Antibiotics and upper respiratory tract infection

Y T Wun

HK Pract 2001;23:16-18

Summary

Antibiotics are frequently prescribed for upper respiratory tract infection in spite of the lack of benefit in relieving symptoms and preventing complications. This paper discusses the prescribing behaviour as a multi-factorial doctor-patient interaction. The prescription of drugs has psychosocial basis in addition to the pharmaceutical purpose. About half of the patients with sore throat expect to have antibiotics. Doctors may be uncertain about the patient’s expectation or whether an antibiotic is required. The health care system also affects antibiotic-prescribing. The doctor should explore the patient’s expectation and negotiate with the patient for a management plan before prescribing an antibiotic.

I recently encountered a patient who complained of cough with occasional whitish sputum for a few days. He had no chronic lung disease nor there were features of bacterial infection. Two months ago, he had similar illness for three weeks without relief from several doctors until he was given an antibiotic at a hospital outpatient with the diagnosis of bronchitis. He explicitly requested me for antibiotics for his cough this time. I spent 15 minutes in persuading him on the management plan without antibiotics. At the end, I did not prescribe any antibiotic. Apparently, I had not convinced him and he never returned ever since.

Such encounter is common among family physicians (FPs). This patient reminds me of an editorial of our journal on the use of antibiotics in upper respiratory tract infection (URTI).¹

In spite of minimal or negligible effect of antibiotics in URTI,² antibiotics are commonly prescribed to patients with URTI in the United States,³ United Kingdom,⁴ and other developed countries.^5-7 Overuse of antibiotics is also observed among physicians practicing internal medicine3 or paediatrics.⁸ The most common reason for that is patient’s expectation for antibiotics.^9-13 Doctors often know that antibiotics are not indicated,^12,14 and recognise the dilemma in their practice.⁹

Though doctors usually overestimate patients’ expectations for prescription,¹⁵ many patients do expect antibiotics.^16,17 Chan¹⁷ showed that 36% (or every third) of patients consulting for URTI expected antibiotics. Other studies showed a figure of around 50%.^{10,12,15,18,19} While patients usually do not express their preference explicitly to their doctors,²⁰ dissatisfaction with prescribing is a reason for changing the FP.²¹

In general, doctors’ decision to prescribe is influenced by their perception of patient expectation,^12,22 their uncertainty of the diagnosis,^23,24 experience of medical misadventure,²³ patients’ demand for drugs,^12,22 patients’ ethnic groups,^12,24 and their social background.²² Patients who can obtain medicine free of charge were more likely to hope for a prescription.¹² Doctors with higher qualifications^12,22,25 or oriented to whole-person care²⁵ are associated with less prescription of antibiotics. Younger doctors also prescribe less than those more senior in age and experience.^22,26 There is no definite explanation for these observations. However younger FPs and FPs with qualifications in family medicine were less likely to perceive pressure from patients to prescribe. [Wun Y T, unpublished data]. Seventy-six percent of the local population always expected and 21% usually expected a prescription when they consulted doctors.²⁷

Prescribing is a complex process with social and medical connotations. It is not solely a doctor’s behaviour, rather it is an outcome of the interaction between the doctor and the patient. Apart from the therapeutic intention, prescribing is an integral part of the doctor-patient encounter, a means of legitimating the patient in the sick role, or as an alternative to doing nothing in an uncertain situation.²² It is affected by biochemical, historical, psychosocial and commercial factors.28 The psychosocial background of the patient significantly affected the doctor’s decision to prescribe antibiotic for sore throat.²⁹

By accusing FPs of misusing antibiotics, it does not help to change our behaviour^12,30 but may deepen the guilty feeling in some of us.²⁸ Overuse of antibiotics is common in different countries and across medical specialties.3 One should recognise the nature of a FP’s work: dealing with lots of uncertainties,²² patients’ suffering, efforts to maintain doctorpatient relationship,⁹ and managing illness after negotiation with patients.³¹ “Our current state of knowledge does not allow us to say what point represents optimum prescribing”.²² Furthermore, it is often impossible, on clinical ground, to be certain that the illness is not due to a bacterial infection. Improvement “will not be achieved simply by bombarding doctors with more and more pharmacological information and exhortations to change the drugs they use”.⁹

Various efforts to improve prescribing have resulted in limited success. These involved small group education to FPs,³² academic detailing (interactive visits by academics to the FPs),^33,34 and improving consulting skill.³⁰ Since prescribing is a doctor-patient interaction, patients are also involved in rational prescribing.^35,36 Public education can help to reduce inappropriate patient demand for antibiotics^37,38 and legislation may be involved. By withdrawing subsidies for antibiotics and educating the public on the danger of antibiotic resistance, it has reduced the sale of antibiotics and incidence of penicillin-resistant pneumococci in Iceland.³⁹

There is a long way to go before quality prescribing can be achieved and it can only be achieved by improving the attitude and knowledge of both the doctor and the patient. Whatever approach we use, one should show empathy to the FPs who have to face the uncertainties in day-to-day management and the expectation from patients for antibiotics. Indeed, URTI is usually a self-limiting disease. However, when a patient presents with an URTI, a series of complex bio-psycho-social illness-behaviour would follow. Time is needed to address all these issues during consultation, and there is seldom enough time.

At present, we might have to accept the situation in which antibiotics are prescribed not for their pharmacological effect after conscientious negotiation between the doctor and the patient. We welcome posters printed by the local health authority to inform the patients that antibiotics are not indicated for URTI.

We must condemn indiscriminate prescribing, and encourage the effort for quality prescribing. I would define quality prescribing as one that gives our patients the best possible outcome to health. Unfortunately, some local FPs prescribe irrationally (though there is no published report on local FPs’ prescribing pattern). For example, a patient was given three different classes of antibiotics for URTI, and some patients were prescribed cephalosporins or quinolones. A local study showed that most antibiotics given for pharyngitis or URTI were not appropriate for the presumed bacteria [Dickinson J A, personal communication]. We should not defend ourselves in such situations by saying that our patients demand antibiotics. We can, however, audit ourselves and go for quality primary care. All of us should share health information, including the use of antibiotics, with our patients. As practising FPs, we should ask ourselves “Should I give this antibiotic, if at all, for this situation?” If we do give, be sure that (a) we understand our patient’s expectation (b) we have negotiated with the patient (c) we know why we give and (d) choose one that will do the least harm.

Acknowledgment:

I am grateful to Prof J A Dickinson for his advice on preparing the manuscript.