Labelling of acute respiratory illness: evidence of between-practitioner variation in the UK

BACKGROUND: It is unclear which symptoms and signs GPs use when attributing diagnostic labels to patients with acute respiratory illness (ARI). OBJECTIVE: We sought to ascertain GPs' self-reported definitions of ARI. METHODS: A postal questionnaire concerned with the diagnosis of ARI was sent to all registered GPs in Avon Health Authority. GPs were asked to choose a clinical term that would describe the clinical presentation in four hypothetical patients, and the next three questions asked them to define acute bronchitis, upper respiratory tract infection (URTI) and any other term they used for ARI (excluding pneumonia). We measured proportions and compared responses across the three diagnostic categories. RESULTS: The majority (88%) of GPs agreed that cough associated with fever should be labelled as a URTI. When sputum and chest signs were also present, opinion was more divided, with 62% diagnosing acute bronchitis in young patients and 72% lower respiratory tract infection in old patients. CONCLUSIONS: This study demonstrates that there is more consistent use of diagnostic labels for URTI than for acute bronchitis or other terms used to label ARI. In the future, researchers should quantify the prognostic significance of symptoms and signs in ARI and provide GPs with a more rational approach to the diagnosis and management of ARI.     

Improving quality or shifting diagnoses? What happens when antibiotic prescribing is reduced for acute bronchitis?

BACKGROUND: A quality improvement project in an academic practice demonstrated a reduction in antibiotic prescribing for acute bronchitis. However, it was unclear whether this represented a reduction in antibiotic use or whether physicians assigned new diagnoses to the same patients to avoid scrutiny and continue to use antibiotic therapy. OBJECTIVE: To examine whether a substantial amount of diagnostic shifting occurred while antibiotic prescribing for acute bronchitis decreased during a 14-month period (from January 1, 1996, to February 28, 1997). METHODS: All patient diagnoses of acute bronchitis, acute sinusitis, upper respiratory tract infection, and pneumonia were determined for the 14 months of the acute bronchitis intervention. The relative distribution of patients among these 4 diagnostic categories was compared to determine if the percentage of patients with acute bronchitis decreased while those with acute sinusitis and pneumonia increased during the acute bronchitis intervention. RESULTS: The percentage of patients with the diagnosis of acute bronchitis remained unchanged during the 14-month period while antibiotic use for this condition decreased from 66% of cases to less than 21% of cases. Instead of the patients being assigned a different diagnosis such as acute sinusitis so that antibiotic prescribing would not be scrutinized, as we hypothesized, the relative number of diagnoses for acute sinusitis compared with acute bronchitis actually declined during the 14 months. No change was noted in the relative frequency of acute bronchitis cases compared with pneumonia cases. CONCLUSION: During a 14-month period when an intervention was successful at reducing antibiotic use for acute bronchitis, there was no evidence that physicians shifted patients from the diagnosis of acute bronchitis to other diagnoses.     

Appropriate antibiotic use: variation in knowledge and awareness by Hispanic ethnicity and language

BACKGROUND: Recent campaigns are informing the public that antibiotics are inappropriate for viral respiratory infections. As little is known about their effect on populations challenged by less access to care, lower education, low income, low English proficiency, or non-mainstream cultural backgrounds, this study assessed knowledge, attitudes, and awareness in an ethnically diverse community. METHODS: A telephone survey in English or Spanish of a cross-sectional, random sample of 692 non-Hispanic whites (NHWs) and 300 Hispanics in Colorado. RESULTS: For all respondent groups, knowledge of appropriate antibiotic use for colds and bronchitis was low. Hispanics surveyed in Spanish, compared with non-Hispanic whites, had significantly lower knowledge about antibiotics for colds, higher knowledge for bronchitis, lower awareness about antibiotic resistance, and greater dissatisfaction if an antibiotic were not prescribed. In all comparisons, English-language Hispanics tended to reflect non-Hispanic white response patterns. Independent predictors of awareness were ethnicity, education, and age. Independent predictors of dissatisfaction were ethnicity, knowledge about antibiotic use for colds, and bronchitis. Ethnicity was an independent predictor of knowledge about the inappropriateness of antibiotics for colds and bronchitis. CONCLUSIONS: To bridge knowledge gaps, educational campaigns for all segments of the population are needed. Content should be responsive to heterogeneity within populations.     

Does acute bronchitis really exist? A reconceptualization of acute viral respiratory infections

BACKGROUND: Considerable overlap exists in patient presentations and physical findings in viral upper respiratory tract infections (URIs) and acute bronchitis. Our goal was to determine whether there are any clinical cues that could help physicians differentiate between these 2 conditions. METHODS: We performed a retrospective chart audit on 135 patients who had been given a diagnosis of acute bronchitis and a random sample of 409 patients with URIs over a 2.5-year period. Patient and provider characteristics, patient symptoms, and physical findings were compared with bivariate analyses and then entered into a logistic regression model. RESULTS: In bivariate analyses, a number of demographic variables, symptoms, and signs were associated with acute bronchitis. Multivariate analysis showed that the strongest independent predictors of acute bronchitis were cough (adjusted odds ratio [AOR]=21.12; 95% confidence interval [CI], 6.01-74.26), and wheezing on examination (AOR=12.16; 95% CI, 5.39-27.42). Nausea was the strongest independent predictor that the diagnosis would not be acute bronchitis (AOR=0.01; 95% CI, 0.01-0.85). However, there was considerable overlap between the 2 conditions, and the logistic model explained only 37% of the variation between the diagnoses. CONCLUSIONS: We hypothesize that sinusitis, URI, and acute bronchitis are all variations of the same clinical condition (acute respiratory infection) and should be conceptualized as a single clinical entity, with primary symptoms related to different anatomic areas rather than as different conditions.     

Is co-morbidity taken into account in the antibiotic management of elderly patients with acute bronchitis and COPD exacerbations?

BACKGROUND: Guidelines on acute lower respiratory tract infections recommend restrictive use of antibiotics, however, in patients with relevant co-morbid conditions treatment with antibiotics should be considered. Presently, it is unknown whether GPs adhere to these guidelines and target antibiotic treatment more often at patients with risk-elevating conditions. OBJECTIVES: We assessed whether in elderly primary care patients with acute bronchitis or exacerbations of chronic pulmonary disease (COPD), antibiotics are more often prescribed to patients with risk-elevating co-morbid conditions. METHODS: Using the Utrecht GP research database, we analysed 2643 episodes in patients of 65 years of age or older with a GP-diagnosed acute bronchitis or exacerbation of COPD. Multivariable logistic regression analysis was applied to determine independent determinants of antibiotic use. RESULTS: Antibiotic prescribing rates were high in both acute bronchitis (84%) and in exacerbations of COPD (53%). In acute bronchitis, only age was an independent determinant of antibiotic use [odds ratio (OR) 1.03, 95% confidence interval (CI) 1.003-1.048], whereas in exacerbations of COPD antibiotics were more often prescribed to male patients (OR 1.3, 95% CI 1.0-1.5), patients with diabetes (OR 1.7, 95% CI 1.1-2.4) and heart failure (OR 1.3, 95% CI 1.0-1.7). CONCLUSION: Dutch GPs prescribe antibiotics in the majority of elderly patients with acute bronchitis and in half of the episodes of exacerbations of COPD. Tailoring their antibiotic treatment according to the presence or absence of high-risk co-morbid conditions could help GPs in improving antibiotic use in patients with respiratory tract infections in primary care.     

Clinical features and treatment of acute bronchitis

Although several surveys rank acute bronchitis as one of the ten most frequent diagnoses made by primary care physicians, its clinical features are poorly defined and treatment with antibiotics is controversial. This study was designed to determine the clinical characteristics that providers use to diagnose acute bronchitis and to examine the use of antibiotics in treating this illness. Charts of patients with the diagnosis of acute bronchitis or upper respiratory tract infection (URI) were randomly selected and progress notes from these visits were reviewed. Signs, symptoms, laboratory tests, and antibiotics prescribed were recorded. Patients with a diagnosis of acute bronchitis had more productive cough, purulent sputum, and abnormal lung examinations than patients with a diagnosis of URI (P less than .05 for each characteristic). Laboratory tests, including chest roentgenograms, were not frequently used in making the diagnosis of acute bronchitis. Antibotics were prescribed for 27 of 29 patients (92 percent) with a diagnosis of acute bronchitis but for only 4 of 19 patients (21 percent) with a diagnosis of URI. Erythromycin was prescribed for 60 percent of patients with acute bronchitis. From this study it can be concluded that providers use the term acute bronchitis to designate a specific clinical syndrome that they treat with antibiotics. Further clinical trials are needed to evaluate the efficacy of such antibiotic therapy.     

Clinical and radiologic study of the frequency and presentation of chest infection in children with severe protein energy malnutrition.

The association between P.E.M. and frequent and severe life threatening infections including lower respiratory tract infections have been always reported. Lack of the usual general and local signs of infection in P.E.M. makes the diagnosis difficult and sometimes only postmortem. This study evaluated the frequency of chest infections as well as the sensitivity, specificity and predictivity of different signs and symptoms of the disease in 100 children with severe P.E.M. (marasmus, kwashiorkor, and marasmic kwashiorkor). Sixty two percent of the studied children had chest infection (33% pneumonia, 29% bronchitis). Although most patients were symptomatic, yet, signs and symptoms were few and mostly non specific. Chest roentgenograms are thus mandatory in evaluating patients with P.E.M. whenever possible. The only valuable signs suggestive of chest infection in P.E.M. were tachypnea (> or = 40/min) and/or chest indrawing. Both were moderately sensitive, highly specific and predictive of the disease particularly pneumonia. Their presence thus, its indicative of the need for early institution of antibiotic therapy even before the results of chest roentgenograms. Total Leucocytic count was of little diagnostic value while contrary to the common belief that tuberculin test is usually negative in P.E.M., the use of double the usual dose of P.P.D. (i.e. 10 TU) yielded positive reaction in some of the studied patients and thus must not be omitted from the routine investigations of malnourished patients.     

Why are antibiotics prescribed for patients with acute bronchitis? A postintervention analysis

BACKGROUND: Despite the findings in controlled trials that antibiotics provide limited benefit in the treatment of acute bronchitis, physicians frequently prescribe antibiotics for acute bronchitis. The aim of this study was to determine whether certain patient or provider characteristics could predict antibiotic use for acute bronchitis in a system where antibiotic use had already been substantially reduced through quality-improvement efforts. METHODS: A retrospective chart review was performed in an academic family medicine training center that had previously instituted a quality-improvement project to reduce antibiotic prescribing for acute bronchitis. Patients who had acute bronchitis diagnosed during an 18-month period and who had no other secondary diagnosis for respiratory distress or a condition that would justify antibiotics were selected from a computerized-record database and included in the study (n = 135). Charts were reviewed to document patient symptoms, physical findings, provider and patient characteristics, and treatment. RESULTS: Thirty-five (26%) patients received antibiotics for their acute bronchitis. Adults were more likely to receive antibiotics than children (34% vs 3%, P < .001). Analysis of 20 different symptoms and physical findings showed that symptoms and signs were poor predictors of antibiotic use. Likewise, no significant differences were found based on prescribing habits of individual providers or provider level of training. CONCLUSION: In a setting where antibiotic use for acute bronchitis had been decreased through an ongoing quality-improvement effort, it did not appear that providers selectively used antibiotics for patients with certain symptoms or signs. Other factors, such as nonclinical cues, might drive antibiotic prescribing even after clinical variation is suppressed.     

Definition of low respiratory tract infections

Lower respiratory tract infection is easily suggested on clinical signs (cough and sputum) associated with fever. To discriminate between pneumonia and acute bronchitis is crucial because of the mortality associated with pneumonia and of its specific management. Chest X-ray is a key exam for the diagnosis and should be performed on the basis of validated clinical signs that are however of weak diagnostic value. Clinical as well as radiological signs cannot be reliably used to identify the causative germ. Sputum examination, the search for pneumococcal and legionella urinary antigens are of good diagnostic value. An associated COPD may lead to an acute respiratory failure. Acute exacerbation of chronic bronchitis results from various causes but infection is involved in about 50% of the cases, mostly viral and most often due to a rhinovirus. Viral infection can be associated to bacterial infection and the most frequently isolated germs are Streptococcus pneumoniae, Haemophilus influenzae, and B. catarrhalis. Severity assessment relies on the value of basal FEV1 that is often non available. Therefore Afssaps suggests using a dyspnea index to assess exacerbation severity.     

The effect of acute broncho-pulmonary infections on the FEV1 change in 13-year follow-up. The Cracow study

The aim of this study was to assess the effect of acute bronchitis and pneumonia on the FEVI decline rate in a random sample of Cracow inhabitants followed over a 13-year period. A total of 718 males and 1029 females completed the spirometric testing and interview in 13-year follow-up period. Acute chest diseases diagnosed and treated by doctors and reported by respondents in surveys were the source of data on broncho-pulmonary infections. The rate of FEVI change, expressed in ml per year was estimated for each person in 13-year follow-up period.Persons who reported recurrent bronchitis and pneumonia had significantly lower initial FEVI levels than those without infections. The effect was controlled for confounders like age, height, smoking and chronic chest symptoms. The initial low ventilatory function by itself was not a predisposing factor for chest infections, unless they were associated with chronic respiratory symptoms.Lung function in men decreased steeply after pneumonia infection, but the effect appeared to be reversible. This effect was not limited to people with pre-existing chronic respiratory disease. The data indicated that in some subjects who reported new symptoms of dyspnea on effort, the acceleration of FEVI decline due to pneumonia was greater than in people without the symptoms. This may result from the fact that in lower respiratory infection, bacterial or viral agents can produce serious dysfunction of small airways.Corresponding author.     

3种抗生素治疗呼吸道感染的成本-效果分析

目的 呼吸道感染以下呼吸道感染为主要的常见病,多发病包括急性气管-支气管炎、慢性支气管炎急性发作、支气管扩张合并感染、肺胀肿胀胸、医院获得性肺炎、社区获得性肺炎等肺实质感染,目前治疗常用β内酰胺类抗生素.方法 我们通过回顾性分析2009年9月份~2010年6月份呼吸内科常用三种抗生素治疗方案进行成本-效果分析.结果 以期寻找既能得到理想的治疗方案又能得到经济效益较佳的治疗方案,同时为临床合理用药提供依据.结论 3种治疗方案的临床疗效比较,差异无统计学意义(P＞0.05),但费用最低的是头孢米诺钠组,因此,从实验结果分析得出,头孢米诺钠是治疗下呼吸道感染的最佳方案.     

北京地区2010年10月-2011年5月急性呼吸道感染病毒临床特征分析

目的:分析急性呼吸道感染的临床特征,为临床特异性诊断和治疗,以及呼吸道传染病的防治提供依据。方法:选取2010年10月-2011年5月采集的352份呼吸道感染病例,收集病例的临床资料,采集咽拭子样本,检测呼吸道相关病毒,用SPSS软件进行统计分析。结果:352病例中,病毒检测阳性率为39.2%,多份标本存在合并感染,感染病例80%以上都有咳嗽症状,50%以上有发热症状,乙型流感病毒感染患者中头痛的比例(100%)和胸痛的比例(50%)远高于其他患者;MPV感染患者呼吸困难的比例要远高于其他。甲型流感病毒单纯感染和腺病毒单纯感染的标本中头痛的比例要高于有其他病毒合并感染的标本。结论:不同呼吸道病毒感染有一定的临床特征,且各病毒之间易发生合并感染。合并感染的临床表现与单纯病毒感染略有不同。     

Severe acute respiratory syndrome coronavirus 2 and respiratory syncytial virus coinfection in children

Coronavirus disease 2019 (COVID-19) is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which has infected many people around the world. Children are considered an important target group for SARS-CoV-2, as well as other viral infections such as respiratory syncytial virus infection. Both SARS-CoV-2 and respiratory syncytial virus can affect the respiratory tract. Coinfection of SARS-CoV-2 and respiratory syncytial virus can pose significant challenges in terms of diagnosis and treatment in children. This review compares the symptoms, diagnostic methods, and treatment of COVID-19 and respiratory syncytial virus infection in children.     

Office-related antibiotic prescribing for persons aged ≤ 14 years--United States, 1993-1994 to 2007-2008

In 2003, the Institute of Medicine identified antibiotic resistance as a key microbial threat to health in the United States and recommended promoting appropriate antibiotic use as an important strategy to address this threat. Antibiotic use contributes to development of antibiotic resistance on both the individual and country level. To examine trends in pediatric antibiotic prescribing in physician offices, CDC analyzed data from the National Ambulatory Medical Care Survey (NAMCS) for the period 1993-1994 to 2007-2008. This report summarizes the results of that analysis, which found that antibiotic prescribing rates for persons aged ≤ 14 years who had visited physician offices decreased 24% from 300 antibiotic courses per 1,000 office visits in 1993-1994 to 229 antibiotic courses per 1,000 office visits in 2007-2008. Among the five acute respiratory infections (ARIs) examined, antibiotic prescribing rates decreased 26% for pharyngitis and 19% for nonspecific upper respiratory infection (common cold); prescribing rates for otitis media, bronchitis, and sinusitis did not change significantly. Although the overall antibiotic prescribing rate for persons aged ≤ 14 years has decreased, the rate remains inappropriately high. Further efforts are needed to decrease inappropriate antibiotic prescribing for persons aged ≤ 14 years.