Request Antibiotics Research Articles

Low Request of Antibiotics from Patients with Respiratory Tract Infections in Six Countries: Results from the Happy Audit Study.

A total of 59,535 patients with respiratory tract infections were registered in the Happy Audit project, an audit-based, before-and-after study conducted in primary care centres of six countries (Argentina, Denmark, Lithuania, Russia, Spain, and Sweden) in 2008 and 2009. An antibiotic was explicitly requested by the patient in 1,255 cases (2.1%), with a great variation across countries ranging from 0.4%–4.9%. Antibiotics were significantly more often prescribed to patients requesting them compared to those who did not (64% vs. 28%; p < 0.001). Patients with acute exacerbations of chronic bronchitis/chronic obstructive pulmonary disease were most likely to request antibiotics while those with common colds were least likely (3.9% vs. 1.2%, respectively). The presence of tonsillar exudates and dyspnoea were more commonly associated with a demand for antibiotics. Even though physicians very often perceive that patients demand an antibiotic, the results of this study clearly show that patients only request antibiotics in a low percentage of cases. Patients were most likely to request antibiotics when they had symptoms of lower respiratory tract infections and when they came with more severe symptoms. Furthermore, there were considerable differences between countries, suggesting that the different backgrounds and traditions largely explain this variability in patients’ requests for antibiotics.

Colds, flu and coughing: a review of over-the-counter cold and flu medicines

The common cold is the most frequent human illness, and may be caused by several families of viruses, particularly the more than 100 serotypes of rhinoviruses. Inaccurate perceptions that antibiotics improve patient outcomes fuel the number of doctor visits and parental requests for antibiotics. The inappropriate use of antibiotics for minor, self-limiting, usually viral, upper-respiratory tract infections does not alter the course of the disease, and adds to the burden of antibiotic resistance. In addition, there is also no evidence to suggest that antibiotics prevent secondary bacterial complications following viral upper-respiratory tract infections. While most over-the-counter cold and flu remedies have no proven efficacy, they appear to attenuate the immune response to the infecting virus, and there is little doubt that appropriate symptomatic treatment can make the patient feel better. Therefore, symptomatic therapy remains the mainstay of common cold treatment. This article briefly reviews the components of cold and flu remedies, and provides a symptom-based assessment for the selection of appropriate over-the-counter medicine.

Addressing Requests by Patients for Nonbeneficial Interventions

PATIENTS FREQUENTLY EXPRESS STRONG PREFERENCES FOR medical tests or treatments of their own choosing, even when physicians believe that those interventions are not beneficial. Physicians grant such requests for various reasons. One compelling reason is to avoid confrontation: patient-physician relationships flourish in an atmosphere of trust and goodwill, and physicians rightly worry that disagreement will threaten those relationships. Moreover, explaining why an intervention is not beneficial takes time. For patients with the common cold, granting requests for antibiotics is far less time-consuming than discussing viral microbiology and harms of antibiotic overuse. Although patients’ preferences are key factors in clinical decision making, a patient’s preference for a diagnostic or therapeutic intervention is not decisive unless a modicum of potential benefit, viewed from a conventional medical perspective, is present. When diagnostic or therapeutic choices are consistent with such a modicum of benefit, patients’ preferences should drive decisions. In contrast, physicians should not provide interventions that do not meet this criterion. Patients are increasinglywilling tochallengephysicians’ intellectual authority. Patients request interventions based on media publicity about new research findings, sometimes before physicians learn about them. Internet sources of clinical information empower patients to make medical judgments independent of consultations with physicians. Directto-consumer advertising prompts patients to diagnose themselveswithconditions tied toadvertiseddrugs. Inone respect, physiciansshouldwelcomethesechanges: clinical encounters involving informedpatientsbecomegratifyingwhenbothparties collaborate to advance patients’ best interests. However, patients who misinterpret self-acquired medical information may request unnecessary or even harmful interventions. Physicians may respond to requests for nonbeneficial interventions not only through individualized clinical reasoning but also by applying practice guidelines. When guidelines recommend against a requested intervention, physicians can appeal to them as external sources of authority and depersonalize potential conflict with the patient. However, guidelines also can be problematic: those who create guidelines may have conflicts of interest, guidelines from different sources may conflict, and applicable guidelines are unavailable for many clinical problems. Patient Autonomy and Professional Integrity Patient autonomy is often invoked to support patients’ requests for specific interventions. According to this perspective, patients’ preferences are always decisive because medical decisions reflect value judgments, and patients are always better suited to choose interventions consistent with their personal values than are physicians. However, this rationale is flawed. Distorting biases may influence a patient’s clinical judgment, and autonomous patients sometimes make decisions that confer no benefit or put their health at risk. Using patient autonomy to justify acquiescence to patients’ requests for nonbeneficial services violates professional integrity. Professional integrityrequiresphysicianstoadheretostandards of intellectual and moral excellence. Physicians achieve intellectual excellence by submitting clinical judgment to disciplined, evidence-based reasoning. Physicians achieve moral excellence by protecting patients’ health-related interests as a primaryconcern,keepingself-interests systematically secondary. Commitment to professional integrity requires that physicianschallenge requests fornonbeneficial interventions.For example, patients may derive subjective value from taking antibiotics for viral infections; however, such value is not decisive intheabsenceofbenefit fromthemedicalperspective.Over time,allowingpatients’demandsforunnecessary interventions to trumpcarefulclinical reasoningresults inanondeliberative, rote practice style that undermines clinical excellence. Patient autonomy is not an unqualified right to choose. A broader view of autonomy includes the ability to understand and apply relevant information in making clinical judgments. Correspondingly, the physician’s obligation is to promote coherent deliberation and not simply to dispense whatever the patient wants. The interpersonal nature of patient-physician encounters is better captured by the idea of respect for autonomy than by an abstract principle of autonomy. This idea underscores the physician’s obligation to consider seriously patients’ values and preferences while protecting their health-related interests.

Phytotherapeutic and naturopathic adjuvant therapies in otorhinolaryngology

Phytotherapeutic pharmaceuticals and herbal medicinal products with its roots in classical phytotherapeutic medicine have a well-established role in otolaryngological therapy, especially for diseases of the upper airways and acute and chronic infections. A thorough selection and application could mean huge benefit for the patient, in particular in cases with contraindications, chemo- and antibiotic resistance or patient request. Besides, it might spare other medications. Phytotherapeutic pharmaceuticals must fulfil the same criteria of quality, effectiveness and harmlessness of evidence-based medicine like chemical pharmaceuticals, although they are often prescribed due to its well established or traditional based use. This review focuses on phytotherapeutic therapies well established within the European Community for otolaryngologic disease patterns by referring to clinical studies or meta-analysis.

Do Indonesian community pharmacy workers respond to antibiotics requests appropriately?

To quantify antibiotics sales without a prescription and to explore provision of patient assessment and medicine information related to antibiotics requested with or without a prescription in Surabaya community pharmacies. Scenarios of specific product requests (ciprofloxacin tablets and tetracycline capsules) and a request of amoxicillin dry syrups based on a new prescription were presented by simulated patients to 105 purposively selected pharmacies. Data were recorded by simulated patients after their purchase of each product. They documented the questions asked in patient assessment, the content of information given, recommendations provided and pharmacy workers' characteristics. Antibiotics requested without a prescription were sold in 80 (91%) pharmacies. Information related to ciprofloxacin tablets and tetracycline capsules was only provided when requested by the simulated patient in 69% and 68% of pharmacies for the two scenarios, respectively. Very few pharmacies assessed patients. Medicine information on indication, dosing, duration and direction for use was provided more frequently in all cases. Medicine information was more likely to be given when a new prescription of amoxicillin dry syrups being presented. Overall, the majority of sampled pharmacies responded antibiotics requests inappropriately. Inappropriate responses to antibiotic requests with or without a prescription remain an issue in Indonesia with pharmacy workers often failing to adequately assess patients. The illegality of delivering antibiotics without a prescription is of a considerable concern. Therefore, strategies to control antibiotics dispensing in community pharmacies should be seriously considered.

POLST Offers Next Stage in Honoring Patient Preferences

National advocacy groups have spent considerable effort promoting advance care planning and encouraging completion of advance directives in order to enhance congruence between the kind of medical care people say they would want to receive during serious or terminal illness and the care they typically receive. These efforts continue despite a growing body of evidence suggesting that conventional advance directives have not been as helpful as proponents hoped. A new and rapidly diffusing approach to ensuring care concordant with patient preferences, executed closer to the time of need, is called the Physician Orders for Life-Sustaining Treatment or POLST. POLST translates patient preferences into specific medical orders to be honored by physicians and other health care workers during a medical crisis. POLST advocates emphasize that this approach, first developed in Oregon in 1991 and recently adopted statewide in California and New York, is not an advance directive but rather is a set of medical orders. An advance directive is a legal document, such as living will or durable power of attorney for health care decisions, which is completed far in advance to inform a potential future medical circumstance in which the individual may be incapable of making decisions or expressing preferences for care. POLST, by contrast, is a medical order signed by a physician, after consultation with the patient or—if the patient lacks capacity—with the patient’s legal surrogate. POLST is appropriate for people who already have an advanced chronic illness, for whom the prognosis is measured in 1 to 2 years. It specifically addresses medical decisions and options that are likely to arise in the near future, including cardiopulmonary resuscitation, antibiotics for infections, artificial food and fluids, and whether or not the patient would want to be rehospitalized. More relevant and specific than conventional advance directives, POLST provides explicit guidance to health professionals under predictable future circumstances (such as development of pneumonia in a patient with advanced dementia). (See Fig. 1 for an illustration of a POLST form.) The Center for Ethics in Health Care at Oregon Health & Sciences University (OHSU) describes POLST as a new paradigm for the health care system. The center established the National POLST Paradigm Initiative Task Force (see www .polst.org) to facilitate the development, implementation, and evaluation of POLST initiatives nationwide. Subsequent to the Oregon initiative, a number of states have implemented POLST programs, either statewide (Idaho, New York, North Carolina, Washington, and West Virginia) or as regional or community projects. Others are exploring POLST coalition building, dissemination and implementation, with consultation, facilitator training and technical assistance from OHSU. (See Fig. 2 for a map showing participating states.) The basic POLST approach provides actionable information on how to honor the wishes of a patient with a lifethreatening condition regarding a range of available medical treatments; documents those wishes in a physician-signed medical order on a brightly colored (typically pink) form that accompanies the patient across and between settings of care, including ambulance rides; and formalizes agreement by health professionals across all settings in the community to honor medical orders contained in the POLST form. Experts emphasize that POLST is not just a glorified donot-resuscitate (DNR) order. Patients with POLST may indicate their desire either for or against specific life-sustaining treatments, and may endorse different combinations of relevant treatments. According to one study in Oregon, a majority of patients requesting DNR via POLST actually wanted potentially life-prolonging interventions in at least one other treatment category. (For example, a nursing home patient’s POLST might specify no rehospitalization and no cardiopulmonary resuscitation [CPR], but request antibiotics in case of infection, and tube feeding for nutrition and hydration.) Through its specificity and provision of yes-or-no answers for each of the common decision points (hospitalization, CPR, intensive care, ventilatory support, artificial nutrition and hydration) POLST provides quick and clear guidance to any health professional who simply reads the single-page form. Patients may also revoke an old POLST form and write a new one as their disease and other circumstances change. When combined with state policies and=or legislation recognizing the document as a valid medical order and broadbased education for health care professionals on how it works, POLST can convert patient preferences into immediately actionable medical orders that are readily accessible to medical

Antibiotic prescribing practices in primary and secondary health care facilities in Uttar Pradesh, India

Emerging antibiotic resistance in common pathogens is a worldwide problem known to be related to inappropriate overuse of antibiotics. Wide variability in antibiotic use throughout the world is because of various factors, including socio-cultural differences. To study the rate of antibiotic prescribing for common outpatient illnesses and the various disease, patient, physician and health facility characteristics, which influence this in primary and secondary healthcare settings in Uttar Pradesh. After sampling of health facilities - both private and government, rural and urban, a cross-sectional survey of prescriptions for patients presenting with runny or blocked nose, cough, sore throat, diarrhoea or fever without localizing symptoms was conducted. Information on disease, patient, physician and facility characteristics was collected. Outcome factors: antibiotic prescription and group of antibiotic prescribed. No intervention was made. Overall antibiotic prescription rate was 81.8%. It was significantly higher in urban private than in government settings, and higher in rural than in urban settings. Presence of fever prompted antibiotic use across all strata. Lower age of patients and higher socioeconomic status were associated with higher antibiotic use. Patient requests for antibiotics were very rare. Specialist practices with staff with higher qualifications and better opportunities for updating knowledge were associated with lower antibiotic prescribing. Government health-facilities with larger staff complement and better infrastructure was associated with lower prescribing rates. The most common antimicrobial agents used were the penicillin, sulfonamides and fluoroquinolones. Injection use paralleled antibiotic use. These data on overprescribing of antibiotics can be used to design educational programs for physicians working in these settings.

Accuracy of consultations performed by infectious diseases trainees and factors associated with adherence to them

Infectious diseases (ID) trainees should be familiar with duties relevant to consultation practice. In this study we aimed to analyze the ID trainee night/weekend shift consultation process in terms of consultant characteristics, types of recommendations, and compliance with recommendations. All consultations performed by ID trainees on the night shift and at the weekends between 10 June and 10 August 2004 were recorded prospectively on standardized forms. Infectious diseases specialists assessed the appropriateness of recommendations the day after each consultation. Recommendations were considered complied with if they were carried out within 72 hours of the consultation. Of 440 consultations, 163 were for a clinically diagnosed infection (without specific antibiotic request) and 79 were for treatment continuation. Overall, 152 consultations were for requesting specific antibiotic(s), and 327 antibiotics were recommended or approved in 270 consultations. Eight of these recommendations were inappropriate. Overall compliance to ID recommendations was 75.3% (418/555). In univariate analysis, the compliance rate to non-treatment recommendations (microbiologic cultures, radiology, biochemistry, etc.) was found to be lower than the rate of compliance to antibiotic recommendations (186/308 vs. 232/247, p<0.05). In addition, compliance to recommendations made by the first-year trainees was lower than to the recommendations made by the other trainees. In logistic regression analysis only recommendations including antibiotic treatment was associated with higher compliance (p=0.0001, odds ratio=10.2, 95% CI=5.7-18.3). ID trainees are capable of evaluating patients and recommending appropriate antibiotics. Methodologies to improve the compliance to non-treatment-based recommendations and optimizing antibiotic selection seem to be necessary.

Delayed Prescribing—A Sensible Approach to the Management of Acute Otitis Media

BASED ON EXPERIENCE IN HOLLAND, 1 EVIDENCE FROM systematic reviews, and recent evidence in the United Kingdom, many northern European countries, including the United Kingdom, have developed guidelines to advise physicians to delay for a short time before prescribing antibiotics for children with acute otitis media (AOM). The Dutch developed a policy of no prescription for AOM unless the patient has significant otalgia, fever, or both 72 hours after seeing the physician, or if a prolonged otic discharge develops. One study showed that if this watchful-waiting approach is used, there are likely to be few cases of complications (only 1 case of mastoiditis occurred in a 5000-patient cohort, and this patient had waited nearly a week). Patients and their families should be given clear advice about returning to see their physician if signs of complications occur, ie, worsening systemic features such as fever or vomiting. The study by Spiro and colleagues in this issue of JAMA is a welcome addition to the literature, suggesting that a “waitand-see” approach in the management of AOM is effective in the emergency department setting. Children randomized to the wait-and-see approach used fewer antibiotics (38% compared with 87%), and there was no difference in subsequent fever, otalgia, or unscheduled visits for medical care. The study provides evidence that there is probably little to be gained in terms of symptom resolution by immediate prescription of antibiotics for most children. Compared with previous trials of delayed antibiotic prescribing, the effect sizes are smaller than a Canadian study and similar to a United Kingdom study that used similar exclusion criteria. Further evidence of the limited utility of providing immediate antibiotics comes from a Cochrane review that suggests more than 15 children have to be treated for 1 child to benefit. The study by Spiro at al demonstrates that the wait-andsee approach is acceptable to parents in the United States, a finding that could have a substantial influence on the traditionally high rate of prescribing antibiotics for AOM in the United States. It also demonstrates that a wait-and-see approach works in the emergency department setting, where patients have no ongoing relationship with a physician. That children in such a setting might have worse outcomes had been a concern. However, several notes of caution are required. Both this study and previous studies excluded children whom clinicians considered to be toxic, and thus it would be unwise to extrapolate these results to very sick children. Furthermore, most children with AOM present within 24 hours after symptom onset. It would be unwise to suggest a further delay of 72 hours if the child already has a high fever and severe otalgia for 72 hours or longer, so the delaying times should be adjusted for the length of prior severe otalgia and fever. Especially in an emergency department setting, it would be advisable for physicians to emphasize the importance of repeat assessment if symptoms do not improve following the delayed prescription. There are several potential advantages of delayed prescribing. First, delayed prescribing rationalizes antibiotic use. Evidence from a systematic review of delayed prescribing trials for a variety of respiratory infections supports findings from the current study that delayed prescribing is likely to reduce antibiotic use. The study by Spiro et al suggests that a waiting period of 48 hours is likely to result in 62% of patients not using antibiotics; advising a wait of 72 hours is likely to result in even fewer antibiotic prescriptions being used. When patients are asked to return to collect their delayed antibiotic prescription from the physician’s office, antibiotic use is likely to be little greater than using a policy of no initial offer of antibiotics. Second, delayed prescribing changes patient and family beliefs about antibiotics. Prescribing antibiotics probably fuels a cycle of belief in antibiotics, subsequent reattendance, and further antibiotic request and use. Delayed prescribing appears to be as effective as not prescribing antibiotics in changing beliefs, and it also changes subsequent consultation behavior. Delayed prescribing has similar or lower rates of reattendance when compared with not prescribing. Third, delayed prescribing achieves acceptable symptom control. Previous systematic reviews of delayed prescribing have called for more evidence on this point. Most trials, including the trial by Spiro

Resistance to Anti-Infective Drugs and the Threat to Public Health

Increasing resistance of pathogens to anti-infective drugs is an urgent public health problem that must be addressed through more prudent use of these drugs in human medicine and in animal husbandry, agriculture, and aquaculture.

Use of antibiotics without medical prescription

The inappropriate use of antibiotics for the treatment of infections is a worldwide problem that has implications for the cost of treatment and the development of resistant strains of bacteria. The use of antibiotics should follow specific criteria; they are on top of the list of self-medication drugs in countries that do not control their commercialization. To determine the percentage of pharmacies that attend the public and sell antibiotics without medical prescription in a medium-sized city in Brazil, and analyze the variables involved in this procedure. 107 of the 136 pharmacies registered in our city were evaluated. These pharmacies were visited by actresses who simulated having a sister with symptoms of a non-complicated rhino-sinusitis, so that they could obtain antibiotics without a medical prescription. Each pharmacy was visited only once; the only variable in the simulated clinical setting was the report of fever temperature, which was randomly assigned between 38.5 and 40 degrees Celsius. Antibiotics were offered in 58% of the pharmacies, and this offer was increased to 74% after the actresses insisted on having them. In 65.4% of the pharmacies, the actresses were attended by a pharmacist, and 84.2% of them said they would sell antibiotics. When the request for antibiotics was denied (26%), only 7.5% was due to absence of prescription. The most frequent reason for refusal to sell antibiotics, was because the attendant deemed it unnecessary (46.6%) Antibiotics can be easily bought in the great majority of the pharmacies in our town without a medical prescription and a clear indication. Fever temperature did not modify the attendant's indication of the drug.

Patient Ethics and Evidence-Based Medicine—The Good Healthcare Citizen

Should patients request antibiotics from their physicians for common upper respiratory infections?I am grateful to Drs. Richard Bukata and Jerome Hoffman and the staff of Primary Care Medical Abstracts for retrieving and analyzing some of the references used in this paper.

Adult victims of sexual assault: acute medical response and police reporting among women consulting a center for victims of sexual assault.

The medical response to adult sexual assault should comprise: the collection of forensic evidence, the treatment of injuries, and follow-up counselling. In the past, victims of sexual assault reporting directly to the police may not have received this total medical care. The Copenhagen Center for Victims of Sexual Assault at Rigshospitalet, Denmark offers a 24-h service. Medical treatment and psychosocial follow up is offered independent of police reporting. The aim of this study was to assess whether adult sexual assault victims who reported to the police differed from those who did not report to the police. Using clinical records, sociodemographics, characteristics of the assault, and type of preventive medical treatment received were obtained for 156 consecutive women consulting the Copenhagen Center (March 1st to December 31st 2000). Comparisons between characteristics of victims who reported to the police or not were determined. Ninety-four (60.2%) of the women reported to the police. Women who sought services within 24 h of the assault, had experienced use of force, were subjected to assault outdoors, and among whom nongenital injuries were observed were more likely to report to the police (p < 0.05). However, in the multivariate model these associations fell below significance, and only the type of perpetrator remained significantly related to police reporting. The adjusted odds ratio for police reporting when the perpetrator was a friend was 0.4 (95% CI 0.17-0.94). There was no statistical difference between the victims who did or did not report to the police to request prophylactic antibiotics or emergency contraception. Observed injuries and requests for prophylactic antibiotics or emergency contraception were not influenced by whether the woman did or did not report directly to the police. Hence the need for medical treatment appears to be similar in the two groups, and available specialized care for victims of sexual assault should not be restricted to those who immediately report to the police.

Correlates of Parental Antibiotic Knowledge, Demand, and Reported Use

Clinicians cite parental misconceptions and requests for antibiotics as reasons for inappropriate prescribing. To identify misconceptions regarding antibiotics and predictors of parental demand for antibiotics and to determine if parental knowledge and attitudes are associated with use. Survey of parents in 16 Massachusetts communities. Domains included antibiotic-related knowledge, attitudes about antibiotics, antibiotic use during a 12-month period, demographics, and access to health information. Bivariate and multivariate analyses evaluated predictors of knowledge and proclivity to demand antibiotics. A multivariate model evaluated the associations of knowledge, demand, and demographic factors with parent-reported antibiotic use. A total of 1106 surveys were returned (response rates: 54% and 32% for commercially-insured and Medicaid-insured families). Misconceptions were common regarding bronchitis (92%) and green nasal discharge (78%). Two hundred sixty-five (24%) gave responses suggesting a proclivity to demand antibiotics. Antibiotic knowledge was associated with increased parental age and education, having more than 1 child, white race, and receipt of media information on resistance. Factors associated with a proclivity to demand antibiotics included decreased knowledge, pressure from day-care settings, lack of alternatives offered by clinicians, and lack of access to media information. Among all respondents, reported antibiotic use was associated with younger child age and day-care attendance. Among Medicaid-insured children only, less antibiotic knowledge and tendency to demand antibiotics were associated with higher rates of antibiotic use. Misconceptions regarding antibiotic use are widespread and potentially modifiable by clinicians and media sources. Particular attention should be paid to Medicaid-insured patients in whom such misconceptions may contribute to inappropriate prescribing.

Evaluation of antibiotic use in a hospital with an antibiotic restriction policy

The study was designed to evaluate rational antibiotic use in relation to diagnosis and bacteriological findings. All hospitalized patients who received antibiotics were evaluated by a cross-sectional study. Of the 713 patients hospitalized, 281 (39.4%) patients received 377 antibiotics. Among 30 different antibiotics the most frequently requested were first generation cephalosporins (19.9%), ampicillin–sulbactam (19.1%) and aminoglycosides (11.7%). Antibiotic use was appropriate in 64.2% of antibiotic requests. In analysis of appropriate use, a request after an infectious diseases consultation was a frequent reason (OR=14, P<0.001, CI=0.02–0.24). Antibiotics requested in conjunction with susceptibility results were found to be more appropriate than those ordered empirically (OR=4.5, P=0.017, CI=0.06–0.76). Inappropriate antibiotic use was significantly higher among unrestricted antibiotics than restricted ones ( P<0.001). Irrational antibiotic use was high for unrestricted antibiotics. Additional interventions such as postgraduate training programmes and elaboration of local guidelines could be beneficial.

Fewer patients request antibiotics for minor illness.

Patients with minor illnesses are less likely to ask GPs for antibiotics, according to Liverpool researchers.

Parent expectations for antibiotics, physician-parent communication, and satisfaction.

To explore how parents communicate their preferences for antibiotics to their child's physician and to examine whether physicians can communicate why antibiotics are not being prescribed in a way that maintains satisfaction with the visit. Previsit survey of parents, audiotaping of the study encounters, and a postvisit survey of parents and physicians. Two private pediatric practices. Ten physicians (response rate = 77%) and a consecutive sample of 295 eligible parents (response rate = 86%) who attended acute care visits for their children between October 1996 and March 1997. Physician-perceived pressure to prescribe antibiotics and parental visit-specific satisfaction. Fifty percent of parents expressed a previsit expectation for antibiotics. Among these parents, only 1% made a direct verbal request for them. Even when no direct requests for antibiotics were made, physicians still perceived an expectation for antibiotics 34% of the time. Among parents who did not receive expected antibiotics, those offered a contingency plan from the physician (i.e., the possibility of receiving antibiotics in the future if their child did not get better) had a higher mean satisfaction score than parents not receiving a contingency plan (76 vs. 58.9; P<.05). Physicians should consider providing a contingency plan to parents who expect antibiotics for their children when there is no clinical indication. Further study is needed to determine how parents indirectly communicate their desire for antibiotics and what additional communication techniques physicians can use to resist the overprescribing of antibiotics.

Interventions of an Antibiotic Management Team

Objective: To evaluate interventions made by medical and pharmacy staff in association with an antibiotic approval system at Box Hill Hospital.Design: Ward pharmacists identified all restricted antibiotics and prescribers then obtained approval numbers from the Infectious Diseases Unit. Details of all antibiotic approvals, including interventions, were recorded by the Unit during a three‐month period. Details of ward pharmacists' antibiotic‐related interventions were extracted from the Pharmacy's computer records.Results: During the study period, 195 requests for antibiotics requiring approval numbers were made. Approval was given in 93% of cases and there were 41 additional interventions made by the Infectious Diseases Unit at the time of issuing the number. Overall, treatment was altered on 55 occasions (28%). Pharmacists recorded a further 37 major interventions subsequent to the approval of antibiotics.Conclusion: An approval system for selected antibiotics can limit inappropriate prescribing particularly when a team approach is used.

Futility and the Common Cold: How Requests for Antibiotics Can Illuminate Care at the End of Life

The dominant approach to futility in medicine assumes that the probability and utility of medical interventions may be separated to provide a quantitative (probabilistic) definition of futility. This assumption is not only misleading but also responsible for much of the confusion that futility has engendered in medical discussions. The divorce of utility from probability is the opposite of how clinicians reason: an improbable intervention looks different if it is cheap, easy, and without morbidity than if it is technology intensive, expensive, and likely to involve great pain and suffering. Futility is how physicians describe the sense of being compelled to proceed with resource intensive care for marginal benefits. Outside the intensive care unit, physicians weigh and sometimes reject patient requests without the need to invoke futility. By examining the ways that physicians can legitimately evaluate patient requests, we can show that appeals to futility are both unnecessary and counterproductive. In cases where such appeals are unavoidable, the outpatient model suggests a process to adjudicate the competing claims of patient autonomy and physician responsibility.

Advance Directives: Can Patients?? Stated Treatment Choices Be Used to Infer Unstated Choices?

Advance directives have been widely endorsed as a method to match medical interventions to patients' preferences. However, applying advance directives to unspecified future decisions may be problematic. We wondered how well scenario-based treatment choices in advance directives can be used to infer other choices specified by the same patients. We asked 495 out-patients from the Massachusetts General Hospital to state 11 treatment choices in each of four illness scenarios. We calculated likelihood ratios (LRs) to see how well one choice could predict another. Predictions within a given scenario were strong and followed a pattern that reflected the invasiveness of the treatment. Thus, decline of antibiotics predicted decline of major surgery, in the same scenario (LR 36.0-108.3). Requests for major surgery strongly predicted requests for antibiotics (LR 90.4-244.1). Requests for major surgery and decline of antibiotics were the two most predictive preferences; more traditionally considered decisions about cardiopulmonary resuscitation and mechanical ventilation ranged from the third to ninth most predictive among the 11 interventions. Predictions between scenarios were weaker, but still potentially useful, and followed a pattern that reflected the prognoses of the scenarios. Declining treatment in the best prognosis scenario (coma-with-a-chance) predicted declining the same treatment in other scenarios with LRs of 2.5-6.1. Requests for treatment in the worst prognosis scenario (dementia-with-terminal-illness) predicted the same request in the other scenarios with LRs of 5.2-30.5. These data suggest that patients' advance scenario-based treatment choices can provide potentially useful information to apply to unspecified decisions if inferences follow considerations of prognosis and treatment invasiveness. For maximal predictive power, treatment directives should use a range of illness scenarios and include choices, among several others, on antibiotic use and major surgery.