Clinical tips: RTIs and antibiotic use explained

RTIs - girl blowing her nose

Presentations with respiratory tract infections may offer pharmacists an opportunity to educate patients about their antibiotic use, writes Ben Basger

We know that the vast majority of antibiotics are prescribed in primary care. Respiratory tract indications (RTIs – that is, acute otitis media, rhinosinusitis, acute sore throat and acute cough) are the most common reasons.

Antibiotics are heavily overprescribed for respiratory disease, with a recent study showing that nearly half of antibiotic prescriptions for RTIs were not in accordance with guideline recommendations.

Overprescribing was highest for adults between 18 and 65 years of age (Fam Pract 2015, Vol. 32, No. 4, 401–407).

Primary care guidelines recommend restrictive antibiotic use for upper and lower RTIs because of their limited treatment effectiveness in the majority of these indications. Most RTIs are of viral origin and self-limiting.

In addition, the use of antibiotics results in development of resistant micro-organisms, which affects both the individual and the population. Inappropriate antibiotic use furthermore encourages medicalisation and unnecessarily exposes patients to side effects; this all results in unnecessary costs.

Why does this inappropriate prescribing occur? The following factors have been identified:

  • GPs’ perception of high patient’s expectation of receiving an antibiotic;
  • the presence of fever;
  • GPs’ judgement of more severe illness;
  • age > 18; and
  • duration of symptoms ≥ 7 days.

While pharmacists cannot influence GP judgement of severity, we can certainly assist in efforts towards patients having realistic expectations of antibiotic efficacy.

How can we do this? A number of strategies come to mind.

You may uncover the fact that some patients already have doubts about their antibiotic prescription, and this can be explored. Patients can be reassured that their doubts may be justified.

Reasons for non-use can be explained, such as the limited nature of the symptoms, cost and the possibility of gastrointestinal side effects and development of resistance.

Suggesting to wavering patients that they consider delaying administration has been shown to be effective. Finally, posters regarding inappropriate use of antibiotics and patient leaflets have also been shown to be beneficial.

Where does this leave the ‘pre-contemplators’? In dealing with patients who don’t want to change, it has been suggested that we do the following: provide the facts in a non confrontational way ─ that is, “antibiotics are unlikely to help these symptoms;” supply the antibiotic; and offer to provide more information in the future.

Ben Basger is a lecturer and tutor in pharmacy practice, Faculty of Pharmacy, The University of Sydney.

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