Antibiotic Inappropriateness

Submitted by Dr. JG Kaplan on Mon, 2009-06-15 06:56
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Lower Respiratory Tract Infections and Inappropriate Antibiotic Use
Primum non nocere  The evidence is overwhelming! We must reduce the use of antibiotics in patients suspected of having virus "infections" such lower respiratory tract infections, acute bronchitis (another name for "cough" [1]) or sinusitis, if not mild otitis media or middle ear infection. In such situations, antibiotics have no value and they can be harmful, if not making things dangerously confusing for subsequent care.
A cluster-randomized controlled trial in the Netherlands evaluated the practices of 40 general practitioners, working in 20 practices. The researchers improved physician–patient communication skills through training and they got the doctors to use a simple lab test—C-reactive protein (CRP) [2]
Results:
  • CRP testing reduced the percentage of patients prescribed antibiotics at the index visit from 53% in the control group to 31%
  • Specific training in communicating about antibiotic appropriateness reduced prescribing from 54% to 27%.
  • Combining the two interventions did not increase the benefit over either one alone.
  • Antibiotic prescribing remained significantly lower in the CRP-testing group and the enhanced-communication group for at least the observation period—28 days.
  • Outcomes and patient satisfaction were similar among groups.
 
Comment: "Using evidence-based practice to restrict antibiotic prescriptions to patients who are likely to benefit from them will decrease local antibiotic resistance as well as global emergence of resistant bacterial strains. Good communication makes sense. We should continue to educate patients that most lower respiratory tract infections improve without antibiotic therapy. However, if you suspect pneumonia, forget bedside CRP testing and get a chest x-ray!"
Kristi L. Koenig, MD, FACEP, Journal Watch Emergency Medicine May 22, 2009
 
Citations: 

[1] Hay AD and Jüttner KV. Antibiotics for acute cough in primary care. BMJ 2009 May 5; 338:b834. [Medline® Abstract—actually, this is just a reference to the original article]

[2] Cals JWL et al. Effect of point of care testing for C reactive protein and training in communication skills on antibiotic use in lower respiratory tract infections: Cluster randomised trial. BMJ 2009 May 5; 338:b1374. [Medline® Abstract] [Free full-text article] 

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