Predictors for antibiotic prescribing in patients with exacerbations of COPD in general practice

Llor, Carles; Bjerrum, Lars; Munck, Anders; Hansen, Malene Plejdrup; Córdoba, Gloria; Strandberg, Eva Lena; Ovhed, Ingvar; Radzevičienė, Rūta; Cots, Josep M.; Reutskiy, Anatoliy; Caballero, Lidia

doi:10.1177/1753465812472387

Cited by 33 publications

(44 citation statements)

References 24 publications

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“…Quantitative investigations on GPs’ prescribing behavior for AECOPD (and other respiratory diseases) have shown that symptoms and signs such as colored sputum, severe dyspnea, and CRP testing are associated with treatment decisions for antibiotics and/or oral corticosteroids 29–32. Our findings confirm that GPs consider these clinical cues relevant to their decision-making, yet also show that GPs cannot always rely on their presence and significance.…”

Section: Discussionsupporting

confidence: 70%

How do general practitioners implement decision-making regarding COPD patients with exacerbations? An international focus group study

Laue

Melbye

Halvorsen

et al. 2016

COPD

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PurposeTo explore the decision-making of general practitioners (GPs) concerning treatment with antibiotics and/or oral corticosteroids and hospitalization for COPD patients with exacerbations.MethodsThematic analysis of seven focus groups with 53 GPs from urban and rural areas in Norway, Germany, Wales, Poland, Russia, the Netherlands, and Hong Kong.ResultsFour main themes were identified. 1) Dealing with medical uncertainty: the GPs aimed to make clear medical decisions and avoid unnecessary prescriptions and hospitalizations, yet this was challenged by uncertainty regarding the severity of the exacerbations and concerns about overlooking comorbidities. 2) Knowing the patient: contextual knowledge about the individual patient provided a supplementary framework to biomedical knowledge, allowing for more differentiated decision-making. 3) Balancing the patients’ perspective: the GPs considered patients’ experiential knowledge about their own body and illness as valuable in assisting their decision-making, yet felt that dealing with disagreements between their own and their patients’ perceptions concerning the need for treatment or hospitalization could be difficult. 4) Outpatient support and collaboration: both formal and informal caregivers and organizational aspects of the health systems influenced the decision-making, particularly in terms of mitigating potentially severe consequences of “wrong decisions” and concerning the negotiation of responsibilities.ConclusionFear of overlooking severe comorbidity and of further deteriorating symptoms emerged as a main driver of GPs’ management decisions. GPs consider a holistic understanding of illness and the patients’ own judgment crucial to making reasonable decisions under medical uncertainty. Moreover, GPs’ decisions depend on the availability and reliability of other formal and informal carers, and the health care systems’ organizational and cultural code of conduct. Strengthening the collaboration between GPs, other outpatient care facilities and the patients’ social network can ensure ongoing monitoring and prompt intervention if necessary and may help to improve primary care for COPD patients with exacerbations.

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Section: Discussionsupporting

confidence: 70%

How do general practitioners implement decision-making regarding COPD patients with exacerbations? An international focus group study

Laue

Melbye

Halvorsen

et al. 2016

COPD

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“…A cross-sectional study showed prescribing rates of 92.9% in Russia, 81.1% in Spain, 80.6% Lithuania, and only 48.9% in Denmark 14. Since we detected pathogens in only a limited percentage of cultures, our local data suggest that the role of bacteria in AECOPD in primary care is limited.…”

Section: Discussionmentioning

confidence: 60%

“…CRP as point of care test is already feasible and in use by general practitioners in the Netherlands. The addition of CRP testing during AECOPD showed a strong reduction in antibiotic prescription in patients with AECOPD with purulent sputum, and antibiotic prescription rates were 26% lower in general practitioners using CRP tests 14. The guidelines of Norway and Denmark recommend the use of biomarkers for treatment with antibiotics of outpatients with AECOPD 20.…”

Section: Discussionmentioning

confidence: 99%

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Real-life data on antibiotic prescription and sputum culture diagnostics in acute exacerbations of COPD in primary care

Bathoorn¹,

Groenhof²,

Hendrix³

et al. 2017

COPD

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BackgroundAcute exacerbations of chronic obstructive pulmonary disease (AECOPD) are generally treated with optimization of bronchodilation therapy and a course of oral corticosteroids, mostly without antibiotics. The Dutch guidelines recommend prudent use of antibiotics, with amoxicillin or doxycycline as first choice. Here we evaluate adherence to these guidelines with regard to antibiotic prescription in AECOPD in primary care and the use of sputum cultures.MethodsWe retrospectively analyzed a longitudinal cohort of patients in three primary care practices in the north-eastern region of the Netherlands from 2009 to 2013 (n=36,172 subjects) participating in the Registration Network Groningen. Antibiotics prescribed for AECOPD −10/+28 days from the start date of corticosteroid courses were evaluated. In addition, we assessed regional data on the susceptibility of respiratory pathogens from COPD patients.ResultsWe identified 1,297 patients with COPD. Of these, 616 experienced one or more exacerbations, resulting in a total of 1,558 exacerbations, for which 1,594 antibiotic courses were prescribed. The recommended antibiotics doxycycline and amoxicillin accounted for 56% of the prescribed antibiotics overall and for 35% in subsequent antibiotic courses. The alternative choices were not based on culture results because only in 67 AECOPD events (2.9%) sputum samples were taken. Regional data including 3,638 sputum samples showed that pathogens relevant in AECOPD were detected in 19% of cultures.ConclusionOur study shows that guidelines regarding the prescription of antibiotics are poorly followed, particularly in recurrent exacerbations. Sputum cultures were performed in a small minority of cases. Performing sputum diagnostics in patients with early treatment failure or a repeated exacerbation when antibiotic treatment is started may further rationalize antibiotic treatment.

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“…32 Next, we included prescriptions for the most frequently used antibiotics in the treatment of exacerbations. 33 …”

Section: Methodsmentioning

confidence: 99%

Stability of the frequent COPD exacerbator in the general population: A Danish nationwide register-based study

Reilev

Lykkegaard

Halling

et al. 2017

npj Prim Care Resp Med

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Exacerbation frequency is central in treatment strategies for chronic obstructive pulmonary disease. However, whether chronic obstructive pulmonary disease patients from the general population with frequent exacerbations continue to have frequent exacerbations over an extended period of time is currently unknown. In this study, we aimed to investigate the stability of the frequent exacerbator in a population-based setting. To this end, we conducted a nationwide register-based descriptive study with a 10-year follow-up period of chronic obstructive pulmonary disease patients with at least one medically treated exacerbation in 2003. Each subsequent year, we divided the population into frequent, infrequent and non-exacerbators and quantified the flow between categories. Further, we estimated the percentage of frequent exacerbators at baseline who stayed in this category each year during a 5-year follow-up. We identified 19,752 patients with chronic obstructive pulmonary disease and an exacerbation in 2003. Thirty percent were frequent exacerbators. Overall, the majority of exacerbators in 2003 were non-exacerbators in the following years (60% in 2004 increasing to 68% in 2012). Approximately half of frequent exacerbators in one year experienced a decrease in exacerbation frequency and had either zero or one exacerbation in the subsequent year. This pattern was stable throughout follow-up. During a 5-year follow-up period, a substantial proportion (42%) of frequent exacerbators in 2003 had no additional years as frequent exacerbators, while the minority (6%) remained in this category each year. In conclusion, the rate of exacerbations shows considerable variation over time among chronic obstructive pulmonary disease patients in the general population. This might hold implications for chronic obstructive pulmonary disease treatment guidelines and their practical application.

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Predictors for antibiotic prescribing in patients with exacerbations of COPD in general practice

Cited by 33 publications

References 24 publications

How do general practitioners implement decision-making regarding COPD patients with exacerbations? An international focus group study

How do general practitioners implement decision-making regarding COPD patients with exacerbations? An international focus group study

Real-life data on antibiotic prescription and sputum culture diagnostics in acute exacerbations of COPD in primary care

Stability of the frequent COPD exacerbator in the general population: A Danish nationwide register-based study

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