Antibiotics and Respiratory Infection
Sources: Gonzales R, et al. Eff Clin Pract. 2001;4:105-111; Sargent J, Welch HG. Eff Clin Pract. 2001;4:136-138.
Gonzales and colleagues provide follow-up information on patient satisfaction after a study that documented the value of a patient education campaign on antibiotic prescribing.1 The intervention led to a drop in antibiotic prescriptions for acute bronchitis from 74% to 48% in outpatient clinics in the Kaiser Permanente system in Denver, Colo, during the winter of 1997-1998.
This study involved 2 clinics, both of which had an office-based program to reduce antibiotic prescribing that consisted of exam room posters, fact sheets, and a 1-hour educational session for clinicians. The intervention clinic also had the benefit of direct patient education with direct mailings to patients, refrigerator magnets, self-care guidelines, CDC brochures on antibiotic use, and a letter from the clinic director. The period under study was the winter of 1998-1999. No new direct patient contact was made, but there was some reinforcement of the prior messages through newsletters and another hour lecture for clinicians on how to say "No."
Records of patients seen at the clinic with a diagnosis of acute bronchitis were reviewed. Satisfaction was assessed with a telephone questionnaire, to which 416 patients responded. One hundred fifty patients were excluded because of missing data or a good reason to get an antibiotic because of another respiratory infection.
Antibiotics were used less frequently in the "intervention" clinic, but the percentage receiving antibiotics rose to 64% from 48% the year before. Nonetheless, the control clinic remained higher, with 85% of patients receiving prescriptions. Patients were interviewed within 4 weeks of evaluation. Sixty-nine percent in the intervention clinic and 63% in the control clinic indicated their level of satisfaction with care was "very good" or "excellent." Further analysis was done to determine satisfaction factors but only a limited correlation was found with age and duration of symptoms.
Comment by Alan D. Tice, MD, FACP
This is a follow-up study with some interesting observations and insight provided in the accompanying editorial. While patient satisfaction has not been reported to correlate with antibiotic prescriptions, physicians commonly report it as a reason why they prescribe antibiotics. This article again demonstrates satisfaction with care among those who did not get prescriptions compared with those who did. It is, however, the first to demonstrate no difference in satisfaction even though there was clearly a change in prescribing. In fact, there was a suggestion that there was a higher rate of satisfaction in the intervention clinic in which antibiotics were less frequently prescribed.
How important a factor patient satisfaction or demands are in the decision to prescribe antibiotics is up for debate. Certainly, time with a patient providing evaluation, education, and assurance correlate well with satisfaction with care. Beyond that, there appears to be little indication that patients feel they know more about antibiotic prescribing than the physician.
What is also interesting about the study is that more than half of the patients received an antibiotic for an illness in which such therapy is not indicated. Is that the fault of the physician or the patient?
As Sargent and Welch point out in the editorial, there are many factors responsible for antibiotic use besides the patient’s wishes. A simple rule is not adequate for the complexity of factors that must be considered in evaluating an infection. Risks of therapy must be weighed against the possibility of serious disease that would easily respond to early therapy but not later on. The risk of a lawsuit for an infection that might have responded to an antibiotic not prescribed is far higher than one in which the drug was prescribed. The cumulative effect on antimicrobial resistance in society is a subtle one and not often appreciated by an ill person or even a physician who is trying to help. It is not an easy situation these days in this litigious society and creates a difficult choice between the individual and society with the rising tide of antimicrobial resistance.
In essence, the decision to prescribe an antibiotic lies with the physician, although the relationship with the patient is essential, and the desire of a patient to receive an antibiotic may be moderated by a careful evaluation, education, and assurance.
Dr. Tice is a member of Infections Limited, PS, Tacoma, Wash.
1. Gonzales R, et al. JAMA. 1999;281:1512-1519.