Published 23 June 2009, doi:10.1136/bmj.b2242
Cite this as: BMJ 2009;338:b2242

Research

Variation in antibiotic prescribing and its impact on recovery in patients with acute cough in primary care: prospective study in 13 countries

¹ Department of Primary Care and Public Health, School of Medicine, Cardiff University, Cardiff CF14 4XN, Wales , ² South East Wales Trials Unit (SEWTU), Department of Primary Care and Public Health, School of Medicine, Cardiff University, Heath Park, Cardiff, Wales, ³ University Medical Centre Utrecht, Julius Center for Health, Sciences and Primary Care, Universiteitsweg 100, Stratenum, 6th Floor, 6.111, 3584 CX Utrecht, Netherlands, ⁴ University of Southampton, Southampton SO16 5ST, ⁵ General Practice Research Unit, Institute of Community Medicine, University of Tromso, 9037 Tromso, Norway, ⁶ Department of Medical and Health Sciences, Linkoping University, and Unit of Research and Development in Primary Care, S-55185 Jonkoping, Sweden, ⁷ Department of Family and Community Medicine, Medical University of Lodz, U190-153 Lodz.Kopcinskiego 20, Poland, ⁸ Unitat de Cures Intensives, Hospital de Mataro, Carretera de Cirera s/n, 08304 Mataro (Barcelona), Spain, ⁹ Servei de Pneumologia i Al·lèrgia Respiratòria, Institut Clínic del Tòrax, Hospital Clínic de Barcelona, CIBERES 06/06/0028, Universitat de Barcelona, Spain, ¹⁰ Finnish Office for Health Technology Assessment, FinOHTA, Stakes Tampere Satellite Office, Fin-Medi 3, Biokatu 10, 7. krs, 33520 Tampere, Finland, ¹¹ University of Antwerp-Campus Drie Eiken, Vaccine and Infectious Disease Institute, Centre for General Practice, Antwerp, Belgium , ¹² Research Foundation, Flanders, Brussels, Belgium., ¹³ University of Antwerp-Campus Drie Eiken, Vaccine and Infectious Disease Institute-Laboratory of Medical Microbiology, Antwerp, Belgium

Objective To describe variation in antibiotic prescribing for acute cough in contrasting European settings and the impact on recovery.

Design Cross sectional observational study with clinicians from 14 primary care research networks in 13 European countries who recorded symptoms on presentation and management. Patients followed up for 28 days with patient diaries.

Setting Primary care.

Participants Adults with a new or worsening cough or clinical presentation suggestive of lower respiratory tract infection.

Main outcome measures Prescribing of antibiotics by clinicians and total symptom severity scores over time.

Results 3402 patients were recruited (clinicians completed a case report form for 99% (3368) of participants and 80% (2714) returned a symptom diary). Mean symptom severity scores at presentation ranged from 19 (scale range 0 to 100) in networks based in Spain and Italy to 38 in the network based in Sweden. Antibiotic prescribing by networks ranged from 20% to nearly 90% (53% overall), with wide variation in classes of antibiotics prescribed. Amoxicillin was overall the most common antibiotic prescribed, but this ranged from 3% of antibiotics prescribed in the Norwegian network to 83% in the English network. While fluoroquinolones were not prescribed at all in three networks, they were prescribed for 18% in the Milan network. After adjustment for clinical presentation and demographics, considerable differences remained in antibiotic prescribing, ranging from Norway (odds ratio 0.18, 95% confidence interval 0.11 to 0.30) to Slovakia (11.2, 6.20 to 20.27) compared with the overall mean (proportion prescribed: 0.53). The rate of recovery was similar for patients who were and were not prescribed antibiotics (coefficient –0.01, P<0.01) once clinical presentation was taken into account.

Conclusions Variation in clinical presentation does not explain the considerable variation in antibiotic prescribing for acute cough in Europe. Variation in antibiotic prescribing is not associated with clinically important differences in recovery.

Trial registration Clinicaltrials.gov NCT00353951 [ClinicalTrials.gov] .

© Butler et al 2009
This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

CiteULike    Complore    Connotea    Del.icio.us    Digg    Reddit    StumbleUpon    Technorati    What's this?

Relevant Article

Effectiveness of a multiple intervention to reduce antibiotic prescribing for respiratory tract symptoms in primary care: randomised controlled trial

Ineke Welschen, Marijke M Kuyvenhoven, Arno W Hoes, and Theo J M Verheij
BMJ 2004 329: 431. [Abstract] [Full Text] [PDF]

This article has been cited by other articles:

• (2009). Antibiotic Prescribing for Acute Cough Is Highly Variable. JWatch Emergency Med. 2009: 4-4 [Full text]  
• (2009). Antibiotic Prescribing and Respiratory Infection Outcomes. JWatch Infect. Diseases 2009: 3-3 [Full text]  

Rapid Responses:

Read all Rapid Responses

Understanding coughs in primary care

Rod A Storring
bmj.com, 30 Jun 2009 [Full text]

A few points that could make the study better

DR.INDRANIL BANERJEE
bmj.com, 5 Jul 2009 [Full text]

Response from author

Christopher C Butler
bmj.com, 10 Jul 2009 [Full text]

Online poll

Find out more on doc2doc >>