Antibiotic resistance and respiratory tract infections
Published in MedicineWise News
Date published: About this date
- Antibiotic resistance requires consideration at both a population and individual level
- Establish patient beliefs and expectations about antibiotics for acute respiratory tract infection and tailor communication strategies accordingly
- Encourage self-management of acute respiratory tract infection and explain why antibiotics may not be appropriate
- Consider the issue of resistance when prescribing antibiotics
- Consider a test's clinical usefulness and the associated risks to your patient before ordering an imaging test
Consider antibiotic resistance at population and individual levels
Infections caused by antibiotic-resistant bacteria can lead to patients being unwell for longer and increased therapeutic costs.1 When signs and symptoms suggest a self-limiting respiratory tract infection, prescribing an antibiotic increases individual and community risk of antibiotic resistance with little or no corresponding health benefit.
Prescribers should inform patients of this risk (see Discuss antibiotic resistance). Patients may be less likely to take an antibiotic for a respiratory tract infection if they understand that it is unlikely to work and exposes them to the risk of harm.
Vaccinate to reduce the need for antibiotics
Pneumococcal and Haemophilus influenzae type b (Hib) vaccination is recommended for all infants from 2 months of age.2 Influenza vaccination is recommended for anyone (≥ 6 months of age) who would like to reduce their likelihood of becoming ill with influenza.
Establish patient beliefs and expectations — tailor communication strategies accordingly
In randomised controlled trials, patient-centred communication skills reduced antibiotic prescribing without adversely affecting repeat consultation rates, patient recovery or satisfaction.3-5 Furthermore, several studies suggest that patient satisfaction is more likely to be influenced by good communication than a prescription for an antibiotic.6-8
Address patient concerns
Repeat visits can be a marker that patient concerns were not adequately addressed during the initial consultation for respiratory tract infection.9 They increase prescriber workload, inappropriate requests for antibiotics and, if prescribed, may lead patients to believe that the antibiotic contributed to their recovery.
Time spent eliciting patient beliefs and expectations may reduce workload by encouraging appropriate self-management. Start by asking patients about their concerns and management expectations.
Use easily understood language, for example:
"Is it the cough that's bothering you, or are you concerned that you have something more serious?"
Avoid using labels such as 'bronchitis'
Survey data suggest that expectations for antibiotics are higher when labels like 'acute bronchitis' or 'bronchitis' are used rather than 'chest cold', 'viral infection' or 'cough with phlegm'.10,11
Provide realistic advice about the duration of illness
Inform patients that most respiratory tract infections resolve without medicines, but this usually takes longer than they might expect. Patients are less likely to seek a repeat visit during the same illness episode if they are made aware of the expected duration of their illness.12
The average durations of respiratory tract infections are:
- acute otitis media: 4 days
- acute sore throat/acute pharyngitis/acute tonsillitis: 1 week
- common cold: 1.5 weeks
- acute rhinosinusitis: 2.5 weeks
- acute cough/acute bronchitis: 3 weeks.13
Use the NPS symptomatic management pad to aid communication
The NPS respiratory tract infection symptomatic management pad is designed to help GPs establish patient beliefs and outline a symptomatic management plan. Using the pad can help you to:
- elicit patient concerns, and ask about management expectations
- provide information about the self-limiting nature of the illness, including the duration (prognosis), and why an antibiotic is not appropriate
- describe approaches to self-management
- confirm advice and management, ensuring that the patient understands, and is in agreement with, the planned approach
- list symptoms that should prompt the patient to consult again.
The symptomatic management pad includes sample questions and statements to use during consultations for respiratory tract infection. Order or download an NPS symptomatic management pad and patient communication tool.
Encourage self-management of acute RTIs — explain why antibiotics may not be appropriate
Antibiotics do not provide meaningful benefits — for example a convincing reduction in the time spent feeling ill — for patients with respiratory tract infections.14,15 And the size of any benefit must be considered in the context of adverse effects, potential to medicalise a self-limiting illness and antibiotic resistance.
Explain why antibiotics are rarely needed
Patients at low risk of developing complications can be reassured that antibiotics are not warranted because they are likely to make little difference to symptoms and may have side effects.13
Educate patients about the self-limiting nature of their illness and provide advice about the specificity and limitations of antibiotics:
- ear, nose, throat, sinus and chest infections are commonly caused by viruses
- antibiotics target bacteria, they are not effective against viruses
- antibiotics can cause adverse effects including serious allergy, thrush, vomiting and diarrhoea.
Assure patients who you do not prescribe an antibiotic for that they are not being disadvantaged. Consider reviewing the reasons to avoid antibiotics, providing additional information as necessary, for patients who object to conservative management.
Explain to patients that antibiotic resistance occurs when antibiotics no longer work against the bacterial infection that they were previously effective against. Prescribers and patients can help to prevent the spread of antibiotic resistance by ensuring that antibiotics are only used when needed.
Describe the consequences of antibiotic resistance: infections may fail to respond to standard treatments; can be severe and long-lasting; and can spread to family and friends.1
Inform patients that if they have taken antibiotics recently they are twice as likely to have antibiotic-resistant bacteria in their body as someone who has not.16-18 This means that antibiotics are less likely to be effective if needed to treat a severe infection in the future.
Provide advice on self-management
Treatment plans that focus on symptomatic management may help to reduce inappropriate antibiotic prescribing.19
Suggest alternatives to antibiotics — including non-pharmacological measures, home remedies, decongestants and simple analgesics — and inform patients that these measures can help them feel better while their immune system fights the infection. Discuss the symptoms that will necessitate a repeat visit.
Use the NPS symptomatic management pad and seek agreement on the intended management plan.
Be frank about cough and cold medicines
A cough medicine is an option for patients who find them soothing, but there is no good evidence to suggest that over-the-counter preparations effectively treat the symptoms of acute cough.20 Better quality studies are needed because many studies to date have been small and poorly designed.
If you recommend a cough and cold medicine, suggest a simple formulation for the most bothersome symptom(s).
Follow prescribing principles that minimise antibiotic resistance
Prescribing antibiotics only when needed can help to preserve their effectiveness. Follow the prescribing principles set out in the 'antibiotic creed' (Box 1).
Box 1: The 'antibiotic creed'21
|M||Microbiology guides therapy wherever possible|
|I||Indications should be evidence-based|
|N||Narrowest spectrum required|
|D||Dosage appropriate to the site and type of infection|
|M||Minimise duration of therapy|
|E||Ensure monotherapy in most situations|
Specify the duration of therapy
Patients may be confused by PBS-listed antibiotic pack sizes that exceed the duration of therapy specified by their prescriber. Ensure that each patient knows and adheres to the intended duration of therapy. Explain that taking antibiotics for longer than instructed increases the risk of adverse effects and antibiotic resistance.22
Refer to the latest edition of Therapeutic Guidelines: Antibiotic for recommendations on duration of antibiotic treatment. Specify the duration on the prescription so that it can be reinforced by the pharmacist when dispensing.
Avoid unnecessary repeat prescriptions
Computer-assisted prescriptions for antibiotics commonly used to treat respiratory tract infections continue to generate high rates of repeat orders.23,24 This may contribute to patient uncertainty about the duration of antibiotic therapy and, additionally, antibiotic resistance.
Review your prescribing software options to see if changes can be made to system defaults for the maximum number of repeats.
Consider an imaging test's benefits and risks
When should you request medical imaging?
Patients presenting with severe illness indicative of pneumonia should have a chest X-ray to confirm the diagnosis.25
Consult, or refer patients to, a specialist when considering computed tomography (CT) for sinusitis.25 CT is indicated only when atypical, severe or chronic (lasting more than 12 weeks) sinusitis has failed to respond to medical treatment.25,26 CT is not a routine investigation in the diagnosis of acute bacterial sinusitis.27
Have an effective, focussed approach to testing
Ensure that the potential benefit of diagnostic radiology outweighs the risk before referring a patient for investigation.28
- the results will alter the provisional diagnosis and subsequent management of the condition
- an imaging specialist's advice would influence your choice of test, particularly in younger patients where preference should be given to techniques that do not use ionising radiation
- the proposed investigation duplicates recent tests, for example those ordered by another doctor
- clinical history, relevant details following examination, and the clinical question to be answered have been made available to the imaging specialist.28,29
Discuss risks and benefits
Provide sufficient information about the imaging procedure to enable patients to make an informed decision about the proposed investigation.28,31
Provide patients with the following information to inform discussion:
- X-rays and CT scans are fast, painless and non-invasiveA
- both techniques result in exposure to ionising radiation, but CT scans expose the individual to considerably larger doses than conventional radiographyB
- CT scans provide detailed images of the sinuses, and can reduce the need for surgery or further procedures
- chest X-rays distinguish pneumonia from other lung conditions, and use very small doses of radiation.32
A clinical decision support tool and educational resources about the risks and benefits of diagnostic imaging are available from the WA Department of Health diagnositc imaging website.
Expert reviewersProf Chris Del Mar, Professor of Public Health, Faculty of Health Sciences and Medicine, Bond University, QLD
Prof Nigel Stocks, Head, Discipline of General Practice, University of Adelaide, SA
- World Health Organization. Combat antimicrobial resistance: fact sheet. 2011 (accessed 14 November 2011).
- The Australian immunisation handbook. 9th ed. Canberra: Australian Government Department of Health and Ageing, 2008.
- Francis NA, Butler CC, Hood K, et al. Effect of using an interactive booklet about childhood respiratory tract infections in primary care consultations on reconsulting and antibiotic prescribing: a cluster randomised controlled trial. BMJ 2009;339:b2885.
- Cals JW, Butler CC, Hopstaken RM, et al. Effect of point of care testing for C reactive protein and training in communication skills on antibiotic use in lower respiratory tract infections: cluster randomised trial. BMJ 2009;338:b1374.
- Altiner A, Brockmann S, Sielk M, et al. Reducing antibiotic prescriptions for acute cough by motivating GPs to change their attitudes to communication and empowering patients: a cluster-randomized intervention study. J Antimicrob Chemother 2007;60:638–44.
- Butler CC, Rollnick S, Pill R, et al. Understanding the culture of prescribing: qualitative study of general practitioners' and patients' perceptions of antibiotics for sore throats. BMJ 1998;317:637–42.
- Welschen I, Kuyvenhoven M, Hoes A, et al. Antibiotics for acute respiratory tract symptoms: patients' expectations, GPs' management and patient satisfaction. Fam Pract 2004;21:234–7.
- Kallestrup P, Bro F. Parents' beliefs and expectations when presenting with a febrile child at an out-of-hours general practice clinic. Br J Gen Pract 2003;53:43–4.
- Cals JW, Hood K, Aaftink N, et al. Predictors of patient-initiated reconsultation for lower respiratory tract infections in general practice. Br J Gen Pract 2009;59:761–4.
- Cals JW, Boumans D, Lardinois RJ, et al. Public beliefs on antibiotics and respiratory tract infections: an internet-based questionnaire study. Br J Gen Pract 2007;57:942–7.
- Phillips TG, Hickner J. Calling acute bronchitis a chest cold may improve patient satisfaction with appropriate antibiotic use. J Am Board Fam Pract 2005;18:459–63.
- Macfarlane JT, Holmes WF, Macfarlane RM. Reducing reconsultations for acute lower respiratory tract illness with an information leaflet: a randomized controlled study of patients in primary care. Br J Gen Pract 1997;47:719–22.
- National Institute for Health and Clinical Excellence. Prescribing of antibiotics for self limiting respiratory tract infections in adults and children in primary care. Clinical guideline CG69. 2008 (accessed 3 January 2012).
- Smith S, Fahey T, Smucny J, et al. Antibiotics for acute bronchitis. Cochrane Database Syst Rev 2004;CD000245.
- Butler CC, Kelly MJ, Hood K, et al. Antibiotic prescribing for discoloured sputum in acute cough/lower respiratory tract infection. Eur Resp J 2011;38:119–25.
- Nasrin D, Collignon PJ, Roberts L, et al. Effect of beta lactam antibiotic use in children on pneumococcal resistance to penicillin: prospective cohort study. BMJ 2002;324:28–30.
- Chung A, Perera R, Brueggemann AB, et al. Effect of antibiotic prescribing on antibiotic resistance in individual children in primary care: prospective cohort study. BMJ 2007;335:429.
- Costelloe C, Metcalfe C, Lovering A, et al. Effect of antibiotic prescribing in primary care on antimicrobial resistance in individual patients: systematic review and meta-analysis. BMJ 2010;340:c2096.
- Mangione-Smith R, Elliott MN, Stivers T, et al. Ruling out the need for antibiotics: are we sending the right message? Arch Pediatric Adolesc Med 2006;160:945–52.
- Smith SM, Schroeder K, Fahey T. Over-the-counter medications for acute cough in children and adults in ambulatory settings. Cochrane Database Syst Rev 2008;CD001831.
- Therapeutic guidelines: antibiotic. 14th ed. Melbourne: Therapeutic Guidelines Ltd, 2010.
- National Prescribing Service. Prescribing Practice Review 36: Judicious antibiotic use in general practice. 2007 (accessed 13 January 2012).
- Newby DA, Fryer JL, Henry DA. Effect of computerised prescribing on use of antibiotics. Med J Aust 2003;178:210–3.
- Newby DA, Robertson J. Computerised prescribing: assessing the impact on prescription repeats and on generic substitution of some commonly used antibiotics. Med J Aust 2010;192:192–5.
- Therapeutic guidelines: respiratory. 4th ed. Melbourne: Therapeutic Guidelines Ltd, 2009.
- Government of Western Australia Department of Health. Diagnostic imaging pathways - Chronic sinusitis (accessed 18 November 2011).
- Government of Western Australia Department of Health. Diagnostic imaging pathways - Acute sinusitis (accessed 18 November 2011).
- Government of Western Australia Department of Health. Diagnostic imaging pathways - Requesting imaging investigations: General principles (accessed 10 January 2012).
- Government of Western Australia Department of Health. Diagnostic imaging pathways - Ionising radiation. (accessed 10 January 2012).
- US National Cancer Institute at the National Institutes of Health. Radiation risks and pediatric comuputed tomography (CT): A guide for health care providers. 2002 (accessed 10 January 2012).
- Baerlocher MO, Detsky AS. Discussing radiation risks associated with CT scans with patients. JAMA 2010;304:2170-1.
- Government of Western Australia Department of Health. Diagnostic imaging pathways - Radiation risks of X-rays and scans (accessed 12 January 2012).