Prescribing Antibiotics for Upper Respiratory Infections
Clinical guidelines and clinician education
Concerns about antibiotic resistance, drug side effects, and the evidence regarding treatment efficacy have led to the publication of guidelines by the Centers for Disease Control and Prevention (CDC) and the American Academy of Pediatrics. The guidelines promote 2 principles for judicious use of antimicrobial medications in patients with URIs: (1) an antimicrobial should not be given for the common cold, and (2) mucopurulent rhinitis (thick, opaque, or discolored nasal discharge) is not an indication for treatment unless it persists for more than 10 to 14 days.13
The use of guidelines, feedback to physicians, and patient education has not clearly influenced patterns of antibiotic prescribing for URIs. In 4 selected primary care practices from a Denver health maintenance organization, multidimensional interventions including household and office-based patient education materials, clinician education, profiling, and academic detailing resulted in a 25% decrease in antibiotic use for uncomplicated acute bronchitis.14 Multidimensional interventions may not be practical or effective in the majority of family practice offices. A Kentucky statewide strategy of using performance feedback and educational materials to reduce antibiotic prescriptions for pediatric respiratory infections had little impact on antibiotic prescribing. Antibiotic prescribing for viral respiratory infections continued to increase during the 5-month postintervention study period.15
Changing the beliefs and behavior of patients and clinicians
Dosh and coworkers5 reported that clinicians diagnosed sinusitis or bronchitis in 66% of all patients with acute URI symptoms and prescribed antibiotics for 98% of sinusitis diagnoses and 80% of bronchitis diagnoses. These percentages support the assertion that clinicians have an inadequate knowledge of the presentation and course of viral URIs, and they prescribe antibiotics at an unacceptably high rate. Hueston and colleagues4 identify the need for research into how clinicians can best advise patients presenting with acute URIs, rather than additional research into defining the differences between sinusitis, bronchitis, and the common cold.
An examination of communication in the examination room and within primary practices provides useful tools for clinicians and patients addressing an acute upper respiratory illness. These tools include: patient education, staff education, group practice buy-in, and the patient-centered interview.
Patient Education. Patient education includes establishing a diagnosis, discussing the natural course of the illness, prescribing comfort measures, and making recommendations for returning to work or school. The CDC has developed useful patient education handouts and tools for health providers that include the advice: “When parents request antibiotics for rhinitis or the ‘common cold’…give them an explanation, not a prescription.”1*
Staff Education. Triage nurses and medical assistants frequently return calls and address patient concerns. They need to understand the evidence behind the recommendations for antibiotic use and the reasons for discussing alternative therapies for treating upper respiratory illnesses. Consistency of advice is essential.
Group Practice Buy-in. Practice partners need to come to an agreement regarding how antibiotics should be prescribed for upper respiratory illnesses. If one clinician liberally prescribes antibiotics, the careful explanations and patient education provided by the other practice partners will be undermined.
Patient-Centered Interview. The patient-centered examination room interview can be used for quickly and explicitly identifying patient expectations and for making sure the patient leaves satisfied. The patient-centered interview should explore (1) the patients’ ideas about what is wrong; (2) their feelings, especially their fears about their problems; (3) their expectations of the physician; and (4) the effect of the illness on functioning.16
Preservation of the physician-patient relationship is not dependent on the patients’ walking out of the examination room with a prescription for antibiotics. Patients are satisfied when they understand their illness, have their questions answered, and feel the physician spent enough time with them.8,10
The studies by Dosh and Hueston and their colleagues indicate the need to develop interventions designed to reduce prescribing antibiotics for URIs. Research is necessary to develop effective examination room scripts for identifying and addressing patient expectations.
