Antibiotic Inappropriateness

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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]

As an example of the blatant mis- or overuse of antibiotics, we often see many persons are knee-jerked treated with antibiotics for "Sinusitis" that is really a cold/URI.

The article, "Acute bacterial rhino-sinusitis in children: Clinical features and diagnosis" by Ellen R. Wald and Editors with table: "Characteristic features of viral versus bacterial rhinosinusitis in children" is compelling about the difference between conditions. It can be accessed on-line, however one must be registered to UpToDate^® [an evidence-based, physician-authored clinical decision support resource] to see it. Here's my take on their table, which is not taking from the original: I'll call it "URI vs a Real Sinus Infection"

Clinical feature	Viral rhinosinusitis	Bacterial rhinosinusitis
Temperature elevated:	Usually there is no fever, but when it occurs in the beginning of the illness, it is not a major symptom and it resolves quickly	When you have this condition, the temperature can be quite high, e.g., 102.2°F (≥39°C ) for more than 3 days or it can reoccur at the end of the first week
Nose discharge:	Coryza, green nasal discharge days 3-6 of the illness; then steadily improves	Worsens
Cough	Same as the nose, above	Worsening cough
Feeling very bad:	Absent	Definitely feeling bad.
Headache:	Usually Absent or minor	Severe headache may be preent early or appear as a complication
Course:	Initially may slightly worsen but then improves	Symptoms are a real burden, often lasting over a week and a half