scholarly journals Clinical presentation and disease course in patients with flu-like illness: does microbiological aetiology matter?

2021 ◽  
pp. BJGP.2021.0344
Author(s):  
Theo Verheij ◽  
Daniela Cianci ◽  
Alike van der Velden ◽  
Christopher C Butler ◽  
Emily Bongard ◽  
...  
Keyword(s):  
Primary Care ◽  
Clinical Presentation ◽  
Randomised Trial ◽  
Bacterial Pathogen ◽  
Pcr Analysis ◽  
Acute Cough ◽  
Viral Pathogen ◽  
Course Of Disease ◽  
Bacterial Aetiology ◽  
Tract Infections

Background: There is little evidence about the relation between aetiology, illness severity and clinical course of respiratory tract infections (RTI) in primary care. Understanding these associations would aid to develop effective management strategies for these infections. Aim: To investigate whether the clinical presentation and illness course differ between RTI in whom a viral pathogen was detected and those in whom a potential bacterial pathogen was found. Design and setting: Post hoc analysis of data from a pragmatic randomised trial on the effects of oseltamivir in patients with influenza-like illness (ILI) in primary care (n=3266) in 15 European countries. Methods: Patient characteristics, signs and symptoms were registered at baseline. Naso-pharyngeal (adults) or nasal and pharyngeal (children) swabs were taken for PCR analysis. Patients were followed up until 28 days after inclusion. Regression models and Kaplan-Meier curves were used to analyse the relation between aetiology, clinical presentation at baseline and course of disease including complications. Results: Except for a less prominent congested nose (OR 0.55, CI 0.35 – 0.86) and acute cough (OR 0.52, CI 0.27 – 0.65) in ILI patients in whom a possible bacterial pathogen was isolated, there were no clear clinical differences in presentations between those with a possible bacterial aetiology than in those with a viral one. Also the course of disease and complications were not related to aetiology. Conclusion: Given the currently available microbiological tests and antimicrobial treatments, and outside pandemics like COVID-19, microbiological testing in primary care patients with ILI seems to have limited value.

scholarly journals Prevalence, aetiologies and prognosis of the symptom cough in primary care: a systematic review and meta-analysis

2021 ◽  
Vol 22 (1) ◽  
Author(s):  
Milena Bergmann ◽  
Jörg Haasenritter ◽  
Dominik Beidatsch ◽  
Sonja Schwarm ◽  
Kaja Hörner ◽  
...  
Keyword(s):  
Systematic Review ◽  
Primary Care ◽  
Respiratory Tract ◽  
Chronic Cough ◽  
Respiratory Tract Infections ◽  
Meta Analysis ◽  
Current Guideline ◽  
Acute Cough ◽  
Reason For Encounter ◽  
Tract Infections

Abstract Background Cough is a relevant reason for encounter in primary care. For evidence-based decision making, general practitioners need setting-specific knowledge about prevalences, pre-test probabilities, and prognosis. Accordingly, we performed a systematic review of symptom-evaluating studies evaluating cough as reason for encounter in primary care. Methods We conducted a search in MEDLINE and EMBASE. Eligibility criteria and methodological quality were assessed independently by two reviewers. We extracted data on prevalence, aetiologies and prognosis, and estimated the variation across studies. If justifiable in terms of heterogeneity, we performed a meta-analysis. Results We identified 21 eligible studies on prevalence, 12 on aetiology, and four on prognosis. Prevalence/incidence estimates were 3.8–4.2%/12.5% (Western primary care) and 10.3–13.8%/6.3–6.5% in Africa, Asia and South America. In Western countries the underlying diagnoses for acute cough or cough of all durations were respiratory tract infections (73–91.9%), influenza (6–15.2%), asthma (3.2–15%), laryngitis/tracheitis (3.6–9%), pneumonia (4.0–4.2%), COPD (0.5–3.3%), heart failure (0.3%), and suspected malignancy (0.2–1.8%). Median time for recovery was 9 to 11 days. Complete recovery was reported by 40.2- 67% of patients after two weeks, and by 79% after four weeks. About 21.1–35% of patients re-consulted; 0–1.3% of acute cough patients were hospitalized, none died. Evidence is missing concerning subacute and chronic cough. Conclusion Prevalences and incidences of cough are high and show regional variation. Acute cough, mainly caused by respiratory tract infections, is usually self-limiting (supporting a “wait-and-see” strategy). We have no setting-specific evidence to support current guideline recommendations concerning subacute or chronic cough in Western primary care. Our study presents epidemiological data under non non-pandemic conditions. It will be interesting to compare these data to future research results of the post-pandemic era.

scholarly journals Coughing children in family practice and primary care: a systematic review of prevalence, aetiology and prognosis

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Milena Bergmann ◽  
Jörg Haasenritter ◽  
Dominik Beidatsch ◽  
Sonja Schwarm ◽  
Kaja Hörner ◽  
...  
Keyword(s):  
Systematic Review ◽  
Primary Care ◽  
Respiratory Tract ◽  
Chronic Cough ◽  
Primary Care Physicians ◽  
Original Research ◽  
Current Guideline ◽  
Upper Respiratory Tract ◽  
Acute Cough ◽  
Tract Infections

Abstract Background For evidence-based decision making, primary care physicians need to have specific and reliable information on the pre-test probabilities of underlying diseases and a symptom’s course. We performed a systematic review of symptom-evaluating studies in primary care, following three research questions: (1) What is the prevalence of the symptom cough in children consulting primary care physicians? (2) What are the underlying aetiologies of cough and the respective frequencies? (3) What is the prognosis of children with cough? Methods Following a pre-defined algorithm and independent double reviewer ratings we searched MEDLINE and EMBASE. All quantitative original research articles in English, French or German were included if they focused on unselected study populations of children consulting a primary care physician for cough. We used the random effects model for meta-analysis in subgroups, if justifiable in terms of heterogeneity. Results We identified 14 eligible studies on prevalence, five on aetiology and one on prognosis. Prevalence estimates varied between 4.7 and 23.3% of all reasons for an encounter, or up to estimates of 60% when related to patients or consultations. Cough in children is more frequent than in adults, with lowest prevalences in adolescents and in summer. Acute cough is mostly caused by upper respiratory tract infections (62.4%) and bronchitis (33.3%); subacute or chronic cough by recurrent respiratory tract infection (27.7%), asthma (up to 50.4% in cough persisting more than 3 weeks), and pertussis (37.2%). Potentially serious diseases like croup, pneumonia or tuberculosis are scarce. In children with subacute and chronic cough the total duration of cough ranged from 24 to 192 days. About 62.3% of children suffering from prolonged cough are still coughing two months after the beginning of symptoms. Conclusion Cough is one of the most frequent reasons for an encounter in primary care. Our findings fit in with current guideline recommendations supporting a thoughtful wait-and-see approach in acute cough and a special awareness in chronic cough of the possibility of asthma and pertussis. Further evidence of aetiological pre-test probabilities is needed to assess the diagnostic gain based on patient history and clinical signs for differential diagnoses of cough in children.

scholarly journals PRINCIPLE trial demonstrates scope for in-pandemic improvement in primary care antibiotic stewardship: a retrospective sentinel network cohort study

BJGP Open ◽  
2021 ◽  
pp. BJGPO.2021.0087
Author(s):  
Simon de Lusignan ◽  
Mark Joy ◽  
Julian Sherlock ◽  
Manasa Tripathy ◽  
Oliver van Hecke ◽  
...  
Keyword(s):  
Primary Care ◽  
Respiratory Tract ◽  
Respiratory Tract Infections ◽  
Negative Binomial ◽  
Randomised Trial ◽  
Risk Difference ◽  
Upper Respiratory Tract ◽  
Sentinel Network ◽  
Rate Ratios ◽  
Tract Infections

BackgroundThe Platform Randomised trial of INterventions against COVID-19 In older peoPLE (PRINCIPLE) has provided in-pandemic evidence that azithromycin and doxycycline were not beneficial in the early primary care management of COVID-19.AimTo explore the extent of azithromycin and doxycycline in-pandemic use, and the scope for trial findings impacting on practice.Design & settingCrude rates of prescribing and respiratory tract infections (RTI) in 2020 were compared with 2019, using the Oxford Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC).MethodA negative binomial model was used to compare azithromycin and doxycycline lower respiratory tract infections (LRTI), upper respiratory tract infections (URTI), and influenza-like-illness (ILI) in 2020 with 2019; reporting incident rate ratios (IRR) between years, and 95% confidence intervals (95% CI).ResultsAzithromycin prescriptions increased 7% in 2020 compared with 2019, whereas doxycycline decreased by 7%. Concurrently, LRTI and URTI incidence fell by over half (58.3% and 54.4%, respectively) while ILI rose slightly (6.4%). The overall percentage of RTI prescribed azithromycin rose from 0.51% in 2019 to 0.72% in 2020 (risk difference of 0.214% [95% CI = 0.211 to 0.217]); doxycycline rose from 11.86% in 2019 to 15.79% in 2020 (risk difference: 3.93% [95% CI = 3.73 to 4.14]). The adjusted IRR showed azithromycin prescribing was 22% higher in 2020 (IRR = 1.22, 95% CI = 1.19 to 1.26, P<0.0001), for every unit rise in confirmed COVID-19 there was an associated 3% rise in prescription (IRR = 1.03, 95% CI = 1.02 to 1.03, P<0.0001); whereas these measures were static for doxycycline.ConclusionPRINCIPLE demonstrates scope for improved antimicrobial stewardship during a pandemic.

scholarly journals Relationship between microbiology of throat swab and clinical course among primary care patients with acute cough: a prospective cohort study

2019 ◽  
Vol 37 (3) ◽  
pp. 332-339
Author(s):  
José M Ordóñez-Mena ◽  
Thomas R Fanshawe ◽  
Chris C Butler ◽  
David Mant ◽  
Denise Longhurst ◽  
...  
Keyword(s):  
Primary Care ◽  
Cohort Study ◽  
Prospective Cohort Study ◽  
Prospective Cohort ◽  
Acute Cough ◽  
Severe Problem ◽  
Duration Of Symptoms ◽  
Presenting Symptoms ◽  
Severity Scores ◽  
Tract Infections

Abstract Background Acute lower respiratory tract infections (ALRTIs) account for most antibiotics prescribed in primary care despite lack of efficacy, partly due to clinician uncertainty about aetiology and patient concerns about illness course. Nucleic acid amplification tests could assist antibiotic targeting. Methods In this prospective cohort study, 645 patients presenting to primary care with acute cough and suspected ALRTI, provided throat swabs at baseline. These were tested for respiratory pathogens by real-time polymerase chain reaction and classified as having a respiratory virus, bacteria, both or neither. Three hundred fifty-four participants scored the symptoms severity daily for 1 week in a diary (0 = absent to 4 = severe problem). Results Organisms were identified in 346/645 (53.6%) participants. There were differences in the prevalence of seven symptoms between the organism groups at baseline. Those with a virus alone, and those with both virus and bacteria, had higher average severity scores of all symptoms combined during the week of follow-up than those in whom no organisms were detected [adjusted mean differences 0.204 (95% confidence interval 0.010 to 0.398) and 0.348 (0.098 to 0.598), respectively]. There were no differences in the duration of symptoms rated as moderate or severe between organism groups. Conclusions Differences in presenting symptoms and symptoms severity can be identified between patients with viruses and bacteria identified on throat swabs. The magnitude of these differences is unlikely to influence management. Most patients had mild symptoms at 7 days regardless of aetiology, which could inform patients about likely symptom duration.

scholarly journals Protocol for an ‘efficient design’ cluster randomised controlled trial to evaluate a complex intervention to improve antibiotic prescribing for CHIldren presenting to primary care with acute COugh and respiratory tract infection: the CHICO study

BMJ Open ◽  
2021 ◽  
Vol 11 (3) ◽  
pp. e041769
Author(s):  
Penny Seume ◽  
Scott Bevan ◽  
Grace Young ◽  
Jenny Ingram ◽  
Clare Clement ◽  
...  
Keyword(s):  
Primary Care ◽  
Respiratory Tract ◽  
Research Ethics ◽  
Phase Iii ◽  
Antibiotic Prescribing ◽  
Acute Cough ◽  
Hospital Admission Rate ◽  
Routinely Collected Data ◽  
Patient Consent ◽  
Tract Infections

IntroductionRespiratory tract infections (RTIs) in children are common and present major resource implications for primary care. Unnecessary use of antibiotics is associated with the development and proliferation of antimicrobial resistance. In 2016, the National Institute for Health Research (NIHR)-funded ‘TARGET’ programme developed a prognostic algorithm to identify children with acute cough and RTI at very low risk of 30-day hospitalisation and unlikely to need antibiotics. The intervention includes: (1) explicit elicitation of parental concerns, (2) the results of the prognostic algorithm accompanied by prescribing guidance and (3) provision of a printout for carers including safety netting advice. The CHIldren’s COugh feasibility study suggested differential recruitment of healthier patients in control practices. This phase III ‘efficiently designed’ trial uses routinely collected data at the practice level, thus avoiding individual patient consent. The aim is to assess whether embedding a multifaceted intervention into general practitioner (GP) practice Information Technology (IT) systems will result in reductions of antibiotic prescribing without impacting on hospital attendance for RTI.Methods and analysisThe coprimary outcomes are (1) practice rate of dispensed amoxicillin and macrolide antibiotics, (2) hospital admission rate for RTI using routinely collected data by Clinical Commissioning Groups (CCGs). Data will be collected for children aged 0–9 years registered at 310 practices (155 intervention, 155 usual care) over a 12-month period. Recruitment and randomisation of practices (using the Egton Medical Information Systems web data management system) is conducted via each CCG stratified for children registered and baseline dispensing rates of each practice. Secondary outcomes will explore intervention effect modifiers. Qualitative interviews will explore intervention usage. The economic evaluation will be limited to a between-arm comparison in a cost–consequence analysis.Ethics and disseminationResearch ethics approval was given by London-Camden and Kings Cross Research Ethics Committee (ref:18/LO/0345). This manuscript refers to protocol V.4.0. Results will be disseminated through peer-reviewed journals and international conferences.Trial registration numberISRCTN11405239.

scholarly journals Guideline Adherence in Antibiotic Prescribing to Patients with Respiratory Diseases in Primary Care: Prevalence and Practice Variation

Antibiotics ◽  
2020 ◽  
Vol 9 (9) ◽  
pp. 571
Author(s):  
Karin Hek ◽  
Thamar E.M. van Esch ◽  
Anke Lambooij ◽  
Yvette M. Weesie ◽  
Liset van Dijk
Keyword(s):  
Primary Care ◽  
Guideline Adherence ◽  
Acute Bronchitis ◽  
Patient Characteristics ◽  
Practice Variation ◽  
Antibiotic Prescribing ◽  
Successful Implementation ◽  
Acute Cough ◽  
Acute Tonsillitis ◽  
Tract Infections

Respiratory tract infections (RTIs) account for a large part of antibiotic prescriptions in primary care. However, guidelines advise restrictive antibiotic prescribing for RTIs. Only in certain circumstances, depending on, e.g., comorbidity, are antibiotics indicated. Most studies on guideline adherence do not account for this. We aimed to assess guideline adherence for antibiotic prescribing for RTIs as well as its variation between general practices (GPs), accounting for patient characteristics. We used data from electronic health records of GPs in the Netherlands. We selected patients who consulted their GP for acute cough, rhinitis, rhinosinusitis or sore throat in 2014. For each disease episode we assessed whether, according to the GP guideline, there was an indication for antibiotics, using the patient’s sociodemographic characteristics, comorbidity and co-medication. We assessed antibiotic prescribing for episodes with no or an unsure indication according to the guidelines. We analysed 248,896 episodes. Diagnoses with high rates of antibiotic prescribing when there was no indication include acute tonsillitis (57%), strep throat (56%), acute bronchitis (51%) and acute sinusitis (48%). Prescribing rates vary greatly between diagnoses and practices. Reduction of inappropriate antibiotic prescribing remains a key target to tackle antimicrobial resistance. Insight into reasons for guideline non-adherence may guide successful implementation of the variety of interventions already available for GPs and patients.

scholarly journals PRINCIPLE trial demonstrates scope for in-pandemic improvement in primary care antibiotic stewardship

2021 ◽  
Author(s):  
Simon de Lusignan ◽  
Mark Joy ◽  
Julian Sherlock ◽  
Manasa Tripathy ◽  
Oliver van Hecke ◽  
...  
Keyword(s):  
Primary Care ◽  
Respiratory Tract ◽  
Respiratory Tract Infections ◽  
Negative Binomial ◽  
Randomised Trial ◽  
Upper Respiratory Tract ◽  
Incident Rate ◽  
Early Primary ◽  
Rate Ratios ◽  
Tract Infections

AbstractBackgroundThe Platform Randomised trial of INterventions against COVID-19 In older peoPLE (PRINCIPLE) trial has provided in-pandemic evidence of what does not work in the early primary care management of coronavirus-2019 disease (COVID-19). PRINCIPLE’s first finding was that azithromycin and doxycycline were not effective.AimTo explore the extent to which azithromycin and doxycycline were being used in-pandemic, and the scope for trial findings impacting on practice.Design and SettingWe compared crude rates of prescribing and respiratory tract infections (RTI) in 2020, the pandemic year, with 2019, using the Oxford-Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC).MethodsWe used a negative binomial model including age-band, gender, socioeconomic status, and NHS region to compare azithromycin and doxycycline lower respiratory tract infections (LRTI), upper respiratory tract infections (URTI), and influenza-like-illness (ILI) in 2020 with 2019; reporting incident rate ratios (IRR) between years and 95% confidence intervals (95%CI).ResultsAzithromycin prescriptions increased 7% in 2020 compared to 2019, whereas doxycycline decreased by 7%. Concurrently, LRTI and URTI incidence fell by over half (58.3% and 54.4% respectively) while ILI rose slightly (6.4%). The overall percentage of RTI prescribed azithromycin rose by 42.1% between 2019 and 2020, doxycycline increased by 33%.Our adjusted IRR showed azithromycin prescribing was 22% higher in 2020 (IRR=1.22, 95%CI:1.19-1.26, p<0.0001), for every unit rise in confirmed COVID there was an associated 3% rise in prescription (IRR=1.026, 95%CI 1.024-1.0285, p<0.0001); whereas these measures were static for doxycycline.ConclusionPRINCIPLE trial flags scope for improvement in antimicrobial stewardship.

Chronic cough in adults

2014 ◽  
Vol 7 (10) ◽  
pp. 604-608
Author(s):  
Haider Al-Najjar
Keyword(s):  
Primary Care ◽  
Chronic Cough ◽  
Significant Proportion ◽  
British Thoracic Society ◽  
Upper Respiratory Tract ◽  
Acute Cough ◽  
Lost Productivity ◽  
The Uk ◽  
Tract Infections ◽  
Care Costs

A cough is the single most common presenting complaint in primary care; it is a major burden on the UK economy in terms of both health care costs and lost productivity. The vast majority of these cases are an acute cough, primarily due to self-limiting upper respiratory tract infections. However, a significant proportion of the general population (between 10 and 20%) will experience chronic cough, which can have a debilitating and often overlooked impact on the patient’s quality of life. This article describes the primary care evaluation and management of chronic cough in adults, particularly when there is no obvious underlying cause, based on the recommendations of the British Thoracic Society. There is also a brief discussion regarding which cases of acute cough should be referred early before they become chronic. The article does not discuss the management of a cough in children.

scholarly journals Coughing Children in Family Practice and Primary Care – A Systematic Review On Prevalence, Aetiology and Prognosis

2021 ◽  
Author(s):  
Milena Bergmann ◽  
Jörg Haasenritter ◽  
Dominik Beidatsch ◽  
Sonja Schwarm ◽  
Kaja Bartsch ◽  
...  
Keyword(s):  
Systematic Review ◽  
Primary Care ◽  
Respiratory Tract ◽  
Chronic Cough ◽  
Total Duration ◽  
Original Research ◽  
Current Guideline ◽  
Upper Respiratory Tract ◽  
Acute Cough ◽  
Tract Infections

Abstract Background: For evidence-based decision-making general practitioners need setting specific knowledge on the pre-test probabilities of underlying diseases and a symptom’s course. We performed a systematic review on symptom evaluating studies in primary care to give evidence on the prevalence, aetiologies and prognosis of coughing children who consult primary care settings. Methods: Following a pre-defined algorithm and independent double reviewer ratings we searched MEDLINE and EMBASE. We included data from all quantitative original research articles in English, French or German assessing unselected study populations of children consulting for cough in primary care. We used the random effects model for meta-analysis in eligible subgroups if comprehensive in terms of heterogeneity. Results: We identified 14 eligible studies on prevalence, five on aetiology and one on prognosis. Prevalence estimates varied between 4.7% and 23.3% of all reasons for encounter or up to estimates of 60% when related to patients or consultations. Cough in children is more frequent than in adults with lowest prevalences in adolescents and in summer. Acute cough is mostly caused by upper respiratory tract infections (62.4%) and bronchitis (33.3%); subacute or chronic cough by recurrent respiratory tract infection (27.7%), asthma (3% in cough of all durations to 50.4% in more than 3 weeks cough), and pertussis (37.2%). Potentially serious diseases like croup, pneumonia or tuberculosis are scarce. In children with subacute and chronic cough the total duration of cough ranged from 24 to 192 days. About 62.3% of children suffering from prolonged cough are still coughing two months after the beginning of symptoms. We found strong heterogeneity across studies and only five studies with an overall low risk of bias. Conclusion: Cough is one of the most frequent reasons of encounter in primary care. Our findings on aetiologies and prognosis fit in with current guideline recommendations supporting a thoughtful wait-and-see approach in acute cough and a special awareness of asthma in chronic cough. There is a remarkable high pre-test probability of pertusssis in children with cough of more than two weeks’ duration. To develop primary-care cough guidelines symptom-evaluating studies assessing setting and age specific aetiologies and prognosis of cough are needed.

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