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Electronic letters published:
![[Read Comment]](/icons/misc/sectionDOWN.gif){kind=icon}
Is there a relation between pain and group A streptococci?
Re: Delayed prescription
Delayed prescription
Re: Patients with sore throat
Patients with sore throat
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Morten Lindbaek, Oslo, Norway professor
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I read the article by dr. van Driel et al with great interest. It is important to focus on patients' expectations as to symptom relief and need for antibiotics. As the authors point out, there is a clear relationship between antibiotic prescription and later belief in the need for antibiotics to recover, as shown by Little et al (1). However, I miss some clinical data from this study. It would have been interesting also to analyse the expectations in relation to the number of Centor criteria or a GAS quick test. In our study, we found a clear relationship between degree of pain and presence of Centor criteria or presence of GAS in the throat. With stronger pain, there was higher probability of GAS-infection (2). As shown by Zwart in his RCT, patients with 3 Centor criteria met, had a significant quicker recovery with penicillin than placebo, although the difference is debatable as to clinical significance (3). But this implies that when patients with strong pain expect to get antibiotics, there may be a clinical rationale for this. Another relevant concern among patients that was not asked was concern about spread of group A streptococci, which is well-known among the population. In our study of families with a member with GAS-throat infection, we found that in 30% of the families another person also had sore throat with GAS. (4). A similar finding was detected in a Swedish study. In the analysis, we found that number of family members and having small children were independent predictors of spread of GAS within the family. Thus it would have been of interest to see whether concern for spread would have been frequent and also associated with a wish for antibiotics. 1. Little P, Williamson I, Warner G, Gould C, Gantley M, Kinmonth AL. Open randomised trial of prescribing strategies in managing sore throat.BMJ. 1997 Mar 8;314(7082):722-7. 2. Lindbaek M, Hoiby EA, Lermark G, Steinsholt IM, Hjortdahl P Clinical symptoms and signs in sore throat patients with large colony variant beta- haemolytic streptococci groups C or G versus group A. Br J Gen Pract. 2005 Aug;55(517):615-9. 3. Zwart S, Sachs AP, Ruijs GJ, Gubbels JW, Hoes AW, de Melker RA. Penicillin for acute sore throat: randomised double blind trial of seven days versus three days treatment or placebo in adults. BMJ. 2000 Jan 15;320(7228):150-4. 4. Lindbaek M, Hoiby EA, Lermark G, Steinsholt IM, Hjortdahl P.Predictors for spread of clinical group A streptococcal tonsillitis within the household. Scand J Prim Health Care. 2004 Dec;22(4):239-43. Morten Lindbæk Professor in general practice University of Oslo, Norway Competing interests: None declared |
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mieke van Driel, Ghent, Belgium researcher, Dept. General Practice & PHC, Ghent University
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Indeed, several studies show that the strategy of 'delayed prescriptions' reduces antibiotic use. But, I always feel uneasy with this strategy. We tell our patients that they don't need antibiotics and at the same time we give them a prescription. As if we're not sure about it. Also, when they don't get better (or get worse), I'd prefer to see them rather than have them pick up a prescription from the pharmacy. It's not easy to break old habits (both for doctors who prescribe antibiotics and for patients who want them). But, if we continue giving the same message, it must be possible to change. We have some indirect evidence from a comparative study of 2 populations living only a few miles apart in The Netherlands and Belgium.(1) Deschepper et al found that people in The Netherlands prefer to label upper respiratory tract symptoms as "a cold" or "a flu" and do not consider antibiotics useful. But for the same condition Belgians speak of "bronchitis" that is associated with a need for antibiotics. In The Netherlands antibiotic prescribing rates have been low compared to Belgium for many years, so patients may have been educated by these restrictive prescribing habits of their physicians. In our study we also included some family physicians from The Netherlands. They had a hard time finding patients with an uncomplicated acute sore throat. Patients know what to do in the acute phase and only consult their doctor when they feel it doesn't get well or gets worse. I guess the main message is that we need to be convinced that it's OK not to prescribe antibiotics and need to educate our patients. It'll take a while, but we must try if we don't want antibiotic resistance to catch up with us. 1. Deschepper R, Vander Stichele RH, Haaijer-Ruskamp FM. Cross- cultural differences in lay attitudes and utilisation of antibiotics in a Belgian and a Dutch city. Patient Educ Couns 2002;48:161-9. Competing interests: None declared |
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John Hickner, Chicago, IL family physician, U of Chicago
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Yes, it is difficult to resist the direct request. A number of investigators have found the "delayed prescription" approach to be quite effective. Only 30 to 50% of patients fill a prescription if they are told "you probably don't need this; your body will fight off the infection just as quick. but here is a presciption to fill in a couple of days just in case." John Competing interests: None declared |
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Mieke L van Driel, Ghent, Belgium researcher, Dept. General Practice & PHC, Ghent University
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Your patients sound very familiar. We found that our patients who hope for antibiotics were significantly more concerned about pain. They might think that antibiotics are the best way to deal with their pain and not prescribing antibiotics could be interpreted as “the doctor wants me to suffer”. Of course, that makes them unhappy. If you want your patients to leave your office satisfied, you could consider using another approach. In stead of (wasting your time) explaining why they don’t need antibiotics, you could explore what they worry about and address these specific concerns. Then you would really have something to offer. Other researchers have also shown that patients aren’t necessarily unsatisfied if they don’t get the antibiotics they initially wanted. They rather value information and being taken seriously. (1) Also, do not underestimate the educational effect of your prescribing practice: the most important predictor of wanting antibiotics is a prescription for antibiotics in the past.(2) Prescribing antibiotics for patients who don’t need them doesn’t save time (3,4), doesn’t address their needs, exposes them to unnecessary side effects, and is far from “good clinical practice”. It may be as simple as just listening, reassuring and alleviating pain. Why not try? 1. Butler CC, Rollnick S, Kinnersley P, Jones A, Stott N. Reducing antibiotics for respiratory tract symptoms In primary care: consolidating ‘why’ and considering ‘how’. Br J Gen Pract 1998;48:1865-70. 2. Mainous A, Zoorob R, Oler M, Haynes D. Patient knowledge of upper respiratory infections: implications for antibiotic expectations and unnecessary utilization. J Fam Pract 1997;45(75-83. 3. Coco A, Mainous AG. Relation of time spent in an encounter with the use of antibiotics in pediatric office visits for viral respiratory infections. Arch Pediatr Adolesc Med 2005;159:1145-1149. 4. Linder JA, Singer DE, Stafford RS. Association between antibiotic prescribing and visit duration in adults with upper respiratory tract infections. Clin Ther 2003;25:2419-30. Competing interests: None declared |
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Corina Nistor, Mill Creek, USA Family Practice Physician
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Most of my patients with sore throat or rhinosinusitis are very explicit for the very beggining about antibiotics. They start saying " I have a sore throat" or "I think I have a sinus infection and I was hoping for an antibiotic". It takes me lot of time to explain to them that they not need the antibiotic and they leave the office unhappy. Lots of time they call back stating they are not any better and requesting it. It does not matter what the study shows because it is based on what patients declare which it might not be accurate. So, although I am still quite fresh out of the residency and these was the way were taught to practice I am giving up now and give the patients what they want. It takes more effort to explain to them the opposite. Thanks Competing interests: None declared |
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