URTI

1
URTI

• Dr Bruce Davies

2
Scope

• Throats.
• Noses.
• Coughs.
• Sinuses.
• Otitis media.
• Otitis externa.

3
Points to Consider

• Frequency.
• Alterable?
• Manageable?
• Why?
• Costs.
• To patients.
• To NHS.
• To GPs.

• Treatment.
• Abx or not.
• Other treatments.
• Research.
• Uncertainties.
• Empiricism.

4
Opportunities

• Education.
• Future consultations.
• Self management.
• Empowerment.
• Other stuff (opportunistically).

5
Role of Investigation

• Swabs.
• X-rays.
• Examination findings.
• PCR.
• Temperature.

6
Inequality

• Different doctors.
• Different patients.
• Different standards.
• Expectations.
• The doctors state of mind.
• The doctors experiences.

7
Research

• Heaps and heaps.
• A lot still leaves questions un-answered.
• What follows is a personal selection.

8
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.

9
Research Sore Throats and Nephritis

• ANTIBIOTICS, SORE THROATS AND ACUTE NEPHRITIS
• No effect
• JL Taylor and JGR Howie JRCGP 1983 33 783-6

10
Research Sore throats

• You cant 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

11
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.

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• 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.

13
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.

14
Research Otitis Media

• Masterly review as expected from the DTB.
• Drug and Therapeutics Bulletin 33 2 12-15.

15
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.

16
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.

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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.

18
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.

19
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.

20
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.

21
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.

22
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 47 815-8.

23
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 surprising).

24
Research Cough Why Attend?

• Both groups were concerned about pollution.
• The study was undertaken in Middlesborough.

25
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.

26
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.

27
Research Acute Cough in Adults

• No significant effect on cough resolution.
• No significant effect on findings on
  re-examination.
• No significant effect on incidence of side
  effects.
• BMJ 1998 316906-10.

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Do We Want to Stop?

• Gains for GP
• Gains for patient
• Any health gain?