Reducing Antibiotic Use for Acute Bronchitis in Primary Care
Reducing Antibiotic Use for Acute Bronchitis in Primary Care
Abstract & Commentary
Synopsis: This current study proved that reassurance in patients with acute bronchitis might be a safe strategy in reducing antibiotic use.
Source: Macfarlane J, et al. BMJ. 2002;324:91-94.
Acute bronchitis is a common condition and it is well known that most adults who consult their primary care doctor for this will receive antibiotics. However, antibiotics do not affect the natural course of the symptoms, and the concern is that overuse of antibiotics will increase the prevalence of drug resistance.
Macfarlane and colleagues performed a nested, single-blind, randomized controlled trial in 3 suburban general practices in Nottingham, England, to assess whether sharing the uncertainty of the value of antibiotics for acute bronchitis would affect the likelihood of patients taking antibiotics. Inclusion criteria were patients aged older than 16 years and previously well and with no significant past medical history (eg, asthma, COPD, DM, CAD, etc). Lower respiratory tract infection was diagnosed if there was an acute illness of less than 21 days, associated with cough as the main symptom, with no alternative explanation. Two hundred fifty-nine patients agreed to enter the study and were divided into 2 groups. Group A (212/254) patients were those in whom antibiotics were not indicated, and group B (44/259) were those who definitely required antibiotics. Patients in Group A were subsequently randomized into 2 groups. Both groups (A1 + A2) were given verbal explanations that the use of antibiotics was not necessary. Group A1 was also given a leaflet reinforcing the verbal warning. Group A2 was the control group and received no leaflet. Both groups were also given a prescription for antibiotics to keep at home and were advised to use their judgment whether to use it in due course. The primary end point was whether the patients took antibiotics. The secondary outcome was whether patients initiated a further consultation for the same symptoms within the next month.
Fewer patients who received the leaflet (Group A1) took antibiotics, compared to the control group (47% vs 62%, risk ratio 0.76; 95% CI, 0.59-0.97, P = 0.04; number needed to treat 6.7). They also found no evidence of confounding by age, sex, smoking status, whether patients paid for their prescriptions, and duration of cough. The reconsultation rates were similar for all patients in Group A.
Comment by David Ost, MD, & Andreas Kyprianou, MD
Most episodes of acute bronchitis resolve on their own, but most patients who consult their primary care physician initially expect to receive antibiotics.1 This study demonstrated that only 20% of patients actually required antibiotics, which is consistent with the results from other studies.2
This study suggests that by sharing information both verbally and in writing, unnecessary antibiotic use can be significantly reduced.
Dr. Ost, Assistant Professor of Medicine, NYU School of Medicine, Director of Interventional Pulmonology, Division of Pulmonary and Critical Care Medicine, Northshore University Hospital, Manhasset, NY, is Associate Editor of Internal Medicine Alert. Dr. Kyprianou is Chief Resident of Internal Medicine, New York Hospital Medical Center, Queens/Cornell Medical Program, New York, NY.
References
1. Arroll B, et al. BMJ. 2001;322:939-940.
2. Gonzales R, et al. Lancet. 1995;345:665-666.
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