Antibiotics for upper respiratory infections
To the editor:
I felt the UPRNet Study by Dosh and colleagues1 was a significant contribution to our understanding of the issue of antibiotic prescribing for upper respiratory infections (URIs). Trying to understand why physicians prescribe antibiotics for these situations is certainly a valuable insight and will contribute to further understanding in this area. I would emphasize some of the comments made in the section on physician knowledge that pointed out the need for a very large randomized control trial in patients with some of the factors mentioned by the physicians in this study. Large studies will be hard to do because of the difficulty of controlling this study for the particular type of patient involved. Patients with these illnesses present in myriad ways, and these separate presentations will have to be further understood and analyzed to see if any of them benefit from antibiotic use. I am not sure this study proved anything about inadequate physician knowledge as much as showed what causes them to use antibiotics in certain circumstances. A recent review of the section of Harrison’s Principles of Internal Medicine discussing rhinoviruses gave the following duration for the length of the common cold: 4 to 9 days. I also recall a quote from Harold Neu, an infectious disease expert at New York University, in which he stated that the common cold only lasts approximately a week and an upper respiratory illness going much beyond that point represents “a complication of the common cold.”
Although the study by Dosh and colleagues showed that there are a few physicians who will prescribe antibiotics for obvious common colds, I think many of the prescriptions written are for cases that are not quite so straightforward.
I would ask the authors of this study what they would do in the following 3 cases, all of which I saw in patients this week:
A 23-year-old woman presented with 7 days of cough, runny nose, and sore throat that improved for 1-day, but on the ninth day of being ill she developed headaches and right-sided facial pain. The nasal discharge during the first week had been thin-to-white in color and was now yellow to green.
A 33-year-old nonsmoking man presented because of a cough and purulent sputum lasting for 17 days.
An 18-year-old man presented with congestion, cough, and runny nose now in approximately the 18th day.
These do not fit the textbook description of viral infections, yet we are now being told that we should not prescribe antibiotics for these illnesses, all of which represent URIs. We clearly need more studies to prove whether these subgroups of patients will get better on their own with symptomatic care as quickly as when antibiotics are introduced. Only when these kinds of studies are done can we legitimately say that the behavior of many of our physicians is based on inadequate knowledge.
Jonathan B. Tocks, MD
Cumberland Family Practice
Enola, Pennsylvania
- Dosh SA, Hickner JM, Mainous AG 3rd, Ebell MH. Predictors of antibiotic prescribing for nonspecific upper respiratory infections, acute bronchitis, and acute sinusitis. J Fam Pract 2000; 49:407-14.
To the editor:
I am writing regarding the article by Dosh and coworkers. This is unfortunately another in a long series of papers that have appeared in JFP on the use of antibiotics in respiratory infections that seem to build on each other’s shaky foundations. The lack of appropriate disease definitions (eg, does wheezing define bronchitis, or does sinus tenderness define sinusitis?) preclude any valid conclusions from being drawn from their data. The whole paper is tautological.
What our discipline demands is a far more rigorous approach to defining upper and lower respiratory infections so appropriate observational or randomized controlled studies can be done. When a group cobbles together a paper of such obvious weakness, prepared only to meet academic requirements, that does nothing to further the appropriate diagnosis and treatment of the most common reason for physician visits, it is an embarrassment to us all.
David Kaufman, MD
Valley Medical Group
Florence, Massachusetts
The preceding letters were referred to Dr Dosh who responded as follows:
We appreciate Dr Tocks’s comments about our recent study of upper respiratory infections (URIs) and the questions raised by the cases he presented. Our primary purpose was to identify factors that are independently associated with the antibiotic prescribing practices of primary care clinicians. It did appear that some of the factors associated with antibiotic prescription use are not supported by current evidence. This is not to say that astute clinicians do not know when antibiotics should be used but that the evidence to support their decisions is sometimes lacking.
