Contemporary use of antibiotics in 1089 adults presenting with acute lower respiratory tract illness in general practice in the U.K.: implications for developing management guidelines

Clinical utility of procalcitonin in implementation of procalcitonin-guided antibiotic stewardship in the South-East Asia and India: evidence and consensus-based recommendations

INTRODUCTION

The South-East Asian (SEA) region and India are highly susceptible to antibiotic resistance, which is caused due to lack of antimicrobial stewardship (AMS) knowledge, uncontrolled use of antibiotics, and poor infection control. Nonadherence to national/local guidelines, developed to combat antimicrobial resistance, is a major concern. A virtual advisory board was conducted to understand the current AMS standards and challenges in its implementation in these regions.

AREAS COVERED

Procalcitonin (PCT)-guided antibiotic use was discussed in various clinical conditions across initiation, management, and discontinuation stages. Most experts strongly recommended using PCT-driven antibiotic therapy among patients with lower respiratory tract infections, sepsis, and COVID-19. However, additional research is required to understand the optimal use of PCT in patients with organ transplantation and cancer patients with febrile neutropenia. Implementation of the solutions discussed in this review can help improve PCT utilization in guiding AMS in these regions and reducing challenges.

EXPERT OPINION

Experts strongly support the inclusion of PCT in AMS. They believe that PCT in combination with other clinical data to guide antibiotic therapy may result in more personalized and precise targeted antibiotic treatment. The future of PCT in antibiotic treatment is promising and may result in effective utilization of this biomarker.

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.

Use of antibiotics and asthma medication for acute lower respiratory tract infections in people with and without asthma: retrospective cohort study

Background

Antibiotics are overused in patients with acute lower respiratory tract infections (ALRTIs), but less is known about their use in patients with asthma, or the use of asthma medication for ALRTI in patients without asthma. Our aim was to describe the frequency, variation and drivers in antibiotic and asthma medication prescribing for ALRTI in adults with and without asthma in primary care.

Methods

A retrospective cohort analysis of patients aged ≥12 years, diagnosed with an ALRTI in primary care in 2014–15 was conducted using data from the Clinical Practice Research Datalink. Current asthma status, asthma medication and oral antibiotic use within 3 days of ALRTI infection was determined. Treatment frequency was calculated by asthma status. Mixed-effect regression models were used to explore between-practice variation and treatment determinants.

Results

There were 127,976 ALRTIs reported among 110,418 patients during the study period, of whom 17,952 (16%) had asthma. Respectively, 81 and 79% of patients with and without asthma received antibiotics, and 41 and 15% asthma medication. There were significant differences in between-practice prescribing for all treatments, with greatest differences seen for oral steroids (odds ratio (OR) 18; 95% CI 7–82 and OR = 94; 33–363, with and without asthma) and asthma medication only (OR 7; 4–18 and OR = 17; 10–33, with and without asthma).

Independent predictors of antibiotic prescribing among patients with asthma included fewer previous ALRTI presentations (≥2 vs. 0 previous ALRTI: OR = 0.25; 0.16–0.39), higher practice (OR = 1.47; 1.35–1.60 per SD) and prior antibiotic prescribing (3+ vs. 1 prescriptions OR = 1.28; 1.04–1.57) and concurrent asthma medication (OR = 1.44; 1.32–1.57). Independent predictors of asthma medication in patients without asthma included higher prior asthma medication prescribing (≥7 vs. 0 prescriptions OR = 2.31; 1.83–2.91) and concurrent antibiotic prescribing (OR = 3.59; 3.22–4.01).

Conclusion

Findings from the study indicate that antibiotics are over-used for ALRTI, irrespective of asthma status, and asthma medication is over-used in patients without asthma, with between-practice variation suggesting considerable clinical uncertainty. Further research is urgently needed to clarify the role of these medications for ALRTI.

Use of point-of-care tests and antibiotic prescribing in sore throat and lower respiratory infections by general practitioners

INTRODUCTION

This study was aimed at assessing general practitioners' (GP) reliance on patient history, examination findings and the influence of the utilisation of point-of-care tests (POCT) in antibiotic prescribing for sore throat and lower respiratory tract infections (LRTI).

METHODS

Audit-based study carried out in 2015. A group of GPs received an intervention six years earlier with provision of POCTs and another group of GPs acted as controls. Odds ratios for clinical variables predicting antibiotic prescribing were calculated by logistic regression analyses.

RESULTS

A total of 238 GPs included 1906 patients with sore throat and 1970 LRTIs. A negative POCT result was negatively associated with antibiotic prescribing, with odds ratios ranging from 0.09 to 0.23. GPs using POCTs attached less weight to clinical criteria.

CONCLUSION

GPs using rapid tests are mainly influenced by POCT results in the decision to prescribe antibiotics. However, antibiotic prescribing is still observed with negative POCT results.

Matching diagnostics development to clinical need: Target product profile development for a point of care test for community-acquired lower respiratory tract infection

Background

Point of care tests (POCTs) are increasingly being promoted for guiding the primary medical care of community acquired lower respiratory tract infections (CA-LRTI). POCT development has seldom been guided by explicitly identified clinical need and requirements of the intended users. Approaches for identifying POCT priorities and developing target product profiles (TPPs) for POCTs in primary medical care are not well developed, and there is no published TPP for a CA-LRTI POCT aimed at developed countries.

Methods

We conducted workshops with expert stakeholders and a survey with primary care clinicians to produce a target product profile (TPP) to guide the development of a clinically relevant and technologically feasible POCT for CA-LRTI.

Results

Participants with clinical, academic, industrial, technological and basic scientific backgrounds contributed to four expert workshops, and 45 practicing primary care clinicians responded to an online survey and prioritised community-acquired pneumonia (CAP) as the CA-LRTI where a new POCT was most urgently needed. Consensus was reached on a TPP document that included information on the intended niche in the clinical pathway in primary medical care; diagnostic product specification (intended use statement and test concept), and minimum and ideal user specifications. Clinicians minimum requirements of a CA-LRTI POCT included the use of minimally invasive samples, a result in less than 30 minutes, no more than a single preparation step, minimum operational requirements, and detection of common respiratory pathogens and their resistance to commonly prescribed antibiotics.

Conclusions

This multidisciplinary, multistage partnership approach generated a clinically-driven TPP for guiding the development of a new POCT, and this approach as well as the TPP itself may be useful to others developing a new POCT.

Comparison of Procalcitonin Guidance-Administered Antibiotics with Standard Guidelines on Antibiotic Therapy in Children with Lower Respiratory Tract Infections: A Retrospective Study in China

OBJECTIVE

To establish the efficacy of an algorithm based on the biomarker procalcitonin (PCT) to reduce antibiotic exposure in pediatric patients with lower respiratory tract infection (LRTI).

MATERIALS AND METHODS

The clinical data of 357 patients (<14 years of age) who were discharged home with LRTI from January 1, 2010 to July 31, 2016 were analyzed. Antibiotic exposure, antibiotic prescription rate, length of hospital stay, and antibiotic-associated adverse effects were compared between the PCT group (n = 183) and the standard group (n = 174) using SAS 9.1.3 software.

RESULTS

The overall adverse effect rates were similar in both the PCT and standard groups: 42 (22.95%) and 51 (29.31%), respectively. The length of hospital stay was not significantly different between the PCT (9.96 ± 5.81 days) and standard groups (10.58 ± 4.24 days) (difference: -0.62%; 95% CI: -1.68 to 0.43). Antibiotic prescribing rates were significantly different in the PCT group compared to the standard group: 54.64% versus 83.91% (difference: -29.26%; 95% CI: -38.31, -20.22; p = 0.23). Mean duration of antibiotic exposure in the PCT group (3.98 ± 2.17 days) was lower than the standard groups (6.66 ± 5.59 days) (difference: -2.68%; 95% CI: -3.21 to -2.16).

CONCLUSION

This study showed that PCT guidance of antibiotic treatment in children and adolescents with LRTI reduced the duration of antibiotic exposure and antibiotic prescribing rates, but did not affect the adverse effect rate and length of hospital stay.

Antibiotic prescription strategies and adverse outcome for uncomplicated lower respiratory tract infections: prospective cough complication cohort (3C) study

Objective To assess the impact on adverse outcomes of different antibiotic prescribing strategies for lower respiratory tract infections in people aged 16 years or more.Design Prospective cohort study.Setting UK general practice.Participants 28 883 patients with lower respiratory tract infection; symptoms, signs, and antibiotic prescribing strategies were recorded at the index consultation.Main outcome measures The main outcomes were reconsultation with symptoms of lower respiratory tract infection in the 30 days after the index consultation, hospital admission, or death. Multivariable analysis controlled for an extensive list of variables related to the propensity to prescribe antibiotics and for clustering by doctor.Results Of the 28 883 participants, 104 (0.4%) were referred to hospital for radiographic investigation or admission, or both on the day of the index consultation, or were admitted with cancer. Of the remaining 28 779, subsequent hospital admission or death occurred in 26/7332 (0.3%) after no antibiotic prescription, 156/17 628 (0.9%) after prescription for immediate antibiotics, and 14/3819 (0.4%) after a prescription for delayed antibiotics. Multivariable analysis documented no reduction in hospital admission and death after immediate antibiotics (multivariable risk ratio 1.06, 95% confidence interval 0.63 to 1.81, P=0.84) and a non-significant reduction with delayed antibiotics (0.81, 0.41 to 1.64, P=0.61). Reconsultation for new, worsening, or non-resolving symptoms was common (1443/7332 (19.7%), 4455/17 628 (25.3%), and 538/3819 (14.1%), respectively) and was significantly reduced by delayed antibiotics (multivariable risk ratio 0.64, 0.57 to 0.72, P<0.001) but not by immediate antibiotics (0.98, 0.90 to 1.07, P=0.66).Conclusion Prescribing immediate antibiotics may not reduce subsequent hospital admission or death for young people and adults with uncomplicated lower respiratory tract infection, and such events are uncommon. If clinicians are considering antibiotics, a delayed prescription may be preferable since it is associated with a reduced number of reconsultations for worsening illness.

Help-seeking and antibiotic prescribing for acute cough in a Chinese primary care population: a prospective multicentre observational study

Acute cough is a common reason to prescribe antibiotics in primary care. This study aimed to explore help-seeking and antibiotic prescribing for acute cough in Chinese primary care population. This is a prospective multicentre observational study that included adults presenting with acute cough. Clinicians recorded patients’ presenting symptoms, examination findings and medication prescription. Patients completed symptom diaries for up to 28 days by charting their symptom severity and recovery. Adjusted binary logistic regression models identified factors independently associated with antibiotic prescription. Primary care clinicians (n=19) recruited 455 patients. A total of 321 patients (70.5%) returned their completed symptom diaries. Concern about illness severity (41.6%) and obtaining a prescription for symptomatic medications (45.9%), rather than obtaining a prescription for antibiotics, were the main reasons for consulting. Antibiotics were prescribed for 6.8% (n=31) of patients, of which amoxicillin was the most common antimicrobial prescribed (61.3%), as it was associated with clinicians’ perception of benefit from antibiotic treatment (odds ratio (OR): 25.9, 95% confidence interval (CI): 6.7–101.1), patients’ expectation for antibiotics (OR: 5.1, 95% CI: 1.7–11.6), anticipation (OR: 5.1, 95% CI: 1.6–15.0) and request for antibiotics (OR 15.7, 95% CI: 5.0–49.4), as well as the severity of respiratory symptoms (cough, sputum, short of breath and wheeze OR: 2.7–3.7, all P<0.05). There was a significant difference in antibiotic prescription rates between private primary care clinicians and public primary care clinicians (17.4 vs 1.6%, P=0.00). Symptomatic medication was prescribed in 98.0% of patients. Mean recovery was 9 days for cough and 10 days for all symptoms, which was not significantly associated with antibiotic treatment. Although overall antibiotic-prescribing rates were low, there was a higher rate of antibiotic prescribing among private primary care clinicians, which warrants further exploration and scope for education and intervention.

Clinical risk scores and blood biomarkers as predictors of long-term outcome in patients with community-acquired pneumonia: a 6-year prospective follow-up study

OBJECTIVE

Prediction of long-term outcomes in patients with community-acquired pneumonia (CAP) is incompletely understood. We investigated the value of clinical risk scores [pneumonia severity index (PSI) and CURB-65] (Confusion, Urea, Respiratory rate, Blood Pressure, Age >65 years) and blood biomarkers of different physiopathological pathways in predicting long-term survival in a well-characterized cohort of patients with CAP enrolled in an antibiotic stewardship trial.

DESIGN, SETTING AND SUBJECTS

Patients admitted with CAP to six medical centres in Switzerland were prospectively followed for 6 years. Cox regression models and area under the receiver operating characteristics curve (AUC) were used to investigate associations between initial risk assessment and all-cause mortality.

MAIN OUTCOME MEASURE

All-cause mortality during a 6-year follow-up period.

RESULTS

Six-year mortality in the present cohort (median age 73 years) was 45.1% [95% confidence interval (CI) 41.8-48.3%]. Initial PSI and CURB-65 scores both had excellent long-term prognostic accuracy, with a stepwise increase in mortality per risk class. The hazard ratios (95% CI) of the highest PSI and CURB-65 classes (reference: lowest class) were 38.0 (14.0-103.0) and 7.8 (2.2-14.5), respectively, after 6 years. The addition of inflammatory (pro-adrenomedullin) and cardiac (pro-atrial natriuretic peptide) blood biomarkers measured upon hospital admission further improved the prognostic capabilities of the PSI (AUC increase from 0.79 to 0.83; P < 0.0001) and the CURB-65 score (AUC increase from 0.73 to 0.80; P < 0.001).

CONCLUSION

Risk assessment using clinical scores allowed accurate long-term prognostication, which was further improved by the addition of two inflammatory (pro-adrenomedullin) and cardiac (pro-atrial natriuretic peptide) blood biomarkers. These data provide a rationale for a more risk-adapted, 'personalized' strategy for long-term management of patients with CAP.

Pneumococcal lower respiratory tract infections in adults: an observational case-control study in primary care in Belgium

Background

Serious lower respiratory tract infections (SLRTIs), especially Streptococcus pneumoniae (SP)-related pneumonia cause considerable morbidity and mortality. Chest imaging, sputum and blood culture are not routinely obtained by general practitioners (GPs). Antibiotic therapy is usually started empirically. The BinaxNOW® and Urine Antigen Detection (UAD) assays have been developed respectively to detect a common antigen from all pneumococcal strains and the 13 pneumococcal serotypes present in the vaccine Prevenar 13® (PCV13).

Methods

OPUS-B was a multicentre, prospective, case-control, observational study of patients with SLRTI in primary care in Belgium, conducted during two winter seasons (2011–2013). A urine sample was collected at baseline for the urine assays. GPs were blinded to the results. All patients with a positive BinaxNOW® test and twice as much randomly selected BinaxNOW® negative patients were followed up. Recorded data included: socio-demographics, medical history, vaccination history, clinical symptoms, CRB-65 score, treatments, hospitalization, blood cultures, healthcare use, EQ-5D score. The objectives were to evaluate the percentage of SP SLRTI within the total number of SLRTIs, to assess the percentage of SP serotypes and to compare the burden of disease between pneumococcal and non-pneumococcal SLRTIs.

Results

There were 26 patients with a BinaxNOW® positive test and 518 patients with a BinaxNOW® negative test. The proportion of pneumococcal SLRTI was 4.8 % (95 % CI: 3.1 %–7.2 %). Sixty-eight percent of positive cases showed serotypes represented in PCV13. In the BinaxNOW-positive patients, women were more numerous, there was less exposure to young children, seasonal influenza vaccination was less frequent, COPD was more frequent, the body temperature and the number of breaths per minute were higher, the systolic blood pressure was lower, the frequency of sputum, infiltrate, chest pain, muscle ache, confusion/disorientation, diarrhoea, pneumonia and exacerbations of COPD was more frequent, EQ-5D index and VAS scale were lower, the number of visits to the GP, of working days lost and of days patients needed assistance were higher.

Conclusions

SP was responsible for approximately 5 % of SLRTIs observed in primary care in Belgium. Pneumococcal infection was associated with a significant increase in morbidity. Sixty-eight percent of serotypes causing SLRTI were potentially preventable by PCV13.

Predictors of treatment with antibiotics and systemic corticosteroids for acute exacerbations of asthma and chronic obstructive pulmonary disease in primary care

Background

Antibiotic and oral corticosteroid prescribing rate in patients suffering from acute exacerbations of chronic obstructive pulmonary disease (COPD) or asthma in general practice are only sparsely described. Our aim was to identify predictors for such prescribing when results from CRP testing, spirometry, and pulse oximetry are available.

Methods

Patients aged 40 years or more diagnosed with asthma, COPD or both, the previous five years from seven general practice offices in Norway, were invited to a baseline examination and asked to visit their GPs during exacerbations the following 12 months. At all visits, symptoms, chest findings, and results from spirometry, pulse oximetry and CRP testing were registered.

Results

Out of the 376 who took part in baseline examination, 95 patients with an exacerbation were included in the analysis. Based on the diagnosis made by GPs, 46 patients (48.4%) were only registered with asthma, and 49 (51.6%) with COPD (or both diagnosis). 11 patients had taken antibiotics and 16 had taken systemic corticosteroids prior to their visit to their GPs. After excluding those already treated, antibiotics were prescribed in 34.9% and systemic corticosteroids in 42.5% of patients diagnosed with COPD compared to 14.6% and 30.8% respectively in patients only diagnosed with asthma (P = 0.02, P = 0.2). In the COPD group, antibiotic prescribing was not significantly associated with purulence or other respiratory symptoms, but increased phlegm was a significant predictor of antibiotic prescribing in the whole sample (P = 0.04). Prolonged expiration, wheezes and diminished breath sounds also predicted the prescribing of both antibiotics and systemic corticosteroids in the whole sample with P values < 0.01. The prescribing rate of antibiotics and systemic corticosteroids also increased with increasing CRP value (P = 0.001 and P = 0.01, respectively) and with decreasing oxygen saturation (P = 0.01 and P = 0.003, respectively). FEV₁/FVC < 0.7 at baseline was as significant predictor in patients with COPD and in the whole sample of patients regarding treatment with antibiotics (P = 0.004 and P = 0.001, respectively) and treatment with systemic corticosteroids (P = 0.004 and P = 0.001, respectively).

Conclusion

Chest findings, raised CRP value and decreased oxygen saturation were stronger predictors of prescribing of antibiotics and systemic corticosteroids than were respiratory symptoms. Further evaluation of the importance of these findings to guide treatment of asthma and COPD exacerbations is warranted.

Patient Attitudes and Beliefs and Provider Practices Regarding Antibiotic Use for Acute Respiratory Tract Infections in Minya, Egypt

The inappropriate use of antibiotics in the community is one of the major causes of antimicrobial resistance. This study aimed to explore the physician prescribing pattern of antibiotics for acute respiratory infections (ARIs) and to explore the knowledge, attitudes, and practices of patients regarding antibiotic use for ARIs. The study was conducted in Upper Egypt and used quantitative and qualitative research techniques. Eligible patients exiting outpatient clinics with ARIs were invited to participate in the study. A qualitative study was conducted through 20 focus group discussions. Out of 350 encounters for patients with various ARIs, 292 (83%) had been prescribed at least one antibiotic. Factors significantly associated with antibiotic prescribing for adults included patient preference that an antibiotic be prescribed. For children younger than 18, presentation with fever, cough, loss of appetite, and sore throat, along with the caregiver’s antibiotic preference, were associated with an antibiotic prescription. Several misconceptions regarding antibiotic use among community members were stated, such as the strong belief of the curing and prophylactic power of antibiotics for the common cold. Interventions to promote proper antibiotic use for ARIs need to be piloted, targeting both physicians and the public. Educational programs for physicians and campaigns to raise public awareness regarding proper antibiotic use for ARIs need to be developed.

The use of unprescribed antibiotics in management of upper respiratory tract infection in children in Enugu, South East Nigeria

BACKGROUND

It is a documented fact that upper respiratory tract infection (URTI) is more of a viral illness.

OBJECTIVES

This study aims at documenting the prevalence of the use of unprescribed antibiotics in children aged <5 years with upper respiratory symptomatology.

METHODS

Four hundred twenty-three mother-child pairs were enrolled for this study. Chi-square and logistic regression analysis were used to find association between use of unprescribed antibiotics and variables of interest.

RESULTS

The prevalence of unprescribed antibiotics in children aged <5 years in the management of URTI is 75.9%. The antibiotics abuse was commoner in older children with URTI (45.9% in children aged 12-24 months) and among mothers with higher educational attainment.

CONCLUSION

Antibiotics abuse among mothers is high. Government, through its responsible agencies, should enforce stricter control or outrightly stop sale of antibiotics over-the-counter to prevent the dreaded antibiotics resistance.

Procalcitonin as a biomarker of bacterial infection in sickle cell vaso-occlusive crisis

Sickle cell anaemia (SCA) patients with vaso-occlusive crisis (VOC) have signs of inflammation and it is often difficult to diagnose a bacterial infection in them. This study was undertaken to evaluate the role of serum procalcitonin (PCT) as a biomarker of bacterial infection in acute sickle cell vaso-occlusive crisis. Hundred homozygous SCA patients were studied at Sickle Cell Clinic and Molecular Biology Laboratory, V.S.S. Medical College, Burla, Odisha, India. All the patients were divided into three categories namely category-A (VOC/ACS with SIRS but without evidence of bacterial infection - 66 patients), category-B (VOC/ACS with SIRS and either proven or suspected bacterial infection - 24 patients) and category-C (SCA patients in steady state without VOC/ACS or SIRS - 10 patients). Complete blood count, C-reactive protein (CRP) estimation and PCT measurement were done in all the patients. There was no significant difference in TLC and CRP values between category-A and B. In category-A, the PCT level was <0.5 ng/mL in 83.3% and 0.5–2 ng/mL in 16.7% of cases. In category-B, all the patients had PCT value >0.5 ng/mL with 87.5% of patients having >2 ng/mL. In category-C, PCT value was <0.5 ng/mL. PCT had a high sensitivity (100%) and negative predictive value (100%) for bacterial infection at a cutoff value of 0.5 ng/mL; whereas the specificity is excellent at a cut-off value of 2 ng/mL. SCA patients with VOC/ACS and SIRS having a PCT level of <0.5 ng/mL have a low probability of bacterial infection whereas PCT value of >2 ng/mL is indicative of bacterial infection necessitating early antimicrobial therapy.

Antibiotic prescribing and C-reactive protein testing for pulmonary infections in patients with intellectual disabilities

BACKGROUND

Excessive prescribing of antibiotics in patients with lower respiratory tract infections (LRTIs) is common in the general population. Due to communication difficulties, it is hypothesised that prescriptions are even more commonplace in the primary care of individuals with intellectual disabilities. Point-of-care C-reactive protein (POC-CRP) testing might lead to more efficient prescribing of antibiotics.

AIM

To evaluate the effect of POC-CRP testing on antibiotic prescriptions for LRTIs by physicians specialising in the care of individuals with intellectual disabilities.

DESIGN AND SETTING

A prospective case-control study in four care centres for individuals with intellectual disabilities in The Netherlands.

METHOD

Between 27 October 2010 and 27 October 2011, a prospective efficiency study was performed with a base population of 1472 individuals. This population consisted of 882 individuals in whom POC-CRP tests were used and a control group (n = 590) in whom no POC-CRP test was performed.

RESULTS

Of the 48 patients in the control group who were diagnosed as having an LRTI, 43 (90%) received antibiotics, compared with 59 out of the 144 patients (41%) in the case group (OR = 12.0; 95% CI = 4.1-35.3). No significant differences in outcome were found between both groups during a follow-up period of 1 month.

CONCLUSION

This study shows that the use of POC-CRP testing in patients with intellectual disabilities and LRTIs can lead to a significant reduction in antibiotic prescriptions, with no significant differences in outcome during follow-up.

Are patient views about antibiotics related to clinician perceptions, management and outcome? A multi-country study in outpatients with acute cough

BACKGROUND

Outpatients with acute cough who expect, hope for or ask for antibiotics may be more unwell, benefit more from antibiotic treatment, and be more satisfied with care when they are prescribed antibiotics. Clinicians may not accurately identify those patients.

OBJECTIVE

To explore whether patient views (expecting, hoping for or asking for antibiotics) are associated with illness presentation and resolution, whether patient views are accurately perceived by clinicians, and the association of all these factors with antibiotic prescribing and patient satisfaction with care.

METHODS

Prospective observational study of 3402 adult patients with acute cough presenting in 14 primary care networks. Correlations and associations tested with multilevel logistic regression and McNemar 's tests, and Cohen's Kappa, positive agreement (PA) and negative agreement (NA) calculated as appropriate.

RESULTS

1,213 (45.1%) patients expected, 1,093 (40.6%) hoped for, and 275 (10.2%) asked for antibiotics. Clinicians perceived 840 (31.3%) as wanting to be prescribed antibiotics (McNemar's test, p<0.05). Their perception agreed modestly with the three patient views (Kappa's = 0.29, 0.32 and 0.21, PA's = 0.56, 0.56 and 0.33, NA's = 0.72, 0.75 and 0.82, respectively). 1,464 (54.4%) patients were prescribed antibiotics. Illness presentation and resolution were similar for patients regardless their views. These associations were not modified by antibiotic treatment. Patient expectation and hope (OR:2.08, 95% CI:[1.48,2.93] and 2.48 [1.73,3.55], respectively), and clinician perception (12.18 [8.31,17.84]) were associated with antibiotic prescribing. 2,354 (92.6%) patients were satisfied. Only those hoping for antibiotics were less satisfied when antibiotics were not prescribed (0.39 [0.17,0.90]).

CONCLUSION

Patient views about antibiotic treatment were not useful for identifying those who will benefit from antibiotics. Clinician perceptions did not match with patient views, but particularly influenced antibiotic prescribing. Patients were generally satisfied with care, but those hoping for but not prescribed antibiotics were less satisfied. Clinicians need to more effectively elicit and address patient views about antibiotics.

Variation in family physicians' recording of auscultation abnormalities in patients with acute cough is not explained by case mix. A study from 12 European networks

BACKGROUND

Conflicting data on the diagnostic and prognostic value of auscultation abnormalities may be partly explained by inconsistent use of terminology.

OBJECTIVES

To describe general practitioners use of chest auscultation abnormality terms for patients presenting with acute cough across Europe, and to explore the influence of geographic location and case mix on use of these terms.

METHODS

Clinicians recorded whether 'diminished vesicular breathing', 'wheezes', 'crackles' and 'rhonchi' were present in an observational study of adults with acute cough in 13 networks in 12 European countries. We describe the use of these terms overall and by network, and used multilevel logistic regression to explore variation by network, controlling for patients' gender, age, comorbidities, smoking status and symptoms.

RESULTS

2345 patients were included. Wheeze was the auscultation abnormality most frequently recorded (20.6% overall) with wide variation by network (range: 8.3-30.8%). There was similar variation for other auscultation abnormalities. After controlling for patient characteristics, network was a significant predictor of auscultation abnormalities with odds ratios for location effects ranging from 0.37 to 4.46 for any recorded auscultation abnormality, and from 0.25 to 3.14 for rhonchi.

CONCLUSION

There is important variation in recording chest auscultation abnormalities by general practitioners across Europe, which cannot be explained by differences in patient characteristics. There is a need and opportunity for standardization in the detection and classification of lung sounds.

Procalcitonin as a biomarker of acute lower respiratory tract infections

BACKGROUND

Procalcitonin (PCT) has emerged as a promising 'acute phase' biomarker used for diagnosis of acute bacterial infections of the respiratory tract. The introduction of new sensitive PCT assays has facilitated implementation of a new clinical approach to reduce antibiotic use in acute lower respiratory tract infections (LRTIs), without compromising patient safety.

OBJECTIVE

Current state of knowledge on the clinical usefulness of serum PCT measurements for the evaluation of acute LRTIs is presented herein, together with basic information on available rapid diagnostic tests for PCT measurement.

METHODS

During the literature search the emphasis was on PCT use as a diagnostic, monitoring and prognostic tool for acute LRTIs. The acute LRTIs have been defined as acute bronchitis, acute exacerbations of chronic obstructive pulmonary disease or asthma, and pneumonia. Original studies involving patients with these conditions have been considered, and recent articles documenting interventional trials on PCT use for guidance of antimicrobial treatment in LRTIs have been reviewed in particular.

RESULTS/CONCLUSION

When measured with sensitive and rapid assays, PCT has proved to be a good biomarker for acute bacterial LRTIs, which enables an early diagnosis, facilitates therapeutic decisions, and can inform clinicians about the course of disease and prognosis. PCT can become a particularly suitable tool for implementation in an emergency and acute medical care setting.

Clinical influences on antibiotic prescribing decisions for lower respiratory tract infection: a nine country qualitative study of variation in care

OBJECTIVES

There is variation in antibiotic prescribing for lower respiratory tract infections (LRTI) in primary care that does not benefit patients. This study aims to investigate clinicians' accounts of clinical influences on antibiotic prescribing decisions for LRTI to better understand variation and identify opportunities for improvement.

DESIGN

Multi country qualitative interview study. Semi-structured interviews using open-ended questions and a patient scenario. Data were subjected to five-stage analytic framework approach (familiarisation, developing a thematic framework from the interview questions and emerging themes, indexing, charting and mapping to search for interpretations), with interviewers commenting on preliminary reports.

SETTING

Primary care.

PARTICIPANTS

80 primary care clinicians randomly selected from primary care research networks based in nine European cities.

RESULTS

Clinicians reported four main individual clinical factors that guided their antibiotic prescribing decision: auscultation, fever, discoloured sputum and breathlessness. These were considered alongside a general impression of the patient derived from building a picture of the illness course, using intuition and familiarity with the patient. Comorbidity and older age were considered main risk factors for poor outcomes. Clinical factors were similar across networks, apart from C reactive protein near patient testing in Tromsø. Clinicians developed ways to handle diagnostic and management uncertainty through their own clinical routines.

CONCLUSIONS

Clinicians emphasised the importance of auscultation, fever, discoloured sputum and breathlessness, general impression of the illness course, familiarity with the patient, comorbidity, and age in informing their antibiotic prescribing decisions for LRTI. As some of these factors may be overemphasised given the evolving evidence base, greater standardisation of assessment and integration of findings may help reduce unhelpful variation in management. Non-clinical influences will also need to be addressed.

Understanding variation in primary medical care: a nine-country qualitative study of clinicians' accounts of the non-clinical factors that shape antibiotic prescribing decisions for lower respiratory tract infection

OBJECTIVES

There is a wide variation between European countries in antibiotic prescribing for patients in primary care with lower respiratory tract infection (LRTI) that is not explained by case mix and clinical factors alone. Variation in antibiotic prescribing that is not warranted by differences in illness and clinical presentation may increase selection of resistant organisms, contributing to the problem of antibiotic resistance. This study aimed to investigate clinicians' accounts of non-clinical factors that influence their antibiotic prescribing decision for patients with LRTI, to understand variation and identify opportunities for addressing possible unhelpful variation.

DESIGN

Multicountry qualitative semistructured interview study, with data subjected to a five-stage analytic framework approach (familiarisation, developing a thematic framework from interview questions and emerging themes, indexing, charting and interpretation), and with interviewers commenting on preliminary analytic themes.

SETTING

Primary care.

PARTICIPANTS

Eighty primary care clinicians randomly selected from primary care research networks based in nine European cities.

RESULTS

Clinicians' accounts identified non-clinical factors imposed by the healthcare system operating within specific regional primary care research networks, including patient access to antibiotics before consulting a doctor (Barcelona and Milan), systems to reduce patient expectations for antibiotics (Southampton and Antwerp) and lack of consistent treatment guidelines (Balatonfüred and Łódź). Secondly, accounts revealed factors related to specific characteristics of clinicians regardless of network (professional ethos, self-belief in decision-making and commitment to shared decision-making).

CONCLUSIONS

Addressing healthcare system factors (eg, limiting patients' self-management with antibiotics before consulting in primary care, increased public awareness and provision of more consistent guidelines) may assist in reducing unhelpful variation in antibiotic prescribing. Promoting clinicians' receptivity to change, confidence in decision-making and readiness to invest in explaining prescribing decisions may also be beneficial. As factors were emphasised differently between networks, local flexibility in interventions is likely to maximise effectiveness.

Presentation, antibiotic management and associated outcome in Polish adults presenting with acute cough/LRTI

OBJECTIVE

In-depth knowledge of existing practice is required to inform interventions aimed at antibiotic prescribing quality improvement. We set out to describe the presentation, antimicrobial management and associated outcome of adults presenting in general practice with acute cough/lower respiratory tract infection (LRTI) in Poland.

METHODS

Observational study of 301 adults with acute cough/LRTI. Clinicians completed a case report form (CRF) describing presentation, history and management and patients completed a symptom diary for up to 28 days after consultation.

RESULTS

Two hundred and twenty-one patients (with CRF and symptom diary completed) were analysed. The median duration of feeling unwell before presentation was 4 days. Clinicians recorded an average of eight symptoms for patients at presentation. Apart from cough, patients most commonly reported feeling generally unwell (91.9%), limitation of normal activities (80.5%), coryza (80.1%) and phlegm production (76.0%). Auscultation abnormalities were present in 55.0%. Overall, medicines were prescribed for 95.0%; 72.4% were prescribed antibiotics [mostly macrolides/lincosamides (38.8%) and amoxicillin/co-amoxiclav (36.3%)) with 11.3% advised to take antibiotics only if still necessary after a specified delay. Mucolytics were prescribed for 61.1%. Antibiotic prescription was strongly associated with a diagnosis of LRTI and the presence of auscultation abnormalities. The median duration of cough after presentation was 8 days.

CONCLUSIONS

Antibiotics continue to be frequently prescribed for acute cough/LRTI in Poland, and the decision to prescribe was strongly associated with clinicians' findings of abnormalities on auscultation and diagnosis of LRTI. Delayed prescribing was infrequent. Mucolytics were commonly prescribed despite evidence of no effect.

Meta-analysis and systematic review of procalcitonin-guided therapy in respiratory tract infections

Circulating procalcitonin (PCT) is a biomarker that can be used in diagnosing bacterial infections. We performed a quantitative meta-analysis of available randomized controlled trials to determine whether antibiotic therapy based on PCT measurements alters clinical outcomes and antibiotic use in patients with lower respiratory tract infections. We identified studies through MEDLINE (1996 to 2010), the ISI Web of Knowledge (1996 to 2010), and Ovid. Studies that met our criteria were prospective, randomized controlled trials involving patients with respiratory tract infections. Outcomes of mortality, intensive care unit (ICU) admission, length of hospital stay, number of antibiotic prescriptions, and duration of antibiotic treatment were evaluated. Eight studies randomizing 3,431 patients met our criteria for inclusion. Pooled analysis showed a significant reduction in number of antibiotic prescriptions and duration of antibiotic use in patients with PCT-guided antibiotic treatment compared to standard therapy. In addition, the use of PCT-guided antibiotic therapy did not impact mortality, ICU admission, or length of hospital stay in these studies. A high degree of heterogeneity was identified in 3 of 5 outcomes that were evaluated, and sensitivity analysis indicated that heterogeneity was decreased among studies using the same PCT-based treatment algorithm. In conclusion, PCT-guided antibiotic therapy in patients with respiratory tract infections appears to reduce antibiotic use without affecting overall mortality or length of stay in the hospital.

Therapeutic antibiotic use patterns in dogs: observations from a veterinary teaching hospital

OBJECTIVES

To describe therapeutic antibiotic use patterns in dogs at a small animal teaching hospital.

METHODS

A retrospective case analysis of randomly sampled antibiotic prescriptions in dogs from May 20, 2008 to May 20, 2009, deemed to be for therapeutic use, was performed. Records were reviewed to determine if there was documentation of confirmed, suspected or no evidence of infection. The five most frequently prescribed antibiotics were identified and analysed for their distribution in these categories.

RESULTS

In 17% of therapeutic antibiotic prescriptions there was confirmed infection, in 45% suspected infection, and in 38% there was no documented evidence of infection. Amoxicillin-clavulanate was the most frequently prescribed antibiotic, followed by cefazolin/cephalexin, enrofloxacin, ampicillin/amoxicillin and doxycycline. Doxycycline was the most frequently prescribed with no documented evidence of infection, and amoxicillin-clavulanate was the most frequently prescribed with either confirmed or suspected evidence of infection.

DISCUSSION

Clinicians use a variety of tools when deciding whether or not to prescribe an antibiotic and which antibiotic to use. As in human medicine, there is likely overuse and inappropriate use of antibiotics in veterinary medicine. Veterinarians should engage in discussions regarding clinically applicable guidelines for appropriate antibiotic use.

Procalcitonin as a potent marker of bacterial infection in febrile Afro-Caribbean patients at the emergency department

Procalcitonin (PCT) has been shown to be of additional value in the work-up of a febrile patient. This study is the first to investigate the additional value of PCT in an Afro-Caribbean febrile population at the emergency department (ED) of a general hospital. Febrile patients were included at the ED. Prospective, blinded PCT measurements were performed in patients with a microbiologically or serologically confirmed diagnosis or a strongly suspected diagnosis on clinical grounds. PCT analysis was performed in 93 patients. PCT levels differentiated well between confirmed bacterial and confirmed viral infection (area under the curve [AUC] of 0.82, sensitivity 85%, specificity 69%, cut-off 0.24 ng/mL), between confirmed bacterial infection and non-infectious fever (AUC of 0.84, sensitivity 90%, specificity 71%, cut-off 0.21 ng/mL) and between all bacterial infections (confirmed and suspected) and non-infectious fever (AUC of 0.80, sensitivity 85%, specificity 71%, cut-off 0.21 ng/mL). C-reactive protein (CRP) levels were shown to be less accurate when comparing the same groups. This is the first study showing that, in a non-Caucasian febrile population at the ED, PCT is a more valuable marker of bacterial infection than CRP. These results may improve diagnostics and eventually decrease antibiotic prescriptions in resource-limited settings.

Influence of CRP testing and clinical findings on antibiotic prescribing in adults presenting with acute cough in primary care

OBJECTIVE

Respiratory tract infections are the most common indication for antibiotic prescribing in primary care. The value of clinical findings in lower respiratory tract infection (LRTI) is known to be overrated. This study aimed to determine the independent influence of a point of care test (POCT) for C-reactive protein (CRP) on the prescription of antibiotics in patients with acute cough or symptoms suggestive of LRTI, and how symptoms and chest findings influence the decision to prescribe when the test is and is not used.

DESIGN

Prospective observational study of presentation and management of acute cough/LRTI in adults.

SETTING

Primary care research networks in Norway, Sweden, and Wales.

SUBJECTS

Adult patients contacting their GP with symptoms of acute cough/LRTI.

MAIN OUTCOME MEASURES

Predictors of antibiotic prescribing were evaluated in those tested and those not tested with a POCT for CRP using logistic regression and receiver operating characteristic (ROC) curve analysis.

RESULTS

A total of 803 patients were recruited in the three networks. Among the 372 patients tested with a POCT for CRP, the CRP value was the strongest independent predictor of antibiotic prescribing, with an odds ratio (OR) of CRP ≥ 50 mg/L of 98.1. Crackles on auscultation and a patient preference for antibiotics perceived by the GP were the strongest predictors of antibiotic prescribing when the CRP test was not used.

CONCLUSIONS

The CRP result is a major influence in the decision whether or not to prescribe antibiotics for acute cough. Clinicians attach less weight to discoloured sputum and abnormal lung sounds when a CRP value is available. CRP testing could prevent undue reliance on clinical features that poorly predict benefit from antibiotic treatment.

Variation in antibiotic prescribing and its impact on recovery in patients with acute cough in primary care: prospective study in 13 countries

OBJECTIVE

To describe variation in antibiotic prescribing for acute cough in contrasting European settings and the impact on recovery.

DESIGN

Cross sectional observational study with clinicians from 14 primary care research networks in 13 European countries who recorded symptoms on presentation and management. Patients followed up for 28 days with patient diaries.

SETTING

Primary care.

PARTICIPANTS

Adults with a new or worsening cough or clinical presentation suggestive of lower respiratory tract infection.

MAIN OUTCOME MEASURES

Prescribing of antibiotics by clinicians and total symptom severity scores over time.

RESULTS

3402 patients were recruited (clinicians completed a case report form for 99% (3368) of participants and 80% (2714) returned a symptom diary). Mean symptom severity scores at presentation ranged from 19 (scale range 0 to 100) in networks based in Spain and Italy to 38 in the network based in Sweden. Antibiotic prescribing by networks ranged from 20% to nearly 90% (53% overall), with wide variation in classes of antibiotics prescribed. Amoxicillin was overall the most common antibiotic prescribed, but this ranged from 3% of antibiotics prescribed in the Norwegian network to 83% in the English network. While fluoroquinolones were not prescribed at all in three networks, they were prescribed for 18% in the Milan network. After adjustment for clinical presentation and demographics, considerable differences remained in antibiotic prescribing, ranging from Norway (odds ratio 0.18, 95% confidence interval 0.11 to 0.30) to Slovakia (11.2, 6.20 to 20.27) compared with the overall mean (proportion prescribed: 0.53). The rate of recovery was similar for patients who were and were not prescribed antibiotics (coefficient -0.01, P<0.01) once clinical presentation was taken into account.

CONCLUSIONS

Variation in clinical presentation does not explain the considerable variation in antibiotic prescribing for acute cough in Europe. Variation in antibiotic prescribing is not associated with clinically important differences in recovery.

TRIAL REGISTRATION

Clinicaltrials.gov NCT00353951.

Effect of point of care testing for C reactive protein and training in communication skills on antibiotic use in lower respiratory tract infections: cluster randomised trial

OBJECTIVE

To assess the effect of general practitioner testing for C reactive protein (disease approach) and receiving training in enhanced communication skills (illness approach) on antibiotic prescribing for lower respiratory tract infection.

DESIGN

Pragmatic, 2x2 factorial, cluster randomised controlled trial.

SETTING

20 general practices in the Netherlands.

PARTICIPANTS

40 general practitioners from 20 practices recruited 431 patients with lower respiratory tract infection.

MAIN OUTCOME MEASURES

The primary outcome was antibiotic prescribing at the index consultation. Secondary outcomes were antibiotic prescribing during 28 days' follow-up, reconsultation, clinical recovery, and patients' satisfaction and enablement.

INTERVENTIONS

General practitioners' use of C reactive protein point of care testing and training in enhanced communication skills separately and combined, and usual care.

RESULTS

General practitioners in the C reactive protein test group prescribed antibiotics to 31% of patients compared with 53% in the no test group (P=0.02). General practitioners trained in enhanced communication skills prescribed antibiotics to 27% of patients compared with 54% in the no training group (P<0.01). Both interventions showed a statistically significant effect on antibiotic prescribing at any point during the 28 days' follow-up. Clinicians in the combined intervention group prescribed antibiotics to 23% of patients (interaction term was non-significant). Patients' recovery and satisfaction were similar in all study groups.

CONCLUSION

Both general practitioners' use of point of care testing for C reactive protein and training in enhanced communication skills significantly reduced antibiotic prescribing for lower respiratory tract infection without compromising patients' recovery and satisfaction with care. A combination of the illness and disease focused approaches may be necessary to achieve the greatest reduction in antibiotic prescribing for this common condition in primary care.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN85154857.

Do antibiotics affect the quality of life of patients with upper respiratory tract illnesses? It might depend on one's luck

OBJECTIVE

Upper respiratory tract illnesses (URTI) are known to cause measurable decline in health-related quality of life (HRQL). We studied whether antibiotics impacted patients' HRQL after obtaining medical care for URTI.

METHODS

Adults seeking care for URTI at a family medicine office were eligible for this study. Decisions to prescribe antibiotics were left to their physicians. Subjects completed the Quality of Well-Being questionnaire on enrolment and on days 3, 7, 14 and 28. Analysis of HRQL was undertaken using repeated measures ANOVA and ANCOVA.

RESULTS

Seventy-three patients (mean age 35.8 years) were studied. Thirty-six of the subjects (50.7%) received prescriptions for antibiotics from their physicians at the index visit. By day 28, 78.4% of the subjects in the antibiotic group and 77.8% of the other group reported cure (p = 0.95). Receiving a prescription for an antibiotic at the initial visit did not influence subsequent HRQL reported by subjects (p = 0.98). However, when subjects receiving antibiotics were subgrouped by whether they reported an antibiotic adverse event we found significant differences in final HRQL. Subjects receiving antibiotics but not experiencing adverse events reported higher HRQL by day 28 than did subjects receiving an antibiotic but also reporting adverse events and subjects not receiving any antibiotics (p = 0.02).

CONCLUSION

Providing patients experiencing URTIs with prescriptions for antibiotics does not, on average, positively impact HRQL over the following 28 days. However, the subgroup of patients who receive antibiotics and do not experience an adverse event may come out ahead.

Antibiotic use for emergency department patients with upper respiratory infections: prescribing practices, patient expectations, and patient satisfaction

STUDY OBJECTIVE

Physicians often prescribe antibiotics to patients even when there is no clear indication for their use. Previous studies examining antibiotic use in acute bronchitis and upper respiratory infections have been conducted in primary care settings. We evaluate the factors that physicians in the emergency department (ED) consider when prescribing antibiotics (eg, patient expectations) and the factors associated with patient satisfaction.

METHODS

Ten academic EDs enrolled adults and children presenting with symptoms consistent with upper respiratory infection. Enrolled patients were interviewed before their physician encounter and were reinterviewed before discharge and 2 weeks later. Physicians were interviewed about factors that influenced their management decisions, including their perceptions of patients' expectations. Patients with a single diagnosis of uncomplicated acute bronchitis or upper respiratory infection were included for analysis.

RESULTS

Of 272 patients enrolled, 68% of bronchitis patients and 9% of upper respiratory infection patients received antibiotics. Physicians were more likely to prescribe antibiotics when they believed that patients expected them (odds ratio [OR] 5.3; 95% confidence interval [CI] 2.9 to 9.6), although they were able to correctly identify only 27% of the patients who expected antibiotics. Satisfaction with the ED visit was reported by 87% of patients who received antibiotics and 89% of those not receiving antibiotics. Satisfaction with the visit was reported by 92% of patients who believed they had a better understanding of their illness but only by 72% of those who thought they had no better understanding (OR 4.4; 95% CI 2.0 to 8.4).

CONCLUSION

Physicians in our academic EDs prescribed antibiotics to 68% of acute bronchitis patients and to fewer than 10% of upper respiratory infection patients. Physicians were more likely to prescribe antibiotics to patients who they believed expected them, although they correctly identified only about 1 in 4 of those patients. Patient satisfaction was not related to receipt of antibiotics but was related to the belief they had a better understanding of their illness.

Prognostic factors for serious morbidity and mortality from community-acquired lower respiratory tract infections among the elderly in primary care

BACKGROUND

Uncertainty about the prognosis of lower respiratory tract infections (LRTI) hinders optimal management in primary care.

OBJECTIVE

We determined prognostic factors for a severe complicated course of LRTI among elderly patients in primary care.

METHODS

In a retrospective clinical database study we examined 455 patients with a first LRTI episode; 226 with physician-diagnosed acute bronchitis or lung exacerbations and 229 with pneumonia. Multivariate logistic regression analysis was used to assess independent associations of the potential predictors with the endpoint.

RESULTS

Occurrence of the combined endpoint 30-day home-treated complications from LRTI (4.4%) or hospitalisation (4.6%), or all-cause mortality (5.3%) was 14.3%. In a logistic regression model, increasing age [odds ratio (OR) 1.04; 95% confidence interval (95% CI) 1.00-1.08], male sex (OR 3.12; 95% CI 1.66-5.87), heart failure (OR 5.14; 95% CI 2.33-11.34), stroke or dementia (OR 3.36; 95% CI 1.18-9.58), use of antidepressants or benzodiazepines (OR 1.89; 95% CI 1.02-3.52) and a diagnosis of pneumonia (OR 4.24; 95% CI 2.17-8.28) were independent predictors.

CONCLUSION

GPs need to be aware of readily available prognostic factors that can be used in primary care to complement physical examination and laboratory data in LRTI to guide preventive and therapeutic management decisions.

Clinical items not helpful in differentiating viral from bacterial lower respiratory tract infections in general practice

OBJECTIVE

Incorrect and unnecessary antibiotic prescribing enhancing bacterial resistance rates might be reduced if viral and bacterial lower respiratory tract infections (LRTI) could be differentiated clinically. Whether this is possible is often doubted but has rarely been studied in general practice.

STUDY DESIGN AND SETTING

This was an observational cohort study in 15 general practice surgeries in the Netherlands.

RESULTS

Etiologic diagnoses were obtained in 112 of 234 patients with complete data (48%). Viral pathogens were found as often as bacterial pathogens. Haemophilus (para-) influenzae was most frequently found. None of the symptoms and signs correlated statistically significantly with viral or bacterial LRTI. Erythrocyte sedimentation rate >50 (odds ratio [OR] 2.3-3.3) and C-reactive protein (CRP) >20 (OR 2.1-4.6) were independent predictors for viral LRTI and bacterial LRTI when compared with microbiologically unexplained LRTI.

CONCLUSION

Extensive history-taking and physical examination did not provide items that predict viral or bacterial LRTI in adult patients in daily general practice. We could not confirm CRP to differentiate between viral and bacterial LRTI.

Antibiotic utilisation in community practices: guideline concurrence and prescription necessity

PURPOSE

To evaluate the indications, concurrence with prescribing guidelines and potential necessity for antibiotic (AB) prescriptions written in community practice.

METHODS

We reviewed the charts of all patients with infection-related illnesses seen by family physicians during two random days of regular practice between 1 Oct 1997 and 30 Jan 1998. Guideline concurrence of AB prescribing was assessed using regional AB prescribing guidelines. Likelihood of AB indication for respiratory tract infections was assessed using published clinical practice guidelines for determination of likely viral versus bacterial etiology.

RESULTS

Of 4218 visits captured, 949 (22%) were for newly acquired infections. Sixty four percent (n=604) of consultations for newly acquired infections resulted in an AB prescription. Based on the doctors' diagnoses, 61% of AB prescriptions were concurrent with prescribing guidelines, 10% were for the wrong drug, 20% were not indicated and in 10% of cases a lower line AB was available. For respiratory tract infections, 12% of these infections were likely bacterial, whereas the physicians determined that 56% were bacterial.

CONCLUSIONS

A large proportion of ABs administered in community practices were not in concurrence with community AB prescribing guidelines. Improvements can be made in AB choice and in decisions about likely viral etiology for respiratory tract infections.

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

OBJECTIVES

To examine the attitudes of patients with rhinosinusitis toward the availability of "back-up" antibiotics, and potential implications for antibiotic use rates.

STUDY DESIGN AND SETTING

A survey that assessed actual and hypothetical antibiotic prescription patterns was administered to a convenience sample of patients treated for rhinosinusitis in one acute care facility between September 1 and December 1, 2001.

RESULTS

Of 386 eligible patients, 114 completed the survey. Seventy-six percent of patients expected antibiotic treatment; satisfaction rates were significantly associated with receiving an antibiotic prescription (P <.05). Over two-thirds of patients (69.7%) reported preference for back-up antibiotic prescriptions in the future, with 91.1% stating they would wait at least 1 day, and 52.7% at least 7 days, to fill a backup prescription. In sensitivity analysis, back-up prescriptions significantly reduced antibiotic use over a wide range of assumptions.

CONCLUSIONS

The majority of patients with rhinosinusitis in this study expected antibiotic prescriptions, and were more satisfied if they were received. Back-up antibiotics have the potential to reduce unnecessary antibiotic use, mitigate risk of nontreatment, and preserve high levels of patient satisfaction.

Public knowledge, attitudes and behaviour regarding antibiotics--a survey of patients in general practice

OBJECTIVE

To assess public knowledge, attitudes and behaviour regarding antibiotics to provide information for a local health education policy.

DESIGN

Postal survey to 605 patients registered with two general medical practices in Grampian, North-East Scotland (351 respondents, 59.3%) in February/ March 2000. Questionnaire topics covered attitudes, knowledge and behaviour towards antibiotic use.

RESULTS

326 (93%) had experience of antibiotic use and 319 (81%) were happy to take antibiotics when necessary. 158 (45%) were concerned about antibiotic resistance. Few would expect antibiotics to treat a slight cold or heavy cold, but around half would expect antibiotics for very sore throats and influenza. 262 (75%) indicated they would ask a pharmacist for advice about the treatment of RTI. Most respondents experienced at least one episode of RTI during the review period. 280 (80%) provided details of their most recent episode; most self-treated, 57 consulted a doctor of whom 43 (75%) were prescribed antibiotics.

CONCLUSIONS

Antibiotic resistance is a matter of concern for the public. Mixed opinions about the use of antibiotics for common respiratory tract infections were heard. Encouragingly the majority of people suffering an RTI during the review period treated themselves with paracetamol-based products for symptom relief. Those who consulted a doctor were in the minority but were likely to be prescribed antibiotics. Future local health education initiatives should target antibiotic use for sore throats as well as colds and 'flu.

Lower respiratory tract infections in adults: non-antibiotic prescriptions by GPs

BACKGROUND

The AIR II study is a prospective multicentre assessing management of lower respiratory tract infections (LRTIs) in adults by general practitioners (GPs). Epidemiological studies generally address the prescriptions of antibiotics. To our knowledge, little is known about the real impact of non-antibiotic therapeutic prescriptions (defined here as co-prescriptions) in LRTI. Therefore, the aim of the study was to evaluate non-antibiotic prescriptions in LRTIs.

METHODS

Two thousand general practitioners (GPs) were randomly selected and asked to participate in each of 30 predefined areas covering mainland France. The patient's sociomedical record was completed by the GP during the consultation and sent to the data processing centre at the same time as an anonymous copy of his prescription. The GP also had to report the inclusion by telephone and agree to a telephone appointment with an interviewer.

RESULTS

GPs (n = 3144) reported 5469 evaluable cases. Pneumonia accounted for 9.6% of diagnoses, acute exacerbations of chronic bronchitis 14.9% and acute bronchitis 72.5%. Antibiotics were prescribed to 96.5% of patients. In addition to the 5270 prescriptions of antibiotics, co-prescriptions proved to be twice as numerous as prescriptions of antibiotics (10,027 prescriptions for 5115 patients). Mucomodifiers, steroidal anti-inflammatory drugs and bronchodilators were significantly more prescribed in AECB than others. Non-steroidal anti-inflammatory drugs and antitussives were significantly more prescribed in acute bronchitis than AECB or CAP.

CONCLUSIONS

Our results suggest that recommendations of management in LRTIs need to take into account co-prescriptions.

The patient's role in the spread and control of bacterial resistance to antibiotics

As the ultimate consumers, patients play an important role in the emergence, spread and control of bacterial resistance to antibiotics. Improved knowledge of antibiotics and the problem of resistance, as well as a better understanding of beliefs, pressures/concerns, and expectations, from both the patient's and physician's perspectives, are fundamental for controlling antibiotic use. There is growing evidence to suggest that empowering patients through implementation of patient-centered health-care strategies, such as shared decision-making, in conjunction with educational initiatives help to change attitudes and behavior, and improve access to and completion of appropriate antimicrobial therapy. This, in turn, may help to control the development and spread of resistance to antibiotics.

Moving from recommendation to implementation and audit: part 2. Review of interventions and audit

There are multiple interventions available that may help to control the development and spread of resistance to antimicrobial agents in bacteria implicated in community-acquired respiratory tract infections. Unfortunately, very few studies have assessed the effectiveness of these interventions using objective end-points, such as reduction in resistance rates and improvement in clinical outcomes. Most interventions are centered on reducing inappropriate or unnecessary use of antibiotics; others focus on reducing disease burden and bacterial colonization. With regard to antibiotic use, efforts should be concentrated at both the prescriber and consumer levels. Interventions that target prescribers include: provision of educational materials; strategies and tools to improve diagnosis; implementation of practice guidelines; personalized interactive sessions with feedback on the practice profile; and use of delayed prescription and alternative prescribing strategies. Optimal results are usually obtained when these interventions are combined with consumer education. Regulatory interventions (e.g. licensing regulations and controlled access to drugs), restrictions in the use of agents for growth promotion in animals, and use of nonantimicrobial therapies (e.g. probiotics) may help further to reduce inappropriate antibiotic use and thereby decrease the selective pressure for development of resistance. Infection-control strategies, public health measures, vaccination programs, and new antibiotics all have a role in minimizing the spread of resistant organisms. Ideally, resistance-control programs should include predefined criteria for success and integral audit processes based on objective end-points (antibiotic use, resistance trends, and health outcomes). Standardization of data collection is imperative so that the relative merits of various interventions can be compared. Effective implementation and audit of interventions is often difficult in developing countries owing to poor health-care infrastructures, lack of resources, poor education/training, and minimal regulatory controls on the supply and quality of antimicrobials. Substantial support from governments and health-care organizations across the globe is required to initiate and sustain effective intervention programs to control antimicrobial resistance.

Combating bacterial resistance in otorhinolaryngology

Bacterial resistance appears to be an ever-increasing problem and is threatening to spiral out of control. The scare caused by the rapid spread of methicillin-resistant Staphylococcus aureus among hospitals in the UK is the most recent. Otorhinolaryngology is deeply involved in this problem, as one of the reasons often cited for increasing bacterial resistance is the use of antibiotics in suspected bacterial infections in ear, nose and throat by primary care physicians. This speciality is also involved in the development of guidelines for antimicrobial use by primary and secondary care. This review attempts to discuss the reason for the development of antimicrobial resistance especially in relation to otorhinolaryngology, what can be done to contain this menace and the surveillance system developed to monitor the trend in the development of bacterial resistance.

Antibiotics for coughing in general practice: a questionnaire study to quantify and condense the reasons for prescribing

BACKGROUND

Antibiotics are being overprescribed in ambulant care, especially for respiratory tract infections (RTIs). Gaining insight into the actual reasons for prescribing remains important for the design of effective strategies to optimise antibiotic prescribing. We aimed to determine items of importance for the antibiotic prescribing decision and to make them operational for an intervention trial.

METHODS

A postal questionnaire based upon focus group findings was sent to 316 Flemish general practitioners (GPs). On a verbal rating scale the GPs scored to what extent they consider the questionnaire items in decision making in case of suspected RTI in a coughing patient and how strongly the items support or counter antibiotic treatment. Factor analysis was used to condense the data. The relative importance of the yielded operational factors was assessed using Wilcoxon Matched Pairs test.

RESULTS

59.5% completed the study. Response group characteristics (mean age: 42.8 years; 65.9% men) approximated that of all Flemish GPs. Participants considered all the items included in the questionnaire: always the operational factor 'lung auscultation', often 'whether or not there is something unusual happening' - both medical reasons - and to a lesser extent 'non-medical reasons' (P < 0.001). Non-medical as well as medical reasons support antibiotic treatment, but non-medical reasons to a lesser extent (P < 0.001).

CONCLUSION

This study quantified, condensed and confirmed the findings of previous focus group research. Practice guidelines and interventions to optimise antibiotic prescribing have to take non-medical reasons into account.

Reducing antibiotic use for acute bronchitis in primary care: blinded, randomised controlled trial of patient information leaflet

OBJECTIVE

To assess whether sharing the uncertainty of the value of antibiotics for acute bronchitis in the form of written and verbal advice affects the likelihood of patients taking antibiotics.

DESIGN

Nested, single blind, randomised controlled trial.

SETTING

Three suburban general practices in Nottingham Participants: 259 previously well adults presenting with acute bronchitis.

INTERVENTION

In group A, 212 patients were judged by their general practitioner not to need antibiotics that day but were given a prescription to use if they got worse and standard verbal reassurance. Half of them (106) were also given an information leaflet. All patients in group B (47) were judged to need antibiotics and were given a prescription and encouraged to use it.

MAIN OUTCOME MEASURES

Antibiotic use in the next two weeks. Reconsultation for the same symptoms in the next month.

RESULTS

In group A fewer patients who received the information leaflet took antibiotics compared with those who did not receive the leaflet (49 v 63, risk ratio 0.76, 95% confidence interval 0.59 to 0.97, P=0.04). Numbers reconsulting were similar (11 v 14). In group B, 44 patients took the antibiotics.

CONCLUSION

Most previously well adults with acute bronchitis were judged not to need antibiotics. Reassuring these patients and sharing the uncertainty about prescribing in a information leaflet supported by verbal advice is a safe strategy and reduces antibiotic use.

Improving parent knowledge about antibiotics: a video intervention

OBJECTIVE

To determine whether an educational video could improve parent knowledge, beliefs, and behaviors about the appropriate use of oral antibiotics.

STUDY DESIGN

A randomized, controlled trial was conducted in an urban primary care clinic and a suburban pediatric practice. Parents were randomly assigned to the intervention or control groups. Parents in the intervention group were asked to view a 20-minute video, specifically developed for this project, over a 2-month period, and given a brochure about antibiotics. Parent knowledge, beliefs, and behaviors were assessed at the time of enrollment and then by telephone 2 months later.

RESULTS

A total of 193 (94%) of 206 parents completed the study. The groups were equivalent with respect to all important baseline characteristics. No differences were found for adjusted posttest means between the intervention and control groups for knowledge, beliefs, or behavior. For example, the intervention group scored 8.04 on the knowledge questionnaire (11 true-false questions), compared with 7.82 for the control group. Subgroup analysis, based on site of enrollment, indicated that families in the intervention group from the primary care urban clinic improved their knowledge score (6.03 to 6.92) and were more likely to report that there were problems with children receiving too many antibiotics (intervention 67% vs control 34%).

CONCLUSION

Overall, this video had only a modest effect on parent knowledge, beliefs, and self-reported behaviors regarding oral antibiotics. We believe that any campaign promoting the judicious use of oral antibiotics must use a multifaceted approach and target both parents and physicians.

Appropriateness of antibiotic prescriptions in community-acquired acute pediatric respiratory infections in Spanish emergency rooms

OBJECTIVE

To describe the variability and appropriateness of antibiotic prescriptions in community-acquired acute respiratory infections (ARI) during childhood in Spain.

METHODS

A descriptive, multicenter study of variability in clinical practice was conducted by evaluating a prospective series of pediatric patients attending the emergency rooms of 11 Spanish hospitals and diagnosed with community-acquired ARI. The appropriateness of the antibiotic prescriptions was assessed by comparing our clinical practice with consensus guidelines developed for this study.

RESULTS

We collected data from 6,249 ARI emergencies studied on 30 separate days. Antibiotics were prescribed in 58.7% of the ARI (bronchiolitis, 11.5%; bronchitis, 40.2%; pharyngotonsillitis, 80.9%; nonspecified ARI, 34.8%; pneumonia, 92.4%; otitis, 93.4%; sinusitis, 92.6%). The most commonly used antibiotics were amoxicillin/clavulanate (33.2%), amoxicillin (30.2%), cefuroxime axetil (8.5%) and azithromycin (6%). According to the consensus guidelines developed for this study, therapy was considered to be appropriate in 63.1% of the ARI (first choice, 52.1%; alternative choice, 11.0%) and inappropriate in 36.9%. The percentages of inappropriate prescription according to ARI groups were: bronchiolitis, 11.5%; bronchitis, 31.5%; pharyngotonsillitis, 54.8%; nonspecified ARI, 34.7%; pneumonia, 13.9%; otitis, 25.6%; and sinusitis, 22.2%.

CONCLUSIONS

There is excessive use of antibiotics in acute respiratory infections that are presumably viral in origin. An important number of ARI of potentially bacterial origin are treated with antibiotics that are not sufficiently efficacious or that have a broader spectrum than necessary.

Threats from patients and their effects on medical decision making: a cross-sectional, randomised trial

BACKGROUND

Negative experiences are not uncommon among doctors in Norway. Our aim was to find out about the various types of negative reactions (eg, complaints, negative exposure to the media, financial claims, and notification to the police) received by physicians from patients or relatives in response to treatment, to identify their cause, and to study their effects on subsequent clinical decisions.

METHODS

We posted questionnaires about negative reactions of patients to a random sample (n=1260) of Norwegian doctors. Each doctor was additionally sent five written case simulations and asked to choose one of several proposed clinical strategies. Half (630) the physicians received cases containing threats from the patient or their relatives.

FINDINGS

988 (78%) physicians returned the questionnaire, 463 (47%) of whom reported negative experiences. Such experiences were reported more frequently by men (357 [51%]) and family physicians (157 [58%]) than by other participants. Negative experiences did not affect choice of strategy for case simulations. For the first case, chest pain, 217 (44%) physicians presented with a threat chose a defensive strategy compared with 145 (30%) of those who were not (difference 14%; 95% CI 8-20). For the second case, a headache case, the corresponding numbers were 278 (57%) and 118 (25%) (32%; 26-38). Physician age, sex, specialty, or experience of negative reactions of patients did not alter the effect of threats received during our study.

INTERPRETATION

Negative experiences do not affect subsequent decision making. However, doctors do comply with wishes from patients or relatives when presented with direct threats.

Prospective study of the incidence, aetiology and outcome of adult lower respiratory tract illness in the community

BACKGROUND

Acute lower respiratory tract illness in previously well adults is usually labelled as acute bronchitis and treated with antibiotics without establishing the aetiology. Viral infection is thought to be the cause in most cases. We have investigated the incidence, aetiology, and outcome of this condition.

METHODS

Previously well adults from a stable suburban population consulting over one year with a lower respiratory tract illness were studied. For the first six months detailed investigations identified predetermined direct and indirect markers of infection. Evidence of infection was assessed in relation to presenting clinical features, indirect markers of infection, antibiotic use, and outcome.

RESULTS

Consultations were very common, particularly in younger women (70/1000 per year in previously well women aged 16-39 years), mainly in the winter months; 638 patients consulted, of whom 316 were investigated. Pathogens were identified in 173 (55%) cases: bacteria in 82 (Streptococcus pneumoniae 54, Haemophilus influenzae 31, Moraxella catarrhalis 7), atypical organisms in 75 (Chlamydia pneumoniae 55, Mycoplasma pneumoniae 23), and viruses in 61 (influenza 23). Seventy nine (24%) had indirect evidence of infection. Bacterial and atypical infection correlated with changes in the chest radiograph and high levels of C reactive protein but not with (a) the GP's clinical assessment of whether infection was present, (b) clinical features other than focal chest signs, and (c) outcome, whether or not appropriate antibiotics were prescribed.

CONCLUSIONS

Over 50% of patients have direct and/or indirect evidence of infection, most commonly bacterial and atypical pathogens, but the outcome is unrelated to the identified pathogens. Many patients improve without antibiotics and investigations do not help in the management of these patients. GPs can reassure patients of the causes and usual outcome of this self-limiting condition.

Trends in the rate of depressive illness and use of antidepressant pharmacotherapy by ethnicity/race: an assessment of office-based visits in the United States, 1992-1997

OBJECTIVE

This study was undertaken to determine ethnicity/race-specific (white, black, and Hispanic) population-adjusted rates of US office-based physician visits in which a diagnosis of a depressive disorder was recorded or in which a diagnosis of a depressive disorder was recorded and antidepressant pharmacotherapy was prescribed.

METHODS

Data from the National Ambulatory Medical Care Survey for 1992 through 1997 were partitioned into three 2-year periods: 1992-1993, 1994-1995, and 1996-1997. For each 2-year period, data from office-based physician visits for patients aged 20 to 79 years were extracted to assess, by ethnicity/race, (1) the number of visits in which a diagnosis of a depressive illness was recorded (International Classification of Diseases, Ninth Revision, Clinical Modification codes 296.2-296.36, 300.4, or 311) and (2) the number of visits in which a diagnosis of a depressive illness was recorded and antidepressant pharmacotherapy was prescribed. We calculated ethnicity/race-specific rates (per 100 US population aged 20 to 79 years) of office-based visits in which a diagnosis of a depressive disorder was recorded and in which a diagnosis of a depressive disorder was recorded and antidepressant pharmacotherapy was prescribed. The specialty of the reporting physician and the proportion of patients receiving a selective serotonin reuptake inhibitor (SSRI) were also discerned.

RESULTS

From 1992-1993 to 1996-1997, the rate of office-based visits (per 100 US population aged 20 to 79 years) in which a diagnosis of a depressive disorder was recorded increased 3.7% for whites (from 10.9 to 11.3; P = 0.001), 31.0% for blacks (from 4.2 to 5.5; P = 0.001), and 72.9% for Hispanics (from 4.8 to 8.3; P = 0.001). The rate of office-based visits in which a diagnosis of a depressive disorder was recorded and antidepressant pharmacotherapy was prescribed increased 18.5% for whites (from 6.5 to 7.7 per 100; P = 0.001), 38.5% for blacks (from 2.6 to 3.6 per 100; P = 0.001). and 106.7% for Hispanics (from 3.0 to 6.2 per 100; P = 0.001). Between 1992-1993 and 1996-1997, use of an SSRI increased among whites and blacks (from 50.0% to 65.8% and from 40.5% to 58.2%, respectively), but declined among Hispanics (from 51.4% to 48.6%; all comparisons P = 0.001).

CONCLUSION

By 1996-1997, the population-adjusted rates for Hispanics were within a quartile of those observed for whites, whereas the rates for blacks remained at less than half those observed in whites. The observed divergence in population-adjusted rates by ethnicity/race may reflect the nature of the patient-physician relationship, sensitivity and specificity of diagnostic techniques and instruments, and the wider social context in which an office-based visit occurs, including access to and type of health insurance and coverage for mental health services.

The need for an iterative process for assessing economic outcomes associated with SSRIs

Pharmacotherapeutic advances in the treatment of depression have included the development of the selective serotonin reuptake inhibitors (SSRIs), thereby providing alternatives to tricyclic antidepressants. Concurrent with these events have been significant structural (e.g. pharmaceutical formularies) and regulatory (e.g. required pharmacoeconomic evaluations) changes in the delivery, financing, and oversight of healthcare programmes throughout the world. International cost-containment initiatives are increasingly mandating a demonstration of value for money, defined in terms of a measurable health and/or financial outcome, and, in the case of medicines, attributable to a given expenditure, for a given pharmacotherapeutic option. We examine the inherent strengths and weaknesses of 5 study designs used to discern and contrast financial outcomes stemming from the use of antidepressant pharmacotherapy for the treatment of depressive illness [randomised controlled trials (RCTs); meta-analyses; decision-analytical models (DAMs); retrospective database investigations; randomised naturalistic inquiry]. We argue that the economic appraisal of pharmacotherapy requires an iterative process extending from the developmental (RCTs; meta-analyses; DAMs) through to the postmarketing phase (database reviews; naturalistic inquiry), thereby resulting in a portfolio of evidence as to the safety, efficacy and effectiveness of a given pharmacotherapeutic category (e.g. SSRIs) and/or a specific medication. Database reviews, while nonrandomised, and prospective naturalistic inquiry afford greater insight into the patterns of use and financial merits of prescribing specific pharmacotherapeutic options for the treatment of depression within the context of clinical practice as compared with RCTs, meta-analyses and DAMs. The portfolio of evidence to date indicates that the first-line use of SSRIs in the treatment of depression is clinically warranted, and represents value for money.