Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Let CRP (C-reactive protein) decide
- Mats Reimer (21 April 2001)
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Do we treat patients with symptoms or diagnoses?
- Chris Gunstone (22 April 2001)
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Coughs-turning our backs on the past
- Anna Eleri Livingstone (22 April 2001)
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A mytical diagnosis or a practicable symptom?
- Samuel Coenen (16 May 2001)
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Cochrane review provides good evidence about the risks and benefits of antibiotic treatment
- Tom Fahey (25 May 2001)
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Reducing antibiotics for respiratory infections
- Lon Jones (6 July 2001)
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Domination by Theory and Bacteriological Reductionism?
- Peter Morrell (10 July 2001)
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Re: Domination by Theory...
- Joseph Watine (11 July 2001)
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Asking some fundamental questions
- Peter Morrell (14 July 2001)
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Defining the Problem
- Annie Jones (16 July 2001)
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authors reply
- Bruce Arroll (17 August 2001)
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Mats Reimer, Community paediatrician Child Clinic Mölnlycke, Sweden
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Here in Sweden CRP (serum level of C-reactive protein, a fast respondning marker for inflammation) is widely used as an aid in the decision wether to prescribe antibiotics or not for bronchitis. In primary care we use inexpensive kits for measuring CRP in capillary blood. |
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Chris Gunstone, GP Gordon Street Surgery, Burton upon Trent, Staffs
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Patients do not present with acute bronchitis in General Practice, but cough. If one were allowed to produce a guideline for treating cough in General practice, I wonder how many GPs would agree with my unofficial, clinical ‘guidelines’ – For any patient presenting with a Cough in General practice, the following form pivotal cues, any of which would make me 80%, or more, likely to prescribe antibiotics – 1. Dirty purulent phlegm (white, clear, yellow or green are equivocal descriptions) OR 2. Age greater than 80 (especially if in a nursing or part 3 home) OR 3. COPD (risks of not prescribing in both these groups greater than not prescribing) OR 4. Frailty (i.e. ‘older than their years’, recovering from recent illness/major operation, multiple pathology etc) OR 5. Crepitations on auscultation OR 6. Social circumstances - i.e. imminent holiday, situations where time off work would have serious consequences (job loss, financial hardship etc) So maybe the question is wrong. We may not need Evidence Based Guidelines on the Treatment of Acute Bronchitis, but evidence of which symptoms/signs and/or circumstances are relevant to our decision making process. Diagnosis is often a slippery subjective subject in Primary Care. | |||
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Anna Eleri Livingstone, general practitioner The Limehouse Practice Gill Street Health Centre E14 8HQ
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I agree with the authors of ‘Antibiotics for acute bronchitis’1 that clinical definitions are at fault and so research studies and reviews haven’t usefully informed treatment. This dilemma is a hangover from the era of the role of the doctor as prognosticator and pacifier with a minimal armamentarium of therapy, largely placebo or palliative. When antibiotics arrived half a century ago, visibly powerful against severe bacterial respiratory infections then commoner than now in the relatively wealthier west, therapist and sufferer alike, whether under pressure of workload or to return to work, often substituted them for the old treatments as the take away product of consultations about almost any throat, ear or respiratory symptom. In primary care records in casualty and general practice there was often almost nothing but the prescription, as I found when I entered inner city practice nearly twenty years ago. Case definition and coding was a luxury in a field where time, symptoms and expectations were determinants. Gradually, more widespread diagnostic tools, promotion of new therapies (e.g. inhaled bronchodilators and steroids) and a shift towards evaluating outcomes in the materialist terms of money and ‘medical science’, has picked off diagnoses such as asthma, pneumonia and acute rhinitis, even though these are often shakily based and may be used to rationalise prescription or non prescription. We are left with what the authors point to, a diverse collection of symptoms and signs often labelled in practice acute bronchitis, no one clinical entity. While a cough is defined by sound as a cough, productivity of sputum can mean many things. Even if produced to order and purulent, it may come from a postnasal drip or deep in the lungs. Even if chest signs are present, the condition may be viral, and or atopic. Many issues need tackling. With computer records, coding allows audit of actions and outcome, and for consistency the classical diagnostic criteria for acute bronchitis should be present of cough and non-focal abnormal chest signs, in contradistinction to acute cough without signs. This is an educational issue and it is important to regard this as a description and not an aetiologically related diagnosis. Reanalysing old studies is of little use if the data isn’t robust and probably new studies should refine in probabilistic terms outcomes with and without various treatments including antibiotics. Explanations sought need to be scientifically based in relation to treatment effects. A relative risk of 0.48 of improving with antibiotics doesn’t tell us anything about the proportion of the study group without bacterial infection being inappropriately treated. So we need to develop more specific classifications friendly to the primary care user, which are based on identifying who improves and why with which treatment. Meanwhile, as a slightly moralistic low antibiotic prescribing general practitioner I am still plagued by the problem Fahey and colleagues 2 tried to look at, the acute cough, which the owner is fed up with or frightened of, and whether I might suggest effective treatment, unlike the advertisers of what I advise against on economic grounds, coloured liquids for dry tickly coughs, wet coughs or chesty coughs, which self managers get from the chemist and the supermarket. Yours sincerely, Anna Eleri Livingstone General Practitioner A.E.Livingstone@qmw.ac.uk No competing interests 1 Arroll B, Kenealy T, Antibiotics for acute bronchitis. BMJ 2001;322:939-40 2 Fahey T Stocks N Thomas T Quantitative systematic review of randomised controlled trials comparing antibiotic with placebo for acute cough in adults. BMJ 1998;316:906-10 |
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Samuel Coenen, Research assistant for the Fund of Scientific Research - Flanders Centre for General Practice - University of Antwerp
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Editor - Arroll and Kenealy have exposed the Procrustean nature of the term acute bronchitis in RCT’s.1 The same holds for daily practice.2-3 In general practice coughing is the most common reason given for consulting with or without a respiratory infection (RTI). In suspected RTI, GPs want to make a distinction between viral and bacterial RTI, and between clinical syndromes such as bronchitis and pneumonia. This cannot be achieved with certainty on the basis of arguments from the medical history and clinical examination. Dealing with diagnostic uncertainty, their decisions are directed at whether or not to prescribe antibiotics. A diagnosis, e.g. acute bronchitis, is then formulated as a justification for the therapeutic decision.4 Then what are the determinants of prescribing antibiotics for coughing patients? In our qualitative decision analysis we found two different kinds of determinants: medical, such as clinical signs and symptoms, and non-medical, such as e.g. (the physician’s perception of) the patient’s expectations.4 Quantifying these results in a postal questionnaire study, we were able to demonstrate that medical determinants were more frequently assessed than non-medical ones. Both however might equally favour antibiotics. To validate our previous findings 76 Flemish GPs included an average of 10 patients with an acute cough. They were asked to register on a pre-printed form whether they knew certain comorbidity, symptoms or clinical signs were present, whether the patient in their perception asked for antibiotics and what the prescribed. Not accounting for cluster effects, 40.5 percent of the patients received an antibiotic. In the GPs’ perception 75 percent did not ask for antibiotics. Using logistic regression, ‘perceiving the patient is asking for antibiotics’ and ‘not knowing whether he/she is asking for antibiotics’ were both significantly associated with an antibiotic prescription(p = 0.02; OR (95% CI) = 1.8 (1.1-3.0) resp. p = 0.01; OR = 2.6 (1.2-5.6)). This association was independent of, and alike medical determinants such as the presence of sputum (p < 0.001; OR = 3.0 (2.0-4.7)). Studying symptoms such as cough with or without purulent sputum or lower respiratory tract signs might therefor be more appropriate not only to answer the important clinical question, whether antibiotics do any good in these conditions, but also to address practising clinicians in a more reliable and more valid way. For example the starting point of a Flemish guideline and educational intervention to promote rational antibiotic use was not the diagnosis of acute bronchitis but the symptom acute cough. Samuel Coenen Paul Van Royen Barbara Michiels Jean-Claude Van der Auwera Joke Denekens * University of Antwerp, Universiteitsplein 1, 2610 Antwerp, Belgium 1. Arroll B, Kenealy T. Antibiotics for acute bronchitis. BMJ 2001; 322: 939-40. 2. Coenen S, Van Royen P, Vermeire E, Hermann I, Denekens J. Diagnosis of Acute Bronchitis. J Fam Pract 1999; 48:471-2. 3. Gunstone C, Livingstone AE. Electronic responses to Arroll B, Kenealy T. Antibiotics for acute bronchitis. eBMJ 2001; http://www.bmj.com/cgi/eletters/322/7292/939. 4. Coenen S, Van Royen P, Vermeire E, Hermann I, Denekens J. Antibiotics for coughing in general practice: a qualitative decision analysis. Fam Pract 2000; 17 (5): 380-5. |
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Tom Fahey, Senior Lecturer in Primary Health Care Division of Primary Health Care, University of Bristol, BS8 2PR
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Dear Sir, Bruce Arroll and Timothy Kenealy are critical of our Cochrane systematic review and previous systematic reviews examining the effect of antibiotics in the treatment of acute bronchitis saying that they come to "clinically unhelpful conclusions".[1] Whilst we share many of their anxieties about the ambiguous nature of the diagnostic label of acute bronchitis we feel that their proposed solutions are simplistic and may be misleading for the following reasons: 1. Risks of treatment- whilst concentrating on the potential benefit of antibiotics they ignore their proven side effects. In our systematic review antibiotics are associated with a significantly higher risk of adverse events (relative risk 1.48, 95% CI 1.02 to 2.14).[2] Thus antibiotics are associated with a number needed to treat (NNT) of between 11 to 14 for improvement in symptoms but at the expense of a number needed to harm (NNH) of 17. For every 100 people treated, about eight will derive benefit from antibiotics whilst six will suffer side effects. Contrary to Arroll and Kenealy's views, we feel this type of information is helpful for patients and health professionals when deciding of the risks and benefits of antibiotic treatment. 2. Clinical examination- they suggest that treatment should be based on the presence of lower respiratory signs so that "clinicians….could be reasonably sure that they were not dealing with some cases of pneumonia". Prospective community studies of patients with cough and lower respiratory tract signs have already established the prior probability of pneumonia (defined by chest x ray) to be less than 6%.[3] In addition, the reliability of chest signs obtained from the clinical examination is poor: the between-doctor agreement when eliciting chest signs such as crackles is only moderate (kappa 0.41).[4] Finally a recent study shows no relationship between general practitioners' clinical assessment that infection is present and bacterial or atypical infection being subsequently confirmed.[3] 3. Use of diagnostic tests - undertaking diagnostic tests, whether they be a chest x ray or sputum culture for what in the vast majority of patients is a self limiting illness seems to us to be costly and unnecessary. It might also have the unwanted effect of "medicalising" what for the vast majority of patients is a self-limiting illness.[3] 4. Subgroup analysis and generalisability- all post-hoc sub-group analyses should be treated with a great deal of caution.[5] We have suggested that sub-groups of patients with more severe co-morbidity or systemic symptoms may benefit from antibiotics but emphasise that there is no direct evidence that this is the case.[2] They propose that identification of a subgroup of confirmed cases of "bacterial bronchitis" based on diagnostic testing might be helpful. In doing so they ignore the fact that confirmation of bacterial infection in observational studies is not associated with better outcome, irrespective of whether antibiotics are prescribed or not.[3] In short, we feel that the majority of patients with acute bronchitis/lower respiratory tract infection will experience a self- limiting illness. Antibiotics may have marginal benefits in some patients but this benefit has to be balanced against side effects, costs of antibiotics, "medicalising" effects of prescribing antibiotics to patients as well as increased antibacterial resistance. Yours sincerely, Tom Fahey
John Smucny
Lorne Becker
Nigel Stocks,
We declare no conflict of interest. References 1. Arroll B, Kenealy T. Antibiotics for acute bronchitis. British Medical Journal 2001;322:939-940. 2. Smuncny, J, Fahey, T, Becker, L., Glazier, R. Antibiotics for acute bronchitis (Cochrane Review). In: The Cochrane Library Issue 2, 2001. Oxford: Update Software. 3. 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;56:109-114. 4. Metlay J, Kapoor W, Fine M. Does this patient have community-acquired pneumonia? Journal of the American Medical Association 1997;278:1440- 1445. 5. Smith GD, Egger M. Incommunicable Knowledge? Interpreting and Applying the Results of Clinical Trials and Meta-Analyses. Journal of Clincial Epidemiology 1998;51, No 4:289-295. |
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Lon Jones, Family Practice Hale Center, Texas, USA
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In attempting to reduce the use of antibiotics for respiratory infections it is profitable to look at the incidence of several of these problems. Ear infections in the US have increased from 9.9 million in 1975 to 24.7 million in 1990 (1). Though there are no comparable large scale studies, sinus disease appears to be increasing as well. All respiratory disease are primarilly caused by bacteria colonizing the nasopharynx. The increases we have experienced parallel our use of antihistamines and decongestants, drugs that were made available without prescription in the early 1970's. I don't think this parallel is accidental. In fact the side effect profile for one of the newer, non-sedating, antihistamines shows a doubling of the incidence of both wheezing and upper respiratory infections when given to children ages 6-12.(2) Svensson points out that the role of histamine in the nasopharynx is to assist in the defensive washing of that area.(3) Eastern bloc countries use substantially less of these drugs and they have not seen the increases in asthma that we have in the west. While asthma is not usually considered a disease of the nose, the common triggers for asthma, viral URI's, chronic sinus, and allergies, are all in the nasopharynx. For the last three years I have encouraged patients in my practice to wash their noses regularly with a solution of 11% xylitol added to the commonly available saline nasal sprays. The results of regular use has been reductions in all nasopharyngeal problems along with significant reductions in the use of antibiotics.(4) The CDC says that washing hands is the most effective means of preventing the spread of communicable disease. Since the bacteria don't get through our hands, but spread by contact through the mouth and nose, I believe it to be just as effective to wash the nose regularly. 1. Schappert SM. Office visits for otitis media: United States, 1975- 90. Adv Data 1992 Sep 8;(214):1-19. 2. Physician's Desk Reference 2000 ed. Medical Economics. 2782. 3. Svensson C, Andersson M, Greiff L, Persson CG. Nasal mucosal endorgan hyperresponsiveness. Am J Rhinol 1998 Jan-Feb;12(1):37-43. 4. Jones AH. Intranasal xylitol, chronic otitis and asthma: three case studies. Clin Prac Alter Med 2001 Jun;2(2):112-7. See also information at my hospitals web site under "research" at www.texasonline.net/hiplains/ |
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Peter Morrell, Hon Research Associate, History of Medicine Staffordshire University, UK
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Sir, "In attempting to reduce the use of antibiotics for respiratory infections it is profitable to look at the incidence of several of these problems. Ear infections in the US have increased from 9.9 million in 1975 to 24.7 million in 1990 (1). Though there are no comparable large scale studies, sinus disease appears to be increasing as well. All respiratory disease are primarilly caused by bacteria colonizing the nasopharynx." [1] 9.9 million to 24.7 million in 25 years, being 149% increase over 25 years, is a 6% annual rise in these conditions. Given the veritable blitz on the bacterial world with antibiotics, sustained in rich countries like the US over this very same period, how can bacteria be the cause of these infections - which are so steeply rising? The one datum supplied simply does not seem to warrant the conclusion drawn. Can Lon Jones please give us the total US consumption of antibiotics in 1975 compared to 1990, so we might evaluate his theory that bacteria CAUSE "all respiratory disease"? "Antibiotic use (and misuse) has soared since the first commercial versions were introduced and now includes many non-medicinal applications. In 1954 two million pounds were produced in the U.S.; today the figure exceeds 50 million pounds." [2] 1954 to 1998 is 44 years; a shift from 2 million pounds to 50 million pounds is 48 million; an increase of 48 million over 44 years is 1.091 million per year and that represents an annual increase of 54.5%. It is hard to interpret such figures against those of respiratory infections given above, as these are global figures for all antibiotics in the USA. However, some might say that a 6% rise in such infections would be much higher without antibiotics. Others might say such a war waged against the microbial world is fundamentally unwinnable and therefore futile. Perhaps Dr Jones could comment upon this aspect? Let me open an historical window for him to gaze out of… "Lest in the eager hunt for specifics against the bacillus, we lose sight of that most important factor, the predisposition, the soil upon which the bacilli seem to flourish...let the bacilli take care of themselves, let us take care of our patients." [3] "Physicians who criticized the proposal to ground therapeutics in bacteriology especially feared that domination by theory would oversimplify practice...the complexity of clinical phenomena and the exercise of judgment could not be bypassed by bacteriological reductionism." [4] Has much progress in this view been made in 120 years? "The flaws in nineteenth century bacteriology were evident to everyone. Why did diphtheria bacilli cause disease in one person and not another whose throat cultures showed the presence of virulent bacilli? Ho did bacilli actually cause disease? All physicians were ignorant of the answers to these and many other fundamental questions." [5] And patently still are. "Physicians were less concerned with how and why a therapy worked then with the demonstrable fact that a therapy was medically valid, demonstrable, and consistent." [6] Does not 'bacteriological reductionism' ignore, exclude and downgrade the importance of previous medical history [of the patient], general level of health, hygiene, psycho-social factors, diet and lifestyle factors in the development of infectious disease? Factors which, in fact, create the very susceptibility to infection, which distinguish 'the infected' as a category from 'the non-infected', not only in the same town, but in the same house or family. Therefore, we might conclude that bacteria, viruses, and other bugs are not 'primarily the cause of all infectious respiratory disease', but secondary, tertiary or even merely associative causes. Finally, Professor Warner gives another clue that might explain both why physicians in the 1890s despised the Germ Theory, and why physicians today give antibiotics by reflex: "Therapeutic conformity, or at least avoidance of criticism, was important to the young practitioner trying to gain approval…regular physicians' attitudes towards therapeutic change were molded by a dialectic between their commitment to progress and their loyalty to tradition." [7] Perhaps the force of conformity in medicine is far more powerful than the desire to answer those 'fundamental questions' that Rothstein lists above or to make progress in the use of antibiotics that Dr Jones suggests in his e-letter. Sources [1] BMJ letter, Re: Reducing antibiotics for respiratory infections, 6 July, Jones, Lon, Family Practice, Hale Center, Texas, USA http://www.bmj.com/cgi/eletters/322/7292/939#EL7 [2] The Challenge of Antibiotic Resistance, Stuart B. Levy, Scientific American 1998 http://www.sciam.com/1998/0398issue/0398levy.html#link4 [3] Eric E Sattler, The Present Status of the Tubercle Bacillus, Cincinnati Lancet and Clinic, 12, 1884, 415; quoted in John H Warner, 1986, The Therapeutic Perspective - Medical Practice, Knowledge and Identity in America 1820-1885, Harvard Univ. Press, USA, 280 [4] Warner, 281 [5] William G Rothstein, 1972, American Physicians in the Nineteenth Century, From Sects to Science, Johns Hopkins Univ. Press, Baltimore, 281 [6] Rothstein, 281 [7] Warner, 183 |
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Joseph Watine Hôpital de Rodez, France
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It seems to me that Peter Morrell makes some good points in his last e-response [1], particularly when he writes that “the force of conformity in medicine is far more powerful than the desire to answer (…) fundamental questions…”, or that “(…) such a war waged against the microbial world is fundamentally unwinnable…”. However, when Peter Morrell writes that “(…) bacteria, viruses, and other bugs are not primarily the cause of all infectious respiratory disease, but secondary, tertiary or even merely associative causes…”, let us hope that he does not forget that antibiotics still have the ability to save the lives of many patients suffering from bacterial respiratory diseases (legionellosis, tuberculosis, etc). [1] http://www.bmj.com/cgi/eletters?lookup=by_date&days=1#322/7292/939/EL8 |
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Peter Morrell, Hon Research Associate, History of Medicine Staffordshire University
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Sir, When Joseph Watine says, "let us hope that he does not forget that antibiotics still have the ability to save the lives of many patients suffering from bacterial respiratory diseases (legionellosis, tuberculosis, etc)." [1], I would say it contains an outer meaning and an inner meaning. Joseph Watine, in making this statement, utters a declaration of his own medical conformity in the presence of his medically qualified brethren, 'beats the drum', and declares his belief in his own training and its underpinning system of beliefs, like a declaration of belief before members of the mother church. If, 1000 years ago, I had criticised a dominant medical practice like purging, medical practitioners would have similarly reacted and pronounced their belief that above all, sickness was "regarded as the finger of Providence. God used illness for a multitude of higher purposes...as a punishment..." [2]. Disease "was routinely interpreted as the consequence of sin, crime, or moral fault, as precipitated by evil spirits, or as the work of black magic. Disease was thus personalized and given a moral or religious meaning." [3]. Doctors would also have declared the healing power of Christ in the world, and that Antimony, prayer and fasting were the sole cures. Such a reaction is broadly similar to that of Joseph Watine. His remark not only reveals the unquestioning and deeply conformist nature of medical training, practice and belief, and the desire to be just another grey brick in a uniformly grey wall - a conformist who questions nothing - but it also denotes how belief-driven, how theory-dominated medicine is. That is no less true today than it was in pagan or medieval times. The beliefs might have changed, but the attitude hasn't. In "the seventeenth century...the accent of therapeutics lay on expelling toxic substances from the body - by purging, sweating, vomiting, and the much favoured surgical technique of bloodletting..." [4]. Milder shadows of these practices persist in herbal and proprietary preparations with laxative, diaphoretic, expectorant or diuretic properties. Getting back to the superficial point his question raises, I would say that because antibiotics do not and cannot even impinge upon, let alone remove, the OTHER causes of disease [other than 'germs'], so it is clear that their power over disease is limited. Indeed, their curative power is very precisely limited to that narrow, specific role. Therefore, in cases where removal of such 'germs' is most urgently required as the main therapeutic objective, then yes, of course, the effect of antibiotics is demonstrably spectacular, even miraculous. However, such is not so commonly the case today as compared to 50 or 100 years ago. It is not the full picture. Today, especially in the rich countries, the power of antibiotics is diminished precisely because the conditions or causes that create infectious disease are largely constitutional, dietary and psycho-social and not so overtly bacteria-driven. "Villermé [in 1828]...was able to prove that morbidity and mortality rates were, in a sense, a function of the living conditions of a given class...filth and overcrowding were proved to act...as the indirect causes of fevers." [5]. And thus it became apparent that "cleanliness was in some way a protection against disease." [6]. Although "water-borne infections were checked by a combination of bacteriological diagnosis and improved sanitary engineering." [7], many physicians remained sceptical of the Germ Theory. It was not unusual in New York for "well known physicians to get up and leave the hall when medical papers were being read which emphasised the germ theory of disease. They wanted to express their contemptuous scorn for such theories and refused to listen to them." [8]. Some physicians "refused to believe that the horrifying effects of many diseases could be traced to an almost invisible micro-organism...nineteenth century bacteriology raised more methodological and substantive questions than it answered...scepticism was…a reasonable position…taken by many leaders of the profession." [9] Some, more reflective persons did exist. "One of Koch's students once asked him why anthrax bacilli caused death in an animal. Koch said, 'Why its vessels are plugged with bacilli!' The student asked, 'A mechanical death?' to which Koch replied, 'Certainly'...such questions, which should have raised serious doubts about all bacteriology, do not appear to have disturbed physicians very deeply." [10] Certainly, there are social, financial, economic and cultural causes of disease every bit as potent as bacteria and just as active today in certain parts of every town and city. Therefore, the power of antibiotics to cure such 'infections' is correspondingly diminished [to zero] and yet they are prescribed in a reflex manner like old-fashioned palliatives to mollify patients and/or their concerned parents, a point made in some letters to this article. Adopting briefly the homeopathic cloak, I would have to say that most 'ear infections' so-called are better treated with Pulsatilla or Belladonna, whichever most closely matches the symptoms of the individual case, and that the vast majority of childhood 'earaches' resolve quickly with such treatment and in an uncomplicated manner. Any practitioner can satisfy themselves on this point, very easily. However, such a point does raise the deeper conceptual question of whether 'the germs' were really there at all in the first place, and what the real cause of such earaches actually is? "The craze of the day is the somewhat hypothetical germ." [11]. It also raises the question of what any treatment actually achieves. We grope in the dark and at best see only dimly through a dark lens. For example, on whose 'side' do the homeopathic remedies work - do they influence 'the enemy' or do they strengthen the innate healing powers of the organism? Antibiotics only affect 'the enemy' and seem to do nothing for the organism. All the natural therapies seem to strengthen the organism rather than touching 'the enemy' at all. Allopathy has a deeply ingrained tendency to attack the enemy and to do little for the innate vital powers. That is predominantly the case. Lest we do believe that 'germs' are the only cause we should recall "A distinguished sanitarian Max von Pettenkofer of Munich…made his magnificent gesture - which by all odds should have killed him - of drinking a whole glassful of cholera bacilli without suffering any harm." [12]. Clearly, the deeper question is not the bacteria themselves, but the 'soil they grow in', which is our relationship with them. In an infection we must be clear about what has happened. In health, we are just as surrounded by 'germs' as an ill person is, but they do not affect us - our relationship with them is normally balanced, harmonious and unproblematic. In the diseased state, this previously harmonious relationship mysteriously somehow deteriorates and 'the germs' come to proliferate. It is certainly not 'the germs' that bring this shift about. It is not a germ-driven change. It is those psycho-social, stress and dietary factors, hygiene, etc, which cause the relationship to deteriorate. No-one can say with certainty why this happens at certain times and in any individual case. What is certain is that these changes are internal to the organism, they are initiated on 'our side', not from the side of 'the germs'. This recognition does not seem to be emphasised in orthodox medicine, where the 'magic bullet ', and attacking 'the enemy' are the central themes of practice. Hence, I would say, that modern medicine can learn from this situation and realise why it stands accused of looking in the wrong place and treating the wrong thing. It should treat the patient, not the disease; the person not 'the germ'. Thus, I would repeat that bacteria do not cause disease, it is the deterioration in our relationship with them that lies at the root of the matter. The 'germs' are manifestly only secondary or merely associative causes of infections. In certain parts of the world it is still a widely held belief that "disease is a supernatural phenomenon governed by a hierarchy of vital powers...disharmony in these vital powers can cause illness. Thus, ancestral spirits can make a person ill. Ingredients obtained from animals, plants, and other objects can restore the decreased power in a sick person and therefore have medicinal properties." [13]. When the acupuncturist says disease is due to an imbalance in the energies flowing in the meridians, they are making a certain conception of the disease process, which their treatment then seeks to adjust. It is not necessarily an incorrect conception, merely a different one from that of the bacteriologist. Likewise, when the homeopath calls disease primarily a derangement of the life force, echoing in this sentiment Stahl's animism. Or, when the naturopath conceives disease to be a product of toxins, which fasting and enemas will eliminate, he comes close to the sentiment that "disease is not an entity...but is only the organic and functional forces, or powers of life, modified by perversion of activity…remedies are relative agents...they only act curatively by a judicious application to the individual case in hand. Individualism, not universalism, attaches therefore to all our therapeutic measures." [14] Such is still a valid sentiment. These are all different apprehensions of the disease process due to different modes of medical conception. All are equally belief-driven or theory-dominated, but each stems from a very different mode of conception of what is nevertheless the same process. They might well be seen as different blind men describing the same elephant! Sources [1] BMJ letter, Re: Domination by Theory..., Joseph Watine, Hôpital de Rodez, France, (11 July 2001) http://www.bmj.com/cgi/eletters?lookup=by_date&days=1#322/7292/939/EL9 [2] Roy Porter, 1987, Disease, Medicine and Society in England 1550- 1860, Macmillan, London, 27 [3] 'Disease' by Roy Porter, in Hutchinson Family Encyclopoedia: http://ebooks.whsmithonline.co.uk/encyclopedia/52/F0000152.htm [4] Porter, 1987, 14 [5] Richard H Shryock, 1966, The Development of Modern Medicine, Philadelphia Univ. Press, 220 [6] Shryock, 240 [7] Shryock, 311 [8] James J Walsh, History of Medicine in New York, 1919, quoted in William G Rothstein, 1972, American Physicians in the 19th Century From Sects to Science, Johns Hopkins Univ. Press, Baltimore, 265 [9] Rothstein, 266-7 [10] Rothstein, 281 [11] New York physician in 1883, quoted in John H Warner, 1986, The Therapeutic Perspective, Harvard Univ. Press, 281 [12] Shryock, 282 [13] Kale, Rajendra, Education and Debate, South African Health: Traditional healers in South Africa: a parallel health care system, BMJ 1995; 310: 1182-85 (6 May) http://www.bmj.com/cgi/content/full/310/6988/1182 [14] John P Harrison, Notes on Empiricism, Western Lancet and Hospital Reporter, 8, 1848, 122, quoted in Warner, 63 |
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Annie Jones, Post Graduate Student Health Sciences, University of York
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Glenn S Tillotson, MSc, FRSM, Public Health Research Institute, New York City, NY 10016, USA & Fusion MD Cheshire CT USA. gtillotson@fusionmdnetwork.com Annie M Jones, BA, MBA Department of Health Sciences, University of York, UK & Magus Strategic Communications, Malton, York, YO17 8ED, UK annie.jones@virgin.net Arroll and Kenealy[1] have re-awakened some old questions and concerns. However, we think that they have also partly answered their own query. It is the clinician’s awareness of the panoply of respiratory conditions which present to the clinic on a daily basis which needs re- enforcing and supporting so that more appropriate use of antimicrobials is made in patients who really need them. It is well accepted that overuse and misuse of these valuable agents has in part been responsible for the inexorable rise in resistance among respiratory pathogens.[2-4] We believe the physician is not solely to blame for these actions. Currently the pressures on doctors are immense, but that is not to condone such willing use of antibiotics. Each patient requires more than cursory evaluation (< 3 minutes) prior to writing a prescription , with careful attention to the clinical manifestation; acute bronchitis should carry the following hallmarks, cough and sputum production of an acute onset (<5 days), associated with symptoms of upper airways involvement with or without fever. The patient should have no history of underlying airways disease such as chronic bronchitis (defined as chronic productive cough for 3 months of two consecutive years[5]) nor should there be signs of pulmonary involvement such as focal sounds or chest pain. Fear of missing pneumonia should be allayed by recognition of the following cardinal signs and symptoms; fever in 80%, respiratory rate>20/min 80%, crackles heard on auscultation 80%, and consolidation recognised on examination 30%. Ideally a chest X-ray will identify any infiltrates. Microbiological samples are taken in approximately 2% of patients but in <50% of cases do they identify a microbial cause.[6] These are the textbook guidelines[6-9], however reality and theory are not often seen together, an audit of antibiotic prescriptions in adults with acute respiratory infections was conducted by Ochoa et al[10] in Spain (a “hot bed” of resistance among respiratory pathogens).They sought to examine how 10 hospitals throughout the country approach community based RTIs . The Emergency Room physicians in Spain see about 50% of patients from the community so it seemed reasonable to assume that the standard of knowledge/care may be slightly higher among these “hospital-based doctors”. Use of a Delphi type evaluation enabled the investigators to gather the collective wisdom of experts a la the NIH consensus approach and assign each of the 2899 patients treated to an appropriate or inappropriate group in terms of whether they had clinical signs of infection warranting antibacterials. Of all emergencies seen in the hospital 5.5% were acute respiratory infections, antibacterials were given to 82.6% of these cases. The experts assessed that 40.5% of these prescriptions were inappropriate ; not surprisingly over a quarter (26.9% ) were for acute bronchitis but also 70.8% in croup , flu or common cold conditions. Ortqvist in 1993[11] highlighted the fact that at least a quarter of RTI cases in the community returned to the doctor due to therapy failure but it was not clear if that failure was due to a resistant strain or a viral disease equally failure can also be caused by exaggerated expectations of the results of therapy, by post-infectious bronchial hyper -reactivity or by a non-infectious cause of cough. It is clear that efforts to better define those patients who are most likely, but not definitively, benefit from antibiotics are needed before further inappropriate use adds to the selective pressure driving resistance. Several groups have strived to create clinical guidelines for chronic bronchitis and have defined which patients do not need managing with antimicrobials[6, 12-16] however, there is still the fear of missing the untreated pneumonia. It is worth bearing in mind that patients with mild-moderate pneumonia recover despite antimicrobials, as shown by recent clinical trials[17, 18] in which apparently atypical infections respond to B-lactam agents (an unexpected event as atypicals are refractory to these antibiotics). Thus if a patient truly has pneumonia and not acute bronchitis the maxim “ take an aspirin and comeback in two days if you are no better” holds true today. Indeed recent work from Rennard et al [19]has shown the value of “ mothers chicken soup” may not be a flippant approach. Although much is made of acute bronchitis and antibiotics, there are other equally dubious reasons for antibiotic prescribing which merit similar scrutiny, such as tonsillopharyngitis, “ sinusitis” and ear- infections in adults along with managing the patient’s expectations, which collectively contribute hugely to the prescription writing of antibiotics in RTIs. The value of systematic reviews to define the place of antibiotic prescribing in the management of bronchitis is also questionable. Definitions of the disease, spectrum and activity of antibiotics available and commonly prescribed, and, changing patterns of resistance have not been included in the four reviews cited by Arroll and Kenealy[1] The FDA removed uncomplicated acute bronchitis as an indication for randomised controlled trials in 1998, and the majority of studies conducted today are comparative and often include “sicker” patients with underlying COPD. Clearly pharmaceutical companies in designing their studies endeavour to enrol as many patients as possible, but sometimes definitions may be vague enough to permit the inclusion of some stray cases of acute bronchitis, as opposed to chronic ones. In our assessment of the value of antibiotic therapy in patients with bronchitis, perhaps the physician’s understanding and recognition of the panoply of respiratory disease should be our starting point. 1. Arroll, B. and T. Kenealy, Antibiotics for acute bronchitis. Bmj, 2001. 322(7292): p. 939-40. 2. Lindbaek, M. and P. Hjortdahl, Resistance to antibiotics. Restricted prescribing resulted in reduction of resistant strains [letter; comment]. Bmj, 1998. 317(7171): p. 1521-2. 3. Lindbaek, M.B.D.S.J.H.P., Influence of prescription patterns in general practice on anti-microbial resistance in Norway. Br J Gen Pract, 1999. 49(443): p. 436-440. 4. Macfarlane, J., Lower respiratory tract infection and pneumonia in the community. Semin Respir Infect, 1999. 14(2): p. 151-62. 5. Wilson, R. and R. Grossman, Introduction: the role of bacterial infection in chronic bronchitis. Semin Respir Infect, 2000. 15(1): p. 1-6. 6. ERS Task Force Report. Guidelines for management of adult community- acquired lower respiratory tract infections. European Respiratory Society. Eur Respir J, 1998. 11(4): p. 986-91. 7. Guidelines for the management of community-acquired pneumonia in adults admitted to hospital. The British Thoracic Society. Br J Hosp Med, 1993. 49(5): p. 346-50. 8. Guideline for prevention of nosocomial pneumonia. Centers for Disease Control and Prevention [see comments]. Respir Care, 1994. 39(12): p. 1191- 236. 9. Niederman, M.S., et al., Guidelines for the initial management of adults with community-acquired pneumonia: diagnosis, assessment of severity, and initial antimicrobial therapy. American Thoracic Society. Medical Section of the American Lung Association. Am Rev Respir Dis, 1993. 148(5): p. 1418-26. 10. Ochoa, C., et al., Assessment of antibiotic prescription in acute respiratory infections in adults. The Spanish Study Group on Antibiotic Treatments. J Infect, 2000. 41(1): p. 73-83. 11. Ortqvist, A., Community-acquired lower respiratory infection. Lancet, 1993. 341(8844): p. 529-30. 12. Straand, J., K.S. Rokstad, and H. Sandvik, Prescribing systemic antibiotics in general practice. A report from the More & Romsdal Prescription Study [published erratum appears in Scand J Prim Health Care 1998 Dec;16(4):252]. Scand J Prim Health Care, 1998. 16(2): p. 121-7. 13. Balgos, A., Guidelines for the role of antibiotics in acute exacerbations of chronic bronchitis in the Asia-Pacific region: report and recommendations of a consensus group. Med Progress, 1998. 25(11): p. 29- 38. 14. Mall, W., H.D. Nolting, and D. Schmidt, [Current status and analysis of diagnostic and therapeutic guidelines in the area of chronic obstructive respiratory tract diseases in adulthood]. Z Arztl Fortbild Qualitatssich, 1997. 91(6): p. 543-9. 15. [Prescription and use of antibiotics in ambulatory care. Drug Agency]. Rev Pneumol Clin, 1999. 55(2): p. 65-74. 16. Niederman, M.S., Guidelines for the management of respiratory infection: why do we need them, how should they be developed, and can they be useful? [editorial]. Curr Opin Pulm Med, 1996. 2(3): p. 161-5. 17. Jolley, A.E., A.J. Davies, and D.T. McLeod, Audit of the use of erythromycin in the treatment of community-acquired lower respiratory infections. Respir Med, 1992. 86(6): p. 503-5. 18. Cunha, B.A., The antibiotic treatment of community-acquired, atypical, and nosocomial pneumonias. Med Clin North Am, 1995. 79(3): p. 581-97. 19. Rennard, B.O., et al., Chicken soup inhibits neutrophil chemotaxis in vitro. Chest, 2000. 118(4): p. 1150-7. |
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Bruce Arroll, Associate Professor deptof General Practice university of auckland
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In reply to the letter from Fahey et al1 we do not agree that we were "concentrating on the potential benefit of antibiotics" and ignoring the proven side effects.2 3 Overuse of antibiotics for acute bronchitis is still clearly a problem. 4 What we would like is better direction for clinicians dealing with patients presenting with the cluster of symptoms of cough, sputum production (purulent or otherwise) and/or lower respiratory signs. An NNT of 11 to 14 for treatment with antibiotics may be clinically unhelpful if it refers to a population with subgroups at very different risks. 5 Limiting antibiotics to patients over 55 years is supported by one study. 7 Those with lower respiratory tract signs are more likely to benefit from antibiotics - in one study the NNT is 3 - 4 (though not statistically significant).6 The odds ratio for reconsultation in patients who presented with abnormal chest signs in the Holmes paper was 1.66. The wide confidence interval (95% CI 0.95-2.91) may reflect low statistical power to detect a difference- it may also reflect ineffective treatment of bronchospasm with antibiotics. In our editorial we recommended the consideration of bronchodilators as an alternative to antibiotics. Diagnostic clarification using an office trial of bronchodilators and consideration of chest x ray in those at high risk of pneumonia is a worthy aim. Rather than medicalising the situation we feel that such an approach would be more likely to provide a diagnosis that could direct future management. To merely give routine antibiotics as happened to 93% of the patients in the Holmes et al (2001) study would certainly medicalise the patient to "needing" antibiotics for each new episode of cough. 4 In personal communication with the authors of the Cochrane review we have learnt that the data is not in a form that would enable an analysis by those with and without lower respiratory tract signs. We would make a plea for those planning studies of "acute bronchitis" that the analysis include stratification by those with and without lower respiratory tract signs so that we can more easily answer the question do antibiotics improve patients with cough and purulent/non purulent sputum. That this "simple" question is unable to be answered after 50 years of antibiotics is a poor reflection on clinical medicine. References 1. Fahey T, Smucny J, Becker L, Stocks N. Cochrane review provides good evidence about the risks and benfits of antibiotic treatment. BMJ 2001;322:25 May. 2. Arroll B, Kenealy T. Antibiotics for acute bronchitis. Four reviews and still no answers: our clinical defintions are at fault. BMJ 2001;322:939- 40. 3. Thomas MG, Arroll B. "Just say no" reducing the use of antibiotics for colds, bronchitis and sinusitis. NZ Med J 2000;113:287-9. 4. Holmes WF, Macfarlane JT, Macfarlane RM, Hubbard R. Symptoms signs and prescribing for acute lower respiratory tract illness. Br J Gen Pract 2001;51:177-181. 5. Smucny J, Fahey T, Becker L, Glazier R, McIsaac W. Antibiotics for acute bronchitis: (Cochrane Review). In: The Cochrane Library, Issue 4, 2000. Oxford: Update Software., 6. Dunlay J, Reinhardt R, Roi LR. A placebo controlled double blind trial of erythromicin in adults with acute bronchitis. J Fam Pract 1987;25:137- 41. 7. Verheij TJ, Hermans J, Mulder JD. Effects of doxycycline in patients with acute cough and purulent sputum; a double blind placebo controlled trial. Br J Gen Pract 1994;44:400-4. |
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