New Studies Question Using Antibiotics for Sore Throat, Sinusitis

Family physicians who fend off requests for antibiotics to treat common respiratory illnesses now have new fuel for their fire. Two research reports and an editorial in the November/December issue of Annals of Family Medicine assail the inappropriate use of antibiotics.

One of the reports, "Are Sore Throat Patients Who Hope for Antibiotics Actually Asking for Pain Relief?" says a patient with an acute sore throat who asks for an antibiotic may, in fact, want treatment for pain.

In the study, 68 family physicians in Belgium obtained post-visit surveys in 2002 from 298 patients ages 12 and older who had a severe sore throat. From the survey's list of 13 reasons for obtaining care, patients indicated their top three reasons were to learn the cause of the illness, obtain "something for the pain" and learn the likely course of the illness.

"I want an antibiotic" ranked as the 11th reason out of 13. However, among the 106 patients who said antibiotics were very or rather important, 97 percent said their reason for the visit was to obtain "something for the pain."

"Our study suggests that the patient's desire for an antibiotic may be based on the mistaken view that this treatment is best for pain relief," say Mieke van Driel, M.D., M.Sc., of the department of general practice and primary health care at Ghent University, Belgium, and the other authors. They call for a clinical trial "to find out whether exploring patients' expectations about treatment for pain and offering adequate analgesic treatment can assist physicians in the management of sore throats more often without prescribing antibiotics."

Another research report, "Predicting Prognosis and Effect of Antibiotic Treatment in Rhinosinusitis," describes a study of 300 patients who were 12 or older and whose complaints indicated acute rhinosinusitis, formerly called acute sinusitis. Patients received amoxicillin or placebo for 10 days from 69 Belgian family physicians in 1998-99 in a study led by An De Sutter, M.D., Ph.D., of the department of general practice and primary health care at Ghent University, Belgium.

"Neither the presence of typical signs or symptoms nor an abnormal radiograph provided information with regard to the prognosis or the effect of amoxicillin," say De Sutter and the other authors. "The time to recovery was longer in patients who felt ill at baseline or who did not feel able to work, but the course of their illness was not influenced by antibiotic treatment."

A related editorial, "A New Look at an Old Problem: Inappropriate Antibiotics for Acute Respiratory Infections," questions physicians' prescribing practices. Writer John Hickner, M.D., M.Sc., professor of family medicine at the University of Chicago and former director of AAFP's National Research Network, notes the "massive" CDC public health campaign against inappropriate use of antibiotics. Hickner also refers to a recent study that says antibiotics are prescribed for 65 percent of episodes of upper respiratory tract infection, 78 percent of acute bronchitis cases, 65 percent of acute pharyngitis episodes and 81 percent of acute sinusitis cases.

"Why do we clinicians have such a hard time mending our wayward prescribing habits?" asks Hickner. "Educating, admonishing and shaming do not seem to be sufficient."

Physicians think "sorting out those patients with streptococcal pharyngitis from those with viral sore throat is our most important task," says Hickner. However, he adds, the research led by van Driel "suggests that pain relief, not establishing the cause of pain, should be at the top of our agenda." Commenting on the study led by De Sutter, Hickner says, "The excuses and quasi-legitimate reasons for prescribing an antibiotic for most patients with acute sinusitis are vanishing quickly!"

Readers who wish to join the anti-antibacterial fray can participate in the Annals Journal Club, which now features the articles on prescribing antibiotics for common respiratory infections, or they can open one of the articles online and use "TRACK Comments: Submit a response."