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Research Review

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VOL: 101, ISSUE: 42, PAGE NO: 51

Reviewed by: Carole Pellowe, PhD, deputy director, Richard Wells Research Centre, Thames Valley University, London

The study

The study
The objective of this study was to estimate the effectiveness of three prescribing strategies and an information leaflet for acute lower respiratory tract infection in primary care.

A randomised control trial was conducted from August 1998 to July 2003 in which patients presenting in a primary care setting in South West England with acute lower respiratory tract infection were allocated to one of six groups: those who were given an information leaflet about their illness and those who were not given one; and to one of three 'antibiotic' groups: those who were given an antibiotic immediately at the initial consultation; those who were given a prescription for antibiotics that could be collected from a box at reception after only 14 days, and those who were not prescribed antibiotics at all.

Everyone in the study was given brief verbal information on the natural history of a lower respiratory tract infection. The key outcome measures were symptoms, duration of illness, and severity of the infection.

A total of 807 patients was enrolled in the study who had had an uncomplicated acute illness for less than 21 days, presenting in primary care with a cough as the main symptom and with at least one symptom or sign of lower respiratory tract infection.

The 37 physicians involved in recruiting the patients documented the clinical history, signs and symptoms of the participants and the results of the chest examination carried out initially.

Participants were given a daily symptom diary in which to record their temperature, their adherence to the drug regime, any use of antipyretics, and their symptoms. They also scored their symptoms and beliefs about antibiotics on a six-point scale. Within one month of the initial consultation, the patients' notes were reviewed for evidence of a further consultation with cough or of complications.

Results
One hundred and thirty-six children were recruited to the study; 17 per cent were under 16 years of age. A total of 562 patients (70 per cent) returned completed diaries and 78 (10 per cent) provided information about both symptom duration and severity. Cough rated as being at least 'a slight problem', lasted a mean of 11.7 days and a 'moderately bad cough' lasted a mean of six days. The prescribed antibiotics reduced the duration of moderately bad symptoms by one day overall.

In comparison with the group that took antibiotics immediately, slightly fewer patients in the 'delayed' and 'no antibiotic' groups were very satisfied with their treatment: fewer used antibiotics and fewer believed in the benefit of antibiotics. There was no significant difference in outcomes between the groups that had been given the leaflet and those that had not (p=0.58).

Overall, there were fewer reattendances with cough in the groups whose prescribing of antibiotics had been delayed and those that had been prescribed antibiotics immediately (p=0.4). The mean attendance for those who had been given a leaflet compared with those who had not been given one (p=0.02). One patient from the group that had not been given antibiotics was admitted to hospital with pneumonia.

Discussion and implications for practice
This study is thought to be the largest trial to date of antibiotic use for lower respiratory tract infection in primary care, and it provides important results.

The study confirms that the natural history of lower respiratory infection is around three weeks. The strategy of not offering antibiotics or delaying the prescription for them was associated with little difference in duration of illness or severity of symptoms compared with those who had been prescribed antibiotics at their initial consultation, and appears acceptable to patients. The reduction in symptoms by one day does not justify antibiotics being prescribed automatically. The lack of effect on outcome associated with being given a leaflet could be accounted for by the verbal information all patients received initially. The increased attendance of participants at their GP's surgery during the following month possibly reflects patients' responding to the advice in the leaflet to re-attend if symptoms persisted.

The number of participants in the delayed prescription group who actually picked up their prescriptions was fewer than in equivalent studies. The authors attribute this to a reduction in need, but practical issues, such as lack of time, may have been the reason. Patients with no previous history of chronic illness presenting with a lower respiratory tract infection who are offered a delayed prescription for antibiotics or who are not prescribed antibiotics at all are unlikely to experience any difference in symptom resolution. More importantly, this study suggests that patients find it acceptable to be given information about their condition, and consequently use fewer antibiotics than if they receive no information.

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