Variation in antibiotic prescribing and its impact on recovery in patients with acute cough in primary care: prospective study in 13 countries

Abstract

Objective To describe variation in antibiotic prescribing for acute cough in contrasting European settings and the impact on recovery. Design Cross sectional observational study with clinicians from 14 primary care research networks in 13 European countries who recorded symptoms on presentation and management. Patients followed up for 28 days with patient diaries. Setting Primary care. Participants Adults with a new or worsening cough or clinical presentation suggestive of lower respiratory tract infection. Main outcome measures Prescribing of antibiotics by clinicians and total symptom severity scores over time. Results 3402 patients were recruited (clinicians completed a case report form for 99% (3368) of participants and 80% (2714) returned a symptom diary). Mean symptom severity scores at presentation ranged from 19 (scale range 0 to 100) in networks based in Spain and Italy to 38 in the network based in Sweden. Antibiotic prescribing by networks ranged from 20% to nearly 90% (53% overall), with wide variation in classes of antibiotics prescribed. Amoxicillin was overall the most common antibiotic prescribed, but this ranged from 3% of antibiotics prescribed in the Norwegian network to 83% in the English network. While fluoroquinolones were not prescribed at all in three networks, they were prescribed for 18% in the Milan network. After adjustment for clinical presentation and demographics, considerable differences remained in antibiotic prescribing, ranging from Norway (odds ratio 0.18, 95% confidence interval 0.11 to 0.30) to Slovakia (11.2, 6.20 to 20.27) compared with the overall mean (proportion prescribed: 0.53). The rate of recovery was similar for patients who were and were not prescribed antibiotics (coefficient −0.01, P<0.01) once clinical presentation was taken into account.

Diagnosing pneumonia in patients with acute cough: clinical judgment compared to chest radiography

“…It is therefore helpful that we found the NPV of clinical judgment to be as high as 96%. This can support GPs to rely on their ability to exclude pneumonia and withhold antibiotic treatment in a large proportion of their patients [12].…”

“…Nevertheless, : pulmonary comorbidity was defined as history of asthma or chronic obstructive pulmonary disease and cardiac comorbidity was defined as history of heart failure or ischaemic heart disease; we believe the findings of the study are at low risk of selection bias because feedback from recruiting clinicians during and after the study indicated that the time required to recruit and assess each patient made sequential recruitment of every eligible patient impossible. A recent observational study [12] in the same recruiting primary care networks used the same case definition and a very similar baseline case record form, but was much simpler to implement and that study recruited patients with similar characteristics to the current study (e.g. age 45 years, 37% male, and 26% comorbidity of either pulmonary, cardiac or diabetes mellitus).…”

Incidental Chest Radiographic Findings in Adult Patients With Acute Cough

“…12 The GRACE project contains an observational study (workpackage [WP] 9) with a trial randomizing patients with LRTI to amoxicillin or placebo (WP 10) nested within. The trial results will be reported separately.…”

Amoxicillin is associated with a lower risk of further antibiotic prescriptions for lower respiratory tract infections in primary care – A database analysis spanning over 30 years

“…Yet treatment decisions are often made independent of these, for example initial clinical severity scores and clinical response to therapy were not related to duration of antibiotic therapy in adults admitted with community acquired pneumonia [19]. Variations in clinical presentation did not explain the large discrepancies in antibiotic prescribing for acute cough in a cross-sectional study of 14 European countries [20]. Repeat prescriptions could have been issued due to genuine anti-microbial failure, but also due to drug failure caused by side effects or incorrect diagnoses.…”