Prescribing For Respiratory Infections Research Articles

Managing respiratory tract infections

Last year, as a previously completely fit and healthy GP of 32, I developed a sore throat, cough, and fever. Nothing so unusual about that and being fully aware of the NICE guidelines on prescribing in respiratory tract infections it did not cross my mind to see a doctor or self-medicate with antibiotics.2 My Centor score of two would have suggested I would be unlikely to benefit. For me, as I suspect for many GPs of my generation, …

Developing a computer delivered, theory based intervention for guideline implementation in general practice

BackgroundNon-adherence to clinical guidelines has been identified as a consistent finding in general practice. The purpose of this study was to develop theory-informed, computer-delivered interventions to promote the implementation of guidelines in general practice. Specifically, our aim was to develop computer-delivered prompts to promote guideline adherence for antibiotic prescribing in respiratory tract infections (RTIs), and adherence to recommendations for secondary stroke prevention.MethodsA qualitative design was used involving 33 face-to-face interviews with general practitioners (GPs). The prompts used in the interventions were initially developed using aspects of social cognitive theory, drawing on nationally recommended standards for clinical content. The prompts were then presented to GPs during interviews, and iteratively modified and refined based on interview feedback. Inductive thematic analysis was employed to identify responses to the prompts and factors involved in the decision to use them.ResultsGPs reported being more likely to use the prompts if they were perceived as offering support and choice, but less likely to use them if they were perceived as being a method of enforcement. Attitudes towards using the prompts were also related to anticipated patient outcomes, individual prescriber differences, accessibility and presentation of prompts and acceptability of guidelines. Comments on the prompts were largely positive after modifying them based on participant feedback.ConclusionsAcceptability and satisfaction with computer-delivered prompts to follow guidelines may be increased by working with practitioners to ensure that the prompts will be perceived as valuable tools that can support GPs' practice.

Point-of-Care C-Reactive Protein Testing and Antibiotic Prescribing for Respiratory Tract Infections: A Randomized Controlled Trial

Antibiotics are only beneficial for subgroups of patients with acute lower respiratory tract infections (LRTI) and rhinosinusitis in family practice, yet overprescribing for these conditions is common. C-reactive protein (CRP) point-of-care testing and delayed prescribing are useful strategies to reduce antibiotic prescribing, but both have limitations. We evaluated the effect of CRP assistance in antibiotic prescribing strategies-including delayed prescribing-in the management of LRTI and rhinosinusitis. We conducted a randomized controlled trial in which 258 patients were enrolled (107 LRTI and 151 rhinosinusitis) by 32 family physicians. Patients were individually randomized to CRP assistance or routine care (control). Primary outcome was antibiotic use after the index consultation. Secondary outcomes included antibiotic use during the 28-day follow-up, patient satisfaction, and clinical recovery. Patients in the CRP-assisted group used fewer antibiotics (43.4%) than control patients (56.6%) after the index consultation (relative risk [RR] = 0.77; 95% confidence interval [CI], 0.56-0.98). This difference remained significant during follow-up (52.7% vs 65.1%; RR = 0.81; 95% CI, 0.62-0.99). Delayed prescriptions in the CRP-assisted group were filled only in a minority of cases (23% vs 72% in control group, P < .001). Recovery was similar across groups. Satisfaction with care was higher in patients managed with CRP assistance (P = .03). CRP point-of-care testing to assist in prescribing decisions, including delayed prescribing, for LRTI and rhinosinusitis may be a useful strategy to decrease antibiotic use and increase patient satisfaction without compromising patient recovery.

Annals Journal Club: Point-of-Care C-Reactive Protein to Assist Antibiotic Prescribing for Respiratory Tract Infections

Annals Journal Club: Point-of-Care C-Reactive Protein to Assist Antibiotic Prescribing for Respiratory Tract Infections

Interactive booklet reduces antibiotic prescribing for respiratory tract infections in children, but not parent satisfaction

Commentary on: NA Francis, CC Butler, K Hood, et al.. Effect of using an interactive booklet about childhood respiratory tract infections in primary care consultations on reconsulting and antibiotic prescribing: a cluster randomised controlled trial. BMJ2009;339:b2885.

Interactive booklet reduces antibiotic prescribing for respiratory tract infections in children, but not parent satisfaction

Interactive booklet reduces antibiotic prescribing for respiratory tract infections in children, but not parent satisfaction

Prescripción de antibióticos en las infecciones del tracto respiratorio y factores predictores de su utilización.

Objective Happy Audit project is a European-funded survey aimed at reducing antibiotic prescribing for respiratory tract infections (RTI). The aim of this study is to investigate the antibiotic treatment administered for these RTIs in Spain and to find out which criteria are associated with its use. Design Cross-sectional study carried out in January and February 2008. Setting Primary health care. Participants General practitioners registered all the RTI during a 3-week period using a template. Principal measurements Age and gender, days with symptoms, signs presented (fever, cough, purulent ear discharge, sore throat, tonsillar exudate, swollen neck glands, dyspnoea, increase in sputum, purulent sputum), diagnosis, antibiotic therapy and demand of antibiotics. A logistic regression with the prescription of antibiotic as the dependent variable was performed. Results Out of the 332 physicians invited to participate, 309 filled in and returned the templates (93.1%), registering 16,751 RTIs, with the common cold (39.7%), pharyngitis (14.4%) and acute bronchitis (12.6%) being the most common. Antibiotic therapy was given to 4,675 RTIs (27.9%), mainly for pneumonia (89.9%), tonsillitis (88.9%), and otitis media (87.3%). The criterion most associated with antibiotic therapy was the presence of tonsillar exudate (OR: 32.1; 95CI%: 24.5–42), followed by ear discharge (25.2; 95%CI: 18.2–35) and purulence of sputum (18.1; 95%CI: 15.5–21.2); conversely, cough (OR: 0.4; 95%CI: 0.3–0.5) was considered as protective factor. Discussion Antibiotic treatment for RTIs is very high in our country. This study provides information on the criteria that predict this antibiotic therapy and is important to take into account if a more rational use of antibiotics is required.

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.

GPs’ antibiotic prescription patterns for respiratory tract infections – still room for improvement

Objective. Inappropriate use of antibiotics is associated with increased antibiotic resistance in the community. About 90% of all antibiotic prescriptions in Norway are issued by general practitioners and in 60% issued for respiratory tract infections. The article describes and analyses antibiotic prescription patterns by general practitioners in Vestfold, Norway. Design. Prospective cohort study. Subjects. A total of 145 list-holding general practitioners in Vestfold, Norway in February to March 2003. Methods. Merging of two electronic administrative data sets: antibiotic prescriptions dispensed in pharmacies and general practitioners’ electronic bills from the National Insurance Agency. Main outcome measures. Proportion and type of antibiotic prescribed for different respiratory tract infectious diagnoses. Results. We found large variations among general practitioners’ antibiotic prescription habits. In 27% of consultations with RTI diagnoses, an antibiotic was prescribed; 37% were for Penicillin V and 28% for a macrolide. Quinolones and cephalosporins were only rarely prescribed. In a logistic regression analysis the following factors were independently associated with antibiotic prescription rate: type of infection, type of contact, being a general practitioner specialist, and years since medical exam. In another logistic regression analysis the following factors were independently associated with broad-spectrum antibiotic prescription: type of infection, age of patient, type of contact, being a specialist, length of list, and being a high prescriber of antibiotics. Conclusion. The variation in proportion of total antibiotic prescribing and broad-spectrum prescription for respiratory tract infections is high, and reveals potentials to change general practitioners’ prescription behaviour, in order to maintain the positive situation in Norway as to antibiotic resistance.

Changes in clinical indications for community antibiotic prescribing for children in the UK from 1996 to 2006: will the new NICE prescribing guidance on upper respiratory tract infections just be ignored?

Objective:To analyse changes in clinical indications for community antibiotic prescribing for children in the UK between 1996 and 2006 and relate these findings to the new NICE guidelines for the...

Clinical, social and relational determinants of paediatric ambulatory drug prescriptions due to respiratory tract infections in Italy

Collecting information on patterns of drug prescriptions and on factors influencing prescribing decisions is fundamental for supporting the rational use of drugs. This study was aimed at investigating patterns of drug prescription in paediatric outpatients and at evaluating determinants of prescriptions for respiratory tract infections (RTIs). We conducted a national cross-sectional survey involving primary care paediatricians and parents. Diagnoses and prescriptions made at each consultation were described. Poisson regression models were used to analyse determinants of drug and antibiotic prescriptions for visits due to RTIs. A total of 4,302 physician and parent questionnaires were analysed. These corresponded to 2,151 visits, 792 of which were due to RTIs. Drugs were prescribed in 83.4% of RTI visits, while antibiotics were prescribed in 40.4%. According to paediatricians' perceptions, 84.2% of parents of children with a RTI expected to receive a drug prescription. Paediatricians' perception of parental expectations was the strongest determinant for prescription of drugs and specifically of antibiotics [adjusted relative risk (RR): 1.7 and 3.6, respectively; P < 0.001]. However, in 77.1% of RTI visits, paediatricians judged themselves as not being influenced at all by parents' expectations in their decision to prescribe. This study underscores that relational factors, in particular perceived parental expectations, are one of the leading factors of drug prescriptions in paediatric ambulatory care settings, reinforcing the opinion that communication between physicians and parents can affect prescription patterns.

Ambulatory Antibiotic Prescribing for Acute Bronchitis and Cough and Hospital Admissions for Respiratory Infections: Time Trends Analysis

To examine the relationship between ambulatory antibiotic prescribing for acute bronchitis and cough with hospital admissions for respiratory infections in the USA between 1996 and 2003. Analysis of data on antibiotic prescribing for episodes of acute bronchitis/cough illness in ambulatory care and hospitalization for respiratory infections for adults between 1996 and 2003 in the USA. USA: ambulatory prescribing behaviour was derived from the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey while hospitalizations in acute care hospitals were assessed in the National Hospital Discharge Survey. Adults 18-64 years old. None. Proportion of visits for acute bronchitis/cough receiving a prescription for antibiotics and hospitalization for respiratory infections. Ambulatory antibiotic prescribing practices for acute bronchitis/cough and hospitalizations for respiratory infections exhibited non-linear patterns over the 8 year period. However, antibiotic prescribing practices for acute bronchitis/cough and hospitalizations for respiratory infections had a weak/moderate negative association. For three of the seven yearly changes in prescribing and hospitalizations as one increased the other decreased (P<0.01). Ambulatory antibiotic prescribing for respiratory tract infections was inversely associated with hospital admissions for respiratory tract infections.

Ambulatory antibiotic prescribing for acute bronchitis and cough and hospital admissions for respiratory infections: time trends analysis

To examine the relationship between ambulatory antibiotic prescribing for acute bronchitis and cough with hospital admissions for respiratory infections in the USA between 1996 and 2003. Analysis of data on antibiotic prescribing for episodes of acute bronchitis/cough illness in ambulatory care and hospitalization for respiratory infections for adults between 1996 and 2003 in the USA. USA: ambulatory prescribing behaviour was derived from the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey while hospitalizations in acute care hospitals were assessed in the National Hospital Discharge Survey. Adults 18-64 years old. None. Proportion of visits for acute bronchitis/cough receiving a prescription for antibiotics and hospitalization for respiratory infections. Ambulatory antibiotic prescribing practices for acute bronchitis/cough and hospitalizations for respiratory infections exhibited non-linear patterns over the 8 year period. However, antibiotic prescribing practices for acute bronchitis/cough and hospitalizations for respiratory infections had a weak/moderate negative association. For three of the seven yearly changes in prescribing and hospitalizations as one increased the other decreased (P<0.01). Ambulatory antibiotic prescribing for respiratory tract infections was inversely associated with hospital admissions for respiratory tract infections.

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

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. 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. 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. 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.

Interventions to Improve Treatment of Respiratory Infections in Ambulatory Managed-Care Patients

To review the literature on managed-care initiatives to improve antimicrobial use in respiratory tract infections (RTIs) and examine whether efforts were successful in decreasing antibiotic prescribing when an antibiotic was not indicated or in increasing the frequency with which a preferred antimicrobial agent was chosen when an antibiotic was appropriate. A computerized search of Ovid MEDLINE was conducted for research articles published between 1966 and September 2004 using a key word search of MeSH subject headings and titles. Search terms included managed care or health maintenance organization and antibacterial agents or antibiotic or antimicrobial. Studies evaluating initiatives in ambulatory managed-care environments and the effects of managed care on treatment of RTIs were chosen. Articles addressing both population and individual level tools were included. Initiatives have been attempted in a variety of managed-care models. In some studies, multidimensional educational interventions were effective in decreasing antimicrobial prescribing rates for RTIs. However, in other studies, no decrease in antimicrobial prescribing after implementation of an evidence-based guideline or initiation of an educational intervention was observed. In one successful study, patient satisfaction was similar between groups. Each study had limitations in design or generalizability. Several studies had strengths, including using randomized groups or offering multidimensional educational efforts. Randomized prospective studies of interventions to improve antimicrobial prescribing for RTIs in managed care have been variably successful. Because the topic is one of ongoing importance, it will continue to be an area of research.

Guidance meetings plus education of assistants and patients reduces antibiotic prescription for respiratory tract infections by general practitioners

QuestionDoes a programme of guidance meetings, monitoring and feedback for general practitioners, and education of assistants and patients, lead to reduced prescription rates of antibiotics for respiratory tract infection?Study DesignRandomised controlled trial.Main resultsAt baseline, there were no significant differences between groups in antibiotic prescription rates (intervention v control: 27% v 29%). At 9 months, the intervention significantly reduced antibiotic prescription rates compared with control (intervention v control; prescription rates 23% v 37%; % change: 4% reduction v 8% increase; mean difference in change -12%, 95%CI -18.9 to -4.0). There was no significant difference in patient satisfaction between groups, either at baseline or after 9 months. After 15 months, the number of antibiotic prescriptions was still reduced in the intervention group.Authors’ conclusionsA multi-stepped intervention programme aimed at general practitioners, their assistants and their patients significantly reduced rates of antibiotic prescription for respiratory tract symptoms.

Antibiotic prescribing for respiratory tract infections in Dutch primary care in relation to patient age and clinical entities

To obtain detailed information on current prescribing rates of antibiotics for respiratory tract infections (RTIs) in Dutch general practice and its relation with age and respiratory tract clinical entities. We assessed the mean proportion of antibiotics prescribed for RTIs per age group, contact-based and population-based using all patient contacts concerning RTIs in the year 2000 selected from the IPCI database, containing information on general practice consultations of 235,290 patients. In one-third of all contacts concerning RTIs, antibiotics were prescribed, with much variation between age groups and clinical entities. For children (0-15 years) and the elderly (over 75 years), the lowest contact-based percentages of prescribed antibiotics for RTIs were found, while population-based, children of age 0-5 years received far more antibiotics for RTIs. High prescribing rates were seen in patients with sinusitis-like complaints (67%) or pneumonia (78%), whereas low rates were found for patients with upper RTIs (16%). Potential over-prescribing of antibiotics for RTIs occurs in the age group 31-65 years, not in children and the elderly, and in patients with upper RTIs, sinusitis and most likely acute bronchitis (contact-based). The management of these subgroups of patients should be addressed in quality assurance programmes. Children and the elderly visit the GP much more often than adults, which can be explained by more frequent (children) or more severe (elderly) RTI morbidity, but in proportion they do not receive more antibiotics.

Why has antibiotic prescribing for respiratory illness declined in primary care? A longitudinal study using the General Practice Research Database

Antibiotic prescribing by general practitioners (GPs) increased in the 1980s and peaked in 1995. Prescribing volumes subsequently fell by over a quarter between 1995 and 2000, mostly accounted for by reduced antibiotic prescribing for acute respiratory illnesses. We aimed to investigate changes in consultation rates and the proportion of consultations with antibiotics prescribed for different types of respiratory tract infections. Data were derived from 108 UK general practices, covering a mean of 642,685 patients, reporting data to the General Practice Research Database (GPRD) continuously between 1994 and 2000. annual age- and sex-standardized consultation rates for 11 different acute respiratory infections per 1000 registered patients and proportions of these consultations resulting in an antibiotic prescription. The standardized consultation rate for 'any respiratory infection' declined by 35 per cent from 422 to 273 per 1000 registered patients, per year. The largest relative reductions in consultation rates were observed for 'common cold' (50 per cent), 'laryngitis' (43 per cent) and 'sore throat' (43 per cent). The standardized proportion of consultations that resulted in an antibiotic prescription for 'any respiratory infection' declined from 79 per cent in 1994 to 67 per cent in 2000. The largest relative reductions in antibiotic prescribing rates occurred in patients recorded as suffering from 'influenza' (52 per cent), 'upper respiratory tract infections' (33 per cent) and 'laryngitis' (30 per cent). Overall, antibiotic prescriptions for all acute respiratory infections declined by 45 per cent. The reduction in antibiotic prescribing in common respiratory infections between 1994 and 2000 has occurred partly because GPs are prescribing antibiotics less frequently when patients consult but mainly because there are fewer consultations with these conditions. Further work should aim to understand the reasons for the decline in consultations for respiratory infections and whether further reductions in antibiotic prescribing are feasible.

Respiratory tract infections: diagnosis and use of antibiotics by family physicians in north-eastern Poland

The aim of our study was to describe the pattern of antibiotic prescribing for respiratory tract infections. Forty-four family physicians from Białystok (north-eastern Poland) filled in questionnaires regarding 1315 patients with respiratory tract infections. Antibiotics were prescribed in 803 cases (61.1%). The four principle diagnoses associated with prescribing an antibiotic were: bacterial pharyngitis/tonsillitis, acute bronchitis, unspecified bacterial superinfection and acute sinusitis for which a total of 572 antibiotic treatments were given (71.2% of all antibiotic prescriptions). The study shows that Polish family physicians diagnose respiratory tract infections empirically and frequently prescribe wide-spectrum antibiotics. More information is required about the diagnostic value of certain clinical symptoms such as purulent sputum, duration of cough and indications for broad-spectrum antibiotic use.

Reduction in antibiotic prescribing for respiratory tract infections is needed!

In general practice, approximately 25% of consultations are related to infectious diseases. The emergence and spread of resistant bacteria are related to antibiotic use on an individual and on a community level. Antibiotic prescribing differs profoundly from one European country to the next, though there is no evidence of differences in the prevalence of infectious diseases. Most respiratory tract infections are self-limiting conditions, and recent evidence shows that antibiotics only slightly modify the course of most respiratory tract infections. The general practitioner should focus on patients with more severe symptoms who might benefit more from antibiotic treatment. In general, antibiotics should be prescribed for acute pneumonia. In addition, we may offer antibiotics to a selected group of patients with more severe symptoms of maxillary sinusitis, pharyngotonsillitis and acute exacerbation of chronic obstructive pulmonary disease/chronic bronchitis. In the diagnostic procedure, rapid tests of Streptococcus pyogenus and C-reactive protein may be valuable in carefully selected cases. Penicillins (penicillin V, amoxycillin) should be the first choice in most respiratory tract infections. Larger studies in general practice are needed to analyse the impact of antibiotic prescribing on morbidity, the occurrence of rare complications and spread of resistance. The greatest challenge will be to implement current knowledge in daily praxis.