Prescribing For Respiratory Infections Research Articles

Delayed antibiotic prescribing in respiratory tract infections: is it an effective and safe strategy for children?

Delayed antibiotic prescribing in respiratory tract infections: is it an effective and safe strategy for children?

General practitioner and nurse prescriber experiences of prescribing antibiotics for respiratory tract infections in UK primary care out-of-hours services (the UNITE study).

BackgroundInterventions are needed to reduce unnecessary antibiotic prescribing for respiratory tract infections (RTIs). Although community antibiotic prescribing appears to be decreasing in the UK, figures for out-of-hours (OOH) prescribing have substantially increased. Understanding the factors influencing prescribing in OOH and any perceived differences between general practitioner (GP) and nurse prescriber (NP) prescribing habits may enable the development of tailored interventions promoting optimal prescribing in this setting.ObjectivesTo explore UK GP and NP views on and experiences of prescribing antibiotics for RTIs in primary care OOH services.MethodsThirty semi-structured interviews were conducted with GPs and NPs working in primary care OOH services. Inductive thematic analysis was used to analyse data.ResultsThe research shows that factors particular to OOH influence antibiotic prescribing, including a lack of patient follow-up, access to patient GP records, consultation time, working contracts and implementation of feedback, audit and supervision. NPs reported perceptions of greater accountability for their prescribing compared with GPs and reported they had longer consultations during which they were able to discuss decisions with patients. Participants agreed that more complex cases should be seen by GPs and highlighted the importance of consistency of decision making, illness explanations to patients as well as a perception that differences in clinical training influence communication with patients and antibiotic prescribing decisions.ConclusionsEnvironmental and social factors in OOH services and a mixed healthcare workforce provide unique influences on antibiotic prescribing for RTIs, which would need to be considered in tailoring interventions that promote prudent antibiotic prescribing in OOH services.

Drug utilization pattern in out-patients with respiratory tract infections in a rural teaching hospital: a prospective observational study

Background: Respiratory tract infections are common clinical problems in the general population. Antimicrobials are the mainstay in the management and irrational use of them may increase resistance to bacteria and the total cost of treatment. Objectives: To evaluate the pattern of drug prescriptions for respiratory tract infections in Medicine and Pediatric outpatient departments of a rural teaching hospital.Methods: Over a period of 18 months, 391 prescriptions of outpatients with respiratory tract infection were collected. The drugs prescribed, their dose and duration of treatment were recorded. DU 90% was calculated.Results: The mean (±SEM) age of the patients was38.55±0.9 years and there were 204 (52.1%) men and 187 (42.1%) women. The most common disorder among the patients was acute rhinitis (61.1%) while the least common was acute bronchitis (1.3%). Microbial culture and sensitivity was done in 23 patients and Klebsiella pneumonia (8.2%) and enterococcus (0.07%) was the most common and least common organism respectively. Penicillins (50.9%), cephalosporins (26.7%), antitubercular drugs (8.5%), macrolides (4.8) constituted DU 90%. Monotherapy was advocated in 91.7% and multidrug therapy in 8.3% of patients. The average number of antimicrobials prescribed per prescription was 0.52. Two thirds (67.6%) of the prescribed drugs were from the national list of essential medicines 2011 (NLEM).Conclusions: Penicillins and cephalosporins were the commonly used antibiotics for respiratory tract infection in outpatients of a rural teaching hospital and two thirds of the prescribed drugs were essential medicines.

Utilization of Antibiotics in Long-Term Care Facilities in British Columbia, Canada

BackgroundAntibiotic use is highly prevalent in long-term care facilities (LTCFs); a resident's annual exposure to at least 1 course of antibiotic is approximately 50% to 80%. The objective of this study was to understand the extent of antibiotic use in the population of residents in British Columbia's (BC) LTCFs from 2007 to 2014. MethodsAntibiotic prescription data for LTCF residents was extracted from the central prescription database and linked to the physician billing plan to obtain antibiotic indication. Total defined daily dose (DDD) per 1000 residents per day was calculated. ResultsOur database had 381 LTCFs with an average of nearly 24,694 residents annually and 419,036 antibiotic prescriptions. Antibiotic utilization did not change dramatically between 2007 and 2014, ranging from 39.2 in 2007 to 35.2 DDD per 1000 residents per day in 2014. Although usage of most antibiotics declined, use of moxifloxacin, amoxicillin-clavulanate, doxycycline, and amoxicillin increased significantly. The indication most frequently linked to prescription was urinary tract infection (6.58 DDD per 1000 residents per day), with nitrofurantoin, ciprofloxacin, and trimethoprim/sulfamethoxazole being the most commonly prescribed agents. This was followed closely by prescriptions for respiratory infections (5.34 DDD per 1000 residents per day), with moxifloxacin being the most commonly prescribed antibiotic, primarily for upper respiratory tract infection (URTI), whereas doxycycline is used commonly for lower respiratory tract infection. Duration of antibiotic therapy in LTCF residents has decreased significantly from 9.29 days to 7.3 days per prescription in 2014. ConclusionAntibiotic use in LTCFs is high relative to the general population. Our study underscores that stewardship in LTCFs should continue to focus on length of treatment, appropriate detection of urinary tract infections, and avoidance of treating URTIs with antibiotics.

Delayed antibiotic prescriptions for respiratory tract infections

Delayed antibiotic prescriptions for respiratory tract infections

Delayed antibiotic prescriptions for respiratory infections.

Delayed antibiotic prescriptions for respiratory infections.

The long shadow of Lemierre’s syndrome

Lemierre's syndrome is a rare and feared complication of pharyngitis, occurring most commonly in adolescents and young adults. It is typically defined by the constellation of septic internal jugular vein thrombophlebitis, pulmonary and other septic emboli, and sterilesite infection by Fusobacterium necrophorum. The rarity and severity of Lemierre's syndrome has made it an attractive subject for case reports but there is a paucity of evidence to inform areas of persistent uncertainty. In recent years, heightened attention and controversy has focused upon speculation that a purported rise in the incidence of Lemierre's syndrome is due to reduced antibiotic prescribing for respiratory tract infections, that F. necrophorum is an under-appreciated cause of acute tonsillopharyngitis and that testing and targeted treatment would prevent cases of Lemierre's syndrome.

Variations in antibiotic use for respiratory tract infections

ABSTRACT
 ObjectivesAntibiotic resistance is a significant public health issue, driven in large part by selection pressure induced by antibiotic use. Despite knowledge that a reduction in inappropriate antibiotic use is important, significant and sustained behaviour change has remained difficult to achieve. Previous studies have suggested that prescribing decisions vary with patient comorbidities and age, as well as the physician’s age, claim volume, specialty, and continuity of care with the particular patient. Regional level variation has also been reported. The goal of this study is to explore variations in antibiotic prescribing for respiratory tract infections (RTIs) at the levels of patients, physicians, and regions.
 ApproachWe used data on fee-for-service physician visits from the universal Medical Services Plan (MSP) for all residents of British Columbia, Canada from 2002 to 2012. We identified a cohort of patient visits for RTI (ICD-9 codes 460-466, 480, or 487). We derived measures of healthcare use and comorbidities at the patient level, and measures of physician claim volume and frequency of respiratory tract infection management, at the level of the physician. We used data on antibiotics filled by individuals, the number of all medications filled by individuals each year, and counts of prescriptions written by physicians (and filled) by month, from the provincial drug insurance database. We linked antibiotic prescriptions to physician visits by patient and prescriber as antibiotics dispensed within 5 days after the RTI visit. We calculated measures of regional population distributions. We used data on meteorological temperature readings assigned to each region, for each day, and calculated 28-day moving averages. We linked data on patient demographics, physician demographics, and hospitalizations to our dataset. Our analysis will use hierarchical generalized linear mixed models (GLMMs) with logit link to account for the clustering effects of patients among physicians and regions, to model the odds of an antibiotic prescription being dispensed. Measures of variation will be discussed.
 ResultsBetween April 1, 2005 and March 31, 2012, there were over 10.5 million visits by nearly 3 million individuals, served by over 8000 physicians in 88 regions. Antibiotics were prescribed in 37% of all visits.
 ConclusionThese are preliminary results, with full analytic results available in the coming months. These results will have implications for better understanding the extent of variations in antibiotic prescribing, and some of the drivers of these variations, as well as the potential to inform ongoing efforts to improve the appropriateness of antibiotic use.

Usefulness of C-reactive Protein Testing in Acute Cough/Respiratory Tract Infection: A Case-Control Study in a UK Based GP Population

Introduction: Point of care testing for C-reactive protein (CRP) has shown promise as a measure to reduce unnecessary antibiotic prescribing in respiratory tract infections (RTI) and has been adopted into NICE guidelines, but its use in primary care is still controversial. We aimed to evaluate the effect of CRP testing on the prescription of antibiotics and the outcome of patients in general practice with acute cough/RTI. Methods: We undertook a case-control study with POC testing with CRP in intervention group (Oct 16-Jan 17) and compared this to similar cohort of patients from a year previously coded with exact diagnosis. Results: A total of 207 patients were included: 69 in the intervention group and 138 in the control group. The two groups were similar in clinical characteristics. In the intervention group, the antibiotic prescribing rate was 31.6%, which was significantly lower than that in the control group (59.9%) (P=0.003). The recovery rate, as recorded by the GPs, was 94.9% and 93.8% in the intervention and control groups, respectively. Referral to Emergency Department for children under 12 was also reduced significantly in the intervention group (4.4%) when compared to the control group (6.5%; P=0.00479). Conclusion: The study showed that CRP testing in patients with acute cough/RTI may reduce antibiotic prescribing and referral to pediatric ED, probably without compromising recovery.

Reduction in antibiotic prescribing for respiratory tract infections in Swedish primary care- a retrospective study of electronic patient records.

BackgroundSwedish studies on antibiotic use in primary care have been based on one-week registrations of infections. In order to study adherence to guidelines, analyses based on large databases that provide information on diagnosis linked prescriptions, are needed. This study describes trends in management of infections in Swedish primary care particularly with regards to antibiotic prescribing and adherence to national guidelines.MethodsA descriptive study of Sweden’s largest database regarding diagnosis linked antibiotic prescription data, the Primary care Record of Infections in Sweden (PRIS), for the years 2008, 2010 and 2013.ResultsAlthough the consultation rate for all infections remained around 30% each year, antibiotic prescribing rates decreased significantly over the years from 53.7% in 2008, to 45.5% in 2010, to 38.6% in 2013 (p = .032). The antibiotic prescribing rate for respiratory tract infections (RTIs) decreased from 40.5% in 2008 to 24.9% in 2013 while those for urinary tract infections and skin and soft tissue infections were unchanged. For most RTI diagnoses there was a decrease in prescription rate from 2008 to 2013, particularly for the age group 0–6 years. Phenoxymethylpenicillin (PcV) was the antibiotic most often prescribed, followed by tetracycline. Tonsillitis and acute otitis media were the two RTI diagnoses with the highest number of prescriptions per 1000 patient years (PY). For these diagnoses an increase in adherence to national guidelines was seen, with regards to treatment frequency, choice of antibiotics and use of rapid antigen detection test. The frequency in antibiotic prescribing varied greatly between different Primary Healthcare Centres (PHCCs).ConclusionFalling numbers of consultations and decreased antibiotic prescription rates for RTIs have reduced the antibiotic use in Swedish primary care substantially. Overprescribing of antibiotics could still be suspected due to large variability in prescribing frequency, especially for acute bronchitis and sinusitis. Continuous evaluation of diagnosis linked prescribing data and feedback to doctors is essential in order to achieve a more prudent antibiotic use.Electronic supplementary materialThe online version of this article (doi:10.1186/s12879-016-2018-9) contains supplementary material, which is available to authorized users.

Public-targeted communication interventions to improve antibiotic use: a systematic review

BackgroundAntimicrobial resistance poses a major threat to global health. Excessive use of antibiotics accelerates the process of resistance. Interventions to prevent the inappropriate use of antibiotics can be targeted at doctors, patients, and the public. The aim of this systematic review was to identify the components of successful communication interventions targeted at the general public to improve antibiotic use. MethodsThe databases Medline, Embase, CINAHL, Web of Science, and Cochrane Library were searched in July, 2015. The main search terms were related to the population (public, community, population, neighbourhood), intervention (communication, campaign, mass media), and outcomes (antibiotic, antimicrobial resistance). For each search term, synonyms and controlled vocabulary for respective databases were used. Titles, abstracts, and full-text references were screened for inclusion by one author with a random subset of 10% screened by a second author. No date restrictions were applied, and only articles in English were considered. Studies had to have a control group or be an interrupted time-series with interventions targeted at the general public. Outcomes had to measure change in antibiotic-related prescribing or consumption, knowledge, attitudes, or behaviour. Two reviewers assessed the quality of studies. Narrative synthesis was performed. Findings14 studies were included with an estimated 74–75 million participants. Most studies were conducted in the USA or Europe, used mass media, targeted both the general public and clinicians, and measured changes in antibiotic prescribing. There was quite strong (p<0·05 to ≥0·01) to very strong (p<0·001) evidence that interventions conducted on a national, community, and household level that targeted antibiotic prescribing for respiratory tract infections could achieve substantial reductions in antibiotic prescribing. The largest change in antibiotic prescribing was a 30% reduction. Insufficient studies were available to distinguish the separate components of interventions. No studies of high quality were identified. InterpretationCommunication interventions that target both the general public and clinicians should be considered as part of policy for reducing antibiotic prescribing in high-income countries. Future research should aim to be of greater quality, attempt to determine whether communication interventions targeted at the public could be effective without a clinician-directed element, and measure the sustainability of reductions in prescribing and potential adverse harms. FundingEC and RT are funded by the South West Public Health Training Programme. RK is funded by the Centre for the Development and Evaluation of Complex Interventions for Public Health Improvement (DECIPHer).

Interacting factors associated with Low antibiotic prescribing for respiratory tract infections in primary health care - a mixed methods study in Sweden.

BackgroundPrescribing of antibiotics for common infections varies widely, and there is no medical explanation. Systematic reviews have highlighted factors that may influence antibiotic prescribing and that this is a complex process. It is unclear how factors interact and how the primary care organization affects diagnostic procedures and antibiotic prescribing. Therefore, we sought to explore and understand interactions between factors influencing antibiotic prescribing for respiratory tract infections in primary care.MethodsOur mixed methods design was guided by the Triangulation Design Model according to Creswell. Quantitative and qualitative data were collected in parallel. Quantitative data were collected by prescription statistics, questionnaires to patients, and general practitioners’ audit registrations. Qualitative data were collected through observations and semi-structured interviews.ResultsFrom the analysis of the data from the different sources an overall theme emerged: A common practice in the primary health care centre is crucial for low antibiotic prescribing in line with guidelines. Several factors contribute to a common practice, such as promoting management and leadership, internalized guidelines including inter-professional discussions, the general practitioner’s diagnostic process, nurse triage, and patient expectation. These factors were closely related and influenced each other. The results showed that knowledge must be internalized and guidelines need to be normative for the group as well as for every individual.ConclusionsLow prescribing is associated with adapted and transformed guidelines within all staff, not only general practitioners. Nurses’ triage and self-care advice played an important role. Encouragement from the management level stimulated inter-professional discussions about antibiotic prescribing. Informal opinion moulders talking about antibiotic prescribing was supported by the managers. Finally, continuous professional development activities were encouraged for up-to-date knowledge.

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

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

Systematic Review of Factors Associated with Antibiotic Prescribing for Respiratory Tract Infections.

Antibiotic use is a modifiable driver of antibiotic resistance. In many circumstances, antibiotic use is overly broad or unnecessary. We systematically assessed factors associated with antibiotic prescribing for respiratory tract infections (RTI). Studies were included if they used actual (not self-reported or intended) prescribing data, assessed factors associated with antibiotic prescribing for RTIs, and performed multivariable analysis of associations. We searched Medline, Embase, and International Pharmaceutical Abstracts using keyword and MeSH (medical subject headings) search terms. Two authors reviewed each abstract and independently appraised all included texts. Data on factors affecting antibiotic prescribing were extracted. Our searches retrieved a total of 2,848 abstracts, with 97 included in full-text review and 28 meeting full inclusion criteria. Compared to other factors, diagnosis of acute bronchitis was associated with increased antibiotic prescribing (range of adjusted odds ratios [aOR], 1.56 to 15.9). Features on physical exam, such as fever, purulent sputum, abnormal respiratory exam, and tonsillar exudate, were also associated with higher odds of antibiotic prescribing. Patient desire for an antibiotic was not associated or was modestly associated with prescription (range of aORs, 0.61 to 9.87), in contrast to physician perception of patient desire for antibiotics, which showed a stronger association (range of aORs, 2.11 to 23.3). Physician's perception of patient desire for antibiotics was strongly associated with antibiotic prescribing. Antimicrobial stewardship programs should continue to expand in the outpatient setting and should emphasize clear and direct communication between patients and physicians, as well as signs and symptoms that do and do not predict bacterial etiology of upper respiratory tract infections.

Changes in early-career family physicians' antibiotic prescribing for upper respiratory tract infection and acute bronchitis: a multicentre longitudinal study.

Inappropriate antibiotic prescription and subsequent antibacterial resistance are major threats to health worldwide. We aimed to establish whether early-career 'apprenticeship-model' experience in family practice influences antibiotic prescribing for respiratory tract infections and to also establish other associations of antibiotic prescribing changes during this early-career experience. A longitudinal analysis (2010-2014) of a cohort study of Australian GP registrars' (vocational trainees') consultations. Registrars from five regional training programs recorded data from 60 consecutive consultations, once each 6-month training Term, including the diagnoses managed and medications prescribed. The outcomes were whether an antibiotic was prescribed for the diagnoses 'upper respiratory tract infection (URTI)' and 'acute bronchitis/bronchiolitis'. Generalized linear mixed modelling was used to account for repeated measures on registrars and to include the time component: 'Term'. A total of 856 registrars recorded 108759 consultations, including 8715 'URTI' diagnoses (5.15% of diagnoses) and 2110 'acute bronchitis/bronchiolitis' diagnoses (1.25%). Antibiotics were prescribed in 16.3% [95% confidence interval (CI) 14.9-17.8] of URTI and 72.2% (95% CI 69.6-74.6) of acute bronchitis/bronchiolitis diagnoses. Moving from an earlier to later term did not significantly influence registrars' antibiotic prescribing for URTI [adjusted odds ratio (OR) 0.95; 95% CI 0.87, 1.04, P = 0.27] or acute bronchitis/bronchiolitis [OR 1.01 (95% CI 0.90-1.14), P = 0.86]. Significant associations of antibiotic prescribing for URTIs were the registrar being non-Australian educated, greater patient age, practices not privately billing patients, pathology being ordered, longer consultation duration and the registrar seeking in-consultation information or advice (including from their supervisor). Early-career experience/training failed to produce rational antibiotic prescribing for URTI and acute bronchitis/bronchiolitis. Our findings suggest that prescribing interventions could target the registrar-supervisor dyad.

How much information about antibiotics do people recall after consulting in primary care?

Background. Sharing information with patients within a consultation about their infection and value of antibiotics can help reduce antibiotic prescriptions for respiratory tract infections. However, we do not know how often information is given about antibiotics or infections, and if this is related to knowledge and attitudes.Objectives. To determine the public’s reported use of antibiotics, receipt of information from health professionals about antibiotics and resistance, trust in health professionals and knowledge levels about antibiotics and resistance.Methods. Face-to-face computer-assisted survey with 1625 adults over 15 years in randomly selected households using multistage sampling. Rim weighting was used to correct for any selection biases.Results. About 88% trusted their GP to determine the need for antibiotics. Of those who took antibiotics in the past year, 62% were for a throat infection, 60% for sinus infection and 42% for a cough. Although 67% who had been prescribed an antibiotic recalled being given advice about their infection or antibiotics, only 8% recalled information about antibiotic resistance. Those in lower social grades were less likely to recall advice. About 44% correctly indicated that antibiotics effectively treat bacterial rather than viral infections. Only 45% agreed that ‘healthy people can carry antibiotic resistant bacteria’.Conclusion. GPs and health carers are trusted decision-makers, but could share more information with patients about the need or not for antibiotics, self-care and antibiotic resistance, especially with younger patients and those of lower social grade. Better ways are needed for effective sharing of information about antibiotic resistance.

Reducing antibiotic prescriptions for respiratory tract infections in family practice: results of a cluster randomized controlled trial evaluating a multifaceted peer-group-based intervention.

Irrational antibiotic use for respiratory tract infections (RTI) is a major driver of bacterial resistance. The aim of this study was to evaluate the effect of a multifaceted peer-group based intervention aiming to reduce RTI-related antibiotic prescriptions in family practice. This was a cluster randomized controlled trial with pre- and follow-up measurement. The intervention was implemented through PharmacoTherapy Audit Meetings (PTAM) in which family physicians (FPs) and pharmacists collaborate. Four PTAM groups received the intervention consisting of: (1) FP communication skills training, including communication about delayed prescribing; (2) implementation of antibiotic prescribing agreements in FPs’ Electronic Prescribing Systems; (3) quarterly feedback figures for FPs. Four other PTAM groups were matched controls. Primary outcome measure was the number of RTI-related antibiotic prescriptions after the intervention, assessed with multilevel linear regression analyses. Total number and number of prescriptions stratified by age (under/over 12 years) were analysed. At baseline, the average total number of RTI-related antibiotic prescriptions per 1,000 patients was 207.9 and 176.7 in the intervention and control PTAM groups, respectively. At follow-up, FPs in both the intervention and control groups prescribed significantly less antibiotics. For adolescents and adults, the drop in number of antibiotic prescription was significantly larger in the intervention groups (−27.8 per 1,000 patients) than the control groups (−7.2 per 1,000 patients; P<0.05). This multifaceted peer-group-based intervention was effective in reducing the number of RTI-related antibiotic prescriptions for adolescents and adults. To affect antibiotic prescribing in children other methods are needed.

Data back up drive to cut antibiotic prescribing for respiratory infections

Data back up drive to cut antibiotic prescribing for respiratory infections

Reducing general practice trainees’ antibiotic prescribing for respiratory tract infections: an evaluation of a combined face-to-face workshop and online educational intervention

Over-prescription of antibiotics for non-pneumonia respiratory tract infections (RTIs) is a major concern in general practice. Australian general practice registrars (trainees) have inappropriately high rates of prescription of antibiotics for RTIs. The ‘apprenticeship’ educational model and the trainee–trainer relationship are drivers of this inappropriate prescribing. We aimed to reduce registrars’ non-pneumonia RTI antibiotic prescribing via an educational intervention (a 90-min face-to-face workshop supported by online modules), complemented by delivery of the same intervention, separately, to their trainers. We conducted a pre- and post-intervention comparison of the registrars’ intention to prescribe antibiotics for common RTIs using McNemar’s test. We similarly tested changes in supervisors’ intended prescribing. Prescribing intentions were elicited by responses to six written clinical vignettes (upper respiratory tract infection, otitis media, sore throat and three acute bronchitis vignettes). We found that, for registrars, there were statistically significant reductions in antibiotic prescribing for the sore throat (24.0% absolute reduction), otitis media (17.5% absolute reduction) and two of the three acute bronchitis (12.0% and 18.0% absolute reduction) vignettes. There were significant reductions in supervisors’ antibiotic prescribing intentions for the same four vignettes. We conclude that our intervention produced a significant change in registrars’ intention to prescribe antibiotics for non-pneumonia RTIs.

What a difference a CRP makes. A prospective observational study on how point-of-care C-reactive protein testing influences antibiotic prescription for respiratory tract infections in Swedish primary health care

Objective: To explore how C-reactive protein (CRP) tests serve to support physicians in decisions concerning antibiotic prescription to patients with respiratory tract infections (RTI). Design. Prospective observational study. Setting: Primary health care centres in western Sweden. Subjects. Physicians in primary health care. Patients with acute RTI. Main outcome measures: Physician willingness to measure CRP, their ability to estimate CRP, and changes in decision-making concerning antibiotic treatment based on error estimate and the physician’s opinion of whether CRP measurement was crucial. Results: Data from 340 consultations were gathered. CRP testing was found to be crucial in 130 cases. In 86% of visits decisions regarding antibiotic prescription were unchanged. Physicians considering CRP crucial and physicians making an error estimate of CRP altered their decisions concerning antibiotic prescription after CRP testing more often than those who considered CRP unnecessary, and those making a more accurate estimate. Physicians changed their decision on antibiotic prescription in 49 cases. In the majority of these 49 cases physicians underestimated CRP levels, and the majority of changes were from “no” to “yes” as to whether to prescribe antibiotics. Conclusion: CRP is an important factor in the decision on whether to prescribe antibiotics for RTIs. Error estimates of CRP and willingness to measure CRP are important factors leading to physicians changing decisions on antibiotic treatment.Key pointsThere is a generally low antibiotic prescription rate and a high frequency of C-reactive protein (CRP) testing for respiratory tract infections (RTIs) in Sweden.CRP testing was considered essential to further management in 38% of cases.In 86% of visits decisions concerning antibiotic prescription were unchanged.The strongest predictors for revised decisions on antibiotic treatment were error estimates of CRP and the physician’s opinion that CRP measurement was crucial.