18 September 2009
An observational study found that adults with new or worsening cough, or symptoms suggestive of lower respiratory tract infection (LRTI) had a similar rate of recovery, whether or not antibiotics were prescribed.
Level of evidence:
Level 2 (limited-quality patient-oriented evidence) according to the SORT criteria.
Health professionals should follow NICE guidance on antibiotic prescribing for self-limiting respiratory tract infections. An immediate antibiotic prescription should only be offered to patients who are likely to be at risk of developing complications, i.e.
- if they are systemically very unwell
- if the symptoms and signs are suggestive of serious illness and/or complications e.g. pneumonia
- if they are at high risk of serious complications because of pre-existing comorbidity
- if they are older than 65 years with acute cough and two or more of the following, or older than 80 years with acute cough and one or more of the following:
- hospitalisation in the previous year
- type 1 or type 2 diabetes
- history of congestive heart failure
- current use of oral glucocorticoids.
A no-antibiotic or delayed-antibiotic strategy should be agreed for most adults and children (>3 months) with acute cough/acute bronchitis. Patients should also be given advice about the usual natural history of the illness, including the average total length of the illness (which in the case of acute cough/acute bronchitis is 3 weeks), and advice about managing symptoms, including fever. The NPC Patient decision aid relating to upper respiratory tract infections (URTIs) may be helpful in some consultations.
What is the background to this?
Acute cough is given as a major reason for antibiotic prescribing in primary care. However, as discussed on the respiratory tract section of NPC and in a MeReC Bulletin, the routine use of antibiotics is unnecessary for previously well patients with acute bronchitis, regardless of the duration of cough. A Cochrane review of 5 randomised controlled trials found that antibiotics reduced the mean duration of cough by half a day over 1–2 weeks, compared with placebo (weighted mean difference 0.58 days, 95% confidence interval [CI] 0.01 to 1.16). However, this modest benefit should be considered in the broader context of potential side-effects, medicalisation for a self-limiting condition, increased resistance to respiratory pathogens and cost of antibiotic treatment.
This cross-sectional observational study examined the variation in antibiotic prescribing for acute cough in 14 primary care networks in 13 European countries, and its impact on recovery, after controlling for clinical presentation.
What does this study claim?
This study recruited 3,402 adults with new or worsening cough, or symptoms suggestive of LRTI. Clinicians completed a case report form in 99% of cases, and 80% of patients returned a symptom diary. There were considerable differences in the decision to prescribe an antibiotic across the networks (range 21–88%, 53% overall, 63% in the English network), and wide variation in the choice of antibiotic prescribed. Overall, amoxicillin was the most common antibiotic prescribed (range 3–83%, 29% overall, 83% in the English network).
The large differences in antibiotic prescribing did not translate to clinically important differences in patient recovery. Although the rate of recovery was statistically significantly different between patients who were and were not prescribed antibiotics (once clinical presentation was taken into account), this was not considered to be clinically significant (a difference of 0.1% in the symptom severity score after 7 days). Indeed, the authors concluded that this was not clinically relevant, and entirely consistent with a placebo effect.
This large study was conducted across 13 European countries, so there may be some inconsistency between their perceptions of health, and patient-reporting of symptoms. However, the findings add further support to NICE guidance that, generally speaking, antibiotics should be avoided for the treatment of self-limiting respiratory tract infections e.g. acute cough/acute bronchitis, except in those at risk of complications. Evidence suggests that most antibiotic prescriptions do not help previously well patients recover more quickly and puts them at unnecessary risk of side effects – some with potentially serious consequences, such as C. diff infection. Antibiotic resistance is also a considerable problem.
Butler CC, Hood K, Verheij T, et al. Variation in antibiotic prescribing and its impact on recovery in patients with acute cough in primary care: prospective study in 13 countries. BMJ 2009;338:b2242
Design: Prospective, cross-sectional observational study.
Patients: 3,402 adults (aged >18 years) consulting for the first time within this illness episode with a new or worsening cough, or a clinical presentation suggestive of LRTI, with a duration of <28 days. Participating GPs from 14 primary care networks in 13 European countries recruited consecutive eligible patients in October and November 2006, and from late January to March 2007.
Intervention: Clinicians recorded aspects of patients’ history, symptoms, comorbidities, clinical findings and management, including antibiotic prescription and other treatments/investigations, on a case report form. They also indicated the presence/absence and severity of 14 symptoms e.g. cough, phlegm production, shortness of breath, fever. Recruited patients were given a symptom diary and asked to rate 13 symptoms each day until recovery (up to a maximum of 28 days), on a seven point scale.
Outcomes: Prescribing of antibiotics by clinicians and total symptom severity scores over time.
Results: Of the 3,402 participants, case report forms were completed for 99% and diary data were obtained from 80% of patients. Those who did not complete a diary were no more or less likely to have been prescribed an antibiotic than the other patients. Mean symptom severity scores ranged from 19 to 38 (scale range 0–100). Antibiotic prescribing by networks ranged from 20–88% (53% overall), for a median of 7 days, with wide variation in the classes of antibiotics prescribed. Overall, amoxicillin was the most common antibiotic prescribed (ranging from 3% in the Norwegian network to 83% in the English network). After adjustment for clinical presentation and demographics, considerable differences remained in antibiotic prescribing. Differences in recovery rate were small, and patients recovered at a similar rate regardless of network. Although the rate of recovery was statistically significantly different between patients who were and were not prescribed antibiotics (once clinical presentation was taken into account), this was not considered to be clinically significant.
Sponsorship: The study was funded by the 6th Framework Programme of the European Commission.
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