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URTI
Dr Bruce Davies
www.bradfordvts.co.uk
Scope
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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 unanswered.
• 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?