Top five misconceptions in management of respiratory tract ...

Top five misconceptions in management of respiratory tract

infections Chris Butler

Professor of primary care medicine Cardiff University ESCMID Online Lectu

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ESCMID Online Lecture Library

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1. “My patients are different…”

• They are sicker, older, smoke more, have a different threshold for consulting, so they do need antibiotics..


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GRACE-01: Objectives

• To describe current presentation, investigation, management and outcomes for patients with community-acquired LRTI in primary care across and within European Countries

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METHODS

• Sample: – Enrolment of consecutive patients consulting with

acute (≤28 days duration) cough as the main symptom.

– 2 recruitment periods of 1 month (Oct/06, Feb/07)

– Target 300 patients per network. ~4200 patients in total. Sample size based on requirements for within network analysis.


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METHODS

Data capture: – CRF (clinician completed)

• Demographics, history, presentation, clinical findings, usual investigations, management, referral, perceived expectations etc.

– One month diary (patient completed) • Expectations, hopes & beliefs of antibiotics, reasons for

consulting, daily symptoms, taking of medications, healthcare resource use.

Data collection coordinated within each network, with data management via a secure online system ESCMID Online Lectu

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GRACE 01: Participant Flow Chart

Patients Recruited and Registered (n=3402)

Excluded Patients (n=4)

Reason: Patients did not meet eligibility criteria

Case Record Form (CRF) (n=3368)

99%

Patient Diary (n=2714)

80%

CRF and Diary Returned N = 2690

(79%)


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Proportion of adult LRTI patients prescribed an antibiotic

Butler C et al. BMJ 2009;338:b2242

Recommended antibiotics (Amoxicillin or tetracycline)

Other antibiotics

Wood J et al. Eur Res J 2011;38:112-8


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Clinician Management: antibiotic prescribing


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Survival modelling

• Models the time to symptom resolution (total symptom severity score of zero) controlling for casemix

• Naturally accounts for censoring • Survival analysis equivalent of hierarchical

modelling is frailty modelling ESCMID Online Lectu

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Types of Antibiotic Prescribed

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

100.0

Brati

slava

Milano

Balat

onfur

edLo

dz

Cardif

f

South

ampton

Helsink

i

Utrech

t

Jonk

oping

Rotenb

urg

Mataro

Trom

so

Antw

erp

Barce

lona

Network

Perc

en

tag

e

Sulfonamide/Trimethoprim

Other

Phenoxymethyl Penicillin

Quinolone

Cephalosporin

Tetracycline

Co-Amoxiclav

Macrolide/Lincosamide

Amoxicillin

Chris Butler RIP


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2. “Amoxicillin is not strong enough for my patients..”

• “Reducing inflammation may play a role” • “Microbial resiatnace is high where I work” • “So my patients require a macrolide or

quinolone”


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Aim

To investigate whether treatment with a particular antibiotic class is associated with

time until patients report they felt recovered

(compared with amoxicillin)


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Antibiotic class

• British National Formulary Classification – Tetracyclines – Amoxicillin – Cephalosporins – Sulfonamides/Trimethoprim – Macrolides/Lincosamides – Quinolones – Phenoxymethylpenicillin/Penicillin G – Co-amoxiclav – Other


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Day Felt Recovered Analysis • Patients were asked “Overall, on what day did you feel

recovered”

• The analysis controlled for - clinician recorded symptoms - sputum type - temperature - age - co-morbidities (cardiovascular, respiratory & diabetes) - the number of days waited before presentation - smoking status - network ESCMID Online Lectu

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Comparison with amoxicillin


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Conclusion

• No meaningful differences in symptom severity scores between those prescribed different antibiotic classes

• No differences between day felt recovered between those prescribed different antibiotic classes ESCMID Online Lectu

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3. “Antibiotics speed recovery in those who are feeling unwell and with discoloured sputum” • “You should only prescribe antibioitcs to those

who are unwell and coughing up discoloured spututm”


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Rapid response to the BMJ paper

“I am not surprised at these findings of the

GRACE group …. Antibiotics in the otherwise healthy are only needed if the patient feels unwell or has purulent phlegm. ”


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Gross!


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Analysis • Analysis controlled for - clinician recorded symptoms - sputum colour - temperature - age - co-morbidities (cardiovascular, respiratory including COPD,

and COPD on its own, and diabetes) - the number of days waited before presentation - smoking status - network ESCMID Online Lectu

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Results • Those producing normal sputum (clear/white) were not more

likely to be prescribed than those not producing sputum (OR: 0.95, 95% CI: [0.61,1.48])

• Those producing discoloured sputum were more likely to be prescribed than those not producing sputum (OR: 3.2, 95% CI: [2.1, 5.0])

• Those feeling generally unwell (mild, moderate or severe) were not prescribed more frequently than those without ESCMID Online Lectu

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Patient outcome results • Those who the clinician recorded as feeling generally

unwell (mild, moderate or severe) – had higher self-reported symptom severity scores at

baseline – recovered marginally faster than those not feeling

generally unwell

• Antibiotic prescription was not associated with recovery rate for those: – feeling generally unwell (any level) – yellow sputum – green sputum – yellow/green sputum and feeling generally unwell


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Recovery trajectories for each subgroup


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Conclusion

• Discoloured sputum does influence clinician

prescribing. Feeling generally unwell does not.

• There was no association between antibiotic prescribing and patient recovery for any patient subgroup investigated


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4. “I speak the same language as my patients..”


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4. “I speak the same language as my patients.


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Interviews conducted Network Clinician Patient Antwerp 10 10 Balatonfüred 10 20 Barcelona 10 19 Cardiff 8 10 Lodz 10 20 Milan 10 13 Southampton 6 9 Tromsø 7 10

Utrecht 10 10

TOTAL 81 121


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Framework Approach

Why? Systematic Procedure, Producing Analyses with ‘Potential for Actionable Outcomes’ (Ritchie & Spencer, 1994)

Five Stages 1. Familiarisation 2. Identifying a thematic framework 3. Indexing 4. Charting 5. Mapping & Interpretation

Each network treated as an independent set initially ESCMID Online Lectu

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Results

1: Body becomes immune to antibiotics

2: Bacteria become immune to

antibiotics ESCMID Online Lecture Library

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The resistant body Commonest view across all 8 networks “Body gets used to antibiotics” “If you take them too much then you get to the

point where it doesn‘t work any more, because the body gets used to it. Then they don’t have the desired effect” (Barcelona 185)


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5. “Clinician patient relationships are not important for antimicrobial

stewardship..’

• Qualitative study


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CHAMP-02 Objective: To achieve a better understanding of the perceptions, expectations and illness behaviour of parents of child patients with RTI Population: Parents of children (6 moths–12 yrs) presenting with RTI in the last 3 months Data Collection: semi-structured interview Topic Guide: Included reflections on management of child and own management of RTI Analysis: Framework analysis ESCMID Online Lectu

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Main Results - Response CHAMP-02 Total no of interviews: 63

Barcelona (20), Cardiff (15), Lodz (16), Tromsø (12)


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European Similarities

• Parental trust in clinician: “I trust my doctor so if she says that an antibiotic is not necessary for sure in this case then I see no reason to insist” (Lodz 2)

• Following advice to not give antibiotics: “he got well again, so … I sort of buy what he said about reducing the use of antibiotics” (Tromsø 9)

• When making decisions on antibiotic management, the majority of parents throughout all networks emphasised the trust that they had in their clinicians which ultimately led to consultation satisfaction and acceptance of clinicians’ decisions.


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Adherence

1290 prescribed immediate AB

639 (49.5%) adhered

651 (50.5%) did not adhere

142 (11.0%) took for < 80% of

duration

140 (10.9%) took another

antibiotic

369 (28.6%) took no antibiotics


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Variation in prescribed and consumed antibiotics

0

10

20

30

40

50

60

70

80

90

100

Bratisl

ava

Milan

Balaton

fured

Lodz

Cardiff

Southa

mpton

Helsink

i

Utrech

t

Jonk

oping

Mataro

Rotenb

urg

Tromso

Antwerp

Barcelo

na

Network

%

Prescribed* Consumed Antibiotic** Consumed Prescribed Antibiotic***

* Prescribed antibiotics at initial consultation** Consumed antibiotics during 28 day study period (whether prescribed or not)*** Consumed antibiotics prescribed at initial consultation


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Top five misconceptions in management of respiratory tract ...

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