Symposium: Erythromycin
Scot.med.J.,1977,22:405
THE USE OF ERYTHROMYCIN IN A GENERAL PRACTICE Paul R. Grab General Practitioner, Addlestone, Surrey Summary. It would appear that erythromycin is a safe drug to use in general practice; it is indicated, and has advantages, in the treatment of infections of both the upper and tower respiratory tracts. decision to prescribe an antibiotic in general practice depends not only on the clinical presentation and probable infecting organism, but also on the patient's social circumstances, age, past history, and competence to deal with the illness sensibly. Added to these more evident considerations is the subtle pressure applied by the patient who presents on the first day of a minor illness expecting to receive an antibiotic. This pressure to prescribe can be resisted but it takes time and is made more difficult when the patient has been given antibiotics on previous occasions. Bacterial resistance to antibiotics has been increasing over the years and is a constant cause for concern and vigilance (Shaw, 1974). However, care should be taken over applying data derived from hospital experience, to general practice as the two situations are not comparable (Manners et al., 1973). In this paper the author presents his personal experience of the use of erythromycin in a general practice in south-east England. A 4-year study was undertaken in which the pathogenic organism isolated from patients with sore throats and skin infections were
T
HE
Table I.
recorded and their antibiotic resistance patterns noted. The object of the study was to see whether the prescribing policy in the practice influenced these resistance patterns. During the first year the antibiotic of first choice given to patients with upper respiratory tract infections was penicillin, and during the second year erythromycin. This pattern was repeated in the second 2-year cycle. Table I shows the results of the study which has been more fully reported elsewhere (Manners et al., 1976). The antibiotic sensitivities of the organisms that were isolated are given in Table II. It is interesting to note that whereas penicillin-resistant staphylococci were relatively common, no strain of staphylococcus resistant to erythromycin was recorded during the 4-year period. No strains of beta-haemolytic streptococci resistant to either of the two antibiotics were encountered. Upper respiratory tract infections Sore throat. This is one of the commonest of clinical problems and we see about 80 cases per 1,000 patients each year. An effective way of basing antibiotic prescribing on the results of
Pathogens isolated from patients with throat and skin infections over a 4-year period.
Period
Throat infections 1971-72 1972-73 1973-74 1974-75 Skin infections 1971-72 1972-73 1973-74 1974-75
No. of swabs
Pathogens isolated
BHS GpA
BHS not GpA
Staph. aureus
Other
(%)
No.
158 80 74 50
21 31 36 36
33 25 27 18
12 12 4 1
14 8 12 10
3 2 8 4
4 3 3 3
60 42 27 20
63 75 84 50
38 38 23 10
2 6 3 0
3 0 0 0
30 31 20 9
3 1 0 1
BHS = beta-haemolytic streptococci.
GpA = Group A.
Downloaded from scm.sagepub.com at MCMASTER UNIV LIBRARY on May 3, 2016
Grob
Table II. Antibiotic sensitivity of pathogenic organisms isolated from patients with throat and skin infections over a 4-year period. Organism
Betahaemolytic streptococci
Staph. aureus
Period
No. of isolates
Sensitivity to: Penicillin
Tetracycline
Erythromycin
(%)
(%)
(%)
1971-72 1972-73 1973-74 1974-75
31 26 19 10
100 100 100 100
78 100 85 90
100 100 100 100
Total
86
100
88
100
1971-72 1972-73 1973-74 1974-75
33 33 28 9
39 33 48 44
73 69 63 77
94 94 100 100
103
41
70
97
Total
bacterial culture is to use culture plates and a small incubator in the surgery. Throat swabs from the patient can then be plated directly on to blood agar and the results read 24 hours later; this avoids the delay of sending the specimens to the laboratory and receiving the reports through the post. The patient is told to contact the surgery the I day after the throat swab was taken, and an antibiotic is then prescribed if needed. The system works well in practice and is an effective means of determining whether or not a particular outbreak of sore throats is due to the beta-haemolytic streptococcus. It is important to recognise that the frequency with which this organism can be isolated from patients varies throughout the year as streptococcal sore throats occur in well-defined epidemics. Virus infections account for nearly one-fifth of cases of sore throat, but probably as many as onethird or more of all sore throats remain a microbiological mystery. Erythromycin may be considered preferable to penicillin in the treatment of sore throat as it is equally effective clinically against the haemolytic streptococcus but does not carry the risk of evoking an allergic response in the patient. Based on the appearance of skin or other manifestations, we have the impression that about 8 per cent of patients in our practice are now allergic to penicillin, but this has not been scientifically proved. Otitis media. Children with otitis media res-
pond well to the administration of a nasal decongestant and an antibiotic such as penicillin, erythromycin or ampicillin. Haemophilus injluenzae seems to be a common causal organism. Lower respiratory tract infections The young child in the first year of life who presents with a wheezy, croup-like cough as part of a generalised illness is often a cause of concern. A good clinical response is produced by the administration of erythromycin, the drug of first choice, especially if it is given early in the illness. The parainfluenza group of viruses or H injluenzae are occasionally isolated from these patients but microbiological investigation in young children is difficult and usually unrewarding. Work on young animals suggests that a double infection, perhaps with a virus and a bacterium or mycoplasma, is often required to produce a clinical infection, and this may also apply to children in which case it may only be the more easily grown organism that is isolated and thereby incriminated. Chronic bronchitis. The treatment of patients with acute exacerbations of chronic bronchitis constitutes the largest segment of a general practitioner's work load during the winter months. A pilot study of the use of erythromycin in these acute exacerbations was therefore undertaken during the winter of 1976/77. Patients with acute exacerbations were
406
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The Use of Erythromycin in a General Practice
assessed clinically: the cough, production of sputum and its appearance, wheeze and dyspnoea were recorded on a five-point scale; the number of days away from work was also recorded. Treatment was started with erythromycin 500 mg. four times a day for 5 to 7 days. Specimens of sputum were examined daily; a film was Gram stained and the presence of pus cells with a relative absence of oral squames indicated that the specimen was in fact sputum and not saliva. Cultures were made on heated blood agar medium containing bacitracin, in addition to which cultures on blood agar were incubated both aerobically and anaerobically. Viral studies were not performed. As the number of cases was small (n::: 19) the results should be interpreted with caution, but the general clinical response was good, most patients recovering within 1 week. The change in the appearance of the sputum from purulent to mucoid correlated well with the disappearance of the infecting organism on culture. H. influenzae was isolated from 11 (51 %) of the patients, the strains being resistant to penicillin but sensitive to ampicillin, tetracycline and erythromycin. It required an average of 4 to 8 days for the H. influenzae to disappear from the sputum. Streptococcus pneumoniae, sensitive to all the main antibiotics, was isolated from a further three patients and beta-haemolytic streptococci from another two. No obvious causal organism was isolated from the remaining two patients, although a klebsiella organism was persistently present in one. The low toxicity of erythromycin encouraged us to undertake a second study in which patients with chronic bronchitis were pre-
scribed this antibiotic prophylactically during the winter months of 1976/77. The patients were randomly divided into two groups; one group received erythromycin 500 mg. three times a day for the first 10 days of each month throughout the winter; the second group acted as controls and received no antibiotic. The number of acute exacerbations in the two groups were recorded and compared. As the number of patients was small (n = 18) caution must be exercised in interpreting the results. The erythromycin was moderately well tolerated; five patients complained of nausea or gastric discomfort, but only one stopped taking the antibiotic on this account. One patient with a past history of neurosis stopped taking the erythromycin as he stated it made him feel depressed. Two other patients dropped out of the investigation. The remaining 14 patients completed the 4-month course and experienced a total of nine acute exacerbations of their bronchitis. Among the 14 patients in the control group there were 11 exacerbations. The patients generally were enthusiastic about taking erythromycin prophylactically, but it must be borne in mind that the incidence of respiratory disease during the winter of the trial was low. The use of erythromycin in chronic bronchitis, both therapeutically and prophylactically therefore requires further investigation. My grateful thanks are due to Dr. B. T. B. Manners, M. R. C. Path and Mr. F. J. Gibbs, F.I.M.L.T., for the continuing advice and support in these investigations. ACKNOWLEDGEMENTS.
REFERENCES Manners, B. T. B. et al. (1973). Bacterial resistbiotic resistance of Staphylococcus aureus in ance in community. British Medical Journal, general practice. Practitioner, 216,439. 2,423. Shaw, E. J. (1974). Recent changes in bacterial Manners, B. T. B., Grob, P. R., Beynon, G. B. J., resistance to antibiotics. Practitioner, 213, Gibbs, F. J. (1976). An investigation of anti: 487.
407
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Scot.med.J.,1977,22:405
THE USE OF ERYTHROMYCIN IN A GENERAL PRACTICE Paul R. Grab General Practitioner, Addlestone, Surrey Summary. It would appear that erythromycin is a safe drug to use in general practice; it is indicated, and has advantages, in the treatment of infections of both the upper and tower respiratory tracts. decision to prescribe an antibiotic in general practice depends not only on the clinical presentation and probable infecting organism, but also on the patient's social circumstances, age, past history, and competence to deal with the illness sensibly. Added to these more evident considerations is the subtle pressure applied by the patient who presents on the first day of a minor illness expecting to receive an antibiotic. This pressure to prescribe can be resisted but it takes time and is made more difficult when the patient has been given antibiotics on previous occasions. Bacterial resistance to antibiotics has been increasing over the years and is a constant cause for concern and vigilance (Shaw, 1974). However, care should be taken over applying data derived from hospital experience, to general practice as the two situations are not comparable (Manners et al., 1973). In this paper the author presents his personal experience of the use of erythromycin in a general practice in south-east England. A 4-year study was undertaken in which the pathogenic organism isolated from patients with sore throats and skin infections were
T
HE
Table I.
recorded and their antibiotic resistance patterns noted. The object of the study was to see whether the prescribing policy in the practice influenced these resistance patterns. During the first year the antibiotic of first choice given to patients with upper respiratory tract infections was penicillin, and during the second year erythromycin. This pattern was repeated in the second 2-year cycle. Table I shows the results of the study which has been more fully reported elsewhere (Manners et al., 1976). The antibiotic sensitivities of the organisms that were isolated are given in Table II. It is interesting to note that whereas penicillin-resistant staphylococci were relatively common, no strain of staphylococcus resistant to erythromycin was recorded during the 4-year period. No strains of beta-haemolytic streptococci resistant to either of the two antibiotics were encountered. Upper respiratory tract infections Sore throat. This is one of the commonest of clinical problems and we see about 80 cases per 1,000 patients each year. An effective way of basing antibiotic prescribing on the results of
Pathogens isolated from patients with throat and skin infections over a 4-year period.
Period
Throat infections 1971-72 1972-73 1973-74 1974-75 Skin infections 1971-72 1972-73 1973-74 1974-75
No. of swabs
Pathogens isolated
BHS GpA
BHS not GpA
Staph. aureus
Other
(%)
No.
158 80 74 50
21 31 36 36
33 25 27 18
12 12 4 1
14 8 12 10
3 2 8 4
4 3 3 3
60 42 27 20
63 75 84 50
38 38 23 10
2 6 3 0
3 0 0 0
30 31 20 9
3 1 0 1
BHS = beta-haemolytic streptococci.
GpA = Group A.
Downloaded from scm.sagepub.com at MCMASTER UNIV LIBRARY on May 3, 2016
Grob
Table II. Antibiotic sensitivity of pathogenic organisms isolated from patients with throat and skin infections over a 4-year period. Organism
Betahaemolytic streptococci
Staph. aureus
Period
No. of isolates
Sensitivity to: Penicillin
Tetracycline
Erythromycin
(%)
(%)
(%)
1971-72 1972-73 1973-74 1974-75
31 26 19 10
100 100 100 100
78 100 85 90
100 100 100 100
Total
86
100
88
100
1971-72 1972-73 1973-74 1974-75
33 33 28 9
39 33 48 44
73 69 63 77
94 94 100 100
103
41
70
97
Total
bacterial culture is to use culture plates and a small incubator in the surgery. Throat swabs from the patient can then be plated directly on to blood agar and the results read 24 hours later; this avoids the delay of sending the specimens to the laboratory and receiving the reports through the post. The patient is told to contact the surgery the I day after the throat swab was taken, and an antibiotic is then prescribed if needed. The system works well in practice and is an effective means of determining whether or not a particular outbreak of sore throats is due to the beta-haemolytic streptococcus. It is important to recognise that the frequency with which this organism can be isolated from patients varies throughout the year as streptococcal sore throats occur in well-defined epidemics. Virus infections account for nearly one-fifth of cases of sore throat, but probably as many as onethird or more of all sore throats remain a microbiological mystery. Erythromycin may be considered preferable to penicillin in the treatment of sore throat as it is equally effective clinically against the haemolytic streptococcus but does not carry the risk of evoking an allergic response in the patient. Based on the appearance of skin or other manifestations, we have the impression that about 8 per cent of patients in our practice are now allergic to penicillin, but this has not been scientifically proved. Otitis media. Children with otitis media res-
pond well to the administration of a nasal decongestant and an antibiotic such as penicillin, erythromycin or ampicillin. Haemophilus injluenzae seems to be a common causal organism. Lower respiratory tract infections The young child in the first year of life who presents with a wheezy, croup-like cough as part of a generalised illness is often a cause of concern. A good clinical response is produced by the administration of erythromycin, the drug of first choice, especially if it is given early in the illness. The parainfluenza group of viruses or H injluenzae are occasionally isolated from these patients but microbiological investigation in young children is difficult and usually unrewarding. Work on young animals suggests that a double infection, perhaps with a virus and a bacterium or mycoplasma, is often required to produce a clinical infection, and this may also apply to children in which case it may only be the more easily grown organism that is isolated and thereby incriminated. Chronic bronchitis. The treatment of patients with acute exacerbations of chronic bronchitis constitutes the largest segment of a general practitioner's work load during the winter months. A pilot study of the use of erythromycin in these acute exacerbations was therefore undertaken during the winter of 1976/77. Patients with acute exacerbations were
406
Downloaded from scm.sagepub.com at MCMASTER UNIV LIBRARY on May 3, 2016
The Use of Erythromycin in a General Practice
assessed clinically: the cough, production of sputum and its appearance, wheeze and dyspnoea were recorded on a five-point scale; the number of days away from work was also recorded. Treatment was started with erythromycin 500 mg. four times a day for 5 to 7 days. Specimens of sputum were examined daily; a film was Gram stained and the presence of pus cells with a relative absence of oral squames indicated that the specimen was in fact sputum and not saliva. Cultures were made on heated blood agar medium containing bacitracin, in addition to which cultures on blood agar were incubated both aerobically and anaerobically. Viral studies were not performed. As the number of cases was small (n::: 19) the results should be interpreted with caution, but the general clinical response was good, most patients recovering within 1 week. The change in the appearance of the sputum from purulent to mucoid correlated well with the disappearance of the infecting organism on culture. H. influenzae was isolated from 11 (51 %) of the patients, the strains being resistant to penicillin but sensitive to ampicillin, tetracycline and erythromycin. It required an average of 4 to 8 days for the H. influenzae to disappear from the sputum. Streptococcus pneumoniae, sensitive to all the main antibiotics, was isolated from a further three patients and beta-haemolytic streptococci from another two. No obvious causal organism was isolated from the remaining two patients, although a klebsiella organism was persistently present in one. The low toxicity of erythromycin encouraged us to undertake a second study in which patients with chronic bronchitis were pre-
scribed this antibiotic prophylactically during the winter months of 1976/77. The patients were randomly divided into two groups; one group received erythromycin 500 mg. three times a day for the first 10 days of each month throughout the winter; the second group acted as controls and received no antibiotic. The number of acute exacerbations in the two groups were recorded and compared. As the number of patients was small (n = 18) caution must be exercised in interpreting the results. The erythromycin was moderately well tolerated; five patients complained of nausea or gastric discomfort, but only one stopped taking the antibiotic on this account. One patient with a past history of neurosis stopped taking the erythromycin as he stated it made him feel depressed. Two other patients dropped out of the investigation. The remaining 14 patients completed the 4-month course and experienced a total of nine acute exacerbations of their bronchitis. Among the 14 patients in the control group there were 11 exacerbations. The patients generally were enthusiastic about taking erythromycin prophylactically, but it must be borne in mind that the incidence of respiratory disease during the winter of the trial was low. The use of erythromycin in chronic bronchitis, both therapeutically and prophylactically therefore requires further investigation. My grateful thanks are due to Dr. B. T. B. Manners, M. R. C. Path and Mr. F. J. Gibbs, F.I.M.L.T., for the continuing advice and support in these investigations. ACKNOWLEDGEMENTS.
REFERENCES Manners, B. T. B. et al. (1973). Bacterial resistbiotic resistance of Staphylococcus aureus in ance in community. British Medical Journal, general practice. Practitioner, 216,439. 2,423. Shaw, E. J. (1974). Recent changes in bacterial Manners, B. T. B., Grob, P. R., Beynon, G. B. J., resistance to antibiotics. Practitioner, 213, Gibbs, F. J. (1976). An investigation of anti: 487.
407
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