Amoxicillin for acute lower respiratory tract infection in primary care: subgroup analysis by bacterial and viral aetiology

Bruyndonckx, Robin; Stuart, Beth; Little, Paul; Hens, Niel; Ieven, Margareta; Butler, Christopher Collett; Verheij, Theo; Goossens, Herman; Coenen, Samuel

doi:10.1016/j.cmi.2017.10.032

Cited by 23 publications

(21 citation statements)

References 21 publications

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“…The reasons for reduced reconsultation rates are unclear, but one suggestion is that if a prescription is delayed, by the time the antibiotic course has finished, symptoms will have had more time to settle and so reconsultation is less likely; or it could be that secondary opportunistic bacterial infections that start later after an initial viral illness are more effectively managed by the later start of a delayed prescription. The second suggestion is supported by findings from the large GRACE trial; one of the groups that reported beneficial effects for antibiotics were people for whom evidence was found of coinfection with viruses and bacterial pathogens 60…”

Section: Discussionmentioning

confidence: 96%

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Delayed antibiotic prescribing for respiratory tract infections: individual patient data meta-analysis

Stuart

Hounkpatin

Becque

et al. 2021

BMJ

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Objective To assess the overall effect of delayed antibiotic prescribing on average symptom severity for patients with respiratory tract infections in the community, and to identify any factors modifying this effect. Design Systematic review and individual patient data meta-analysis. Data sources Cochrane Central Register of Controlled Trials, Ovid Medline, Ovid Embase, EBSCO CINAHL Plus, and Web of Science. Eligibility criteria for study selection Randomised controlled trials and observational cohort studies in a community setting that allowed comparison between delayed versus no antibiotic prescribing, and delayed versus immediate antibiotic prescribing. Main outcome measures The primary outcome was the average symptom severity two to four days after the initial consultation measured on a seven item scale (ranging from normal to as bad as could be). Secondary outcomes were duration of illness after the initial consultation, complications resulting in admission to hospital or death, reconsultation with the same or worsening illness, and patient satisfaction rated on a Likert scale. Results Data were obtained from nine randomised controlled trials and four observational studies, totalling 55 682 patients. No difference was found in follow-up symptom severity (seven point scale) for delayed versus immediate antibiotics (adjusted mean difference −0.003, 95% confidence interval −0.12 to 0.11) or delayed versus no antibiotics (0.02, −0.11 to 0.15). Symptom duration was slightly longer in those given delayed versus immediate antibiotics (11.4 v 10.9 days), but was similar for delayed versus no antibiotics. Complications resulting in hospital admission or death were lower with delayed versus no antibiotics (odds ratio 0.62, 95% confidence interval 0.30 to 1.27) and delayed versus immediate antibiotics (0.78, 0.53 to 1.13). A significant reduction in reconsultation rates (odds ratio 0.72, 95% confidence interval 0.60 to 0.87) and an increase in patient satisfaction (adjusted mean difference 0.09, 0.06 to 0.11) were observed in delayed versus no antibiotics. The effect of delayed versus immediate antibiotics and delayed versus no antibiotics was not modified by previous duration of illness, fever, comorbidity, or severity of symptoms. Children younger than 5 years had a slightly higher follow-up symptom severity with delayed antibiotics than with immediate antibiotics (adjusted mean difference 0.10, 95% confidence interval 0.03 to 0.18), but no increased severity was found in the older age group. Conclusions Delayed antibiotic prescribing is a safe and effective strategy for most patients, including those in higher risk subgroups. Delayed prescribing was associated with similar symptom duration as no antibiotic prescribing and is unlikely to lead to poorer symptom control than immediate antibiotic prescribing. Delayed prescribing could reduce reconsultation rates and is unlikely to be associated with an increase in symptoms or illness duration, except in young children. Study registration PROSPERO CRD42018079400.

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Section: Discussionmentioning

confidence: 96%

“…The second suggestion is supported by findings from the large GRACE trial; one of the groups that reported beneficial effects for antibiotics were people for whom evidence was found of coinfection with viruses and bacterial pathogens. 60 …”

Section: Discussionmentioning

confidence: 99%

Delayed antibiotic prescribing for respiratory tract infections: individual patient data meta-analysis

Stuart

Hounkpatin

Becque

et al. 2021

BMJ

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“…Use of signs and symptoms of disease to rule out acute Q fever would be most appropriate in patients with nonsevere lower respiratory tract infections, i.e., in cases where pneumonia is not suspected clinically. In such cases, use of antibiotics has been shown to provide little benefit in primary care, both overall and in patients aged 60 years and above, but may cause slight harms [25,26]. Nevertheless, inappropriate use of antibiotics remains common in this population, as a study performed in 14, 987 outpatients was recently able to show [27].…”

Section: Discussionmentioning

confidence: 99%

Signs and symptoms do not predict, but may help rule out acute Q fever in favour of other respiratory tract infections, and reduce antibiotics overuse in primary care

2020

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Background From early 2009, the Dutch region of South Limburg experienced a massive outbreak of Q fever, overlapping with the influenza A(H1N1)pdm09 pandemic during the second half of the year and affecting approximately 2.9% of a 300,000 population. Acute Q fever shares clinical features with other respiratory conditions. Most symptomatic acute infections are characterized by mild symptoms, or an isolated febrile syndrome. Pneumonia was present in a majority of hospitalized patients during the Dutch 2007–2010 Q fever epidemic. Early empiric doxycycline, guided by signs and symptoms and patient history, should not be delayed awaiting laboratory confirmation, as it may shorten disease and prevent progression to focalized persistent Q fever. We assessed signs’ and symptoms’ association with acute Q fever to guide early empiric treatment in primary care patients. Methods In response to the outbreak, regional primary care physicians and hospital-based medical specialists tested a total of 1218 subjects for Q fever. Testing activity was bimodal, a first “wave” lasting from March to December 2009, followed by a second “wave” which lasted into 2010 and coincided with peak pandemic influenza activity. We approached all 253 notified acute Q fever cases and a random sample of 457 Q fever negative individuals for signs and symptoms of disease. Using data from 140/229(61.1%) Q fever positive and 194/391(49.6%) Q fever negative respondents from wave 1, we built symptom-based models predictive of Q-fever outcome, validated against subsets of data from wave 1 and wave 2. Results Our models had poor to moderate AUC scores (0.68 to 0.72%), with low positive (4.6–8.3%), but high negative predictive values (91.7–99.5%). Male sex, fever, and pneumonia were strong positive predictors, while cough was a strong negative predictor of acute Q fever in these models. Conclusion Whereas signs and symptoms of disease do not appear to predict acute Q fever, they may help rule it out in favour of other respiratory conditions, prompting a delayed or non-prescribing approach instead of early empiric doxycycline in primary care patients with non-severe presentations. Signs and symptoms thus may help reduce the overuse of antibiotics in primary care during and following outbreaks of Q fever.

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“…In such cases, use of antibiotics has been shown to provide little bene t in primary care, both overall and in patients aged 60 years and above, but may cause slight harms. [25,26] Nevertheless, inappropriate use of antibiotics remains common in this population, as a study performed in 14987 outpatients was recently able to show. [27] In a subgroup of 3306 patients with laboratory-con rmed in uenza, in whom no pneumonia had been diagnosed, 945 (29%) were prescribed an antibiotic.…”

Section: Discussionmentioning

confidence: 99%

Signs and symptoms do not predict, but may help rule out acute Q fever in favour of other respiratory tract infections, and reduce antibiotics overuse in primary care

Hackert¹,

Dukers-Muijrers

Hoebe³

2020

Preprint

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Background: From early 2009, the Dutch region of South Limburg experienced a massive outbreak of Q fever, overlapping with the influenza A(H1N1)pdm09 pandemic during the second half of the year and affecting approximately 2.9% of a 300,000 population. Acute Q fever shares clinical features with other respiratory conditions. Most symptomatic acute infections are characterized by mild symptoms, or an isolated febrile syndrome. Pneumonia was present in a majority of hospitalized patients during the Dutch 2007-2010 Q fever epidemic. Early empiric doxycycline, guided by signs and symptoms and patient history, should not be delayed awaiting laboratory confirmation, as it may shorten disease and prevent progression to focalized persistent Q fever. We assessed signs’ and symptoms’ association with acute Q fever to guide early empiric treatment in primary care patients. Methods: In response to the outbreak, regional primary care and hospital-based specialty physicians tested a total of 1218 subjects for Q fever. Testing activity was bimodal, a first “wave” lasting from March to December 2009, followed by a second “wave” which lasted into 2010 and coincided with peak pandemic influenza activity. We approached all 253 notified acute Q fever cases and a random sample of 457 Q fever negative individuals for signs and symptoms of disease. Using data from 140/229(61.1%) Q fever positive and 194/391(49.6%) Q fever negative respondents from wave 1, we built symptom-based models predictive of Q-fever outcome, validated against subsets of data from wave 1 and wave 2. Results: Our models had poor to moderate AUC scores (0.68% to 0.72%), with low positive (4.6-8.3%), but high negative predictive values (91.7-99.5%). Male sex, fever, and pneumonia were strong positive predictors, while cough was a strong negative predictor of acute Q fever in these models. Conclusion: Whereas signs and symptoms of disease do not appear to predict acute Q fever, they may help rule it out in favour of other respiratory conditions, prompting a delayed or non-prescribing approach instead of early empiric doxycycline in primary care patients with non-severe presentations. Signs and symptoms thus may help reduce the overuse of antibiotics in primary care during and following outbreaks of Q fever.

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Amoxicillin for acute lower respiratory tract infection in primary care: subgroup analysis by bacterial and viral aetiology

Abstract: Amoxicillin may reduce the risk of illness deterioration in patients with a combined bacterial and viral infection. We found no clinically meaningful benefit from amoxicillin treatment in other subgroups.

Cited by 23 publications

References 21 publications

Delayed antibiotic prescribing for respiratory tract infections: individual patient data meta-analysis

Delayed antibiotic prescribing for respiratory tract infections: individual patient data meta-analysis

Signs and symptoms do not predict, but may help rule out acute Q fever in favour of other respiratory tract infections, and reduce antibiotics overuse in primary care

Signs and symptoms do not predict, but may help rule out acute Q fever in favour of other respiratory tract infections, and reduce antibiotics overuse in primary care

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