BMJ 2013;347:f7185 doi: 10.1136/bmj.f7185 (Published 6 December 2013)
Page 1 of 2
Editorials
EDITORIALS Prognosis of respiratory tract infections in primary care Accurate information can help reduce antibiotic prescribing Svein Gjelstad researcher, Morten Lindbæk professor Antibiotic Centre for Primary Care, Institute of Health and Society, University of Oslo, PO Box 1130, Blindern, N-0318 Oslo, Norway
The same year that Alexander Fleming and colleagues received the Nobel prize for work on the antibacterial properties of penicillin (1945), Fleming warned against the risk of bacterial resistance. In Europe today, about 25 000 lives are lost each year as a direct consequence of resistant bacteria.1 Frequent outpatient prescribing of antibiotics is associated with high levels of resistant Streptococcus pneumoniae in comparisons between nations.2 Unnecessary use of antibiotics could be greatly reduced by identifying those patients who would benefit from such treatment. Two linked studies on the prognosis of respiratory tract infections provide new and practical information for the primary care doctors who must guide patients through their treatment choices for these common infections.3 4
In a systematic review (doi:10.1136/bmj.f7027), Thompson and colleagues explored the duration of various respiratory tract infections in children up to 18 years of age attending primary care.3 Reliable and scientifically sound prognostic information is essential to help reassure worried parents that antibiotics may not be necessary. This study included 23 randomised controlled trials and 25 observational studies. Rather than average illness duration—the metric used by the National Institute for Health and Care Excellence and the US Centers for Disease Control and Prevention—the authors report the time taken for symptoms to resolve in 50% and 90% of patients. Their study adds new data to support existing advice about the likely duration of some infection, such as bronchiolitis (23 days) and croup (two days), and suggests substantial extensions to the expected duration of earache (seven to eight days) and common colds (17 days). One problem, though, is that some children in the observational studies had used antibiotics and some studies did not report antibiotic use. It is hard to know how this limitation influenced symptom duration. A primary care doctor will always tackle the question of antibiotics by assessing the severity of each infection. Thompson and colleagues’ findings may not apply to more severe respiratory tract infections because these were excluded from many of the reviewed studies. Doctors also have to judge the likely risk of complications. Because most respiratory tract infections are self limiting, with low complication rates,5 this
study will help reassure parents about the natural course of these illnesses and give them some indication about when to react if their child does not get better. Between 1997 and 2009, the incidence of patients attending primary care for respiratory tract infections in UK fell by 38% during summer and by 48% during winter.6 These changes probably reflect improved public understanding about the limited benefits of antibiotics for common respiratory infections. People attending primary care may have more severe symptoms than those who stay at home. If this is the case, the durations of illness measured in this setting will be longer than the average duration.
In the second linked study (doi:10.1136/bmj.f6867), Little and colleagues report results from a cohort of 14 610 adults seeking help from primary care for sore throat.4 The aim of this large study was to identify clinically useful predictors of common suppurative complications (quinsy or peritonsillar abscess, otitis media, sinusitis, and impetigo or cellulitis) occurring within one month of presentation. The authors also developed and evaluated a new prediction tool called FeverPAIN, partly based on the Centor criteria.7 The findings were disappointing—the clinical criteria in neither Centor nor FeverPAIN were useful for predicting complications. They also found that antibiotics were not associated with a lower risk of complications. The causes of quinsy are not as clear cut as we once thought: quinsy and acute tonsillitis are often caused by different pathogens. Group A streptococci, for example, account for only 20-30% of quinsy cases, and antibiotics may facilitate growth of opportunistic pathogens. Hence, quinsy cannot always be considered a complication of sore throat. Fortunately, Little and colleagues’ study shows that complications are rare (≤2%) in this well resourced setting, and that consequences were curable. The authors warn against prescribing immediate antibiotics to manage uncertainty. Instead they recommend sensible safety netting by advising patients how long they can expect to be ill, what to look out for (such as continuing fever, progressive difficulty swallowing), and what to do if symptoms don’t improve. Delayed prescription of antibiotics is a complementary strategy to manage uncertainty.9
[email protected] For personal use only: See rights and reprints http://www.bmj.com/permissions
Subscribe: http://www.bmj.com/subscribe
BMJ 2013;347:f7185 doi: 10.1136/bmj.f7185 (Published 6 December 2013)
Page 2 of 2
EDITORIALS
In general practice, the decision about whether to treat has to be made within a few minutes. Patients’ expectations and opinions must be heard. Doctors may overestimate patients’ expectations for an antibiotic prescription.10 One strategy for dealing with uncertainty more effectively may be to train primary care doctors in the specific communication skills needed to reduce unnecessary use of antibiotics. Such programmes have had longlasting effects on reduced antibiotic prescribing in trials.11
Both studies are of practical value to primary care doctors who must counsel patients in relatively well resourced settings. However, these studies’ findings may not translate well to less affluent settings or countries with different environmental and cultural influences. Complication rates and duration of symptoms may be different elsewhere because variations in patterns of attendance to healthcare facilities influence the case mix of patients attending for treatment, including the severity of presenting symptoms. In the GRACE study of patients with lower respiratory tract infection in 13 European countries,12 the number of days that patients waited before consulting varied from three in Hungary to 12 in Sweden (Mark Kelly, personal communication, 2013). The use of point of care testing for group A streptococci also varies greatly between countries and may affect the incidence of complications from sore throat. Competing interests: We have read and understood the BMJ Group policy on declaration of interests and declare the following interests: None.
For personal use only: See rights and reprints http://www.bmj.com/permissions
Provenance and peer review: Commissioned; not externally peer reviewed. 1 2 3 4 5 6 7 8 9 10 11 12
European Centre for Disease Control and Prevention/European Medicines Agency. The bacterial challenge: time to react. Technical report. 2009. www.ecdc.europa.eu/en/ publications/Publications/0909_TER_The_Bacterial_Challenge_Time_to_React.pdf. Goossens H, Ferech M, Vander SR, Elseviers M. Outpatient antibiotic use in Europe and association with resistance: a cross-national database study. Lancet 2005;365:579-87. Thompson M, Vodicka TA, Blair PS, Buckley DI, Heneghan C, Hay AD; on behalf of the TARGET Programme Team. Duration of symptoms of respiratory tract infections in children: systematic review. BMJ 2013;347:f7027. Little P, Stuart B, Hobbs FDR, Butler CC, Hay AD, Campbell J, et al. Predictors of suppurative complications for acute sore throat in primary care: prospective clinical cohort study. BMJ 2013;347:f6867. Arroll B. Antibiotics for upper respiratory tract infections: an overview of Cochrane reviews. Respir Med 2005;99:255-61. Fleming DM, Ross AM, Cross KW, Kendall H. The reducing incidence of respiratory tract infection and its relation to antibiotic prescribing. Br J Gen Pract 2003;53:778-83. Centor RM, Witherspoon JM, Dalton HP, Brody CE, Link K. The diagnosis of strep throat in adults in the emergency room. Med Decis Making 1981;1:239-46. Powell EL, Powell J, Samuel JR, Wilson JA. A review of the pathogenesis of adult peritonsillar abscess: time for a re-evaluation. J Antimicrob Chemother 2013;68:1941-50. Arroll B, Kenealy T, Kerse N. Do delayed prescriptions reduce antibiotic use in respiratory tract infections? A systematic review. Br J Gen Pract 2003;53:871-7. Little P, Dorward M, Warner G, Stephens K, Senior J, Moore M. Importance of patient pressure and perceived pressure and perceived medical need for investigations, referral, and prescribing in primary care: nested observational study. BMJ 2004;328:444. Cals JW, de Bock L, Beckers PJ, Francis NA, Hopstaken RM, Hood K, et al. Enhanced communication skills and C-reactive protein point-of-care testing for respiratory tract infection: 3.5-year follow-up of a cluster randomized trial. Ann Fam Med 2013;11:157-64. Butler CC, Kelly MJ, Hood K, Schaberg T, Melbye H, Serra-Prat M, et al. Antibiotic prescribing for discoloured sputum in acute cough/lower respiratory tract infection. Eur Respir J 2011;38:119-25.
Cite this as: BMJ 2013;347:f7185 © BMJ Publishing Group Ltd 2013
Subscribe: http://www.bmj.com/subscribe
Page 1 of 2
Editorials
EDITORIALS Prognosis of respiratory tract infections in primary care Accurate information can help reduce antibiotic prescribing Svein Gjelstad researcher, Morten Lindbæk professor Antibiotic Centre for Primary Care, Institute of Health and Society, University of Oslo, PO Box 1130, Blindern, N-0318 Oslo, Norway
The same year that Alexander Fleming and colleagues received the Nobel prize for work on the antibacterial properties of penicillin (1945), Fleming warned against the risk of bacterial resistance. In Europe today, about 25 000 lives are lost each year as a direct consequence of resistant bacteria.1 Frequent outpatient prescribing of antibiotics is associated with high levels of resistant Streptococcus pneumoniae in comparisons between nations.2 Unnecessary use of antibiotics could be greatly reduced by identifying those patients who would benefit from such treatment. Two linked studies on the prognosis of respiratory tract infections provide new and practical information for the primary care doctors who must guide patients through their treatment choices for these common infections.3 4
In a systematic review (doi:10.1136/bmj.f7027), Thompson and colleagues explored the duration of various respiratory tract infections in children up to 18 years of age attending primary care.3 Reliable and scientifically sound prognostic information is essential to help reassure worried parents that antibiotics may not be necessary. This study included 23 randomised controlled trials and 25 observational studies. Rather than average illness duration—the metric used by the National Institute for Health and Care Excellence and the US Centers for Disease Control and Prevention—the authors report the time taken for symptoms to resolve in 50% and 90% of patients. Their study adds new data to support existing advice about the likely duration of some infection, such as bronchiolitis (23 days) and croup (two days), and suggests substantial extensions to the expected duration of earache (seven to eight days) and common colds (17 days). One problem, though, is that some children in the observational studies had used antibiotics and some studies did not report antibiotic use. It is hard to know how this limitation influenced symptom duration. A primary care doctor will always tackle the question of antibiotics by assessing the severity of each infection. Thompson and colleagues’ findings may not apply to more severe respiratory tract infections because these were excluded from many of the reviewed studies. Doctors also have to judge the likely risk of complications. Because most respiratory tract infections are self limiting, with low complication rates,5 this
study will help reassure parents about the natural course of these illnesses and give them some indication about when to react if their child does not get better. Between 1997 and 2009, the incidence of patients attending primary care for respiratory tract infections in UK fell by 38% during summer and by 48% during winter.6 These changes probably reflect improved public understanding about the limited benefits of antibiotics for common respiratory infections. People attending primary care may have more severe symptoms than those who stay at home. If this is the case, the durations of illness measured in this setting will be longer than the average duration.
In the second linked study (doi:10.1136/bmj.f6867), Little and colleagues report results from a cohort of 14 610 adults seeking help from primary care for sore throat.4 The aim of this large study was to identify clinically useful predictors of common suppurative complications (quinsy or peritonsillar abscess, otitis media, sinusitis, and impetigo or cellulitis) occurring within one month of presentation. The authors also developed and evaluated a new prediction tool called FeverPAIN, partly based on the Centor criteria.7 The findings were disappointing—the clinical criteria in neither Centor nor FeverPAIN were useful for predicting complications. They also found that antibiotics were not associated with a lower risk of complications. The causes of quinsy are not as clear cut as we once thought: quinsy and acute tonsillitis are often caused by different pathogens. Group A streptococci, for example, account for only 20-30% of quinsy cases, and antibiotics may facilitate growth of opportunistic pathogens. Hence, quinsy cannot always be considered a complication of sore throat. Fortunately, Little and colleagues’ study shows that complications are rare (≤2%) in this well resourced setting, and that consequences were curable. The authors warn against prescribing immediate antibiotics to manage uncertainty. Instead they recommend sensible safety netting by advising patients how long they can expect to be ill, what to look out for (such as continuing fever, progressive difficulty swallowing), and what to do if symptoms don’t improve. Delayed prescription of antibiotics is a complementary strategy to manage uncertainty.9
[email protected] For personal use only: See rights and reprints http://www.bmj.com/permissions
Subscribe: http://www.bmj.com/subscribe
BMJ 2013;347:f7185 doi: 10.1136/bmj.f7185 (Published 6 December 2013)
Page 2 of 2
EDITORIALS
In general practice, the decision about whether to treat has to be made within a few minutes. Patients’ expectations and opinions must be heard. Doctors may overestimate patients’ expectations for an antibiotic prescription.10 One strategy for dealing with uncertainty more effectively may be to train primary care doctors in the specific communication skills needed to reduce unnecessary use of antibiotics. Such programmes have had longlasting effects on reduced antibiotic prescribing in trials.11
Both studies are of practical value to primary care doctors who must counsel patients in relatively well resourced settings. However, these studies’ findings may not translate well to less affluent settings or countries with different environmental and cultural influences. Complication rates and duration of symptoms may be different elsewhere because variations in patterns of attendance to healthcare facilities influence the case mix of patients attending for treatment, including the severity of presenting symptoms. In the GRACE study of patients with lower respiratory tract infection in 13 European countries,12 the number of days that patients waited before consulting varied from three in Hungary to 12 in Sweden (Mark Kelly, personal communication, 2013). The use of point of care testing for group A streptococci also varies greatly between countries and may affect the incidence of complications from sore throat. Competing interests: We have read and understood the BMJ Group policy on declaration of interests and declare the following interests: None.
For personal use only: See rights and reprints http://www.bmj.com/permissions
Provenance and peer review: Commissioned; not externally peer reviewed. 1 2 3 4 5 6 7 8 9 10 11 12
European Centre for Disease Control and Prevention/European Medicines Agency. The bacterial challenge: time to react. Technical report. 2009. www.ecdc.europa.eu/en/ publications/Publications/0909_TER_The_Bacterial_Challenge_Time_to_React.pdf. Goossens H, Ferech M, Vander SR, Elseviers M. Outpatient antibiotic use in Europe and association with resistance: a cross-national database study. Lancet 2005;365:579-87. Thompson M, Vodicka TA, Blair PS, Buckley DI, Heneghan C, Hay AD; on behalf of the TARGET Programme Team. Duration of symptoms of respiratory tract infections in children: systematic review. BMJ 2013;347:f7027. Little P, Stuart B, Hobbs FDR, Butler CC, Hay AD, Campbell J, et al. Predictors of suppurative complications for acute sore throat in primary care: prospective clinical cohort study. BMJ 2013;347:f6867. Arroll B. Antibiotics for upper respiratory tract infections: an overview of Cochrane reviews. Respir Med 2005;99:255-61. Fleming DM, Ross AM, Cross KW, Kendall H. The reducing incidence of respiratory tract infection and its relation to antibiotic prescribing. Br J Gen Pract 2003;53:778-83. Centor RM, Witherspoon JM, Dalton HP, Brody CE, Link K. The diagnosis of strep throat in adults in the emergency room. Med Decis Making 1981;1:239-46. Powell EL, Powell J, Samuel JR, Wilson JA. A review of the pathogenesis of adult peritonsillar abscess: time for a re-evaluation. J Antimicrob Chemother 2013;68:1941-50. Arroll B, Kenealy T, Kerse N. Do delayed prescriptions reduce antibiotic use in respiratory tract infections? A systematic review. Br J Gen Pract 2003;53:871-7. Little P, Dorward M, Warner G, Stephens K, Senior J, Moore M. Importance of patient pressure and perceived pressure and perceived medical need for investigations, referral, and prescribing in primary care: nested observational study. BMJ 2004;328:444. Cals JW, de Bock L, Beckers PJ, Francis NA, Hopstaken RM, Hood K, et al. Enhanced communication skills and C-reactive protein point-of-care testing for respiratory tract infection: 3.5-year follow-up of a cluster randomized trial. Ann Fam Med 2013;11:157-64. Butler CC, Kelly MJ, Hood K, Schaberg T, Melbye H, Serra-Prat M, et al. Antibiotic prescribing for discoloured sputum in acute cough/lower respiratory tract infection. Eur Respir J 2011;38:119-25.
Cite this as: BMJ 2013;347:f7185 © BMJ Publishing Group Ltd 2013
Subscribe: http://www.bmj.com/subscribe
