Materials to help healthcare professionals communicate with and educate patients on antibiotic use are available from many national and international bodies, such as the US Center for Disease Control and Prevention (CDC) and the European Centre for Disease Prevention and Control (ECDC).
“Your immune system is equipped to deal with this infection”
These provide advice on consultations and how to manage patient expectations. For example, the US CDC’s guidance on how to communicate with patients about appropriate antibiotic use for upper respiratory tract infection advises:
- offer a specific diagnosis, for example viral bronchitis, rather than saying ‘a virus’ – the panel commented that, in some cases, a specific diagnosis may sound ‘too serious’ for some patients. Prof. van der Velden added that physicians often cannot distinguish infections of viral or bacterial origin
- recommend symptomatic relief – the panel agreed with this approach, where it was appropriate. For example, in some countries the use of some symptomatic, non-analgesic treatments in children is not permitted for upper respiratory tract infections
- share normal findings during the exam, e.g. letting patients know their lungs are clear – the panel believed patient reassurance was important
- discuss potential antibiotic side effects – the panel advocated the need to achieve a balance between communicating the benefits of antibiotics when they are required, with a strong antibiotic resistance message when they are not necessary. Prof. Kozlov raised the possibility that focusing on side effects could dissuade patients from taking antibiotics at a time when there was a genuine need. Dr Duerden commented that he did alert patients to the potential risk of antibiotic-associated diarrhoea
- explain to patients what to expect over the next few days with their ailment – the panel endorsed this, adding it was also important to make patients aware they could return to the practice if they had concerns.
Prof. van der Velden outlined the most important message for patients with sore throat and respiratory tract infections: “Your immune system is equipped to deal with this infection”.
Advising patients why an antibiotic is not required is hard to convey. Although a healthcare professional may say antibiotics are ineffective against viral infections, this may mean little to the patient. “The differences between viruses and bugs are difficult to explain,” said Prof. Altiner. “There are maybe things we can learn from marketing as there is a difference between cognitive awareness and behaviour”. Getting the antibiotic resistance message across to younger generations is also important, although there was some pessimism. “These types of programmes don’t stop children smoking, drinking or taking drugs when they get older”, Dr Duerden pointed out.
“Around two-thirds of children will get antibiotics, around 89% for sore throat”
Overall it was clear that an easy, understandable message and framework for patients on antibiotic use needs to be created, and this may vary by country. Consistent, sustained messaging across healthcare professionals, spanning both primary and secondary care, is also vital. “We have to communicate but we have to communicate effectively and we have to do it over and over again”, said Mr Bell, citing the example of the Australian sunscreen campaign that has run for over 30 years.
A number of strategies have been used to encourage physicians to rationally prescribe antibiotics for sore throat.
To test or not to test
The role of rapid antigen testing for Group A Streptococcus infection in sore throat – one of the bacterial infections for which antibiotics are generally indicated – caused some debate.
Prof. Altiner believed the test is overused in paediatric patients and underused in adults. But it is used effectively in Smolensk, western Russia, as a means of not prescribing antibiotics, said Prof. Kozlov, while Dr Sessa believed testing in Italy had significantly reduced the antibiotic prescribing rate.
Prof. Pignatari said Brazilian GPs had been educated that if a test is negative then antibiotics should not be prescribed, but, as outlined earlier, they are less confident in diagnosing children, so often offer a test and provide a prescription as well. “If they test positive they get antibiotics, if they test negative they get antibiotics”.
Colleagues in Scandinavia experienced increased doctor consultations and pressure, said Prof. van der Velden, adding: “This is an unwanted side effect of pointof-care tests”.
“In the private sector, the antibiotic resistance rate is lower but there is a broader range of drugs against which resistance exists because antibiotic choice is unrestricted”
The Centor criteria feature in a number of national and European guidelines18-21. These advise that the risk of a bacterial infection is raised if 3–4 Centor criteria are present21:
- temperature >38°C
- no cough
- tender anterior cervical adenopathy
- tonsillar swelling or exudate.
In the Netherlands, these criteria are no longer used as a basis for prescription for sore throat. Instead, said Prof. van der Velden the new guideline advises to prescribe for patients with a severe infection, which is characterised by the throat aspect plus the patient’s condition. Reasons to prescribe are:
- severe illness, fever, throat and swallowing complaints that affect daily functioning
- peritonsillar infiltrate or abscess
- extremely swollen, painful lymph nodes across the entire neck and throat region.
In the UK, guidelines recommend either no prescribing, with ‘watchful waiting’, or delayed antibiotic prescribing,18where patients are given an antibiotic prescription but advised only to have it dispensed if symptoms persist or worsen after a few days. In clinical practice 30% of patients still receive an antibiotic prescription22.
Dr Duerden said: “GPs know delayed prescribing is not very meaningful and it is a bit deceptive, if antibiotics are unnecessary but they still do it. A better strategy may be to see the patient again if symptoms persist”.
While a number of national and regional guidelines are available on sore throat management, these often differ between countries and are subject to change. Prof. Pignatari pointed out: “There are guidelines for smaller countries, but what are the options for larger countries? These should be adapted for the BRIC [Brazil, Russia, India, China] countries and for countries where no guidelines exist”.
“If I dissuade them from having an antibiotic in primary care, they then should not be able to go to another GP or their accident and emergency department and get one”
In countries where guidelines do exist, such as Germany, the Netherlands and the UK, there remains irrational prescribing. “GPs will say guidelines are for average patients, but my patients are not average”, explained Prof. van der Velden.
Prof. Essack called for the group to create a framework for nonantibiotic use, rather than a guideline, that was adaptable across countries and cultures. This framework should encompass advice to patients and consider other strategies to manage sore throat, cough and other respiratory tract infections.
Sore throat is one of the leading indications for antibiotic use in many countries, despite up to 95% of sore throat infections being of viral origin24, 25. Multiple strategies can be considered to help physicians determine appropriate use and improve patient management.
“GPs will say guidelines are for average patients, but my patients are not average”
For patients, managing persistent or worsening symptoms is the key reason to seek physician treatment11. The group suggested the following good practice approaches that can also be adapted to other upper respiratory tract infections:
- always examine the patient before reaching a conclusion
- advise on the duration of symptoms, giving a realistic time frame for improvement. Around 80% of patients are sore throat free within seven days14
- recommend symptomatic relief – pain and fever are the leading symptoms. Treat the symptoms from the beginning to prevent sore throat inflammation continuing
- advocate bed rest, if necessary
- ask patients what they expect from antibiotic treatment, if requested inappropriately. Explain that it does not offer symptomatic relief as most sore throats are viral and, therefore, do not benefit from antibiotic treatment
- provide information on what alarm symptoms patients should be concerned about
- allow the patient to talk about their concerns – communication must be two-way
- offer a follow-up consultation if symptoms do not improve or in case patients remain concerned.