics, and motivated for shared decision making. GPs emphasised that patients should be informed thoroughly when receiving a wait-and-see prescription.

CONCLUSION

Not all GPs endorse delayed prescribing; however, it appears to be a feasible approach for managing patients with early symptoms of mild upper respiratory tract infections of a possible bacterial origin. Informing the patients properly while issuing wait-and-see prescriptions is essential.

Upper respiratory infections

It is estimated that >24 million cases of acute bacterial sinusitis occur annually in the United States. Recently, a number of medical societies have issued guidelines to aid in the management of upper respiratory tract infections (URIs). Although these guidelines serve to aid practitioners in the proper use of antibiotics, confusion remains regarding the disparity of guideline recommendations as well as some recommendations being outdated. This review presents 3 illustrative case studies designed to provide some clarity with regard to these guidelines. Case 1 is a typical presentation of a patient with worsening sinus conditions over the previous 2 weeks. Case 2 is a more challenging case of a patient with a sinus condition accompanied by a penicillin allergy that ultimately requires referral to an otolaryngologist. Case 3 is an atypical case with symptoms of a sinus infection accompanied by a normal sinus computed tomography scan. It is hoped that the presentation and discussion surrounding these cases will provide some helpful insights into the management of patients with URIs.

The role of evidence in the decline of antibiotic use for common respiratory infections in primary care

Antibiotic prescribing in primary care for common respiratory infections increased steadily until the mid 1990s, when the trend reversed noticeably. During the subsequent decade, antibiotic prescribing reduced by up to one-third in some countries. Explanations for this reduction have focused on a decline in the incidence and severity of common respiratory infections, and on the resulting decrease in the number of patients seeking consultation. We argue that evidence from primary-care research had a central role in changing the practice of antibiotic prescribing, and discuss the concern that has arisen among some physicians around this issue. Targeted reductions in antibiotic prescribing constitute a balancing act between individual and societal concerns, pitting the expected gains in preserving the usefulness of an antibiotic against any given reduction in use. There may be unintended consequences for decreasing antibiotic use beyond a certain point without adequate supporting evidence. A new approach to antibiotic prescribing requires comprehensive research to answer why change is necessary, and how that change can be safely implemented. Future policies must move beyond a "one size fits all" mindset if public and provider behaviours are expected to become more congruent with the growing research evidence.