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Rapid Responses: Rapid Responses published:
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Understanding coughs in primary care
- Rod A Storring (30 June 2009)
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A few points that could make the study better
- DR.INDRANIL BANERJEE (5 July 2009)
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Response from author
- Christopher C Butler (10 July 2009)
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Rod A Storring, Consultant community chest physician Barking and Dagenham PCT, IG11 8EY
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I am not suprised at these findings of the GRACE group (The Genomics to combat Resistance against Antibiotics in Community-acquired lower respiratory tract infections in Europe).That antibiotic presribing was not associated with clinically important differences in recovery in patients with acute cough in primary care is consistent with an understanding of the causative mechanisms involved and that antibiotics are only infrequently needed in the usually healthy.That this latter number is very small is demonstrated by the fact that in the 3402 patients recruited, benefits from antibiotics were not demonstrated. Coughs in primary care can be very troublesome and prolonged. My understandig of the mechanisms involved is as follows. Approximately 30% of the population tend to get chest symptoms with viral infections (personal findings). It has been demonstrated that viral infections cause an inflammatory reaction in the respiratory tract and it is this that causes the symptoms, usually only a cough, though there may also be chest tightness, wheeze, dyspnoea, phlegm etc. If sufficiently troublesome, these symptoms will settle with anti-asthma treatment. Antibiotics in the otherwise healthy are only needed if the patient feels unwell or has purulent phlegm. As pointed out above, this number is very small. Competing interests: none |
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DR.INDRANIL BANERJEE, MD(PHARMACOLOGY)PGT B.M.C.H,INDIA
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Respected editor, I would like to congratulate every researcher associated with the study 'Variation in antibiotic prescribing and its impact on recovery in patients with acute cough in primary care: prospective study in 13 countries' for doing such wonderful work. However certain improvements in the study design could have made this study more informative. First, while drawing the study design, we did not find any mention about the definition of acute cough. Lack of proper case definition makes inclusion criteria a bit controversial. Again while setting the inclusion criteria, recent drug intake history of individual patients were not considered. This is important so far this study is concerned since intake of certain drugs (ACE inhibitors) can cause episodes of acute cough. The design of the study also overlooks safety concerns associated with drug use. A separate ADR collection form could have been supplied to the researchers. That the antibiotics used exposes the patients to unnecessary hazards without any appreciable impact on recovery could be ellicited then. A cost-benefit analysis could have been included in the study since costs of each antibiotics used in the study vary while outcome expressed as recovery with each drug varies little. Competing interests: None declared |
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Christopher C Butler, Professor Dept of Primary Care and Public Health, Cardiff University, CF14 4YS
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We appreciate the comments of both reviewers to our paper "Variation in antibiotic prescribing and its impact on recovery in patients with acute cough in primary care: prospective study in 13 countries." Dr Storring comments “Antibiotics in the otherwise healthy are only needed if the patient feels unwell or has purulent phlegm. As pointed out above, this number is very small." We plan to soon report more detailed analyses of specific sub-groups (including those with discolored sputum and/or reporting “feeling generally unwell”) to see if they benefit more from antibiotics. Dr Banerjee is concerned that we do not define acute cough. However, we do report an inclusion criterion, “an acute or worsened cough .... with a duration of up to and including 28 days”. We were deliberately broad in our inclusion criteria as our goal was to describe presentation, management and outcome of patients consulting with acute cough in contrasting primary care European research networks: a tight definition would not have allowed us to capture the variation in clinical practice. Finally, there are many components to the GRACE research program (https://www.grace-lrti.org/) and a health economics evaluation is nearing completion. Competing interests: None declared |
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