Antibiotic treatment is contra-indicated Antibiotic treatment is contra-indicated in acute bronchitisin acute bronchitis

Bawoh. M Bawoh. M PhD. Clinical PharmacologyPhD. Clinical Pharmacology

Yaroslavl State Medical AcademyYaroslavl State Medical Academy

Antibiotic use in lower respiratory tract infectionsAntibiotic use in lower respiratory tract infections

• 65 – 95% of all patients

• 18,000,000 treatments per year in EU

Over- and underprescriptions of antibiotics in RTIsOver- and underprescriptions of antibiotics in RTIsAkkerman et al. JAC 2005;56:930-6 Akkerman et al. JAC 2005;56:930-6

-1250 -1000 -750 -500 -250 0 250 500 750

Ear

Upper resp inf

Sinus

Throat

Pneumonia

Cough/ bronchitis

Number of consultations

AB indicated and prescribedAB not indicated but prescribed

AB not indicated, not prescribedAB indicated but not prescribed

ESAC data on outpatient antibiotic use in Europe. ESAC data on outpatient antibiotic use in Europe. Goossens et al. Lancet 2005;365:579-87Goossens et al. Lancet 2005;365:579-87

Resistance of S. pneumoniae against penicilline GResistance of S. pneumoniae against penicilline G EARSS annual report 2006. www.earss.rivm.nlEARSS annual report 2006. www.earss.rivm.nl

Resistance of S. pneumoniae against erythromycineResistance of S. pneumoniae against erythromycine EARSS annual report 2006. www.earss.rivm.nlEARSS annual report 2006. www.earss.rivm.nl

What are we treating? What are we treating?

•Infectious disease?

•Bacterial or viral?

•Self-limiting or not?

Incidence of acute LRTI syndromes in Incidence of acute LRTI syndromes in primary careprimary care

• Acute cough: 100 per 1000 persons per year• Acute bronchitis: 50 per 1000 persons per year• Pneumonia: 5 per 1000 persons per year

Aetiology of lower respiratory tract infections Aetiology of lower respiratory tract infections in the community in the community ((% of cases% of cases))

Patients 40 78 2256 101 187 42 67 206

S. pneumoniae 16 8 12 3 6 30

H. influenzae 14 3 3 0 8

M. catarrhalis 3 0 2

Mycoplasma 5 3 20 16 6 8 3 0.5

Chlamydia species 3 0 2 0 0 0

Influenza 11 12 8 0 4 8 10 5

Other 10 15 17 12 2.5 13 18 6

None 50 74 70 68 79 71 64 56

First important notionFirst important notion

• There are other relevant pathological mechanisms in patients with acute cough

Diagnosis aDiagnosis asthma/COPDsthma/COPD• Characteristics of patients with an acute cough• Asthma 39%• COPD 7%

• Predictors of presence of asthma/COPD• Wheeze• Dyspnoea• Allergy induced symptoms• Prolonged expirium• Pack years• Female gender

Thiadens et al. BMJ 1998;316:1286-90

Copyright ©2002 BMJ Publishing Group Ltd.

van Schayck, C P et al. BMJ 2002;324:1370

Undetected COPD in smokers with acute cough

Second important notionSecond important notion

We cannot distinguish bacterial from non-bacterial disease in busy daily practice

Signs and symptoms have poor positive and negative predictive values

Diagnostic value of CRP and PCT for bacterial Diagnostic value of CRP and PCT for bacterial infectionsinfectionsHolm et al BJGP 2007Holm et al BJGP 2007

Other tests to detect bacterial pathogens

1- Sputum Gram stain

• Takes more than a few minutes

• Exspiry times fluids short

• Never assessed properly in primary care

2- S. Pneumoniae antigen test in urine

• Takes more than a few minutes

• Moderate sensitivity

• Diagnostic value in primary care unknown

Third important notionThird important notion

• Not all bacterial infections need antimicrobial treatment

Antibiotics for acute bronchitis IAntibiotics for acute bronchitis IFahey T et al.Fahey T et al. Cochrane Database of Systematic ReviewsCochrane Database of Systematic Reviews 2008 Issue 32008 Issue 3

Antibiotics for acute bronchitis IAntibiotics for acute bronchitis IFahey T et al. Fahey T et al. Cochrane Database of Systematic ReviewsCochrane Database of Systematic Reviews 2008 Issue 32008 Issue 3

Little, P. et al. JAMA 2005;293:3029-3035.

Duration of Cough After Physician Visit Until Patient Is Feeling BetterRCT in 807 primary care patients

Old questionOld question

Gonzales R, Sande M. Lancet 1995 Mar 18;345(8951):665-6

What will it take to stop physicians from prescribing antibiotics in acute bronchitis?

New answerNew answer

Better tools to diagnose pneumonia and underlying chronic lung disease