In the third article in our series featuring the ïinformation for patients and professionalsÍ section from the latest evidence-based guidelines from SIGN, we reproduce the information section from SIGN guideline number 59, on lower respiratory tract infection in adults.
Community management of lower respiratory tract infection in adults
The reasons for prescription of antibiotics in respiratory illness are complex. Many patients with non-pneumonic LRTI believe that their symptoms are due to an infection which can be cured by antibiotics and such beliefs can significantly influence a general practitionerÍs prescribing.
A primary care study showed a correlation between a patientÍs expectations of receiving an antibiotic and a physician prescribing it. Physicians prescribed antibiotics 77% of the time when they believed that the patients wanted antibiotics, but only 29% of the time when they believed the patients did not want antibiotics; however, in only 47% of patients was the physicianÍs perception correct.
Patient satisfaction in this study was most strongly associated with the physician spending enough time explaining the illness and the choice of treatment.
GPs can reduce a patientÍs expectations of being prescribed an antibiotic and reduce unnecessary reconsultations by addressing four issues at consultation:
- The natural course of the illness
- The lack of effectiveness of antibiotics
- The problems of antibiotic resistance
- The side-effects of antibiotics.
Time constraints are often a difficulty in general practice, and this may influence prescribing habits. However, it has been shown that a decrease in antibiotic prescribing need not lead to an increase in the reconsultation rate, that the reconsultation rate in a single illness episode seems independent of antibiotic prescribing, and furthermore that antibiotic prescriptions may increase the likelihood of future consultations if the patient perceived that the drug had helped in the past. Previous consultation habit, underlying chronic disease and dyspnoea were positively associated with reconsultation.
Attempts to solve this problem are likely to be largely behavioural, multifactorial and multidisciplinary in nature, requiring education of both patients and medical staff. No single intervention is likely to produce a high degree of change.
Nevertheless, intervention strategies adopting a multidimensional approach (educational patient mailings, clinician education in communication and disease management, and surgery based literature) have shown a reduction in antibiotic prescribing of up to 40%.
The provision of patient education alone has been successful in recent studies. These studies have shown that the use of an information leaflet for patients significantly reduces reconsultation rates. In addition, using terms such as ïchest coldÍ with patients, rather than ïbronchitisÍ or ïchest infectionÍ, may reduce their expectations for an antibiotic.
GPs should give non-pneumonic LRTI patients written information to help explain the illness, to explain the decision not to prescribe an antibiotic and to reduce reconsultation rates.
The example patient information leaflet (right) may be copied freely and adapted for use locally. A sample copy of a patient leaflet is also available from the BMJ website: http://bmj.com/cgi/content/full/324/7329/91.
|Example information leaflet for patients with a cough|
Reproduced with kind permission from: SIGN 59. Community Management of Lower Respiratory Tract Infection in Adults. Edinburgh: Scottish Intercollegiate Guidelines Network, June 2002. The full guideline can be downloaded from the SIGN website: www.sign.ac.uk
|Sources of further information|
The British Lung Foundation
78 Hatton Garden,
Chest, Heart & Stroke Scotland
65 North Castle Street
|Adapted from: SIGN 59. Community Management of Lower Repiratory Tract Infection in Adults, Edinburgh: Scottish Intercollegiate Guidelines Network, June 2002.|