Use and misuse of antibiotics in respiratory infections

Dr Jeyaseelan P. Nachiappan Consultant Infectious Disease Paediatrician

Aims
To discuss
common respiratory tract infections data on misuse of antibiotics reasons for misuse of antibiotics recommendations for appropriate use of antibiotics

National Medical Care Survey 2010

What is URTI?
Rhinitis, sinusitis, pharyngitis, tonsilitis, laryngobronchitis (ALTB/ croup), laryngitis, otitis media Usually involves more than one anatomical areas eg rhinosinusitis, ALTB

Common cold syndrome

139 rhinovirus+ patients

Gwaltney JM, Hendley JO, Simon G, Jordan WS. Rhinovirus infections in an industrial population. JAMA 1967;202:158-164

Natural history
a systematic review - aged between 0 - 4 years 8 RCTs and 2 cohort at one week 50% may be still coughing + nasal discharge at two weeks up to 24% of children may be no better

illness duration may be longer than many parents and clinicians expect
Hay AD, Wilson AD. The natural history of acute cough in children aged 0 to 4 years in primary care: a systematic review.. Br J Gen Pract. 2002 May;52(478):401-9

Common cold
prevalence varies by age
highest in age less than 5 yrs school/daycare are a large reservoir

3-8 viral URTI per year

Meneghetti eMedicine Aug 2006

healthy 3yr old child 6 to10 colds/yr

Wald ER Pediatrics. 1991

Exclusively caused by viruses

Pharyngitis / Tonsilitis
streptococcal pharyngitis 5% to 15% difficult to distinguish viral and strep clinical prediction rules Centor fever can be high grade viral tonsilitis

CPG Sore throat KKM 2003

Rhinitis versus Sinusitis

sinusitis if symptoms of rhinorrhea or persistent cough lasting >10-14 days without improvement or worsening Or Severe symptoms of acute sinus infection:
Fever (39oC) with purulent nasal discharge Facial pain or tenderness Periorbital swelling

Acute bronchitis
Acute coughing illness last for 3 weeks > 90% of cases due viruses Purulent sputum not predictive of bacterial infection.

Summary
Common cold
common and recurrent some symptoms persist till 2 weeks

5-15% of tonsillitis may be bacterial Sinusitis = prolonged rhinitis / cough Acute bronchitis
90% viral Prolonged cough

ANTIBIOTIC USE BY INFECTION (URTI, n=795)

With antibiotic (%) (n) Total consultations (n) Nasopharyngitis (Common cold) Pharyngitis/ Sore throat/ Tonsilitis Rhinosinusitis Otitis media URTI
7.0% (16) 65.0% (173) 31.2% (5) 50.0% (3) 32.5% (91) 227 266 16 6 280

Ng Li Meng Pharmacy HRPBI 2013 ( unpublished)

Outpatient Antibiotic Use and Prevalence of Antibiotic- Resistant Pneumococci in France and Germany: A Sociocultural Perspective
prevalence of penicillin resistant pneumococci is sharply divided between France (43%) and Germany (7%). These differences may be explained on different levels: antibiotic-prescribing practices for respiratory tract infections; patient-demand factors and health-belief differences; social determinants, including differing childcare practices; and differences in regulatory practices.
Harbarth S. Emerging Infectious Dis Vol.8, No. 12 Dec 2002

Outpatient antibiotic utilization

Resistance 43%

Resistance 7%

daily defined doses.

Why are antibiotics misused prescribed?

Appropriate use of antibiotics

demands (real or imaginary )

Why are antibiotics misused prescribed?

Patients nowadays are smart. They know when they need an antibiotic.. If they expect antibiotics and dont get it, they will not be satisfied.. Its all my patients fault. They keep on expecting antibiotics to be prescribed. I am sure I only prescribe antibiotics when it is really indicated If I do not prescribe an antibiotic, he/she will keep on coming back to me for the same problem. How else do I reduce my patients anxiety apart from prescribing antibiotics? What do you mean communicate with my patient? I have problems convincing my patient that it is a viral infection I am a busy doctor. Ive got no time to argue with my patient Does interventions really work? Will our patients really be satisfied? But are you sure my patient will not get complications if I do not give him antibiotics? But my patient still insists on antibiotics!

Patients nowadays are smart. They know when they need an antibiotic..

 Face-to-face survey in Britain in 2003. Of 10,981 randomly selected adults from England, Scotland and Wales, 7120 (65%) completed the questionnaire.

Its all my patients fault. They keep on expecting antibiotics to be prescribed.

 22 non randomly selected GP; 336 patients; Newcastle, Australia

likely to be prescribed medicines patients who expected medications general practitioner thought that the patient expected medication

X 3 X 10

the doctors' opinions about patients' expectations that were the strongest determinants of prescribing

But I am sure I only prescribe antibiotics when it is really indicated

Appropriateness of antibiotic prescribing for respiratory tract infections (n = 1469)

Akkerman A E et al. J. Antimicrob. Chemother. 2005;56:930-936

146

GPs; Netherlands; patients with sinusitis, tonsillitis and bronchitis; 4 weeks winter of 2002/2003

But are you sure my patient will not get complications if I do not give him antibiotics?

But what if my patient adamantly insists on antibiotics?

Appropriate use of antibiotics

Communication

REMEMBER: Effective communication is more important than an antibiotic for patient satisfaction.

Disadvantages of inappropriate antibiotic prescribing

Resistance in the patient Resistance in the community Unnecessary side effects Promotes magic bullet ; instant cure mentality Costs - patients, doctors standing, health care systems

TIPS for not overusing antibiotics in primary care

Tell patients about resistance Identify patient concerns Spend time answering questions Recommend specific symptomatic therapy Contingency plan if symptoms worsen. Provide patient education materials

Recommendations

Adult recommendations
Acute Tonsillitis Acute Pharyngitis Acute Bacterial Rhinosinusitis Mild CAP (out-patient) no morbidity Acute tracheobronchitis - usually viral Phenoxymethylpenicillin Amoxycillin EES None unless symptoms persist > 7 days EES EES Amoxycillin EES

Paediatric Recommendations

Otitis media

Amoxycillin

Amoxycillin Clavulanate

Pneumonia (Outpatient)
Bronchiolitis

Amoxycillin
No antibiotics

Summary
common infections respiratory tract infections data on misuse of antibiotics reasons for misuse of antibiotics recommendations for appropriate use of antibiotics

Acknowledgements
Dr Benedict Sim Infectious disease Physician Dr Sheamini Sivasampu CRC Dr Leong Kar Nim Infectious disease Physician Ms Ng Li Meng Pharmacist HRPBI

Thank You