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DOCTORS are prescribing antibiotics for new cases of acute bronchitis in adult patients a staggering 90.6% of the time, despite guidelines and campaigns to reduce the use of antibiotics in such situations, according to unpublished Australian data.
The numbers mirror data from a US survey published in JAMA of ambulatory care delivered by physicians, outpatient practices and emergency departments, which found that the antibiotic prescribing rate for acute bronchitis was 71%. It also found the rate had increased over the 15-year study period despite evidence, guidelines, quality measures and “more than 15 years of educational efforts stating that the antibiotic prescribing rate should be zero”. (1)
Associate Professor Helena Britt, director of the Family Medicine Research Centre at the University of Sydney, which administers the Bettering the Evaluation and Care of Health (BEACH) study, replicated the parameters of the JAMA research for MJA InSight to provide Australian figures.
“Data from the BEACH program demonstrate that in the 5 years from April 2008 to March 2013, new cases of acute bronchitis were managed at encounters with 18–64-year-olds at a rate of 1.50 per 100 GP-patient encounters”, Professor Britt told MJA InSight.
She said the “best estimate” was that systemic antibiotics were prescribed for 90.6% of those new presentations (95% CI, 89.5%–91.7%). Prescription of systemic antibiotics for new acute bronchitis occurred at a rate of 1.36 times (95% CI, 1.29–1.43) per 100 encounters with patients in this age group, she said.
The BEACH calculations were based on records of 220 937 encounters with patients aged 18–64 years from 3909 GPs who managed at least one new case of acute bronchitis during 100 recorded BEACH encounters. The total sample included 4919 GPs who provided records of 491 900 encounters over the 5-year study period, Professor Britt said.
Professor Chris Del Mar, professor of public health at Bond University, Queensland, and an academic GP, said the complicated nature of diagnosing acute bronchitis was part of the reason for possible overprescription of antibiotics.
“Some people might call a cough acute bronchitis in order that they can prescribe antibiotics, but that’s not warranted at all”, Professor Del Mar told MJA InSight.
“The problem is that the latest Cochrane review on this found that there is a tiny benefit in prescribing antibiotics for [people with a clinical diagnosis of bronchitis], either acute or subacute. (2)
“Lower lung infections are difficult to pick up [at the primary care level] so it becomes a matter of GPs worrying about missing pneumonia, so to protect their patients they prescribe antibiotics.”
Professor Del Mar said GPs often did not consider the harms of antibiotics, such as diarrhoea, gut-ache, rash and thrush.
“It’s a question of asking whether the tiny benefits of antibiotics outweigh the harms.”
Dr Andrew Boyden, clinical adviser to NPS MedicineWise and a part-time GP, told MJA InSight that both the US research and the BEACH figures showed that “we have a really long way to go” in terms of antibiotic stewardship at the primary care level.
“Antibiotic stewardship in hospitals is happening and is relatively easy to do in the sense that there are audits and guidelines available”, Dr Boyden said.
“The big challenge is how to apply those ideas in a primary care setting. There are countries, such as the Netherlands, where the antibiotic prescribing rate is much lower. Perhaps we need to be asking what they do differently from us to achieve that.”
The US research and the BEACH numbers were “strong reminders” of the importance of the issue, he said.
Both Professor Del Mar and Dr Boyden said there was evidence that GPs thought their patients wanted to be prescribed antibiotics but in fact that was less common in reality.
“It’s important to emphasise that a shared decision-making process is needed when it comes to the risks and benefits of antibiotic prescribing”, Dr Boyden said.
“There has been a lot of awareness-raising on this issue over the past decade and patients are much more likely not to expect antibiotics.”
1. JAMA 2014; Online 21 May
2. Cochrane summaries 2014; Online 1 March
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We also need to include hidden antibiotic use in things like flu vaccines. There are 2 in the CSL Fluvax 2014, and Neomycin is in many others including childhood vaccines. Is there a way to get the benefits without adding to the overuse of antibiotics? .
Re comments from Emoticon and others – I don’t feel ‘ripped off’. I feel re-assured and more confident that I am doing the right thing for infections like those described. The GP does offer other advice too – not just prescribe.
I agree with anonymous. By the way, how’s your uncle. If I don’t prescribe antibiotic in acute bronchitis, then next day they will probably get another opinion down the road, get antibiotic, and consider me to be uncaring. Just lost another customer.
I agree with Emoticon – patients do feel “ripped off” if they think they needs antibiotics and they don’t get them, but I would argue they only feel that way if you don’t offer them any other advice. I find telling patients they have “a really bad virus” rather than “you just have a virus”, validates their visit and doesn’t give them the impression that YOU think they have wasted your time. Also pointing out that some of the most severe illnesses are viruses (EBV, HIV, HSV), so just because it’s a virus doesn’t mean they don’t feel sick. Then I always follow up with “the worst thing about viruses is that antibiotics don’t work”. And then follow up with symptomatic measures. It always surprises me when people have forgotten, or never known, the simple measures that can help a viral URTI (or bronchitis). I find this approach leaves the patient feeling that i do understand that they feel sick, and I have offered advice that can help their symptoms. They are also more likely to come back if they don’t improve. Win win I think. Maybe then we wouldn’t prescribe so many antibiotics!
I totally agree with the comments from Emoticon, above. I would add that it becomes even more difficult for conscientious GPs to convince patients that antibiotics are not going to be helpful to them when so many of our colleagues are actively undermining that message by continuing to prescribe to anyone with a “chesty cough”. This practice is disheartening in the extreme- it suggests that many (?most) GPs either lack the clinical skills to distinguish pneumonia from bronchitis (most of the time- I agree there are grey areas) or are unaware that antibiotics don’t work for acute bronchitis, or, worse still, choose to prescribe antibiotics anyway, just to keep the customers happy. If we all give a consistent message, the message does actually get through, so how about it guys?
With a cough and increased amounts of discoloured sputum, patients have an expectation that these symptoms have ‘earned’ themselves an antibiotic. They are convinced that this is the only way to a quick cure. Patients understand that the doctor may be reluctant to prescribe antibiotics but the they see themselves as a special case with important events ahead. They want this nuisance cough and infected sputum fixed pronto.
After relevant discussion, many will reluctantly accept that antibiotics will not benefit them or hasten recovery, but most feel that they have wasted their time and money coming to the GP and make that resentment clear.