Management of acute asthma attacks associated with respiratory tract infection: a postal survey of general practitioners in the U.K

How appropriate is asthma therapy in general practice?

High association between burden of asthma and inadequate disease control make asthma management a major public health issue. We studied asthma management practices of general practitioners (GPs) in France to describe drug therapy and more specifically, to identify correlates of antibiotic prescriptions, a marker of inappropriate asthma management. Patients with persistent asthma aged 17-50 years were evaluated in a 12-month retrospective study using a computerized GPs database (Thales) and a patient survey, in which patients reported hospital contacts, use of oral corticosteroids and recent asthma symptoms. Therapy was described and the correlates of antibiotic prescriptions in the previous year were identified using multivariate logistic regression. During the study period, 16.4% of 1038 patients received one or more prescriptions of theophylline, 31.3% long-acting beta-agonists and 61.6% inhaled corticosteroids. Rates of prescription of antibiotics, expectorants, antihistamines, antitussives and nasal corticosteroids were 57.6, 42.0, 33.0, 19.9, and 14.4%, respectively. In parallel, 15% of patients reported at least one hospital contact for asthma and 43.1% used oral corticosteroids. Antibiotic prescriptions were more likely co-prescribed in patients using expectorants [odds ratio (OR) = 13.0, 95% confidence interval (CI) = 8.5-19.8] and antitussives (OR = 6.5, 95% CI = 3.7-11.6). Moreover, patients using courses of oral corticosteroids, and often visiting their GP (more than four times) during the study period were more likely to receive antibiotics. The results were unchanged when analyses were restricted to non-smokers and younger patients (< or = 40 years). Asthma management was sub-optimal among asthma patients treated by general practitioners in France. Antibiotics, expectorants, antihistamines, antitussives and nasal corticosteroids were commonly prescribed while asthma controllers were under-used.

Respiratory infections and asthma: current treatment strategies

Infections such as lower respiratory illness potentially contribute to the initiation of asthma and are major factors in recurring acute exacerbations of the condition. Although typical bacterial respiratory pathogens such as Streptococcus pyogenes, Streptococcus pneumoniae and Hemophilus influenzae do not initiate asthmatic exacerbations, data from a subgroup of adults suggest a potential role for Mycoplasma pneumoniae and Chlamydia pneumoniae in the onset of asthma. Common cold viruses, predominantly respiratory syncytial virus (RSV) in young children and rhinoviruses in older children and adults, are the major causes of acute exacerbations of asthma. These exacerbations are not prevented with maintenance therapies that are used for chronic asthma, but do respond to short courses of systemic corticosteroids. There are continued attempts to produce a successful vaccine and antiviral agents for the treatment of RSV that are more effective and more practical to use than ribavirin, which is currently the only available antiviral for RSV. The prevention and treatment of rhinovirus infections have focused on the major receptor for the virus, intercellular adhesion molecule-1 (ICAM-1), which is located on respiratory epithelial cells. A multivalent, recombinant, antibody fusion protein identified as CFY196 has high avidity for ICAM-1 and has the potential to protect against rhinovirus infection. Another approach for preventing and treating rhinovirus infection uses a recombinant, soluble, truncated form of ICAM-1 in which the transmembrane and intracellular domains of the protein have been deleted. An initial clinical study on this agent demonstrated clinical efficacy in ameliorating the symptoms of experimental rhinovirus infection in volunteers, but did not significantly prevent infection.

Antibiotics in asthma

Asthma pathogenesis appears to be a result of a complex mixture of genetic and environmental influences. There is evidence that Mycoplasma pneumoniae and Chlamydia pneumoniae play a role in promoting airway inflammation that could contribute to the onset and clinical course of asthma. If antimicrobial therapy can eradicate these organisms, it might be possible to alter the course of the disease. Although antibiotics have no role in the routine management of acute exacerbations of asthma, certain macrolide antibiotics have been shown to have anti-inflammatory activity. Part of this effect is due to their known inhibition of steroid and theophylline metabolism, but through a myriad of mechanisms that are incompletely understood, macrolide antibiotics have additional broad anti-inflammatory properties that might prove useful in the management of asthma and other inflammatory diseases.

Association between asthma control in children and loss of workdays by caregivers

BACKGROUND

Although the economic burden of pediatric asthma is a significant public health issue, the loss of workdays by caregivers because of their children's asthma remains scarcely investigated.

OBJECTIVES

To evaluate asthma-related loss of workdays incurred by caregivers of asthmatic children and its association with the level of asthma control.

METHODS

A retrospective observational study was conducted based on a French computerized general practitioners' database and a survey questionnaire. Children aged 6 to 16 years with persistent asthma (Global Initiative for Asthma grade > or = 2) were included in the study. Level of children's asthma control was evaluated from recent asthma symptoms. Caregivers reported the number of workdays lost because of their child's asthma during the 12-month study.

RESULTS

Nearly 30% of caregivers lost workdays during the study because of their children's asthma. More than 13% of caregivers lost more than 5 days. Caregiver absenteeism significantly correlated with all components of asthma control (use of relievers, nocturnal symptoms, impairment of activities, and asthma crises). A significant 8-fold risk of losing more than 5 workdays by caregivers was observed when the child's asthma was poorly controlled (odds ratio, 8.6; 95% confidence interval, 2.4-30.5); caregivers' absenteeism also increased significantly with the number of episodes of oral corticosteroid use during the study.

CONCLUSIONS

Caregivers' loss of workdays owing to their children's asthma is substantial and is highly correlated with the level of asthma control. These findings highlight the necessity of educational programs for children with poor asthma control and their caregivers to prevent severe asthma attacks that lead to caregiver absenteeism.

Relationship between asthma medication and antibiotic use

STUDY OBJECTIVES

Increasing morbidity due to asthma and antimicrobial resistance among human pathogens are both major public-health concerns. Numerous studies describe the overuse of antibiotics in general populations and underuse of anti-inflammatory medications by asthmatic patients. However, little is known about the relationship between asthma medication and antibiotic use in asthmatics. Specifically, we tested the hypothesis that higher use of bronchodilator and anti-inflammatory medication by asthmatics, as a marker of problematic asthma, is associated with greater antibiotic use. We also test the hypothesis that physicians who are low prescribers of anti-inflammatory medications are high prescribers of antibiotics.

DESIGN

We conducted a retrospective cohort study evaluating asthma medication and antibiotic use by children and adults with asthma and the prescribing of these medications by primary-care physicians.

SETTING/PATIENTS

Subjects were continuously enrolled asthma patients aged 6 to 55 years receiving care in an urban, group-model, health maintenance organization.

INTERVENTIONS

None.

MEASUREMENT AND RESULTS

Main outcome measures were (1) antibiotic use by asthmatics stratified by low, moderate, and high bronchodilator use; (2) antibiotic use by asthmatics stratified by no, intermittent, and long-term anti-inflammatory use; and (3) correlation between physician-level anti-inflammatory agent to bronchodilator ratio (AIF:BD) and their rate of antibiotic prescribing. We found that (1) high bronchodilator users received 1.72 antibiotics per person-year (95% confidence interval [CI], 1.62 to 1.83), whereas low bronchodilator users received 1.23 antibiotics per person-year (95% CI, 1.19 to 1.27; p < 0.0001); (2) long-term users of anti-inflammatory agents received 1.85 antibiotics per person-year (95% CI, 1.76 to 1.95), whereas those not receiving an anti-inflammatory agent received 0.95 antibiotics per person-year (95% CI, 0.90 to 1.00; p < 0.0001); and (3) despite variations in physician AIF:BDs and antibiotic prescribing, respectively, these measures were not correlated.

CONCLUSIONS

Antibiotic use and asthma medication use are positively associated in a cohort of asthma patients. Greater effort is needed to define the appropriate role of antibiotics in asthma management.

Hospital-based management of acute asthmatic exacerbation: an assessment of physicians' behavior in Taiwan

This retrospective study was conducted to assess Taiwanese emergency physicians for their preference in management and adherence to guidelines in treating patients with acute exacerbation of asthma. One hundred twenty patients from hospitals of three different levels were evaluated by reviewing their medical records. Our study revealed that physicians from medical centers and regional hospitals assessed patients more often with arterial blood gas or pulse oximetry; prescribed more doses of beta2-agonist nebulizers; administered more doses of beta2-agonist nebulizers before administering parenteral aminophylline; and prescribed ipratropium nebulizers more often as adjunctive therapy. On the other hand, physicians from district hospitals more frequently prescribed parenteral aminophylline as the first-line medication and more often prescribed only a single dose of beta2-agonist nebulizer. Most emergency physicians in Taiwan did not adhere to guidelines. Specifically, these included omission of peak expiratory flow as the means to assess the severity of asthma exacerbation and response to treatment; suboptimal use of inhaled bronchodilators, such as beta2-agonists and ipratropium; and inappropriate use of parenteral aminophylline as the first-line medication.

The management of asthma: a case-scenario-based survey of family physicians and pulmonary specialists

This study assessed family physicians' and pulmonary specialists' approaches to the treatment of adult outpatient asthma using a self-administered questionnaire consisting of six asthma scenarios of varying severity levels. One hundred sixty-three randomly selected family physicians and pulmonary specialists completed the questionnaire (response rate of 80%). We observed that, regardless of asthma severity, more than 75% of physicians (regardless of specialty) would not include oral theophylline or nonsteroidal anti-inflammatory preparations in their treatment approach. Pulmonary specialists' and family physicians' approaches to mild asthma were similar (more than 90% recommended an inhaled beta2-agonist). However, considerable differences existed among and between physician groups for the remaining scenarios. For example, with an exacerbation associated with an upper respiratory tract infection, family physicians were more likely to recommend oral antibiotics (p<0.0001) and a same-day outpatient visit (p<0.0001), whereas specialists were more likely to increase the inhaled corticosteroid dosage (p<0.0001). Overall, disagreement was observed almost twice as often among family physicians than among specialists. Our results suggest that physicians vary markedly in their reported use of most interventions available to treat asthma, even when the disease severity is specified.

Are doctors still failing to assess and treat asthma attacks? An audit of the management of acute attacks in a health district

This audit aimed to observe the management of acute asthma by primary and secondary care within a Health District. Asthma attacks occurring during the first 6 weeks of 1996 to patients between the ages of 3 and 74 years in Canterbury and Thanet District were notified by general practitioners, out-of-hours co-operatives and hospitals. Data were obtained retrospectively from the patient records. A total of 378 episodes was registered: 342 (90%) to primary care. Of these 234 (76% of patients aged 6 years or over) had a peak flow recorded; 114 (30%) were given emergency bronchodilation: oxygen was not used in primary care; 204 (54%) were given systemic steroids; and 43 (11%) were referred for hospital care of whom 36 were admitted. Of the attacks, 212 (69% of the patients aged 6 years or over) could be classified by percentage predicted peak flow and management compared to the Guidelines published by the British Thoracic Society. Twenty-eight patients presented with 'life-threatening' asthma: 20 (71%) were given emergency bronchodilation; oxygen was used in only two; 24 (86%) were given systemic steroids; and six (21%) were referred for admission. In their confidential enquiry into the asthma deaths the British Thoracic Society identified a failure to appreciate the severity of the attack, resulting in inadequate emergency treatment and delay in referring to hospital. These data suggest that, 15 years later, these problems may still exist.

General practitioner prescribing of antibiotics for asthma

Although asthma management guidelines in New Zealand do not advise prescribing antibiotics, almost a quarter of asthma consultations result in a prescription for antibiotics. This study, as part of a repeat audit of asthma care at an after-hours medical centre, describes general practitioners' perspectives on prescribing antibiotics to patients presenting with asthma. The results show that GPs have tended to overestimate the risk of bacterial infection in such patients.