ANTIBIOTICS FOR UPPER RESPIRATORY INFECTIONS.
I felt the UPRNet Study by Dosh and colleagues 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
[1.] Dosh SA, Hickner JM, Mainous AG 3rd, Ebell MH. Predictors of antibiotic prescribing for non-specific 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.
Dr Tocks has correctly pointed out that the duration of the common cold is typically approximately 1 week, although symptoms often persist longer. The 3 cases he presented suggest that at some point the symptoms have been present too long to be a viral URI. This is a question we believe deserves careful study, because it is possible that bacterial infections may be more common among patients with prolonged symptoms of a URI. In the absence of evidence from the medical literature, clinicians will need to practice the art of medicine to decide whether to use antibiotics for patients with URI symptoms lasting longer than 7 to 10 days. Interestingly, in our study duration of symptoms was not independently associated with antibiotic prescribing patterns.
Dr Tocks's first patient, the 23-year-old woman with a URI, presents an interesting dilemma. First, she clearly has a high probability of acute sinusitis because worsening symptoms after stable or waning symptoms (second sickening), unilateral facial pain, and purulent rhinorrhea have each been associated with acute sinusitis as documented by computed tomography. Second, the use of an antibiotic (amoxicillin if the patient is not allergic to penicillin) for acute sinusitis is supported by a small number of clinical trial. Third, the Centers for Disease Control and Prevention recommend symptomatic treatment before instituting antibiotic treatment for acute uncomplicated sinusitis for patients with mild to moderate symptoms of less than 7 days duration. If she has not been taking a decongestant, should the patient be given a trial of decongestant therapy before starting an antibiotic? We believe that most clinicians would choose to start an antibiotic regardless of whether she had been taking a decongestant. However, this falls under the category of the art of medicine and awaits an evidence-based answer.
Dr Kaufman's frustration with the lack of clear definitions of the differences and similarities among various viral and bacterial illnesses is understandable. The primary care physicians in the rural primary care research network responsible for the design and execution of this study share this frustration. Hueston and colleagues have suggested that sinusitis, bronchitis, and URI may all be variations of the same clinical condition (acute respiratory infection) whether viral or bacterial. In 1967, Evans described the 5 realities of respiratory tract infections: (1) the same clinical condition may be produced by a variety of agents; (2) the same etiologic agent may produce a variety of clinical syndromes; (3) the predominating agent in a given clinical syndrome may vary according to the age group, the year, the geographic location, and the type of population; (4) diagnosis of the etiologic agent is frequently impossible on the basis of the clinical findings alone; and (5) the causes of a large percentage of common infectious disease syndromes are still unknown. His words remain true today. Thus, it appears that our diagnostic understanding of acute respiratory tract infections has progressed very little in the past 3 decades. Faced with these realities physicians choose to prescribe antibiotics for some patients with nonspecific URIs, many patients with bronchitis, and nearly all patients with acute sinusitis. This is true even though many of these illnesses are viral in origin. Clearly, clinicians realize that bacterial infections may cause any of the 3 clinical syndromes of respiratory tract infection.
In the light of the realities of respiratory tract infections, our primary care research group (in the absence of the publish-or-perish mentality of academia) chose to evaluate those factors our clinicians used to justify antibiotic prescriptions, regardless of how they labeled the illness. Presumably the factors we identified are those that our clinicians believe reflect the presence of a bacterial infection whether it is called a URI, sinusitis, or bronchitis. We think that the observational study we presented represents a new and interesting perspective on how clinicians make the decision to prescribe an antibiotic. We also think this study provides a basis for randomized controlled trials to assess whether patients with discolored nasal drainage, rales or rhonchi, postnasal drainage, or sinus tenderness benefit from antibiotics.
Steven Dosh, MD OSF Medical Group Escanaba, Michigan
[1.] Lauber B. The common cold. J Gen Intern Med 1996; 11:229-36.
[2.] Lindbaek M, Hjortdahl P, Johnsen UL. Use of symptoms, signs, and blood tests to diagnose acute sinus infection in primary care: comparison with computed tomography. Fam Med 1996; 28:183-88.
[3.] De Ferranti SD, Ioannidis JP, Lau J, Anninger WV, Barza M. Are amoxicillin and folate inhibitors as effective as other antibiotics for acute sinusitis? A meta-analysis. BMJ 1998; 317:632-37.
[4.] Hueston W, Mainous AG 3rd, Dacus EN, Hopper JE. Does acute bronchitis really exist? J Fam Pract 2000; 49:401-06.
[5.] Evans A. Clinical syndromes in adults caused by respiratory infection. Med Clin North Am 1967; 51:803-18.