Antibiotics in Acute Bronchitis and Exacerbations of Chronic Bronchitis: What Is General Practitioners’ Habit?

Abstract

The annual charge for antibiotics represents one of the heaviest pharmaceutical expenses for the Italian National Health Service (NHS), and the increasing use of new-generation, high-cost antibiotics is worsening the situation. Upper respiratory tract infections represent a high percentage of all ambulatory patient encounters with primary care physicians, and their treatment is the leading indication for use of antimicrobial agents.1Dixon R.E. Economic costs of respiratory tract infections in the United States.Am J Med. 1985; 78: 45-51Abstract Full Text PDF PubMed Scopus (111) Google Scholar We examined the outpatient management of acute bronchitis (AB) in previously fit persons and acute exacerbations of chronic bronchitis (AECB) by general practitioners (GPs), in order to evaluate their customary criteria for the use of antibiotics in these diseases. An anonymous questionnaire was mailed to all GPs of the health district of Ferrara. The questionnaire consisted of two parts, the first concerning AB and the second AECB. The appropriate definitions, taken from the current literature, were given in the questionnaire. Four questions concerning the use of antibiotics and the type of antibiotic selected were common to both AB and AECB; two questions were structured as multiplechoice questions (Fig 1). A fifth question concerned AECB only. A daily cost of L3,600 (Italian) (about $2.20 US) was fixed as a cutoff for distinguishing low-cost and high-cost antibiotics. The low-cost group included amoxicillin, bacampicillin, amoxicillin plus clavulanic acid, erythromycin, myocamycin, and co-trimoxazole. One hundred eighteen of 184 GPs (64.1%), attending about 123,000 patients and observing about 8,200 cases of AB and 2,400 cases of AECB during the winter season, answered the questionnaire. As concerns AB, 20 physicians used antibiotics in all cases and 97 in selected cases, whereas one physician never used antibiotics. Penicillins and macrolides were considered firstchoice antimicrobial agents by 80% of physicians. In 47.8% of cases, high-cost compounds were prescribed, and only 20 physicians (17%) indicated that low cost was among the factors influencing the choice of the drug. As concerns AECB, 46.6% of the GPs prescribed antibiotics to all patients and 53.4% in selected cases. Quinolones and macrolides were the drugs most frequently used (59.3%), and high-cost antibiotics were used by a significantly higher percentage of physicians than in AB (72% vs 47.8%; p < 0.001). Only nine GPs considered price before choosing the type of antibiotic. These results suggest that GPs prescribe antibiotics most frequently as a first-line treatment for patients with both AB and AECB. The tendency of GPs to prescribe antibiotics too quickly in AB has been previously reported by other authors,2Verheij T.J. Hermans J. Kaptein A.A. et al.Acute bronchitis: general practitioners’ views regarding diagnosis and treatment.Fam Pract. 1990; 7: 175-180Crossref PubMed Scopus (38) Google Scholar although such a tendency is not in keeping with the current literature, which supports the use of antibiotic treatment for AB only in selected cases.3Orr P.H. Scherer K. Macdonald A. et al.Randomized placebo-controlled trials of antibiotics for acute bronchitis: a critical review of the literature.J Fam Pract. 1993; 36: 507-512PubMed Google Scholar Conversely, patients with AECB are reported to get a significant benefit from antibiotic therapy, and such a benefit is greater in selected groups of patients.4Saint S. Bent S. Vittinghoff E. et al.Antibiotics in chronic obstructive pulmonary disease exacerbations: a meta-analvsis.JAMA. 1995; 273: 957-960Crossref PubMed Scopus (590) Google Scholar, 5Ball P. Epidemiology and treatment of chronic bronchitis and its exacerbations.Chest. 1995; 108: 43S-52SAbstract Full Text Full Text PDF PubMed Scopus (246) Google Scholar The overuse of antibiotics (in particular the high-cost agents) found in our survey is uselessly expensive and not justifiable from the clinical point of view. In our opinion, it is likely due to the imbalance between the propagandistic hammering of the pharmaceutical industry and the inert silence of the public health authorities, who fail to plan educational programs in pharmacoeconomics for physicians working in NHS (Italy).