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URTI
Dr Bruce Davies
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
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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: 1215.
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-
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
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 reexamination.
• 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?