Antibiotic prescription strategies and adverse outcome for uncomplicated lower respiratory tract infections: prospective cough complication cohort (3C) study

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Abstract

Objective To assess the impact on adverse outcomes of different antibiotic prescribing strategies for lower respiratory tract infections in people aged 16 years or more.

Design Prospective cohort study.

Setting UK general practice.

Participants 28 883 patients with lower respiratory tract infection; symptoms, signs, and antibiotic prescribing strategies were recorded at the index consultation.

Main outcome measures The main outcomes were reconsultation with symptoms of lower respiratory tract infection in the 30 days after the index consultation, hospital admission, or death. Multivariable analysis controlled for an extensive list of variables related to the propensity to prescribe antibiotics and for clustering by doctor.

Results Of the 28 883 participants, 104 (0.4%) were referred to hospital for radiographic investigation or admission, or both on the day of the index consultation, or were admitted with cancer. Of the remaining 28 779, subsequent hospital admission or death occurred in 26/7332 (0.3%) after no antibiotic prescription, 156/17 628 (0.9%) after prescription for immediate antibiotics, and 14/3819 (0.4%) after a prescription for delayed antibiotics. Multivariable analysis documented no reduction in hospital admission and death after immediate antibiotics (multivariable risk ratio 1.06, 95% confidence interval 0.63 to 1.81, P=0.84) and a non-significant reduction with delayed antibiotics (0.81, 0.41 to 1.64, P=0.61). Reconsultation for new, worsening, or non-resolving symptoms was common (1443/7332 (19.7%), 4455/17 628 (25.3%), and 538/3819 (14.1%), respectively) and was significantly reduced by delayed antibiotics (multivariable risk ratio 0.64, 0.57 to 0.72, P<0.001) but not by immediate antibiotics (0.98, 0.90 to 1.07, P=0.66).

Conclusion Prescribing immediate antibiotics may not reduce subsequent hospital admission or death for young people and adults with uncomplicated lower respiratory tract infection, and such events are uncommon. If clinicians are considering antibiotics, a delayed prescription may be preferable since it is associated with a reduced number of reconsultations for worsening illness.

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Most cited references 22

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Article: not found

Overestimation of risk ratios by odds ratios in trials and cohort studies: alternatives to logistic regression.

Mirjam J Knol, Saskia Le Cessie, Ale Algra … (2012)

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Why do general practitioners prescribe antibiotics for sore throat? Grounded theory interview study.

Parvathi Kumar, Nicky Britten, Paul Little (2003)

To understand why general practitioners prescribe antibiotics for some cases of sore throat and to explore the factors that influence their prescribing. Grounded theory interview study. General practice. 40 general practitioners: 25 in the maximum variety sample and 15 in the theoretical sample. General practitioners are uncertain which patients will benefit from antibiotics but prescribe for sicker patients and for patients from socioeconomically deprived backgrounds because of concerns about complications. They are also more likely to prescribe in pressured clinical contexts. Doctors are mostly comfortable with their prescribing decisions and are not prescribing to maintain the doctor-patient relationship. General practitioners have reduced prescribing for sore throat in response to research and policy initiatives. Further interventions to reduce prescribing would need to improve identification of patients at risk of complications and be workable in busy clinical situations.

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Is Open Access

Amoxicillin for acute lower-respiratory-tract infection in primary care when pneumonia is not suspected: a 12-country, randomised, placebo-controlled trial.

Paul Little, Beth Stuart, Michael Moore … (2013)

Lower-respiratory-tract infection is one of the most common acute illnesses managed in primary care. Few placebo-controlled studies of antibiotics have been done, and overall effectiveness (particularly in subgroups such as older people) is debated. We aimed to compare the benefits and harms of amoxicillin for acute lower-respiratory-tract infection with those of placebo both overall and in patients aged 60 years or older. Patients older than 18 years with acute lower-respiratory-tract infections (cough of ≤28 days' duration) in whom pneumonia was not suspected were randomly assigned (1:1) to either amoxicillin (1 g three times daily for 7 days) or placebo by computer-generated random numbers. Our primary outcome was duration of symptoms rated "moderately bad" or worse. Secondary outcomes were symptom severity in days 2-4 and new or worsening symptoms. Investigators and patients were masked to treatment allocation. This trial is registered with EudraCT (2007-001586-15), UKCRN Portfolio (ID 4175), ISRCTN (52261229), and FWO (G.0274.08N). 1038 patients were assigned to the amoxicillin group and 1023 to the placebo group. Neither duration of symptoms rated "moderately bad" or worse (hazard ratio 1.06, 95% CI 0.96-1.18; p=0.229) nor mean symptom severity (1.69 with placebo vs 1.62 with amoxicillin; difference -0.07 [95% CI -0.15 to 0.007]; p=0.074) differed significantly between groups. New or worsening symptoms were significantly less common in the amoxicillin group than in the placebo group (162 [15.9%] of 1021 patients vs 194 [19.3%] of 1006; p=0.043; number needed to treat 30). Cases of nausea, rash, or diarrhoea were significantly more common in the amoxicillin group than in the placebo group (number needed to harm 21, 95% CI 11-174; p=0.025), and one case of anaphylaxis was noted with amoxicillin. Two patients in the placebo group and one in the amoxicillin group needed to be admitted to hospital; no study-related deaths were noted. We noted no evidence of selective benefit in patients aged 60 years or older (n=595). When pneumonia is not suspected clinically, amoxicillin provides little benefit for acute lower-respiratory-tract infection in primary care both overall and in patients aged 60 years or more, and causes slight harms. European Commission Framework Programme 6, UK National Institute for Health Research, Barcelona Ciberde Enfermedades Respiratorias, and Research Foundation Flanders. Copyright © 2013 Elsevier Ltd. All rights reserved.

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Author and article information

Contributors

Paul Little: Role: professor of primary care research

Beth Stuart: Role: statistician

Sue Smith: Role: study coordinator

Matthew J Thompson: Role: professor in family medicine

Kyle Knox: Role: general practitioner

Ann van den Bruel: Role: associate professor of general practice

Mark Lown: Role: clinical lecturer

Michael Moore: Role: professor of general practice

David Mant: Role: emeritus professor of general practice

Journal

Journal ID (nlm-ta): BMJ

Journal ID (iso-abbrev): BMJ

Journal ID (publisher-id): bmj

Title: The BMJ

Publisher: BMJ Publishing Group Ltd.

ISSN (Print): 0959-8138

ISSN (Electronic): 1756-1833

Publication date Collection: 2017

Publication date (Electronic): 23 May 2017

Volume: 357

Electronic Location Identifier: j2148

Affiliations

[1 ]University of Southampton, Primary Care Medical Group, PCPS Unit, Aldermoor Health Centre, Southampton SO16 5ST, UK

[2 ]Nuffield Department of Primary Health Care Sciences, University of Oxford, Radcliffe Observatory Quarter, Oxford, UK

[3 ]University of Washington, Seattle WA, USA

Author notes

Correspondence to: P Little p.little@ 123456soton.ac.uk

Article

Publisher ID: litp035286

DOI: 10.1136/bmj.j2148

PMC ID: 5439222

PubMed ID: 28533265

SO-VID: 1f0ee142-534c-48a1-8da3-981920470519

License:

This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: http://creativecommons.org/licenses/by/4.0/.

Antibiotic prescription strategies and adverse outcome for uncomplicated lower respiratory tract infections: prospective cough complication cohort (3C) study

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Most cited references 22

Overestimation of risk ratios by odds ratios in trials and cohort studies: alternatives to logistic regression.

Why do general practitioners prescribe antibiotics for sore throat? Grounded theory interview study.

Amoxicillin for acute lower-respiratory-tract infection in primary care when pneumonia is not suspected: a 12-country, randomised, placebo-controlled trial.

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