Objective To assess the effect of general practitioner testing for C reactive protein (disease approach) and receiving training in enhanced communication skills (illness approach) on antibiotic prescribing for lower respiratory tract infection.Design Pragmatic, 2×2 factorial, cluster randomised controlled trial.Setting 20 general practices in the Netherlands.Participants 40 general practitioners from 20 practices recruited 431 patients with lower respiratory tract infection.Main outcome measures The primary outcome was antibiotic prescribing at the index consultation. Secondary outcomes were antibiotic prescribing during 28 days’ follow-up, reconsultation, clinical recovery, and patients’ satisfaction and enablement.Interventions General practitioners’ use of C reactive protein point of care testing and training in enhanced communication skills separately and combined, and usual care.Results General practitioners in the C reactive protein test group prescribed antibiotics to 31% of patients compared with 53% in the no test group (P=0.02). General practitioners trained in enhanced communication skills prescribed antibiotics to 27% of patients compared with 54% in the no training group (P<0.01). Both interventions showed a statistically significant effect on antibiotic prescribing at any point during the 28 days’ follow-up. Clinicians in the combined intervention group prescribed antibiotics to 23% of patients (interaction term was non-significant). Patients’ recovery and satisfaction were similar in all study groups.Conclusion Both general practitioners’ use of point of care testing for C reactive protein and training in enhanced communication skills significantly reduced antibiotic prescribing for lower respiratory tract infection without compromising patients’ recovery and satisfaction with care. A combination of the illness and disease focused approaches may be necessary to achieve the greatest reduction in antibiotic prescribing for this common condition in primary care.Trial registration Current Controlled Trials ISRCTN85154857.

SummaryBackgroundHigh-volume prescribing of antibiotics in primary care is a major driver of antibiotic resistance. Education of physicians and patients can lower prescribing levels, but it frequently relies on highly trained staff. We assessed whether internet-based training methods could alter prescribing practices in multiple health-care systems.MethodsAfter a baseline audit in October to December, 2010, primary-care practices in six European countries were cluster randomised to usual care, training in the use of a C-reactive protein (CRP) test at point of care, in enhanced communication skills, or in both CRP and enhanced communication. Patients were recruited from February to May, 2011. This trial is registered, number ISRCTN99871214.ResultsThe baseline audit, done in 259 practices, provided data for 6771 patients with lower-respiratory-tract infections (3742 [55·3%]) and upper-respiratory-tract infections (1416 [20·9%]), of whom 5355 (79·1%) were prescribed antibiotics. After randomisation, 246 practices were included and 4264 patients were recruited. The antibiotic prescribing rate was lower with CRP training than without (33% vs 48%, adjusted risk ratio 0·54, 95% CI 0·42–0·69) and with enhanced-communication training than without (36% vs 45%, 0·69, 0·54–0·87). The combined intervention was associated with the greatest reduction in prescribing rate (CRP risk ratio 0·53, 95% CI 0·36–0·74, p<0·0001; enhanced communication 0·68, 0·50–0·89, p=0·003; combined 0·38, 0·25–0·55, p<0·0001).InterpretationInternet training achieved important reductions in antibiotic prescribing for respiratory-tract infections across language and cultural boundaries.FundingEuropean Commission Framework Programme 6, National Institute for Health Research, Research Foundation Flanders.

BackgroundRecently, many scientists including bacteriologists have begun to focus on social aspects of antibiotic management especially the knowledge, attitude and practice (KAP) among the general population regarding antibiotic use. However, relatively few works have published on the relationship between KAP and medical education. In this study, we analyze the present status of Chinese medical (MS)- and non-medical (NS) students’ KAP on the use of antibiotics, and examine the influence of Chinese medical curriculum on the appropriate usage of antibiotics among medical students.MethodsIn this study, 2500 students from 3 universities (including one medical university) in Northeastern China participate in the questionnaire survey on students’ knowledge, attitude and practice toward antibiotic usage. Wilcoxon rank sum test and Chi square test were used to analyze questionnaire-related discrete and categorical variables respectively, in order to assess the impact of the medical curriculum on students’ KAP towards antibiotics.Results2088 (83.5%) respondents (MS-1236 and NS-852) were considered valid for analysis. The level of knowledge of MS on the proper use of antibiotics was significantly higher than that of NS (p < 0.0001). However, based on their responses on actual practice, MS were found to rely on antibiotics more than NS (p < 0.0001). Moreover, the knowledge and attitude of MS towards antibiotic use improved with the increase in grade with discriminate use of antibiotics concurrently escalating during the same period.ConclusionsThis study indicates that Chinese medical curriculum significantly improves students’ knowledge on antibiotics and raises their attention on antibiotic resistance that may result from indiscriminate use of antibiotics. The study also shows an excessive use of antibiotics especially among the more senior medical students, signifying a deficiency of antibiotics usage instruction in their curriculum. This might explain why there are frequent abuses of antibiotics in both hospital and community settings from a certain angle.

PURPOSE Antibiotics are only benefi cial for subgroups of patients with acute lower respiratory tract infections (LRTI) and rhinosinusitis in family practice, yet overprescribing for these conditions is common. C-reactive protein (CRP) pointof-care testing and delayed prescribing are useful strategies to reduce antibiotic prescribing, but both have limitations. We evaluated the effect of CRP assistance in antibiotic prescribing strategies-including delayed prescribing-in the management of LRTI and rhinosinusitis. METHODSWe conducted a randomized controlled trial in which 258 patients were enrolled (107 LRTI and 151 rhinosinusitis) by 32 family physicians. Patients were individually randomized to CRP assistance or routine care (control). Primary outcome was antibiotic use after the index consultation. Secondary outcomes included antibiotic use during the 28-day follow-up, patient satisfaction, and clinical recovery. RESULTSPatients in the CRP-assisted group used fewer antibiotics (43.4%) than control patients (56.6%) after the index consultation (relative risk [RR] = 0.77; 95% confi dence interval [CI], 0.56-0.98). This difference remained signifi cant during follow-up (52.7% vs 65.1%; RR = 0.81; 95% CI, 0.62-0.99). Delayed prescriptions in the CRP-assisted group were fi lled only in a minority of cases (23% vs 72% in control group, P <.001). Recovery was similar across groups. Satisfaction with care was higher in patients managed with CRP assistance (P = .03).CONCLUSIONS CRP point-of-care testing to assist in prescribing decisions, including delayed prescribing, for LRTI and rhinosinusitis may be a useful strategy to decrease antibiotic use and increase patient satisfaction without compromising patient recovery. Ann Fam Med 2010;8:124-133. doi:10.1370/afm.1090. INTRODUCTIONR espiratory tract infections are among the most common reasons to consult in family practice. Although antibiotic treatment is considered necessary only for community-acquired pneumonia and for small subgroups of the other lower and upper respiratory tract infections, [1][2][3][4][5] antibiotics are prescribed to roughly 80% of patients consulting for lower respiratory tract infection (LRTI) or acute rhinosinusitis. 6,7 Signs and symptoms are of limited value in identifying those patients in need of antibiotic treatment for these conditions. 2,[8][9][10] Diagnostic uncertainty and patient-related factors, such as patient expectations and pressure, often lead to unjustifi ed antibiotic prescribing by family physicians. 11,12 C-reactive protein (CRP) is an acute-phase protein with levels quickly rising during infl ammatory processes. Currently, CRP can be measured by using a point-of-care test, which has been proved both accurate and robust in a family practice setting. 13 T ES T ING CR P F OR A N T IBIOT IC PR ES CR IBINGparameters, increases diagnostic certainty [14][15][16] and may thereby help identify those patients who will benefi t from antibiotic treatment. Latest randomized evidence has shown that antibiotic prescribing rates ...

SummaryBackgroundInappropriate antibiotic use for acute respiratory tract infections is common in primary health care, but distinguishing serious from self-limiting infections is difficult, particularly in low-resource settings. We assessed whether C-reactive protein point-of-care testing can safely reduce antibiotic use in patients with non-severe acute respiratory tract infections in Vietnam.MethodWe did a multicentre open-label randomised controlled trial in ten primary health-care centres in northern Vietnam. Patients aged 1–65 years with at least one focal and one systemic symptom of acute respiratory tract infection were assigned 1:1 to receive either C-reactive protein point-of-care testing or routine care, following which antibiotic prescribing decisions were made. Patients with severe acute respiratory tract infection were excluded. Enrolled patients were reassessed on day 3, 4, or 5, and on day 14 a structured telephone interview was done blind to the intervention. Randomised assignments were concealed from prescribers and patients but not masked as the test result was used to assist treatment decisions. The primary outcome was antibiotic use within 14 days of follow-up. All analyses were prespecified in the protocol and the statistical analysis plan. All analyses were done on the intention-to-treat population and the analysis of the primary endpoint was repeated in the per-protocol population. This trial is registered under number NCT01918579.FindingsBetween March 17, 2014, and July 3, 2015, 2037 patients (1028 children and 1009 adults) were enrolled and randomised. One adult patient withdrew immediately after randomisation. 1017 patients were assigned to receive C-reactive protein point-of-care testing, and 1019 patients were assigned to receive routine care. 115 patients in the C-reactive protein point-of-care group and 72 patients in the routine care group were excluded in the intention-to-treat analysis due to missing primary endpoint. The number of patients who used antibiotics within 14 days was 581 (64%) of 902 patients in the C-reactive protein group versus 738 (78%) of 947 patients in the control group (odds ratio [OR] 0·49, 95% CI 0·40–0·61; p<0·0001). Highly significant differences were seen in both children and adults, with substantial heterogeneity of the intervention effect across the 10 sites (I2=84%, 95% CI 66–96). 140 patients in the C-reactive protein group and 137 patients in the routine care group missed the urine test on day 3, 4, or 5. Antibiotic activity in urine on day 3, 4, or 5 was found in 267 (30%) of 877 patients in the C-reactive protein group versus 314 (36%) of 882 patients in the routine treatment group (OR 0·78, 95% CI 0·63–0·95; p=0·015). Time to resolution of symptoms was similar in both groups. Adverse events were rare, with no deaths and a total of 14 hospital admissions (six in the C-reactive protein group and eight in the control group).InterpretationC-reactive protein point-of-care testing reduced antibiotic use for non-severe acute respiratory tract infection w...