Upper respiratory tract infections in general practice: diagnosis, antibiotic prescribing, duration of symptoms and use of diagnostic tests

Antibiotic consumption for sore throat and the potential effect of a vaccine against group A Streptococcus: a systematic review and modelling study

BACKGROUND

Antibiotic consumption can lead to antimicrobial resistance and microbiome imbalance. We sought to estimate global antibiotic consumption for sore throat, and the potential reduction in consumption due to effective vaccination against group A Streptococcus (Strep A).

METHODS

We reviewed and analysed articles published between January 2000 and February 2022, identified though Clarivate Analytics' Web of Science search platform, with reference to antibiotic prescribing or consumption, sore throat, pharyngitis, or tonsillitis. We then used those analyses, combined with assumptions for the effectiveness, duration of protection, and coverage of a vaccine, to calculate the estimated reduction in antibiotic prescribing due to the introduction of Strep A vaccines.

FINDINGS

We identified 101 studies covering 38 countries. The mean prescribing rate for sore throat was approximately 5 courses per 100 population per year, accounting for approximately 5% of all antibiotic consumption. Based on 2020 population estimates for countries with empiric prescribing rates, antibiotic consumption for sore throat was estimated to exceed 37 million courses annually, of which half could be attributable to treatment for Strep A. A vaccine that reduces rates of Strep A infection by 80%, with 80% coverage and 10 year's duration of protection, could avert 2.8 million courses of antibiotics prescribed for sore throat treatment among 5-14 year-olds in countries with observed prescribing rates, increasing to an estimated 7.5 million averted if an effective vaccination program also reduced precautionary prescribing.

INTERPRETATION

A vaccine that prevents Strep A throat infections in children may reduce antibiotic prescribing for sore throat by 32-87% depending on changes to prescribing and consumption behaviours.

FUNDING

The Wellcome Trust, grant agreement number 215490/Z/19/Z.

Reflexology for acute rhinosinusitis - Results from a blinded, early-phase comparative trial

BACKGROUND

Reflexology is commonly used as an adjunct to conventional treatment by patients with respiratory tract infections. The effect of reflexology needs to be tested in a full-scale randomized controlled study. Small early-phase trials can give an indication on whether full-size clinical trials are warranted. The objective of this study is to determine whether the study design is feasible in a full-scale study of reflexology as an add-on to usual care compared to usual care alone in acute rhinosinusitis, and further if there is a statistical indication of an effect of reflexology warranting a full-scale study.

METHODS

20 patients with symptoms compatible with acute rhinosinusitis, and an illness duration of 28 days or less were randomized to additional reflexology treatment along with usual medical care, or usual care alone. The patients scored how much each of 16 sinus-related symptoms bothered them in the past few days on a six-point scale (zero = no problem to five = severe problem). To determine if there is a statistical indication of an effect of reflexology warranting a full-scale study, the separation test was used.

RESULTS

The methodology was considered feasible and could therefore be applied in a full-scale study of reflexology for acute rhinosinusitis. The mean reduction in symptom score from baseline to day two was 0.95 in the reflexology group and 0.78 in the control group. From baseline to day ten the mean reduction in symptom score was 2.12 in the reflexology group and 1.63 in the control group. A statistical indication of effect in a full-scale study in favor of reflexology was found from baseline to day ten but not from baseline to day two.

CONCLUSIONS

The research methodology in this study could be used in a full-scale study of reflexology in acute sinusitis. The results from the separation test indicates an effect warranting a full-scale study of reflexology regarding effects in acute sinusitis ten days after treatment.

What Promotes Medical Overuse: Perspective on Evolutionary Game between Administration and Medical Institutions

Medical overuse is the leading cause of high expenditure among healthcare systems worldwide, with the degree varying from region to region. There is increasing evidence to indicate that in China, National Healthcare Security Administration (NHSA) supervision plays the most crucial role in decreasing medical overuse. For medical overuse, traditional studies focus on empirical researches and qualitative analysis, most of which ignore how the two important participants, i.e., medical institutions and NHSA, affect the strategy of each other. To reduce the losses incurred by insufficient supervision, this study starts from bounded rationality, builds an evolutionary game model to study the relations between the NHSA and medical institutions, and reveals the dynamic evolution process of the supervision of NHSA and overuse of medical institutions. Through stable evolutionary strategy analysis, numerical simulation results, and sensitive experiments under diverse scenarios, we found that when profit gap of medical overuse is high or low, medical institution will adopt fixed strategy, which is medical overuse or appropriate medical use. Only when the profit gap is at a medium level will NHSA's choice affects medical institutions' strategy. Furthermore, NHSA's strategy is affected by the profit gap between medical use and supervision cost. Our work enriches the understanding of supervision for medical overuse and provides theoretical support for the NHSA to make decisions to reach an ideal condition, i.e., to supervise without exertion.

The aetiology of pharyngotonsillitis in primary health care: a prospective observational study

Background

Few studies on pharyngotonsillitis have examined the clinical presentation of different aetiologies where pathogens have been detected using molecular methods. We aimed to assess how well clinical signs and symptoms can predict (1) the presence or absence of a broad range of viruses and bacteria, and (2) reconsultations for a sore throat or a complication.

Methods

In this descriptive observational prospective study in primary health care 220 patients aged 15–45 with suspected pharyngotonsillitis were sampled from nose, throat and blood and screened for 20 bacteria and viruses using polymerase chain reaction (PCR), culture and serology. Odds ratios (OR) and predictive values with 95% confidence intervals (CI) were used to show association between microbiological findings and clinical signs and symptoms. Patients were followed up after 3 months by reviewing electronic medical records.

Results

Both cough and coryza were more common in patients with only viruses (67%) than in patients with only bacteria (21%) (p < 0.001), whereas tonsillar coating was more common in patients with only bacteria (53%) than in patients with only viruses (29%) (p = 0.006). Tonsillar coating (adjusted OR 6.0; 95% CI 2.5–14) and a lack of cough (adjusted OR 3.5; 95% CI 1.5–8.0) were significantly associated with Streptococcus pyogenes (group A streptococci; GAS) and with any bacterial finding. A Centor score of 3–4 had a positive predictive value of 49% (95% CI 42–57) for GAS and 66% (95% CI 57–74) for any bacterial findings. The use of rapid antigen detection test for GAS increased the positive predictive value for this group to 93%.

Conclusions

Signs and symptoms, both single and combined, were insufficient to rule in GAS or other pathogens. However, both cough and coryza were useful to rule out GAS. The results support the clinical approach of restricting rapid antigen detection testing to patients with 3–4 Centor criteria. The low carriage rate of bacteria among asymptomatic controls implied that most detections in patients represented a true infection.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-021-06665-9.

A Case of Co-occurrence of COVID-19 and Group A Streptococcal Pharyngitis

Coronavirus disease 2019 (COVID-19) has swept the world with over hundred million of cases and millions of deaths. Upper respiratory tract symptoms including acute pharyngitis are the common symptoms of COVID-19, with a reported incidence of about 5%-17.4%. Group A Streptococcus (GAS) pharyngitis is a common cause of bacterial pharyngitis, with highest incidence between age 5 and 15, and it can still occur in adults with peak incidence at age 40. Herein, we report a case of co-occurrence of GAS and COVID-19 in a middle-aged man who presented with fever, sore throat, cough, and runny nose. To the best of our knowledge, we are the first to report this unique co-occurrence. Our case report aimed to raise the awareness among physician particularly in ambulatory and emergency department of not to have a singular focus on COVID-19 and forget to screen patient with acute pharyngitis for GAS.

Change in the use of diagnostic tests in the management of lower respiratory tract infections: a register-based study in primary care

Background

Differentiating between pneumonia and acute bronchitis is often difficult in primary care. There is no consensus regarding clinical decision rules for pneumonia, and guidelines differ between countries. Use of diagnostic tests and change of management over time is not known.

Aim

To calculate the proportion of diagnostic tests in the management of lower respiratory tract infections (LRTIs) in a low antibiotic prescribing country, and to evaluate if the use and prescription pattern has changed over time.

Design & setting

A register-based study on data from electronic health records from January 2006 to December 2014 in the Kronoberg county of south east Sweden.

Method

Data regarding use of C-reactive protein (CRP), chest x-rays (CXRs), microbiological tests, and antibiotic prescriptions were assessed for patients aged 18–79 years, with the diagnosis pneumonia, acute bronchitis, or cough.

Results

A total of 54 229 sickness episodes were analysed. Use of CRP increased during the study period from 61.3% to 77.5% for patients with pneumonia (P<0.001), and from 53.4% to 65.7% for patients with acute bronchitis (P<0.001). Use of CXR increased for patients with acute bronchitis from 3.1% to 5.1% (P<0.001). Use of microbiological tests increased for patients with pneumonia, from 1.8% to 5.1% (P<0.001). The antibiotic prescription rate decreased from 18.6 to 8.2 per 1000 inhabitants per year for patients with acute bronchitis, but did not change for patients with pneumonia.

Conclusion

Use of CRP and microbiological tests in the diagnostics of LRTIs increased despite the fact that the incidence of pneumonia and acute bronchitis was stable.

Factors associated with antibiotic prescribing in patients with acute respiratory tract complaints in Malta: a 1-year repeated cross-sectional surveillance study

OBJECTIVE

To identify factors that influence general practitioners' (GPs') oral antibiotic prescribing for acute respiratory tract complaints (aRTCs) in Malta.

DESIGN

Repeated, cross-sectional surveillance.

SETTING

Maltese general practice; both public health centres and private GP clinics.

PARTICIPANTS

30 GPs registered on the Malta Medical Council's Specialist Register and 3 GP trainees registered data of 4831 patients of all ages suffering from any aRTC. Data were collected monthly between May 2015 and April 2016 during predetermined 1-week periods.

OUTCOME MEASURES

The outcome of interest was antibiotic prescription (yes/no), defined as an oral antibiotic prescription issued for an aRTC during an in-person consultation, irrespective of the number of antibiotics given. The association between GP, practice and consultation-level factors, patient sociodemographic factors and patient health status factors, and antibiotic prescription was investigated.

RESULTS

The antibiotic prescription rate was 45.0%. Independent factors positively associated with antibiotic prescribing included female GP sex (OR 2.3, 95% CI 1.22 to 4.26), GP age with GPs ≥60 being the most likely (OR 34.7, 95% CI 14.14 to 84.98), patient age with patients ≥65 being the most likely (OR 2.3, 95% CI 1.71 to 3.18), number of signs and/or symptoms with patients having ≥4 being the most likely (OR 9.6, 95% CI 5.78 to 15.99), fever (OR 2.6, 95% CI 2.08 to 3.26), productive cough (OR 1.3, 95% CI 1.03 to 1.61), otalgia (OR 1.3, 95% CI 1.01 to 1.76), tender cervical nodes (OR 2.2, 95% CI 1.57 to 3.05), regular clients (OR 1.3, 95% CI 1.05 to 1.66), antibiotic requests (OR 4.8, 95% CI 2.52 to 8.99) and smoking (OR 1.4, 95% CI 1.13 to 1.71). Conversely, patients with non-productive cough (OR 0.3, 95% CI 0.26 to 0.41), sore throat (OR 0.6, 95% CI 0.53 to 0.78), rhinorrhoea (OR 0.3, 95% CI 0.23 to 0.36) or dyspnoea (OR 0.6, 95% CI 0.41 to 0.83) were less likely to receive an antibiotic prescription.

CONCLUSION

Antibiotic prescribing for aRTCs was high and influenced by a number of factors. Potentially inappropriate prescribing in primary care can be addressed through multifaceted interventions addressing modifiable factors associated with prescription.

TRIAL REGISTRATION NUMBER

NCT03218930.

Effects of primary care antimicrobial stewardship outreach on antibiotic use by general practice staff: pragmatic randomized controlled trial of the TARGET antibiotics workshop

Objectives

To determine whether local trainer-led TARGET antibiotic interactive workshops improve antibiotic dispensing in general practice.

Methods

Using a McNulty–Zelen-design randomized controlled trial within three regions of England, 152 general practices were stratified by clinical commissioning group, antibiotic dispensing rate and practice patient list size, then randomly allocated to intervention (offered TARGET workshop that incorporated a presentation, reflection on antibiotic data, promotion of patient and general practice (GP) staff resources, clinical scenarios and action planning, 73 practices) or control (usual practice, 79 practices). The primary outcome measure was total oral antibiotic items dispensed/1000 patients for the year after the workshop (or pseudo-workshop date for controls), adjusted for the previous year’s dispensing.

Results

Thirty-six (51%) intervention practices (166 GPs, 51 nurses and 101 other staff) accepted a TARGET workshop invitation. In the ITT analysis total antibiotic dispensing was 2.7% lower in intervention practices (95% CI −5.5% to 1%, P = 0.06) compared with controls. Dispensing in intervention practices was 4.4% lower for amoxicillin/ampicillin (95% CI 0.6%–8%, P = 0.02); 5.6% lower for trimethoprim (95% CI 0.7%–10.2%, P = 0.03); and a non-significant 7.1% higher for nitrofurantoin (95% CI −0.03 to 15%, P = 0.06). The Complier Average Causal Effect (CACE) analysis, which estimates impact in those that comply with assigned intervention, indicated 6.1% (95% CI 0.2%–11.7%, P = 0.04) lower total antibiotic dispensing in intervention practices and 11% (95% CI 1.6%–19.5%, P = 0.02) lower trimethoprim dispensing.

Conclusions

This study within usual service provision found that TARGET antibiotic workshops can help improve antibiotic use, and therefore should be considered as part of any national antimicrobial stewardship initiatives. Additional local facilitation will be needed to encourage all general practices to participate.

Delayed antibiotic prescription for upper respiratory tract infections in children under primary care: Physicians' views

BACKGROUND

Overprescribing antibiotics for common or inaccurately diagnosed childhood infections is a frequent problem in primary healthcare in most countries. Delayed antibiotic prescriptions have been shown to reduce the use of antibiotics in primary healthcare.

OBJECTIVE

The aim was to examine primary care physicians' views on delayed antibiotic prescriptions to preschool children with symptoms of upper respiratory tract infections (URTIs).

METHODS

A questionnaire was sent to 1180 physicians working in general practice in the Capital Region of Denmark, between January and March 2015. The questions focused on physicians' attitude and use of delayed antibiotic prescriptions to children with URTIs.

RESULTS

The response rate was 49% (n = 574). Seven per cent of the physicians often used delayed prescriptions to children with symptoms of URTI, but 46% believed that delayed prescription could reduce antibiotic use. The physicians' views on delayed antibiotic prescription were significantly associated with their number of years working in general practice. Parents' willingness to wait-and-see, need for reassurance, and knowledge about antibiotics influenced the physicians' views. Also, clinical symptoms and signs, parents' willingness to shoulder the responsibility, the capability of observation without antibiotic treatment, and structural factors like out-of-hour services were relevant factors in the decision.

CONCLUSIONS

Most physicians, especially those with fewer years of practice, had a positive attitude towards delayed antibiotic prescription. Several factors influence the views of the physicians-from perceptions of parents to larger structural elements and years of experience.

Evidence for overuse of medical services around the world

Overuse, which is defined as the provision of medical services that are more likely to cause harm than good, is a pervasive problem. Direct measurement of overuse through documentation of delivery of inappropriate services is challenging given the difficulty of defining appropriate care for patients with individual preferences and needs; overuse can also be measured indirectly through examination of unwarranted geographical variations in prevalence of procedures and care intensity. Despite the challenges, the high prevalence of overuse is well documented in high-income countries across a wide range of services and is increasingly recognised in low-income countries. Overuse of unneeded services can harm patients physically and psychologically, and can harm health systems by wasting resources and deflecting investments in both public health and social spending, which is known to contribute to health. Although harms from overuse have not been well quantified and trends have not been well described, overuse is likely to be increasing worldwide.

Microbiological point of care testing before antibiotic prescribing in primary care: considerable variations between practices

Background

Point-of-care testing (POCT) in primary care may improve rational antibiotic prescribing. We examined use of POCT in Denmark, including patient- and general practitioner (GP)-related predictors.

Methods

We linked nationwide health care databases to assess POCT use (C-reactive protein (CRP), group A streptococcal (GAS) antigen swabs, bacteriological cultures, and urine test strips) per 1,000 overall GP consultations, 2004–2013. We computed odds ratios (OR) of POCT in patients prescribed antibiotics according to patient and GP age and sex, GP practice type, location, and workload.

Results

The overall use of POCT in Denmark increased by 45.8% during 2004–2013, from 147.2 per 1,000 overall consultations to 214.8. CRP tests increased by 132%, bacteriological cultures by 101.7% while GAS swabs decreased by 8.6%. POCT preceded 28% of antibiotic prescriptions in 2004 increasing to 44% in 2013. The use of POCT varied more than 5-fold among individual practices, from 54.9 to 394.7 per 1,000 consultations in 2013. POCT use varied substantially with patient age, and males were less likely to receive POCT than females (adjusted OR = 0.75, 95% CI 0.74-0.75) driven by usage of urine test strips among females (18% vs. 7%). Odds of POCT were higher among female GPs and decreased with higher GP age, with lowest usage among male GPs >60 years. GP urban/rural location and workload had little impact.

Conclusion

GPs use POCT increasingly with the highest use among young female GPs. In 2013, 44% of all antibiotic prescriptions were preceded by POCT but testing rates vary greatly across individual GPs.

Antibiotic prescriptions for suspected respiratory tract infection in primary care in South America

OBJECTIVES

To describe and compare antibiotic prescribing patterns for primary care patients with respiratory tract infections (RTIs) in four South American countries.

METHODS

This was a prospective observational study. General practitioners (GPs) from Argentina, Bolivia, Paraguay and Uruguay registered data about all consultations of patients with suspected RTIs in the winter of 2014 (June-August). Variation in antibiotic prescriptions was assessed using a two-level hierarchical logistic model.

RESULTS

Participating GPs (n = 171) registered 11 446 patients with suspected RTI; 3701 (33%) of these received an antibiotic prescription. There was a wide variation across countries in the use and selection of antibiotics. For example, 94% of patients with acute bronchitis were prescribed antibiotics in Bolivia, while in Uruguay only 21% received antibiotics. Amoxicillin was the most commonly prescribed antibiotic across countries, but prescription rates varied between 45% in Bolivia and 69% in Uruguay. Compared with the overall mean prescribing rate, and after adjusting for clinical presentation and demographics, prescribing of antibiotics varied by a factor of 6, the OR ranging from 0.37 (95% CI = 0.21-0.65) in Uruguay to 2.58 (95% CI = 1.66-4) in Bolivia.

CONCLUSIONS

The large variation in use and selection of antibiotics across countries is not explained by different patient populations. It could be explained by diagnostic uncertainty and contextual characteristics beyond clinical practice. Reducing uncertainty and country variation requires greater support from the healthcare systems by providing GPs with evidence-based guidelines and tools to apply them.

Combined assessment of clinical and patient factors on doctors' decisions to prescribe antibiotics

BACKGROUND

Antibiotic overprescription is a worldwide problem. Decisions regarding antibiotic prescription for respiratory tract infections (RTIs) are influenced by medical and non-medical factors.

METHODS

In family medicine practices in Białystok, Poland, family medicine residents directly observed consultations with patients with RTI symptoms. The observing residents completed a questionnaire including patient data, clinical symptoms, diagnosis, any prescribed antibiotic, and assessment of ten patient pressure factors.

RESULTS

Of 1546 consultations of patients with RTIs, 54.26 % resulted in antibiotic prescription. Antibiotic prescription was strongly associated with rales (OR 26.90, 95 % CI 9.00-80.40), tonsillar exudates (OR 13.03, 95 % CI 7.10-23.80), and wheezing (OR 14.72, 95 % CI 7.70-28.10). The likelihood of antibiotic prescription was increased by a >7-day disease duration (OR 3.94, 95 % CI 2.80-5.50), purulent nasal discharge (OR 3.87, 95 % CI 2.40-6.10), starting self-medication with antibiotics (OR 4.11, 95 % CI 2.30-7.30), and direct request for antibiotics (OR 1.87, 95 % CI 1.30-2.80). Direct request not to prescribe antibiotics decreased the likelihood of receiving antibiotics (OR 0.34, 95 % CI 0.27-0.55).

CONCLUSION

While clinical signs and symptoms principally impact prescribing decisions, patient factors also contribute. The most influential patient pressure factors were starting self-medication with antibiotics, and directly requesting antibiotic prescription or no antibiotic prescription. Interventions aiming to improve clinical sign and symptom interpretation and to help doctors resist direct patient pressure could be beneficial for reducing unnecessary antibiotic prescribing.

WITHDRAWN: Antibiotics for acute maxillary sinusitis in adults

Currently, two separate Cochrane reviews, ‘Antibiotics for acute maxillary sinusitis in adults ’ and ‘Antibiotics for clinically diagnosed acute rhinosinusitis in adults ’ describe the effect of antibiotics for acute rhinosinusitis. Although both Cochrane reviews study the same condition, they look at different populations (patients in which the diagnosis was based on clinical signs and symptoms and patients in which the diagnosis was confirmed by imaging). Because of this, the conclusions are different in these Cochrane reviews. This was confusing for clinicians who needed to read both Cochrane reviews to know which conclusions are most applicable to their patients.
 
 This review is being withdrawn and will be incorporated into the updated publication of ‘Antibiotics for clinically diagnosed acute rhinosinusitis in adults ’. This ‘merged’ review will still maintain the relevant distinction between the two populations. However, information on the effectiveness of antibiotics for rhinosinusitis will be published in the ‘merged’ Cochrane review. We will omit the comparison between antibiotics (as published in this Cochrane review) because the choice for certain antibiotics and/or doses differs according to the local antibiotic resistance patterns and therefore this comparison is less relevant.

The editorial group responsible for this previously published document have withdrawn it from publication.

Does additional antimicrobial treatment have a better effect on URTI cough resolution than homeopathic symptomatic therapy alone? A real-life preliminary observational study in a pediatric population

BACKGROUND

The effectiveness of a homeopathic syrup on cough has been demonstrated in an adult population in a previous double-blind randomized study. The present prospective observational study investigated children affected by wet acute cough caused by non-complicated URTIs, comparing those who received the homeopathic syrup versus those treated with the homeopathic syrup plus antibiotic.

OBJECTIVES

The aims were: 1) to assess whether the addition of antibiotics to a symptomatic treatment had a role in reducing the severity and duration of acute cough in a pediatric population, as well as in improving cough resolution; 2) to verify the safety of the two treatments.

METHODS

Eighty-five children were enrolled in an open study: 46 children received homeopathic syrup alone for 10 days and 39 children received homeopathic syrup for 10 days plus oral antibiotic treatment (amoxicillin/clavulanate, clarithromycin, and erythromycin) for 7 days. To assess cough severity we used a subjective verbal category-descriptive (VCD) scale.

RESULTS

Cough VCD score was significantly (P < 0.001) reduced in both groups starting from the second day of treatment (-0.52 ± 0.66 in the homeopathic syrup group and -0.56 ± 0.55 in children receiving homeopathic syrup plus oral antibiotic treatment). No significant differences in cough severity or resolution were found between the two groups of children in any of the 28 days of the study. After the first week (day 8) cough was completely resolved in more than one-half of patients in both groups. Two children (4.3 %) reported adverse effects in the group treated with the homeopathic syrup alone, versus 9 children (23.1 %) in the group treated with the homeopathic syrup plus antibiotics (P = 0.020).

CONCLUSIONS

Our data confirm that the homeopathic treatment in question has potential benefits for cough in children as well, and highlight the strong safety profile of this treatment. Additional antibiotic prescription was not associated with a greater cough reduction, and presented more adverse events than the homeopathic syrup alone.

Inappropriate antibiotic prescribing and demand for antibiotics in patients with upper respiratory tract infections is hardly different in female versus male patients as seen in primary care

BACKGROUND

Unnecessary prescribing of antibiotics is a major public health concern. General practitioners (GPs) prescribe most antibiotics, often for upper respiratory tract infections (URTIs), and have in general been shown to prescribe antibiotics more often to women. No studies have examined the influence of patient gender on unnecessary antibiotic prescribing.

OBJECTIVES

To study a possible gender difference in unnecessary antibiotic prescriptions for URTIs in general practice; to assess whether a possible difference is explained by patient demand for antibiotics.

METHODS

Post-hoc analysis of a cross-sectional study including 15,022 patients with URTI (acute rhinitis, acute otitis media, acute sinusitis, acute pharyngotonsillitis) from Argentina, Denmark, Lithuania, Russia, Spain and Sweden (HAPPY AUDIT Project). The association between gender and unnecessary antibiotic prescriptions, unadjusted and adjusted for treatment demand, was analysed using logistic regression models.

RESULTS

A total of 25% of patients with URTI received antibiotics; in 45% of the cases, antibiotics were unnecessary. Overall, no gender difference for unnecessary prescribing of antibiotics for URTIs was found. Women with acute otitis media received an unnecessary antibiotic twice as often as men (14.4% versus 7.1%). In Danish patients with acute pharyngotonsillitis, there was a gender difference in unnecessary prescriptions for antibiotics (women 29.1% versus men 48.6%). Some 14% of patients receiving unnecessary antibiotics demonstrated a demand for antibiotics, but no gender difference was found in this group.

CONCLUSION

This study indicated a high rate of unnecessary antibiotic prescribing for URTIs in general practice, but overall found no gender differences in receiving unnecessary antibiotic prescriptions.

Clinical and haematological predictors of antibiotic prescribing for acute cough in adults in Swiss practices--an observational study

Background

Acute cough is a common problem in general practice and is often caused by a self-limiting, viral infection. Nonetheless, antibiotics are often prescribed in this situation, which may lead to unnecessary side effects and, even worse, the development of antibiotic resistant microorganisms worldwide. This study assessed the role of point-of-care C-reactive protein (CRP) testing and other predictors of antibiotic prescription in patients who present with acute cough in general practice.

Methods

Patient characteristics, symptoms, signs, and laboratory and X-ray findings from 348 patients presenting to 39 general practitioners with acute cough, as well as the GPs themselves, were recorded by fourth-year medical students during their three-week clerkships in general practice. Patient and clinician characteristics of those prescribed and not-prescribed antibiotics were compared using a mixed-effects model.

Results

Of 315 patients included in the study, 22% were prescribed antibiotics. The two groups of patients, those prescribed antibiotics and those treated symptomatically, differed significantly in age, demand for antibiotics, days of cough, rhinitis, lung auscultation, haemoglobin level, white blood cell count, CRP level and the GP’s license to self-dispense antibiotics. After regression analysis, only the CRP level, the white blood cell count and the duration of the symptoms were statistically significant predictors of antibiotic prescription.

Conclusions

The antibiotic prescription rate of 22% in adult patients with acute cough in the Swiss primary care setting is low compared to other countries. GPs appear to use point-of-care CRP testing in addition to the duration of clinical symptoms to help them decide whether or not to prescribe antibiotics.

Appropriateness of antibiotic prescribing for upper respiratory tract infections in general practice: Comparison between Denmark and Iceland

OBJECTIVE

To compare the appropriateness of antibiotic prescribing for upper respiratory tract infections (URTIs) in two countries with different prevalence of antimicrobial resistance: Denmark and Iceland.

DESIGN

A cross-sectional study.

SETTINGS AND SUBJECTS

General practitioners (GPs) in Denmark (n = 78) and Iceland (n = 21) registered all patients with URTI according to the Audit Project Odense (APO) method during a three-week period in the winter months of 2008 and 2009.

MAIN OUTCOME MEASURES

Appropriateness of antibiotic prescribing in patients with URTI in Denmark and Iceland.

RESULTS

A total of 1428 patients were registered (Denmark: n = 1208; Iceland: n = 220). A majority of patients in both countries were prescribed antibiotics, and only a minority of the prescriptions could be classified as appropriate prescribing. In general, Icelandic GPs more often prescribed antibiotics (Iceland = 75.8% vs. Denmark = 59.3%), but Danish GPs had a higher percentage of inappropriate antibiotic prescribing for sinusitis, and Icelandic GPs for pharyngotonsillitis. No differences were found for acute otitis media (AOM). The different antibiotic prescribing patterns between Denmark and Iceland could not fully be explained by different symptoms and signs among patients.

CONCLUSION

Icelandic GPs have a higher antibiotic prescribing rate compared with Danish GPs, but the percentage of inappropriate antibiotic prescribing is highest in Denmark for sinusitis, and in Iceland for pharyngotonsillitis. Key points Within the Nordic countries there are marked differences in antimicrobial resistance and antibiotic use. Iceland differs from Denmark by a higher antibiotic prescribing rate and a higher prevalence of antimicrobial resistance. The majority of antibiotics are prescribed in primary care and most often for upper respiratory infections (URTIs). Only a minor amount of antibiotic prescriptions for URTIs can be classified as appropriate; inappropriate antibiotic prescribing is higher in Denmark than in Iceland for sinusitis and the opposite for pharyngotonsillitis. The different antibiotic prescribing patterns between Denmark and Iceland cannot be fully explained by different clinical criteria among patients.

Diarrhea in preschool children and Lactobacillus reuteri: a randomized controlled trial

OBJECTIVES

To evaluate whether daily administration of Lactobacillus reuteri DSM 17938 reduces the frequency and duration of diarrheal episodes and other health outcomes in day school children in Mexico.

METHODS

Healthy children (born at term, aged 6-36 months) attending day care centers were enrolled in this randomized, double-blind, placebo-controlled trial. They received L reuteri DSM 17938 (dose 10(8) colony-forming unit; n = 168) or identical placebo (n = 168) by mouth, daily for 3 months, after which they were followed-up after a further 3 months without supplementation.

RESULTS

Data from all children were included in the final analysis. L reuteri DSM 17938 significantly reduced the frequency and duration of episodes of diarrhea and respiratory tract infection at both 3 and 6 months (P < .05). Additionally, the number of doctor visits, antibiotic use, absenteeism from day school and parental absenteeism from work were significantly reduced in the L reuteri group (P < .05). A cost-benefit analysis revealed significant reductions in costs in the L reuteri-treated children. No adverse events related to the study product were reported.

CONCLUSIONS

In healthy children attending day care centers, daily administration of L reuteri DSM 17938 had a significant effect in reducing episodes and duration of diarrhea and respiratory tract infection, with consequent cost savings for the community.

Are procalcitonin or other infection markers useful in the detection of group A streptococcal acute tonsillitis?

BACKGROUND

The Centor criteria and the streptococcal rapid antigen detection test (RADT) are commonly used to differentiate sore throat patients with group A streptococci (GAS) from patients with other pathogens. We aimed to investigate if procalcitonin (PCT), C-reactive protein (CRP), white blood cell count (WBC), and absolute neutrophil count (ANC) could increase the diagnostic accuracy when added to the Centor score and RADT, or be used instead of the RADT, in the differential diagnosis.

METHODS

A 6-month prospective study was carried out in a Danish general practice with 8 physicians. One hundred acute tonsillitis patients aged 15 to 40 y were included.

RESULTS

The prevalence of GAS was 26%. The sensitivity (90%) and specificity (97%) of the RADT were high. Mean values of CRP, WBC, and ANC were significantly higher in patients with GAS compared to non-GAS patients (p < 0.001). However, the sensitivities (66-90%) and specificities (45-75%) were low. No difference in PCT levels was found (p = 0.334). CRP was the most reliable infection marker (sensitivity 90% and specificity 45%) for GAS aetiology.

CONCLUSIONS

The sensitivity, specificity, and area under the curve of the RADT were higher than those of the 4 measured infection markers in the differentiation between GAS and non-GAS acute tonsillitis patients. The infection markers did not increase the diagnostic accuracy when added to the Centor score and RADT. When RADT is not available, measurement of CRP or ANC may increase the diagnostic accuracy in the detection of GAS-positive patients.

Antibiotics for acute maxillary sinusitis in adults

BACKGROUND

Sinusitis is one of the most common diagnoses among adults in ambulatory care, accounting for 15% to 21% of all adult outpatient antibiotic prescriptions. However, the role of antibiotics for sinusitis is controversial.

OBJECTIVES

To assess the effects of antibiotics in adults with acute maxillary sinusitis by comparing antibiotics with placebo, antibiotics from different classes and the side effects of different treatments.

SEARCH METHODS

We searched CENTRAL 2013, Issue 2, MEDLINE (1946 to March week 3, 2013), EMBASE (1974 to March 2013), SIGLE (OpenSIGLE, later OpenGrey (accessed 15 January 2013)), reference lists of the identified trials and systematic reviews of placebo-controlled studies. We also searched for ongoing trials via ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP). We imposed no language or publication restrictions.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing antibiotics with placebo or antibiotics from different classes for acute maxillary sinusitis in adults. We included trials with clinically diagnosed acute sinusitis, confirmed or not by imaging or bacterial culture.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened search results, extracted data and assessed trial quality. We calculated risk ratios (RRs) for differences between intervention and control groups in whether the treatment failed or not. All measures are presented with 95% confidence intervals (CIs). We conducted the meta-analyses using either the fixed-effect or random-effects model. In meta-analyses of the placebo-controlled studies, we combined data across antibiotic classes. Primary outcomes were clinical failure rates at 7 to 15 days and 16 to 60 days follow-up. We used GRADEpro to assess the quality of the evidence.

MAIN RESULTS

We included 63 studies in this updated review; nine placebo-controlled studies involving 1915 participants (seven of the studies clearly conducted in primary care settings) and 54 studies comparing different classes of antibiotics (10 different comparisons). Five studies at low risk of bias comparing penicillin or amoxicillin to placebo provided information on the main outcome: clinical failure rate at 7 to 15 days follow-up, defined as a lack of full recovery or improvement, for participants with symptoms lasting at least seven days. In these studies antibiotics decreased the risk of clinical failure (pooled RR of 0.66, 95% CI 0.47 to 0.94, 1084 participants randomised, 1058 evaluated, moderate quality evidence). However, the clinical benefit was small. Cure or improvement rates were high in both the placebo group (86%) and the antibiotic group (91%) in these five studies. When clinical failure was defined as a lack of full recovery (n = five studies), results were similar: antibiotics decreased the risk of failure (pooled RR of 0.73, 95% CI 0.63 to 0.85, high quality evidence) at 7 to 15 days follow-up.Adverse effects in seven of the nine placebo-controlled studies (comparing penicillin, amoxicillin, azithromycin or moxicillin to placebo) were more common in antibiotic than in placebo groups (median of difference between groups 10.5%, range 2% to 23%). However, drop-outs due to adverse effects were rare in both groups: 1.5% in antibiotic groups and 1% in control groups.In the 10 head-to-head comparisons, none of the antibiotic preparations were superior to another. However, amoxicillin-clavulanate had significantly more drop-outs due to adverse effects than cephalosporins and macrolides.

AUTHORS' CONCLUSIONS

There is moderate evidence that antibiotics provide a small benefit for clinical outcomes in immunocompetent primary care patients with uncomplicated acute sinusitis. However, about 80% of participants treated without antibiotics improved within two weeks. Clinicians need to weigh the small benefits of antibiotic treatment against the potential for adverse effects at both the individual and general population levels.

Antibiotic prescribing in patients with acute rhinosinusitis is not in agreement with European recommendations

OBJECTIVE

To assess the potential overprescribing in patients with acute rhinosinusitis across six countries with different antibiotic prescribing rates and different prevalence of antibiotic resistance.

DESIGN, SETTING AND SUBJECTS

A cross-sectional study including GPs from two Nordic countries, two Baltic countries and two Hispano-American countries registered patients with respiratory tract infections (RTIs) during three weeks in January 2008 as part of the EU-funded project "Health Alliance for Prudent Prescribing, Yield And Use of antimicrobial Drugs In the Treatment of respiratory tract infections" (HAPPY AUDIT).

MAIN OUTCOME MEASURES

Use of antibiotics for acute rhinosinusitis based on the recommendations in the European Position Paper on Rhinosinusitis and Nasal Polyps 2007 (EP3OS).

RESULTS

In total, 618 participating GPs registered 33 273 patients with RTI of whom 1150 (3.46%) were considered to have acute rhinosinusitis. Over 50% of the patients with acute rhinosinusitis had symptoms for < 5 days and 81% were prescribed antibiotics. In total, 68% of the patients included were not prescribed antibiotics according to guidelines; 45% had symptoms < 5 days or no fever (possible overprescribing) and 23% had symptoms < 5 days and no fever (probable overprescribing).

CONCLUSION

A considerable number of patients with symptoms of acute rhinosinusitis were not managed according to European recommendations (EP3OS guidelines). To prevent overprescribing, efforts should be made to implement the recommendations in daily practice.

Enabling factors for antibiotic prescribing for upper respiratory tract infections: perspectives of Lithuanian and Russian general practitioners

INTRODUCTION

General practitioners (GPs) write about 80% of all antibiotic prescriptions, the greatest number of them for patients with respiratory tract infections. However, there is a lack of research targeting the influence of external factors on antibiotic prescribing by physicians. This study aimed to explore experiences of GPs in Lithuania and the Russian Federation with regard to antibiotic prescription for upper respiratory tract infections. By such means it might be possible to reveal external enabling factors that influence antibiotic prescribing in these countries.

METHOD

Five focus groups were performed with 22 GPs from Lithuania and 29 GPs from the Kaliningrad Region of the Russian Federation; then, thematic analysis of data was performed.

RESULTS

Six thematic categories were identified that are related to external forces enabling antibiotic prescription: the necessity for political leadership to encourage clinically grounded antibiotic use; over-the-counter sale of antibiotics; designation of antibiotics as reimbursable medications; supervision by external oversight institutions; lack of guidelines for the treatment of upper respiratory tract infections; and pharmaceutical company activities.

CONCLUSIONS

Comprehensive efforts to reduce the burden of non-clinically grounded antibiotic prescription should go beyond addressing factors at the physician-patient level and take into account important factors in the enabling environment as well.

Attitudes of community pharmacists to antibiotic dispensing and microbial resistance: a qualitative study in Portugal

BACKGROUND

The inappropriate use of antibiotics is considered a main cause of microbial resistance. This is an important public health problem. Community pharmacists have an important role in the management of drugs for outpatients.

OBJECTIVE

Our study sought to explore pharmacists' knowledge, attitudes, perceptions and dispensing habits insofar as to antibiotics and microbial resistance.

SETTING

The study was developed with community pharmacists in the North of Portugal.

METHODS

Qualitative research in the form of focus groups (FG). Focus groups were conducted with 4-7 pharmacists, using a moderator. A topic guide was developed to lead the discussions, which were audio-recorded and transcribed. The study was carried out between December 2010 and March 2011 in the five districts of the Northern Health Region of Portugal (ARS-N). Pharmacists from different regions of each district were invited to participate in the study by an investigator responsible for the study. Participants were informed about the study and that sessions were audio-recorded to facilitate data interpretation. They signed an informed consent form before taking part in the focus groups. The Ethical Committee of ARS-N was informed of this study.

MAIN OUTCOME MEASURE

Pharmacists' knowledge and perceptions on antibiotic use and microbial resistance, attitudes related to antibiotic dispensing habits, and pharmacists' suggestions to improve antibiotic use.

RESULTS

A total of 6 focus groups were conducted with community pharmacists (n = 32). Attitudes related to the problem of resistance were attributed external responsibility, to patients, to physicians, to other pharmacies, and to veterinary consumption. Some attitudes were identified that could lead to antibiotic dispensing without a prescription. These attitudes are complacency, precaution and external complacency.

CONCLUSIONS

Portuguese pharmacists perceive that antibiotic use and bacterial resistance could be improved, showing a behavioural intention to improve antibiotic dispensing habits.

In primary health care, never prescribe antibiotics to patients suspected of having an uncomplicated sore throat caused by group A beta-haemolytic streptococci without first confirming the presence of this bacterium

BACKGROUND

There are several consensus-describing decision rules for patients in primary health care with a sore throat. The objective of this study was to estimate the number of unnecessary antibiotic prescriptions in primary health care given to patients with a sore throat, due to these different decision rules. A further aim was to suggest revised rules for decision-making in primary health care, when a sore throat caused by group A beta-haemolytic streptococci (GAS) is suspected.

METHODS

The design was a reanalysis of previously published articles describing the prevalence of GAS and physician behaviour when treating patients with a sore throat. The risk of unnecessary antibiotic prescribing in different situations was estimated and applied to the Swedish population.

RESULTS

Introducing the rule of never prescribing antibiotics without first confirming the presence of GAS would result in an annual reduction in Sweden of 20,360-25,192 unnecessary antibiotic prescriptions in children and 65,311-98,160 in adults.

CONCLUSIONS

The single most important rule in primary health care to minimize the risk of unnecessary antibiotic prescription to patients with an uncomplicated sore throat, and where an infection with GAS is suspected, is to never prescribe antibiotics at the first visit without first confirming the presence of this bacterium. Adding more decision rules may to some extent further reduce the number of unnecessary antibiotic prescriptions.

Health Alliance for prudent antibiotic prescribing in patients with respiratory tract infections (HAPPY AUDIT) -impact of a non-randomised multifaceted intervention programme

Background

Excessive use of antibiotics is worldwide the most important reason for development of antimicrobial resistance. As antibiotic resistance may spread across borders, high prevalence countries may serve as a source of bacterial resistance for countries with a low prevalence. Therefore, bacterial resistance is an important issue with a potential serious impact on all countries. Initiatives have been taken to improve the quality of antibiotic prescribing in primary care, but only few studies have been designed to determine the effectiveness of multifaceted strategies across countries with different practice setting. The aim of this study was to evaluate the impact of a multifaceted intervention targeting general practitioners (GPs) and patients in six countries with different health organization and different prevalence of antibiotic resistance.

Methods

GPs from two Nordic countries, two Baltic Countries and two Hispano-American countries registered patients with respiratory tract infections (RTIs) in 2008 and 2009. After first registration they received individual prescriber feedback and they were offered an intervention programme that included training courses, clinical guidelines, posters for waiting rooms, patient brochures and access to point of care tests (Strep A and C-Reactive Protein). Antibiotic prescribing rates were compared before and after the intervention.

Results

A total of 440 GPs registered 47011 consultations; 24436 before the intervention (2008) and 22575 after the intervention (2009). After the intervention, the GPs significantly reduced the percentage of consultations resulting in an antibiotic prescription. In patients with lower RTI the GPs in Lithuania reduced the prescribing rate by 42%, in Russia by 25%, in Spain by 25%, and in Argentina by 9%. In patients with upper RTIs, the corresponding reductions in the antibiotic prescribing rates were in Lithania 20%, in Russia 15%, in Spain 9%, and in Argentina 5%.

Conclusion

A multifaceted intervention programme targeting GPs and patients and focusing on improving diagnostic procedures in patients with RTIs may lead to a marked reduction in antibiotic prescribing. The pragmatic before-after design used may suffer from some limitations and the reduction in antibiotic prescribing could be influenced by factors not related to the intervention.

Health Alliance for Prudent Prescribing, Yield and Use of Antimicrobial Drugs in the Treatment of Respiratory Tract Infections (HAPPY AUDIT)

Background

Excessive and inappropriate use of antibiotics is considered to be the most important reason for development of bacterial resistance to antibiotics. As antibiotic resistance may spread across borders, high prevalence countries may serve as a source of bacterial resistance for countries with a low prevalence. Therefore, bacterial resistance is an important issue with a potential serious impact on all countries.

The majority of respiratory tract infections (RTIs) are treated in general practice. Most infections are caused by virus and antibiotics are therefore unlikely to have any clinical benefit. Several intervention initiatives have been taken to reduce the inappropriate use of antibiotics in primary health care, but the effectiveness of these interventions is only modest. Only few studies have been designed to determine the effectiveness of multifaceted strategies in countries with different practice setting. The aim of this study is to evaluate the impact of a multifaceted intervention targeting general practitioners (GPs) and patients in six countries with different prevalence of antibiotic resistance: Two Nordic countries (Denmark and Sweden), two Baltic Countries (Lithuania and Kaliningrad-Russia) and two Hispano-American countries (Spain and Argentina).

Methods/Design

HAPPY AUDIT was initiated in 2008 and the project is still ongoing. The project includes 15 partners from 9 countries. GPs participating in HAPPY AUDIT will be audited by the Audit Project Odense (APO) method. The APO method will be used at a multinational level involving GPs from six countries with different cultural background and different organisation of primary health care. Research on the effect of the intervention will be performed by analysing audit registrations carried out before and after the intervention. The intervention includes training courses on management of RTIs, dissemination of clinical guidelines with recommendations for diagnosis and treatment, posters for the waiting room, brochures to patients and implementation of point of care tests (Strep A and CRP) to be used in the GPs'surgeries.

To ensure public awareness of the risk of resistant bacteria, media campaigns targeting both professionals and the public will be developed and the results will be published and widely disseminated at a Working Conference hosted by the World Association of Family Doctors (WONCA-Europe) at the end of the project period.

Discussion

HAPPY AUDIT is an EU-financed project with the aim of contributing to the battle against antibiotic resistance through quality improvement of GPs' diagnosis and treatment of RTIs through development of intervention programmes targeting GPs, parents of young children and healthy adults. It is hypothesized that the use of multifaceted strategies combining active intervention by GPs will be effective in reducing prescribing of unnecessary antibiotics for RTIs and improving the use of appropriate antibiotics in suspected bacterial infections.

Prescription rates and diagnostic patterns are stable: A comparison of high-, medium- and low-prescribing primary care physicians treating community-acquired respiratory tract infections

The objective was to study prescription practices of primary care physicians in prescribing antibiotics for community-acquired respiratory tract infections. Design was time series analysis and cross-sectional survey. The setting was 30 community primary health care centres. A case report form was completed for 3478 patient consultations treated by 198 office-based primary care physicians. Main outcome measures were: classification of diagnoses of respiratory tract infections made by each physician; number of antibiotic prescriptions related to these diagnoses; each physician's mean weekly number of antibiotic prescriptions during 6 months before and after the survey. Patients' risk (odds ratio: OR) to receive an antibiotic prescription from the high and medium prescribers was 5.81 (95% confidence interval [CI] 4.85-6.96) and 2.41 (95% CI 2.04-2.86), compared to low prescribers. High and medium prescribers made more diagnoses of otitis media (OR 2.07, 95% CI 1.70-2.53 and 1.85, 95% CI 1.51-2.26, respectively) and fewer diagnoses of unspecified upper respiratory tract infection (OR 0.32, 95% CI 0.26-0.38 and 0.57, 95% CI 0.48-0.68, respectively) than low prescribers. The rank of the prescription rate of high, medium and low prescriber groups remained the same for all diagnoses except pneumonia. In addition, the annual rank between high, medium and low prescriber groups remained stable; high group prescribed more antibiotics during the year than medium group, which prescribed more than low prescriber group.

Incidence, microbiology and clinical history of peritonsillar abscesses

The objective of this study was to describe the incidence and microbiology of peritonsillar abscesses (PTA) and to study the clinical history with special reference to primary care management of these patients. We performed a retrospective study of hospital records to determine the incidence of PTA in 2000-2006, and a prospective study of consecutive PTA patients to study the microbiology of PTA, the clinical history and previous management in primary care of these patients. The incidence of PTA varied between 19 and 37/100,000 per y in the y 2000-2006. In total, 89 patients were included in the prospective study (54M, 35F), with a median age of 22 y (range 13-83 y). The most frequent single bacterial agent found was group A beta- haemolytic Streptococcus (GAS), identified in 18% of throat swabs and 24% of aspirates. The majority of PTA developed within 5 d of onset of sore throat and 54% of patients presented without prior consultation for sore throat. In the studied population the patient that first presented to primary care seems to have been appropriately managed and referred.

Trends in number of consultations and antibiotic prescriptions for respiratory tract infections between 1999 and 2005 in primary healthcare in Kalmar County, Southern Sweden

BACKGROUND. Respiratory tract infections (RTIs) comprise the most common indication for consulting a general practitioner and obtaining an antibiotic prescription.

OBJECTIVE

To study changes in the number of visits, diagnoses, and antibiotic prescriptions for RTI in primary healthcare during the period 1999-2005.

DESIGN

A retrospective, descriptive, population-based study of electronic patient records. Setting. County of Kalmar in southeastern Sweden.

PATIENTS

Patients visiting primary healthcare units in Kalmar County for an RTI between 1 July 1999 and 31 December 2005.

MAIN OUTCOME MEASURES

RTI diagnoses, antibiotic prescriptions, age groups.

RESULTS

A total of 240 447 visits for RTI made between 1999 and 2005 were analysed. The yearly consultation rates for the diagnoses acute tonsillitis and AOM decreased by 12% and 10%, respectively (p = 0.001). Of all patients consulting for an RTI diagnosis, 45% received antibiotics. Of all prescribed antibiotics, 60% were for phenoxymethylpenicillin (PcV) and 18% doxycycline. Amoxicillin or amoxicillin + clavulanic acid was prescribed to a lesser extent. The proportion of patients obtaining an antibiotic prescription was almost constant over time (44-46%). The prescriptions of doxycycline showed increasing values (NS). The prescriptions of remaining antibiotics decreased significantly especially for patients up to middle age.

CONCLUSION

This large population study, comprising more than six years of observations, showed the number of primary healthcare patients receiving an RTI diagnosis decreased during the period 1999-2005, but the proportion of patients receiving an antibiotic prescription remained the same. The large seasonal variations indicate a need for further interventions to decrease antibiotic use for RTIs.

Family Practitioners' Diagnostic Decision-Making Processes Regarding Patients with Respiratory Tract Infections: An Observational Study

Background. The influence of patient characteristics on family practitioners' (FPs') diagnostic decision making has mainly been investigated using indirect methods such as vignettes or questionnaires. Direct observation— borrowed from social and cultural anthropology— may be an alternative method for describing FPs' real-life behavior and may help in gaining insight into how FPs diagnose respiratory tract infections, which are frequent in primary care. Objective. To clarify FPs' diagnostic processes when treating patients suffering from symptoms of respiratory tract infection. Methods. This direct observation study was performed in 30 family practices using a checklist for patient complaints, history taking, physical examination, and diagnoses. The influence of patients' symptoms and complaints on the FPs' physical examination and diagnosis was calculated by logistic regression analyses. Dummy variables based on combinations of symptoms and complaints were constructed and tested against saturated (full) and backward regression models. Results. In total, 273 patients (median age 37 years, 51% women) were included. The median number of symptoms described was 4 per patient, and most information was provided at the patients' own initiative. Multiple logistic regression analysis showed a strong association between patients' complaints and the physical examination. Frequent diagnoses were upper respiratory tract infection (URTI)/common cold (43%), bronchitis (26%), sinusitis (12%), and tonsillitis (11%). There were no significant statistical differences between ``simple heuristic'' models and saturated regression models in the diagnoses of bronchitis, sinusitis, and tonsillitis, indicating that simple heuristics are probably used by the FPs, whereas ``URTI/common cold'' was better explained by the full model. Conclusion. FPs tended to make their diagnosis based on a few patient symptoms and a limited physical examination. Simple heuristic models were almost as powerful in explaining most diagnoses as saturated models. Direct observation allowed for the study of decision making under real conditions, yielding both quantitative data and ``qualitative'' information about the FPs' performance. It is important for investigators to be aware of the specific disadvantages of the method (e.g., a possible observer effect).

Antibiotics for acute maxillary sinusitis

BACKGROUND

Expert opinions vary on the appropriate role of antibiotics for sinusitis, one of the most commonly diagnosed conditions among adults in ambulatory care.

OBJECTIVES

We examined whether antibiotics are effective in treating acute sinusitis, and if so, which antibiotic classes are the most effective.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, 2007, Issue 3); MEDLINE (1950 to May 2007) and EMBASE (1974 to June 2007).

SELECTION CRITERIA

Randomized controlled trials (RCTs) comparing antibiotics with placebo or antibiotics from different classes for acute maxillary sinusitis in adults. We included trials with clinically diagnosed acute sinusitis, whether or not confirmed by radiography or bacterial culture.

DATA COLLECTION AND ANALYSIS

At least two review authors independently screened search results, extracted data and quality assessed trials. Risk ratios (RR) were calculated for differences in the intervention and control groups to see whether or not the treatment was a failure. In meta-analysing the placebo-controlled studies, the data across antibiotic classes were combined. Primary outcomes were the clinical failure rates at 7 to 15 days and 16 to 60 days follow up.

MAIN RESULTS

Fifty-seven studies were included in the review; six placebo-controlled studies and 51 studies comparing different classes of antibiotics. Five studies involving 631 participants provided data for comparison of antibiotics to placebo, when clinical failure was defined as a lack of cure or improvement at 7 to 15 days follow up. These studies found a slight statistical difference in favor of antibiotics, compared to placebo, with a pooled RR of 0.66 (95% confidence interval (CI) 0.44 to 0.98). However, the clinical significance of the result is equivocal, also considering that cure or improvement rate was high in both the placebo group (80%) and the antibiotic group (90%). Based on six studies, when clinical failure was defined as a lack of total cure, there was significant difference in favor of antibiotics compared to placebo with a pooled RR of 0.74 (95% CI 0.65 to 0.84) at 7 to 15 days follow up. None of the antibiotic preparations was superior to each other.

AUTHORS' CONCLUSIONS

Antibiotics have a small treatment effect in patients with uncomplicated acute sinusitis in a primary care setting with symptoms for more than seven days. However, 80% of participants treated without antibiotics improve within two weeks. Clinicians need to weigh the small benefits of antibiotic treatment against the potential for adverse effects at both the individual and general population level.

Antibiotics for adults with clinically diagnosed acute rhinosinusitis: a meta-analysis of individual patient data

BACKGROUND

Primary-care physicians continue to overprescribe antibiotics for acute rhinosinusitis because distinction between viral and bacterial sinus infection is difficult. We undertook a meta-analysis of randomised trials based on individual patients' data to assess whether common signs and symptoms can be used to identify a subgroup of patients who benefit from antibiotics.

METHODS

We identified suitable trials--in which adult patients with rhinosinusitis-like complaints were randomly assigned to treatment with an antibiotic or a placebo--by searching the Cochrane Central Register of Controlled Trials, Medline, and Embase, and reference lists of reports describing such trials. Individual patients' data from 2547 adults in nine trials were checked and re-analysed. We assessed the overall effect of antibiotic treatment and the prognostic value of common signs and symptoms by the number needed to treat (NNT) with antibiotics to cure one additional patient.

FINDINGS

15 patients with rhinosinusitis-like complaints would have to be given antibiotics before an additional patient was cured (95% CI NNT[benefit] 7 to NNT[harm] 190). Patients with purulent discharge in the pharynx took longer to cure than those without this sign; the NNT was 8 patients with this sign before one additional patient was cured (95% CI NNT[benefit] 4 to NNT[harm] 47). Patients who were older, reported symptoms for longer, or reported more severe symptoms also took longer to cure but were no more likely to benefit from antibiotics than other patients.

INTERPRETATION

Common clinical signs and symptoms cannot identify patients with rhinosinusitis for whom treatment is clearly justified. Antibiotics are not justified even if a patient reports symptoms for longer than 7-10 days.

Sustained reduction of antibiotic use and low bacterial resistance: 10-year follow-up of the Swedish Strama programme

Increasing use of antibiotics and the spread of resistant pneumococcal clones in the early 1990s alarmed the medical profession and medical authorities in Sweden. Strama (Swedish Strategic Programme for the Rational Use of Antimicrobial Agents and Surveillance of Resistance) was therefore started in 1994 to provide surveillance of antibiotic use and resistance, and to implement the rational use of antibiotics and development of new knowledge. Between 1995 and 2004, antibiotic use for outpatients decreased from 15.7 to 12.6 defined daily doses per 1000 inhabitants per day and from 536 to 410 prescriptions per 1000 inhabitants per year. The reduction was most prominent in children aged 5-14 years (52%) and for macrolides (65%). During this period, the number of hospital admissions for acute mastoiditis, rhinosinusitis, and quinsy (peritonsillar abscess) was stable or declining. Although the epidemic spread in southern Sweden of penicillin-resistant Streptococcus pneumoniae was curbed, the national frequency increased from 4% to 6%. Resistance remained low in most other bacterial species during this period. This multidisciplinary, coordinated programme has contributed to the reduction of antibiotic use without measurable negative consequences. However, antibiotic resistance in several bacterial species is slowly increasing, which has led to calls for continued sustained efforts to preserve the effectiveness of available antibiotics.

[Prescribing practices in the treatment of upper respiratory tract infections in anthroposophic medicine]

BACKGROUND

Upper respiratory tract infections (URTI) are among the leading reasons for doctor consultations. This study investigates the prescribing practices of medical doctors specialized in anthroposophic medicine in the treatment of URTI with a special focus on the prescription of antibiotics, complications, recurrence rates and costs.

MATERIALS AND METHODS

Starting in May 2004 all prescriptions within a 1-year period by 35 primary care practitioners in Germany were analysed. Data were extracted from practice software with special interfaces with additional linking of medications and diagnoses by practitioners.

RESULTS

21,818 prescriptions for 12,081 patients (73.7%children) with 19,050 cases of URTI were analysed. The most common diagnosis was common cold (63.3%), followed by acute tonsillitis (12.9%). 63.0% were treated purely with complementary medicine. Antibiotics were given in 6.3% of cases (minimum: common cold 1.9%, maximum: tonsillitis 24.3%). Predictive factors for antibiotic prescribing were the diagnoses tonsillitis (odds ratio [OR]: 6.7; 95% confidence interval [CI]:4.5-9.9) and sinusitis (OR: 1.9; 95% CI: 1.1-3.1), concomitant disease (OR: 1.2; 95% CI: 1.0-1.4), complications (OR: 7.2; 95% CI:5.5-9.4) and the specialty paediatrics (OR: 2.1; 95% CI: 1.7-2.6). In cases that were initially treated with only complementary medicine, antibiotics were eventually prescribed in 0.7%. Overall complication rates were 2.9% and follow-up visits occurred in 6.3%. Patients had an average of 2.4 URTI/year (adults 1.7,children 2.7). Treatment costs did not differ between complementary care and antibiotics.

CONCLUSION

Prescription practices in the treatment of URTI by anthroposophic practitioners were documented through the processing of routine medical data with minimal additional data. The therapy was found to be in accordance with the guidelines, however, the prescription rate for antibiotics was well below the German average.

Occurrence and management of acute respiratory illnesses in early childhood

AIM

Acute respiratory illnesses (ARI) impose massive economic burden on health services. The growing costs, limited benefits of pharmacotherapeutic agents, and alarming rise in antibiotic resistance poses a major health challenge. Analysis of the nature and burden of ARI through well-designed epidemiologic studies will help in the development of a uniform public health approach to identify methods to reduce disease transmission and maximise prevention strategies. The aim of this study was to analyse the nature and magnitude of the burden of ARI encountered by a cohort of children in the first 5 years of life.

METHODS

This community-based prospective study of ARI followed a cohort of children from birth until 5 years of age. Information on all episodes of ARI encountered, and their management, was collected through daily symptom diary and fortnightly telephone calls.

RESULTS

Four episodes of ARI/year were reported in the first 2 years and 2-3 episodes/year between 2 and 5 years. The majority were upper respiratory infections. 53% had at least one lower respiratory infection in the first year. For the majority, symptoms lasted 1-2 weeks. 53% were treated with antitussives or cough mixtures, 44% with paracetamol and 23% with antibiotics. A total of 46% of the episodes presented to a family physician, with younger children and those with lower respiratory infection more likely to seek attention.

CONCLUSION

ARI are common in childhood and although symptoms may last for 4 weeks, the majority resolve spontaneously. Use of medication does not appear to significantly alter the course or duration of symptoms of ARI.

Clinical course of suspected viral sore throat in young adults: cohort study

OBJECTIVE

To evaluate the natural clinical course of suspected viral sore throat.

DESIGN

Prospective cohort study.

SETTING

Five military camps in Norway.

METHODS

In a randomized placebo-controlled trial comparing the effect of bovine colostrum tablets or placebo on non-streptococcal sore throat in young adults no statistically significant difference in illness duration was found. The participants were thus regarded as one cohort. The authors analysed 10.0 cm visual analogue scales (VAS) scores for 'sickness' and sore throat, using 1.0 cm as a cut-off for recovery. They furthermore explored whether the VAS for sore throat was a good test to discriminate between recovered/not recovered by use of a receiver operating characteristic (ROC) curve.

RESULTS

For sore throat, it was found that 51% had recovered by day 6 and 91% had recovered by day 8. Similarly for sickness, 65% had recovered by day 6 and 94% by day 8. The daily VAS scores for 'sickness' and sore throat were highly correlated (p = 0.001). The mean day of recovery from 'sickness' and sore throats (based on VAS scores) was 5.5 and 4.7 respectively and 5.3 based on the dichotomous outcome for throat pain. The ROC curve revealed that a VAS score < 1.0 was the best cut-off point for recovery, with a sensitivity of 0.74 and a specificity of 0.90.

CONCLUSION

Almost all the patients had recovered by day 8. A high correlation was found between sickness and sore throat. These data will assist clinicians and others promoting self-care to set realistic expectations regarding recovery from URTI in young adults.

The Antimicrobial Treatment Strategies (MIKSTRA) Program: A 5-Year Follow-Up of Infection-Specific Antibiotic Use in Primary Health Care and the Effect of Implementation of Treatment Guidelines

BACKGROUND

A national 5-year follow-up study of infection-specific antibiotic use in primary care was conducted to see if prescribing practices change after implementing new treatment guidelines.

METHODS

The data were collected during 1 week of November each year from 1998 to 2002 from 30 health care centers that covered a total population of 819,777 persons and in 2002 from 20 control health care centers that covered a population of 545,098 persons. National guidelines for 6 major infections (otitis media, sinusitis, throat infection, acute bronchitis, urinary tract infection, and bacterial skin infection) were published in 1999-2000. Multifaceted interventions were performed by local trainers teaching his or her coworkers, supported by feedback and patient and public information.

RESULTS

The 6 infections targeted for intervention, together with unspecified upper respiratory tract infection constituted 80%-85% of all infections. The proportion of patients who received prescriptions for antibiotics did not change significantly. However, use of first-line antibiotics increased for all infections, and the change was significant for sinusitis (P<.001), acute bronchitis (P=.015), and urinary tract infections (P=.009). Also, the percentage of antibiotic treatments prescribed for the recommended duration increased significantly. Correct prescribing for respiratory tract infections improved by 6.4 percentage units (P<.001). However, there was no statistically significant difference in performance between study and control health care centers at follow-up.

CONCLUSIONS

Moderate qualitative improvements in antibiotic use were observed after multifaceted intervention, but prescribing for unjustified indications, mainly acute bronchitis, did not decrease. Obtained infection-specific information on management of patients with infections in primary health care is an important basis for planning targeted interventions in the future.

Analysis of under- and overprescribing of antibiotics in acute otitis media in general practice

OBJECTIVES

To assess clinical determinants of under- and overprescribing of antibiotics according to the Dutch national guideline for patients with acute otitis media (AOM) in general practice.

PATIENTS AND METHODS

A total of 146 general practitioners (GPs) from the Netherlands included all patients with AOM during a 4 week period in winter, and recorded patient characteristics, clinical presentation and management. Under- and overprescribing of antibiotics in AOM was assessed using the Dutch national guideline.

RESULTS

A total of 458 AOM consultations were recorded. In seven out of 10 consultations (310/439; excluding 19 consultations in which patients were referred to secondary care), antibiotic prescribing decisions were according to the national guideline. In 11% of all consultations (50/439), there was underprescribing and in 18% (79/439) there was overprescribing. Patients with an antibiotic indication but without an antibiotic prescription (underprescribing; n=50) had more short-term symptoms (OR: 0.93), relatively few inflammation signs (OR: 0.47) and were less severely ill (OR: 0.30), compared with patients with an antibiotic indication and an antibiotic prescription (n=167). Patients without an antibiotic indication but with an antibiotic prescription (overprescribing; n=79) were more often younger than 24 months (OR: 0.34), more severely ill (OR: 3.30) and expected more often an antibiotic as perceived by their GP (OR: 2.11), compared with patients without an antibiotic indication and without an antibiotic prescription (n=143).

CONCLUSIONS

Clinical determinants which are stated as criteria for antibiotic treatment of AOM in the Dutch national guideline were recognized by GPs as important items, but were frequently given too much weight.

Analysis of the causes and consequences of decreased antibiotic consumption over the last 5 years in Slovenia

OBJECTIVES

Compared with European countries, the use of antibiotics in Slovenia is moderate. In the period 1999-2002 an 18.67% decrease in outpatient antibiotic consumption was noted. The aim of the present study was to analyse this decrease and its consequences.

METHODS

The data on outpatient antibiotic consumption were obtained from the Institute of Public Health and Health Insurance Institute of Slovenia and expressed in defined daily doses (DDD)/1000 inhabitant-days. The number of media publications on 'antibiotic drugs' and 'bacterial resistance' during the study period was obtained. In 2000, the prescription of co-amoxiclav and fluoroquinolones was restricted because of a constant increase in the consumption of these drugs. The data on incidence of acute mastoiditis and penicillin resistance among invasive pneumococci were obtained.

RESULTS

The total outpatient consumption of antibacterials increased from 15.21 DDD/1000 inhabitant-days in 1996 to 20.08 in 1999, and decreased to 16.97 in 2003. The consumption of restricted antibiotics decreased from 7.29 in 1999 to 5.25 DDD/1000 inhabitant-days in 2003. There was a positive correlation between antibiotic consumption and the number of newspaper articles (r=0.92), and a negative correlation between the number of diagnostic tests and antibiotic consumption (r=-0.73 for the C-reactive protein test and -0.68 for the streptococcal antigen detection test). Reduced antibiotic consumption was paralleled by a decrease in penicillin resistance among invasive pneumococci. No increase in mastoiditis cases was observed in spite of reduced antibiotic consumption.

CONCLUSION

Restriction of antibiotic prescription proved to be effective in reducing outpatient antibiotic consumption. The effect was prolonged and affected restricted antibiotics as well as non-restricted drugs.

Physician behaviour for antimicrobial prescribing for paediatric upper respiratory tract infections: a survey in general practice in Trinidad, West Indies

Background

Upper respiratory tract infections (URTIs) are among the most frequent reasons for physician office visits in paediatrics. Despite their predominant viral aetiology, URTIs continue to be treated with antimicrobials. We explored general practitioners' (GPs) prescribing behaviour for antimicrobials in children (≤ 16 years) with URTIs in Trinidad, using the guidelines from the Centers for Disease Control and Prevention (CDC) as a reference.

Methods

A cross-sectional study was conducted on 92 consenting GPs from the 109 contacted in Central and East Trinidad, between January to June 2003. Using a pilot-tested questionnaire, GPs identified the 5 most frequent URTIs they see in office and reported on their antimicrobial prescribing practices for these URTIs to trained research students.

Results

The 5 most frequent URTIs presenting in children in general practice, are the common cold, pharyngitis, tonsillitis, sinusitis and acute otitis media (AOM) in rank order. GPs prescribe at least 25 different antibiotics for these URTIs with significant associations for amoxicillin, co-amoxiclav, cefaclor, cefuroxime, erythromycin, clarithromycin and azithromycin (p < 0.001). Amoxicillin alone or with clavulanate was the most frequently prescribed antibiotic for all URTIs. Prescribing variations from the CDC recommendations were observed for all URTIs except for AOM (50%), the most common condition for antibiotics. Doctors practicing for >30 years were more likely to prescribe antibiotics for the common cold (p = 0.014). Severity (95.7%) and duration of illness (82.5%) influenced doctors' prescribing and over prescribing in general practice was attributed to parent demands (75%) and concern for secondary bacterial infections (70%). Physicians do not request laboratory investigations primarily because they are unnecessary (86%) and the waiting time for results is too long (51%).

Conclusions

Antibiotics are over prescribed for paediatric URTIs in Trinidad and amoxicillin with co-amoxiclav were preferentially prescribed. Except for AOM, GPs' prescribing varied from the CDC guidelines for drug and duration. Physicians recognise antibiotics are overused and consider parents expecting antibiotics and a concern for secondary bacterial infections are prescribing pressures. Guidelines to manage URTIs, ongoing surveillance programs for antibiotic resistance, public health education on non-antibiotic strategies, and postgraduate education for rational pharmacotherapy in general practice would decrease inappropriate antibiotic use in URTIs.

The use of CRP tests in patients with respiratory tract infections in primary care in Sweden can be questioned

A diagnosis-antibiotic prescribing study was performed in 5 counties in Sweden during 1 week in November in 2000 and 2002 respectively. As a part of the study, the use and results of C-reactive protein (CRP) tests in relation to duration of symptoms and antibiotic prescribing in 6778 patients assigned a diagnosis of respiratory tract infections were analysed. In almost half (42%) of the patients, a CRP test was performed. The majority of CRP tests (69%) were performed in patients assigned diagnosis upper respiratory tract infection, where the test is not recommended. Overall, there was a minor decrease in antibiotic prescribing when CRP was used (41%), in comparison to 44% of the patients where no CRP was performed (p < 0.01). Patients assigned diagnoses implying a bacterial aetiology were prescribed antibiotics irrespective of result of CRP or length of symptoms before consultation. For patients assigned viral diagnoses, antibiotic prescribing increased with increasing duration of symptoms and increasing value of CRP. The use of CRP decreased antibiotic prescribing in patients assigned to viral diagnoses and with longstanding symptoms (p < 0.001). However, 59% of the patients assigned viral diagnoses with CRP > or = 25 received antibiotics, which seems to indicate a misinterpretation of CRP and a non-optimal use of antibiotics.

Data from electronic patient records are suitable for surveillance of antibiotic prescriptions for respiratory tract infections in primary health care

Diagnoses and antibiotic treatments were analysed in relation to respiratory tract infections (RTI). A 1-y retrospective study was made of electronic patient records (EPR) for encounters concerning RTIs in primary health care in Sweden. The study covered a registered population of 102,050 individuals at 12 primary health care centres in 3 counties. Data were recorded on number of episodes, encounters, diagnostic codes and antibiotic prescriptions. The yearly number of episodes of RTIs was 16,964 or 166 per 1000 inhabitants per y. The total number of encounters was 19,965. The most frequent diagnoses were common cold (40%), acute tonsillitis (18%), and acute bronchitis (15%). The yearly number of antibiotic prescriptions was 7961, accounting for 47% of the episodes or 78 per 1000 inhabitants per y. The most frequently prescribed antibiotics were phenoxymethylpenicillin (61%), tetracyclines (18%) and macrolides 8%). Standard EPRs provide a feasible source of clinical information which, taking limitations into consideration, could be used for the follow-up of trends in antibiotic prescribing and of adherence to guidelines with regard to RTIs.