Treating patients not diagnoses: challenging assumptions underlying the investigation and management of LRTI in general practice

Rogier M. Hopstaken1,*, Samuel Coenen2,3 and Christopher C. Butler4

1 Maastricht University, Care and Public Health Research Institute, Department of General Practice, PO Box 616, 6200 MD Maastricht, The Netherlands; 2 Fund for Scientific Research, Flanders, Brussels, Belgium; 3 Department of General Practice, University of Antwerp, Universiteitsplein 1, 2610 Antwerp, Belgium; 4 Department of General Practice, Cardiff University, Llanedeyrn Health Centre, Llanedeyrn, CF23 9PN, Cardiff, UK


* Corresponding author. Tel: +31-433882323; Fax: +31-433619344; E-mail: rogier.hopstaken{at}hag.unimaas.nl

Received 3 June 2005; returned 5 August 2005; revised 10 August 2005; accepted 19 August 2005


    Abstract
 Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 References
 
Objectives: Many clinicians treat patients with a lower respiratory tract infection (LRTI) due to bacterial infection with antibiotics, and regard antibiotic treatment as obligatory for patients with radiographic evidence of pneumonia. The necessity of antibiotic treatment is largely unknown and rarely challenged.

Patients and methods: Twenty-five general practitioners (GPs) recorded clinical information on 247 adult patients presenting with LRTI. Standard microbiological, susceptibility and serological analysis, and chest radiography was performed for all patients. At 28 days after entry into the study, the GPs took a history and conducted a physical examination again and decided whether or not the patient was fully recovered.

Results: Thirty of 63 patients with cultured pathogenic bacteria were either not treated with antibiotics, or treated with an antibiotic to which the cultured bacterium was non-susceptible. All but one recovered spontaneously, although it took more than 28 days for two patients. The other patient recovered with an additional course of antibiotics. Five patients from this cohort with radiological evidence of pneumonia fully recovered without antibiotic treatment.

Conclusions: Not all patients with bacterial LRTI and/or pneumonia require antibiotic treatment in order to recover. Managing the patient rather than treating a diagnosis appears safe and effective in general practice.

Keywords: respiratory tract infections , pneumonia , antibiotics , prognosis


    Introduction
 Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 References
 
Many clinicians consider that most adults consulting with lower respiratory tract infections (LRTIs) due to bacterial infection should be treated with antibiotics, and regard antibiotic treatment as obligatory for patients with radiographic evidence of pneumonia. A significant research effort has therefore been directed at distinguishing bacterial from viral LRTI using history, examination and simple tests, but clinical factors have poor predictive value.1 Distinguishing pneumonia from acute bronchitis with clinical findings and simple tests is also highly problematic, although point-of-care C-reactive protein (CRP) testing appears promising.2,3 General practitioners (GPs) fear missing pneumonia, which contributes to high levels of antibiotic prescribing in LRTI.4 However, not all bacterial infections require antibiotic treatment.5 Here, we report on patients with bacterial LRTI not treated with antibiotics or treated with antibiotics to which the identified bacterial organisms were non-susceptible. We also report on five patients who were diagnosed with acute bronchitis but who were found to have radiographic evidence of pneumonia. Four did not receive any treatment and one was given an inappropriate antibiotic.


    Patients and methods
 Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 References
 
This work was part of a study protocol approved by the Medical Ethics Committee of Maastricht University and the Maastricht University Hospital. Patients aged 18 years and over who were consulting their GPs were eligible to enter the study if they met the following inclusion criteria: new (<29 days) or increased cough, combined with at least one of the following four: shortness of breath, wheezing, chest pain, auscultation abnormalities; and at least one of the following four: reported fever (≥38°C), perspiring, headache, myalgia. Moreover, the GP had to be convinced of the LRTI diagnosis. GPs decided after history-taking and physical examination whether or not to prescribe an antibiotic. If a decision was made to prescribe an antibiotic, consenting patients were entered into a randomized controlled trial in which the efficacy of amoxicillin was compared with that of a macrolide antibiotic (roxithromycin).6 The patients who had not received antibiotic treatment were also followed-up. Additional management decisions were at the GPs' discretion. Sputum samples, oral washings and venous blood samples were (repeatedly) taken for standard microbiological, susceptibility and serological analysis for all patients. Chest radiographs were assessed in a blinded fashion by two independent radiologists. In the event of a lack of consistency in the independent findings of the two radiologists, a third independent radiologist examined the X-ray and this opinion was considered final. A pulmonary infiltrate was regarded as evidence of pneumonia. All biological samples and chest radiographs were taken after the GPs' prescribing decision.

At 28 days after entry into the study, the GPs took a history and conducted a physical examination again and decided whether or not the patient was fully recovered. More detailed information on study methods can be found in earlier publications on the same cohort of patients.1,2


    Results
 Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 References
 
Twenty-five GPs in the Netherlands recruited 247 patients with a mean age of 52 (range 18–89) years. Most patients suffered from acute cough (92%) and dyspnoea (78%) and showed abnormalities on auscultation (84%). Patients suffered from LRTI symptoms for an average of 9 (range 1–28) days before consulting. An antibiotic was prescribed for 196 patients (80%). Conservative treatment or reassurance was given to the remaining 51 patients. Nine of these 51 patients, however, received a prescription for an antibiotic at a subsequent consultation, which took place a mean of 10.8 (range 4–21) days after the first presentation.

Pathogenic bacteria were cultured from 63 patients, indicating bacterial LRTI (Figure 1). Fifty-two patients with a positive bacterial culture, including 57 bacterial strains, received an antibiotic. In vitro resistance to the antibiotic prescribed was found in 22 (39%) strains: 12/28 Haemophilus influenzae, 1/11 Streptococcus pneumoniae, 2/7 Haemophilus parainfluenzae, 4/6 Moraxella catarrhalis and 3/5 (various) other bacteria. Patient recovery at 28 days was similar for patients treated with an antibiotic to which the cultured bacterium was susceptible (27/30 patients recovered), for patients not treated with an antibiotic (9/10), and for patients treated with an antibiotic to which the cultured bacterium was non-susceptible (17/19). All patients considered not (fully) cured by their GPs after 28 days recovered soon after. One patient with possible signs of an infiltrate on repeated chest X-rays was treated with an additional course of antibiotics. He fully recovered after two more weeks. All seven patients with bacterial LRTI and radiographic evidence of pneumonia treated with an antibiotic to which the cultured bacterium was non-susceptible were considered fully recovered at 28 days of follow-up.



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Figure 1. Cure rates according to the GPs for 63 patients with bacterial LRTI, differentiated for type of bacterial LRTI (pneumonia or acute bronchitis), as well as for antibiotic treatment (yes or no) and susceptibility of the bacterial strains to the antibiotic prescribed.

 
Radiographic pneumonia was identified in 32 patients (13%). In 14 of them an independent and decisive judgement by the third radiologist was necessary to confirm the diagnosis of pneumonia.7 Bacterial pneumonia was present in 14 patients (Figure 1). Five patients with radiographic evidence of pneumonia did not receive an antibiotic prescription at baseline (Table 1). All five patients, including one patient with proven bacterial pneumonia (infiltrates on X-ray and a pathogenic bacterium isolated), recovered fully without the appropriate antibiotic treatment. One patient took longer than 28 days to recover.


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Table 1. Clinical course in five patients with radiographic evidence of pneumonia, clinically diagnosed as acute bronchitis, who did not receive antibiotic treatment at baseline

 

    Discussion
 Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 References
 
Not all patients with bacterial LRTI, including pneumonia, need antibiotic treatment in order to recover.5 In our study, nearly half of the patients with evidence of bacterial LRTI were not treated with antibiotics or were treated with an antibiotic to which the cultured bacterium was non-susceptible. Despite this, the recovery rates for these patients were similar when compared with patients treated with an antibiotic to which the cultured bacterium was susceptible. The sample included several patients with proven bacterial pneumonia. Similarly, all patients with pneumonia (viral, bacterial, or unexplained origin) not treated with (appropriate) antibiotics recovered fully. This report challenges the commonly held assumptions that all patients with bacterial LRTI, including patients with pneumonia, need antibiotic treatment in order to recover. It is possible that the GPs in this study were good at targeting antibiotic treatment to those most likely to benefit or who really needed antibiotic treatment in order to recover, as opposed to trying to ensure that all patients who might have X-ray evidence of pneumonia and/or laboratory evidence of bacterial infection were treated with antibiotics. ‘Managing the patient’ (rather than treating a potential bacterial and/or radiographic diagnosis) appears safe and effective, even if it means that some patients with radiographic evidence of pneumonia or evidence of bacterial infection on further laboratory testing are not treated with antibiotics. These findings do not address the issue of whether or not antibiotics improve clinical outcomes for LRTI. However, this evidence might reduce anxiety in clinicians about failing to prescribe antibiotics to patients who might have evidence of pneumonia or pathogenic bacterial infection if investigated at a later point.


    Acknowledgements
 
We thank the patients, general practitioners, and physicians' assistants for their participation in this study. The study was supported by a grant from the Research Institute for Extramural and Transmural Health Care, Maastricht. The sponsor of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the report. The corresponding author had full access to all the data in the study and had final responsibility for the decision to submit for publication.


    References
 Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 References
 
1. Hopstaken RM, Stobberingh EE, Knottnerus JA et al. Clinical items not helpful in differentiating viral from bacterial lower respiratory tract infections in general practice. J Clin Epidemiol 2005; 58: 175–83.[CrossRef][ISI][Medline]

2. Hopstaken RM, Muris JWM, Knottnerus JA et al. Contributions of symptoms, signs, erythrocyte sedimentation rate and C-reactive protein to a diagnosis of pneumonia in acute lower respiratory tract infection. Br J Gen Pract 2003; 53: 358–64.[ISI][Medline]

3. Flanders SA, Stein J, Shochat G et al. Performance of a bedside C-reactive protein test in the diagnosis of community-acquired pneumonia in adults with acute cough. Am J Med 2004; 116: 529–35.[CrossRef][ISI][Medline]

4. Coenen S, Van Royen P, Vermeire E et al. Antibiotics for coughing in general practice: a qualitative decision analysis. Fam Pract 2000; 17: 380–5.[Abstract/Free Full Text]

5. Macfarlane J, Holmes W, Gard P et al. Prospective study of the incidence, aetiology and outcome of adult lower respiratory tract illness in the community. Thorax 2001; 56: 109–14.[Abstract/Free Full Text]

6. Hopstaken RM, Nelemans P, Stobberingh EE et al. Is roxithromycin better than amoxicillin in the treatment of acute lower respiratory tract infections in primary care? A double-blind randomized controlled trial. J Fam Pract 2002; 51: 329–36.[ISI][Medline]

7. Hopstaken RM, Witbraad T, van Engelshoven JMA et al. Interobserver variation in the interpretation of chest radiographs for pneumonia in community-acquired lower respiratory tract infections. Clin Radiol 2004; 59: 743–52.[CrossRef][ISI][Medline]





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