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Some considerations
- Wenbin Liang (23 September 2005)
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Re: Some considerations
- Rakesh Biswas (23 September 2005)
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Optimizing Antibiotic usage in the community using a time tested but underutilized tool
- Rakesh Biswas, Vineeth Dineshan, N S Narasimhamurthy, A S Kasthuri (24 September 2005)
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Wenbin Liang, taking master of public health Curtin University of Technology
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Dear Editor, In this study,[1] more attention of nurses and physicians in the intervention arm may be drawn to the diagnosis of urinary tract infections by the intervention. They may be motivated to spend more time to observe and analyse symptoms related to urinary tract infections, and achieved a better diagnosis on the disease. Would it be appropriate to perform a “control intervention” which would also draw the professionals’ attention to the problem, in the control arm? In the article The rate of admission to hospital for sepsis was 0.026 per 1000 resident days in the intervention arm and 0.018 in the usual care arm,[1] thus the risk ratio was 1.4--a considerable increase. Total resident days in the two arms would be needed to further calculate the confident interval for the ratio. Reference 1. Loeb M., Brazil K., Lohfeld L., McGeer A., Simor A., Stevenson k., Zoutman D.,Smith S., Liu X. Walter S, Effect of a multifaceted intervention on number of antimicrobial prescriptions for suspected urinary tract infections in residents of nursing homes: cluster randomised controlled trial. bmj,doi:10.1136/bmj.38602.586343.55 (published 8 September 2005) Competing interests: None declared |
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Rakesh Biswas, Associate professor Vydehi Hospital, Whitefield, Bangalore, 560066
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I agree with Wenbin in that any intervention which is hypothetically better would gain special attention in meticulous execution. Each and every treating health care worker has his own intutive algorithm for proper patient management. What is more necessary is awareness among health workers in recognizing the important fact that antibiotics need rational prescribing. Competing interests: None declared |
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Rakesh Biswas, Associate professor, Internal medicine Vydehi Hospital, Whitefield, Bangalore, 56066, Vineeth Dineshan, N S Narasimhamurthy, A S Kasthuri
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Rational antibiotic usage is still a mattern of extreme concern that the present article tries to address. Antibiotic use is unregulated in many developing countries and as a result they are frequently misused and overused. Resistance to anti-microbial drugs is causing increasing mortality and morbidity from infectious diseases. To maintain the useful life of antimicrobial drugs in developing countries there needs to be improved access to diagnostic laboratories, improved surveillance of the emergence of resistance, better regulation of the use of antibiotics, and better education of the public, doctors, and veterinarians in the appropriate use of the drugs.(1) A recent survey on the attitudes of physicians practicing in a southern part of India revealed fever as one of the compelling reasons for them to prescribe an antibiotic.(2) Many practitioners in the community resort to adding an antibiotic for any kind of fever without bothering to localize the reason behind the fever hoping to hit the salmonella in case it turns out to be typhoid or the pneumococci if it is in case perhaps lurking somewhere. It is the uncertainty in diagnosis of fevers particularly the inability to tell the harmless viral fever from the debilitating Salmonella that compel many physicians to blindly start antibiotics. Fever is usually clinically understood by its presenting symptoms and signs, which initially give us a morphologic/anatomic area of localization followed by an etiological localization where the infecting agent or immunological disturbance is further specifically identified, as may be the case. However in many situations it may not be readily apparent even after a screening urine routine, CBC and chest X-ray (especially in bacterial infections like salmonella, which more often localize in the reticulo-endothelial system (more so when the blood culture results are pending or expected to give a low yield). In such situations patients would require a wait and watch policy to understand the nature of the fever before one jumps to further advanced tests like an ultrasound or CT scan (to locate occult intra-abdominal abscesses or retro-peritoneal lymph-nodes. The wait is not easy especially with a spiking fever in a patient looking very toxic. The temptation to blindly start antibiotics is very high in such instances. However time tested simple antipyretics can do wonders in many patients. The watch is relatively easier with a simple thermometer and a fever chart along with a detailed elucidation of other symptoms like headache, myalgia, anorexia and apathy. A recent study suggested that, Fever charting as a means to localize salmonella verses other fevers is still an invaluable clinical tool. If used judiciously it can be used as a cost effective means (also reducing antibiotic misuse) in the diagnosis and treatment of patients of initially non-localizable fevers in the community. Patience must be exercised in starting antibiotics, not until the fever pattern of 2 days suggest enteric. In cases of viral fevers the chart registers a spontaneous decline in fever thus ruling out the need to institute antibiotics (3). With a view to changing the antibiotic prescribing practice patterns in the community we undertook this study. We hoped to point out this invaluable tool that community physicians (CPs) could use to help resolve their diagnostic uncertainties while dealing with fever patients. Methods and design: Patients presenting with recent onset fever to the Vydehi Institute of Medical Sciences and Research Centre, Bangalore were monitored only with simple fever charting and managed based on their fever patterns for 2 days (as has been previously reported)(3). Initially only antipyretics were given in optimal doses and later if the fever showed a continuous pattern suggestive of enteric (or any other) septicemia, antibiotics instituted. Inclusion Criteria: 1) Patients with an elevation of body temperature to a level >38.3° C (101° F), 2) No clinical localization for example, cough with muco-purulent sputum, hemoptysis, chest pain suggesting pneumonia or urinary dysuria, frequency suggesting UTI. 3) Recent onset fever (1-2 days) when the diagnostic uncertainty is high. 4) Age > 14years Exclusion Criteria: 1) Obvious clinical localization 2) Underlying disease suggesting particular localization (like spontaneous bacterial peritonitis in cirrhotic patients with ascites or immunocompromised states). 3) Already investigated and diagnosed fevers on their way to recovery. The patients were evaluated by one of the authors soon after admission to check if they fitted in to the inclusion and exclusion criteria’s and subsequently followed up noting the changes in fever pattern, fresh clinical findings/clues, and laboratory results. Antibiotics were only instituted if the fever showed a septicemic continuous pattern. The usual antibiotic of choice was a quinolone in view of the endemicity of Typhoid in this part of the world (making it one of the commonest organisms responsible for the continuous fever pattern here). The different clinical profiles of these real patients of viral and enteric fevers were circulated among the community practitioners (CPs) in the form of a questionnaire and an assessment of their approach to these same patients was made through their written responses. The questionnaire (see annexure 1) contained our real patient data and asked the CPs to write out their line of management. At the end of the study the CP responses were compared with the real outcome of the same patients. Results: 4289 patients presented to Vydehi institute of medical sciences during the study period from 7th August to 25th September. Of these 192 fitted into our inclusion criteria and were managed with generous doses of antipyretics and analgesics by one independent observer along with advice to chart their fevers. Of these patients 13 were managed as inpatients and their fever charts (Annexure 2) suggested a diagnosis of viral in 9 who received no antibiotics, enteric fever was suggested by a continuous pattern in 2 patients and recovered on quinolones. Two patients of 13 were also treated for malaria as their fever charts revealed a high grade intermittent pattern. These 13 patient scenarios were offered to the community physicians as questionnaires asking the CPs to write out their line of management. 23 CPs were approached practicing within an urban area of 9 Square Km of which 15 finally agreed to participate in the study. All the CPs approached wrote antibiotics for all these case scenarios making out an antibiotic prescribing of 100% whereas in reality only 4 out of 13 (30.76%), required antibiotics. Once presented with these findings there was a mixed response: They agreed that in a controlled hospital setting the results could be spectacular but in the arena of community practice it was a different ball game altogether. However most agreed that it was an interesting learning exercise and fever charting would at least be considered where they encountered marked diagnostic uncertainty. Of these 192 patients 183 were managed as outpatients. Different physicians apart from the ones carrying out the study were managing the outpatients. Of these 183 patients 81(44%) were only offered antipyretics and advise to chart their fevers whereas 102 (56%) were given antibiotics on individual unbiased judgment of the various treating physicians who were not part of the study. There was no statistically significant difference in the proportion of patients receiving and not receiving antibiotics when compared among inpatients and outpatients. See Table below: |Antibiotics| Inpatient| Outpatient| Total | | Yes | 04 (31) | 102 (56) | 106 | | No | 09 (69) | 81 (44) | 90 | | Total | 13 | 183 | 196 | Table: (Percentages are in parentheses) Chi square = 3.033; DF = 1; p> 0.05 Of the 183 outpatients one independent observer RB managed 39 and as a part of the study all patients were asked to chart their fevers along with prescriptions of antipyretics-analgesics. Most patients as outpatients did not monitor their fever charts meticulously, only noting it when there was a spike and not following the standard dictum of 4 hourly which was emphasized to them beforehand. In spite of this most patients recovered spontaneously only on analgesics-antipyretics. The CPs were approached also with the results of the hospital outpatient management outcome of observer RB as this was more analogous to a community setting. It was emphasized that most patients recovered spontaneously only on analgesics-antipyretics even if they did not monitor their fever charts meticulously thus demonstrating the enormous benefit incurred on the community in terms of cost savings, fewer side effects and last but not least fewer chance of antibiotic resistance. Discussion: Problem solving is inherent in human trouble-shooting and is reflected in the day-to-day challenges a physician faces. Fever is one such important challenge, more so in parts of the world where infections are rife. There have been a lot of elegant studies on fever earlier (4-5) however each and every time and place pose their own unique set of problems. In the absence of an antimicrobial/antibiotic control program, CPs in developing countries are left to their own devices when it comes to using broad spectrum antibiotics in solving fever problems (6). Most CPs agree to using broad spectrum antimicrobials in various fevers, not waiting to see if they are viral and may not require antibiotics. There is also a common myth of trying to prevent secondary bacterial infections that is often used as an excuse to validate their antibiotic misuse. The present study carried out from 7th August to 25th September 2004 needed to prove the usefulness of fever charting as an effective tool to guide community physicians in managing fevers and creating simultaneous awareness among them of the importance of preventing antibiotic misuse in the community. The limitations of the study were a short time frame resulting in a small study sample. Also in spite of an objective study design the outcome measures were subjective. It would have been more objective to estimate the incidence and prevalence of antibiotic misuse prior to and after the study with the difference indicating the outcome measure of this educational intervention amongst community physicians. However the study design brought out the fact that it was possible to spread the message of antibiotic misuse prevention in the community in a realistic and amiable manner. It spells the need for a wider coverage of a larger population of community physicians with Medical colleges and other tertiary care centers throughout the country guiding their sub-centers in this manner. Most community physicians on interviewing gave an impression of initial hostility, which was expected but as we were trying to educate them by setting an example rather than enforce a rule they co-operated in the end. A sizeable majority of our fever patients who recovered without using antibiotics were managed on an OPD basis although they didn't meticulously chart their fevers even when told to do so. We concluded that even if patients don't follow their fever charting strictly if they are viral they recover and if typhoid they would need to reappear for resolution of their problem and could then be admitted and instituted on antibiotics after charting their fevers in the hospital setting for 2 days. Off course one practical problem is that if they turn out to be typhoid they may never go back to the CP. However if a proper explanation is offered to the patients and the CP makes himself readily available to them so that they can contact him easily on phone and let him know their progress (chart or no chart) a lot can be achieved in terms of symptomatic improvement of the patients without mis/using antibiotics. In developed countries the above approach can be made further user-friendly using technology to create electronic thermometers capable of preparing their own graphs and emailing it to the physician’s handheld. It is hoped that this initial effort will make a dent in established knee jerk antibiotic prescription practices. It will be a long and slow battle that will involve similar educational approaches world wide both developing and developed where antibiotic prescribing patterns suggest misuse. References: 1) Hart C A, Kariuki S, Antimicrobial resistance in developing countries, BMJ 1998;317:647-650 2) Sivagnanam G, Thirumalaikolundusubramanian P, Mohanasundaram J, Raaj AA, Namasivayam K, Rajaram S. A survey on current attitude of practicing physicians upon usage of antimicrobial agents in southern part of India. MedGenMed. 2004 May 11;6(2):1 3) Biswas R, Dhakal B, Das RN, Shetty KJ. Resolving diagnostic uncertainty in initially poorly-localizable-fevers:-a-prospective-study. Int J Clin Pract.(UK) 2004 Jan;58(1):26-8. 4) Bor DH, Makadon HJ, Friedland G, et al.: Fever in hospitalized medical patients: Characteristics and significance. J Gen Intern Med 3:119, 1988. 5) Kazanjian PH: Fever of unknown origin: Review of 86 patients treated in community hospitals. Clin Infect Dis 15:968, 1992 6) Kasturi AS, Antibiotic policy, Jl Asso Phy India 1998, Vol 46, No 2, 215-217. Competing interests: None declared |
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