Antibiotic prescribing for adults with acute cough/LRTI:
congruence with guidelines
J.Wood* C.Butler* K.Hood* M.Kelly* T.Verheij P.Little A.Torres F.Blasi T.Schaberg H.Goossens
*South East Wales Trials Unit (SEWTU), Department of Primary Care and Public Health, School of Medicine, Cardiff University
Introduction and purpose
Methods
European guidelines for treating acute cough/lower respiratory
tract infection (LRTI) aim to reduce non-evidence based
variation in prescribing, and better target and increase the
use of first line antibiotics. The guideline developers faced
challenges arising from gaps in the supporting evidence
base and hence some recommendations were based on
consensus and compromise rather than empirical evidence.
The application of these guidelines in primary care is unknown.
ERS-ESCMID guideline
recommendation
Must have Acute Cough
and one of:
1.New Focal Chest Sign
2. Dyspnoea
3. Tachypnoea
4. Fever Lasting 4 days
Data available in case report form (CRF) or diary in the GRACE study
Suspected or
definite pneumonia
Cough – present on the day of inclusion
Diminished Vesicular Breathing – present on the day of inclusion
Crackles – present on the day of inclusion
Rhonchi – present on the day of inclusion
Shortness of breath – present on the day of inclusion
Respiratory rate (breaths per minute) – more than 20 per minute
How many days were you unwell before you saw your GP or nurse for this
cough? – minimum 4 days
Temperature recorded using a disposable thermometer – more than 37.8°c
ERS recommended antibiotics
for LRTI
Preferred
Alternative
Tetracycline
Macrolides
Amoxicillin
Co-amoxiclav
Levofloxacin
Moxifloxacin
We explored congruence of both antibiotic prescribing and
antibiotic choice with European Respiratory SocietyEuropean Society Clinical Microbiology and Infectious
Diseases (ERS-ESCMID) guidelines for managing LRTI in
the GRACE (Genomics to combat Resistance against
Antibiotics in Community-acquired LRTI in Europe;
www.grace-lrti.org) dataset.
Prospective observational data from
patients presenting to primary care with
acute cough/LRTI.
Clinicians recorded symptoms on
presentation, and their examination and
management.
Patients were followed up with selfcomplete diaries.
Selected exacerbations of COPD
Must have Chronic Obstructive Pulmonary COPD - present on the day of inclusion
Disease (COPD) and all of:
1. Increased dyspnoea
Shortness of breath – present on the day of inclusion
2. Increased sputum volume
Phlegm production – present on the day of inclusion
3. Increased sputum purulence
If producing phlegm, what colour? – Colour is yellow, green or bloodstained
Or Severe COPD
Pulse Oximitery (% saturation) – less than 90%
Aged 75 yrs and fever
Must be over 75 years old
Fever
Age – over 75 years
Temperature recorded using a disposable thermometer – more than 37.8°c
Cardiac Failure
Insulin-dependent diabetes mellitus
Heart Failure - present on the day of inclusion
Diabetes - present on the day of inclusion
Serious Neurological Disorder
Insulin - present on the day of inclusion
N/A
Results
Given patients’ clinical presentation, clinicians could have
justified an antibiotic prescription for 1915 (71.2%) patients
according to the ERS-ESCMID guideline.
761 (42.8%) of those who were prescribed antibiotics received a
first choice antibiotic (i.e. tetracycline or amoxicillin).
Ciprofloxacin was prescribed for 37 (2.1%) and cephalosporins for
117 (6.6%).
Conclusion
A lack of specificity in definitions in the ERS-ESCMID guidelines
could have enabled clinicians to justify a higher rate of antibiotic
prescription. More studies are needed to produce specific clinical
definitions and indications for treatment. First choice antibiotics
were prescribed to the minority of patients who received an
antibiotic prescription.