URTI

Dr Bruce Davies

Scope

• Throats.• Noses.• Coughs.• Sinuses.• Otitis media.• Otitis externa.

Points to Consider• Frequency.

– Alterable?– Manageable?– Why?

• Costs.– To patients.– To NHS.– To GPs.

• Treatment.– Abx or not.– Other treatments.

• Research.– Uncertainties.– Empiricism.

Opportunities

• Education.• Future

consultations.• Self management.• Empowerment.• Other stuff

(opportunistically).

Role of Investigation

• Swabs.• X-rays.• Examination

findings.• PCR.• Temperature.

Inequality• Different doctors.• Different patients.• Different

standards.• Expectations.• The doctors state

of mind.• The doctors

experiences.

Research

• Heaps and heaps.• A lot still leaves

questions un-answered.

• What follows is a personal selection.

Research: Sore Throats• Satisfaction with the consultation was

independent predictor of illness duration.• 700 patients: randomised to no Abx, Abx

immediately, delayed Abx.• Consultation satisfaction better predictor

of patient satisfaction than prescribing decision.

• Psychosocial factors better predictor of duration than physical findings.

• BMJ 1999; 319: 736-7.

Research: Sore Throats and Nephritis

• ANTIBIOTICS, SORE THROATS AND ACUTE NEPHRITIS

• No effect

• JL Taylor and JGR Howie

JRCGP 1983; 33: 783-6

Research: Sore throats

• You can’t tell from appearances.

• Remains a clinical decision.• Pen V or erythromycin remain

drugs of choice if anything is used.

• Drug and Therapeutics Bulletin 33; 2: 9-12

Research: Sore Throats• 716 patients aged 4years

or more with a sore throat and an abnormal physical sign in the throat were randomised to receive a prescription for 10 days of antibiotics, no prescription or a prescription for antibiotics to be obtained in a further three days if symptoms were not beginning to settle by that time.

• Prescribing antibiotics only marginally affects the resolution of symptoms but enhances belief in antibiotics and intention to consult in future. Psychosocial factors are important in the decision to see a general practitioner and in predicting the course of illness.

Research: Sore Throat• Complications and early return from no or

delayed prescribing of antibiotics for sore throat are rare.Current and previous prescribing both increase re-attendance rates. To avoid unnecessary treatment of a self-limiting illness and help to control demand for limited consultations most sore throats should be managed with no prescription or a delayed prescription.

• P little et al. BMJ 1997; 315: 350-2.

Research: Otitis Media

• Masterly review as expected from the DTB.

• Drug and Therapeutics Bulletin 33; 2: 12-15.

Research: Otitis Media

• Are antibiotics indicated as initial treatment for children with acute OTITIS media? A meta-analysis.

• C del mar et al. BMJ 1997; 314: 1526-9.

Research: Otitis Media

• 60% of placebo-treated children are pain free by 24hours after presentation and antibiotics do not improve on this. At 2-7 days after presentation (only 14% of children have pain at this time) early use of antibiotics reduces the risk of pain by 43%.

Research: Otitis Media• Longer term end points show no definite

benefits for antibiotic use. • Antibiotics are associated with a near

doubling of the risk of vomiting, diarrhoea or rashes. Even in the younger age group who develop otitis media as under-twos (who have been described as being possibly an otitis media-prone sub-set) the current high prescribing rates are not supported by the evidence with no statistical difference between children treated.

Research: Management Of Feverish Children At Home• Giving paracetamol is

more effective and more acceptable to parents than tepid sponging or removing clothing from hot children. Sponging works quicker than paracetamol and adds to its effectiveness.

• A-L Kinmouth et al BMJ 1992; 305: 1134-6.

Research: Repeat Consultations

• REPEAT CONSULTATIONS AFTER ANTIBIOTIC PRESCRIBING FOR RESPIRATORY INFECTION: A STUDY IN ONE GENERAL PRACTICE.

• P Davey et al BJGP 1994; 44: 509-13.

Research: Repeat Consultations• It is sometimes argued, often by drug

companies, that use of newer antibiotics in primary care can be justified on the basis of fewer repeat consultations - either for treatment failure or because of a higher incidence of side effects with established drugs. This study shows that repeat consultations are not common with any treatment for respiratory infections , and there is therefore little evidence to support the use of newer antibiotics on this basis.

Research: Adult Sinusitis

• In 130 adults with a CT diagnosis of acute sinusitis both penicillin V and amoxycillin are more effective than placebo in the treatment of acute sinusitis.

• M Lindbaek et al BMJ 1996; 313: 325-9.

Research: Cough – Re-attendance• These studies illustrate that patient

expectations rather than significant bacterial infections are important determinants of both the initial consultation with a LRTI and any subsequent consultation. Changing patients’ perceptions of their illness remains a key part of any policy on treating LRTIs.

• WF Holmes et al. BJGP 1997; 47: 815-8.

Research: Cough – Why Attend?• Yet more evidence that

exploring patients concerns is an essential part of even the most routine expectations.

• In the group of patients who consulted with their symptom of cough, among the reasons for attending were understanding that the cough was unusually severe and would interfere with usual social activities (not so surprising).

Research: Cough – Why Attend?

• Both groups were concerned about pollution.

• The study was undertaken in Middlesborough.

Research: Cough – Why Attend?

• However, other reasons reported were concern about their heart (50% of those consulting). Neither group distinguished between bacteria and viruses, nor did they differ in their beliefs about the effectiveness of antibiotics.

• CS Cornford. BJGP 1998; 48: 1751-4.

Research: Acute Cough in Adults

• A analysis of 6 trials. (700 patients).

• Use of Abx.• Defined as a cough of less than 2

weeks duration with no abnormal chest findings.

Research: Acute Cough in Adults

• No significant effect on cough resolution.

• No significant effect on findings on re-examination.

• No significant effect on incidence of side effects.

• BMJ 1998; 316:906-10.

Do We Want to Stop?

• Gains for GP• Gains for patient• Any health gain?