Responsible prescribing for upper respiratory tract infections

Acute sinusitis

Clinical diagnosis of acute sinusitis is troublesome because it involves use of a cluster of diagnostic criteria that have only moderate sensitivity. Ancillary testing with radiography or antral puncture is impractical, expensive, and usually unnecessary in the primary care setting. Antibiotic therapy is not beneficial for most patients in whom acute sinusitis is suspected, even when radiographic abnormalities are found. Simple management algorithms and patient information are now available to aid primary care physicians in offering appropriate therapeutic measures and reassuring patients who are expecting "'a pill for every ill' when that pill is an antibacterial."

The prevalence, diagnosis, and management of voice disorders in a National Ambulatory Medical Care Survey (NAMCS) cohort

OBJECTIVES

The purpose of this study was to analyze the prevalence, presentation, and treatment of voice complaints (VC) using a national cohort of ambulatory care patients and describe how this care conforms to guidelines for the treatment of vocal disorders.

METHODS

Cross-sectional study of 2005-2007 National Ambulatory Medical Care Survey (NAMCS) database.

RESULTS

Of 87,835 outpatient encounters, 0.26% and 3.2% of total and otolaryngology visits, respectively, were for VC. Patients with a VC were more likely to be female, have a history of asthma and tobacco use, present with acute symptoms, and have been referred to a specialist than those without VC. As recommended in national guidelines, the most common diagnostic procedure was endoscopic laryngoscopy (22%) with few other diagnostic imaging modalities performed (8%). Laryngeal diagnoses were more common than infectious or gastrointestinal diagnoses and were more likely to be chronic in presentation and associated with a diagnostic laryngoscopy evaluation (P = .02, <.001). They were not associated with gender, age, or tobacco use (P = .51, .35, .07). The most common intervention was antireflux medication (27%), with 13% receiving antibiotics, usually from primary care physicians. Only 8% were referred for voice therapy, despite strong national recommendations to consider this intervention for those with voice disorders.

CONCLUSIONS

The current study demonstrates that nationally a significant proportion of diagnostic and treatment plans for patients with VC are consistent with published guidelines. However, physicians from all specialties should be aware of these guidelines to improve care for patients with voice disorders.

Autologous blood therapy for common cold--a randomized, double-blind, placebo-controlled trial

BACKGROUND

In Germany autologous blood therapy (ABT) is a widespread therapy for infectious diseases in complementary medicine. Clinical data for its use for common cold is lacking.

METHODS

In a double-blind randomized controlled trial 139 patients with common cold were enrolled either to ABT (gluteal intramuscular reinjection of venous blood three times a week) or to placebo (sterile sodium chloride solution). Main criterion was time period of illness after initiation of treatment, measured by a modified symptom diary adapted from Jackson.

RESULTS

58 and 56 patients completed therapy. In both groups illness duration was 7 days (5.0-10.0 for verum and 5.25-9.0 for placebo).

CONCLUSIONS

This trial found no effect of ABT as treatment for common cold. Because of a rather highly selected patient sample another RCT on this topic is reasonable. Further research to analyse the effect of other doses or of autologous blood therapy in addition to homeopathic preparations or vitamin preparations is needed.

Rhinosinusitis: Developing guidance for clinical trials

The Rhinosinusitis Initiative was developed by 5 national societies. The current guidance document is an expansion of the 2004 publication, "Rhinosinusitis: Establishing definitions for clinical research and patient care" and provides templates for clinical trials in antimicrobial, anti-inflammatory, and symptom-relieving therapies for the following: (1) acute presumed bacterial rhinosinusitis, (2) chronic rhinosinusitis (CRS) without nasal polyps, (3) CRS with nasal polyps, and (4) classic allergic fungal rhinosinusitis. In addition to the templates for clinical trials and proposed study designs, the Rhinosinusitis Initiative has developed 6 appendices, which address (1) health outcomes, (2) nasal endoscopy and staging of CRS, (3) radiologic imaging, (4) microbiology, (5) laboratory measures, and (6) biostatistical methods.

Rhinosinusitis: developing guidance for clinical trials

The Rhinosinusitis Initiative was developed by 5 national societies. The current guidance document is an expansion of the 2004 publication "Rhinosinusitis: Establishing definitions for clinical research and patient care" and provides templates for clinical trials in antimicrobial, anti-inflammatory, and symptom-relieving therapies for the following: (1) acute presumed bacterial rhinosinusitis, (2) chronic rhinosinusitis (CRS) without nasal polyps, (3) CRS with nasal polyps, and (4) classic allergic fungal rhinosinusitis. In addition to the templates for clinical trials and proposed study designs, the Rhinosinusitis Initiative has developed 6 appendices, which address (1) health outcomes, (2) nasal endoscopy and staging of CRS, (3) radiologic imaging, (4) microbiology, (5) laboratory measures, and (6) biostatistical methods.

Judicious antibiotic use and intranasal corticosteroids in acute rhinosinusitis

Most patients with symptoms of acute rhinosinusitis are treated with antibiotics. However, many cases of rhinosinusitis are secondary to viral infections and unlikely to benefit from antibiotic therapy. Inappropriate use of antibiotics in patients with acute nonbacterial rhinosinusitis contributes to the increase in bacterial antibiotic resistance. Consequently, safe and effective alternatives to antibiotics are needed in the treatment of acute rhinosinusitis caused by viral infections. Recent results from controlled trials have shown that intranasal corticosteroids, used in combination with antibiotics or as monotherapy in selected cases, provide significant symptom relief and resolution of acute rhinosinusitis. The use of intranasal corticosteroids in acute rhinosinusitis therefore might reduce the inappropriate use of antimicrobial therapy in acute rhinosinusitis.

A community-based intervention to reduce antibiotic use for upper respiratory tract infections in regional South Australia

OBJECTIVE

To evaluate the effectiveness of a community-based and GP-based intervention in reducing unnecessary antibiotic prescribing for upper respiratory tract infections (URTIs) including sore throats, sinusitis and otitis media.

DESIGN

Analysis of pharmacy dispensing data in June to October before (2000) and after (2001) the intervention, which commenced on 25 June 2001.

SETTING AND PARTICIPANTS

Local consumers, health professionals, the Adelaide Southern Division of General Practice, the South Australian Government, and the local media in a rural region of South Australia, covering about 2000 square kilometres, with a population of over 20 000.

INTERVENTION

Community dissemination of consumer information on antibiotic use for URTIs (including a local media campaign) and education of health professionals (including sessions with general practitioners at the four practices in the study area) on current Australian therapeutic guidelines for antibiotics, and a validated clinical scoring system for decision making in managing sore throat.

MAIN OUTCOME MEASURES

Total dispensing data from local pharmacies for the months of June to October in 2000 and 2001, covering the six antibiotics considered most likely to be used for URTIs (amoxycillin, amoxycillin/clavulanic acid, cefaclor, doxycycline, erythromycin and roxithromycin).

RESULTS

The dispensing of the six antibiotics reduced by 32% overall, from 77.1 to 52.9 defined daily doses per 1000 population per day, with statistically significant reductions in the range of 31%-70% for individual antibiotics; there was no reduction for amoxycillin with or without clavulanic acid.

CONCLUSION

The intervention was associated with reduced dispensing of unnecessary antibiotics for URTIs.