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Am Fam Physician. 1999;60(7):1932-1933

to the editor: In a recent “Curbside Consultation” entitled, “When a Parent Insists on Antibiotics for a Virus,”1 Dr. Marcy offers readers a wonderful pearl. The prescription of antibiotics for viral infections in children is all too common in ambulatory care, and the scenario often relates to the quality of physician-parent-patient interaction.2 The succinct, five-step approach to patient care is well-described and works in everyday practice: (1) affirmation and reassurance, (2) education on etiology, (3) anticipatory guidance, (4) empowerment and (5) follow-up. In our residency clinic, we have been highly successful in reducing inappropriate antibiotic prescriptions in much the same way.

We have enhanced the process by making use of an existing respiratory virus surveillance system in Wisconsin.3 Our faculty and resident physicians are able to provide patients (and their parents) with the name of the most likely etiologic agent (e.g., rhinovirus, influenza, respiratory syncytial virus or parainfluenza virus) based on ongoing surveillance information. Knowing the likely name of the apparent viral infection appears to decrease parents' desire for antibiotics. This approach has resulted in an estimated 3.3 percent rate of antibiotic prescribing for upper respiratory infections (URIs) by all clinicians in our clinic in 1998. Furthermore, URI is by far our most common acute respiratory infection diagnosis.

Recent microbiologic studies4,5 support Dr. Marcy's approach of education and watchful waiting in most acute respiratory infections. Moreover, studies of patients and parents have demonstrated the important role of information and education.2,6 Although respiratory virus surveillance is not readily available in most locations, several Web sites offer influenza surveillance (see the accompanying table).

Centers for Disease Control and Prevention
(Provides the gold standard for influenza surveillance with data resulting from four surveillance mechanisms.)
Johns Hopkins Health Information
(Features an interactive flu map on a seasonal basis.)
ZymeTx, Inc.
(Features results of rapid influenza antigen tests [commercial site sponsored by the makers of ZstatFlu].)

Because of the ever-increasing problems associated with the emergence of antibiotic-resistant bacteria, reasonable steps to promote more judicious use of antibiotics are most welcome. Family physicians should be encouraged to follow Dr. Marcy's approach through this time-efficient enhancement of physician-patient interactions.

in reply: Dr. Temte offers an additional method of reassuring parents and patients that antibiotics may not be required for an upper respiratory infection (URI). Although physicians in Wisconsin are essentially telling their patients that “it's just a virus,” knowing the most likely agent and identifying it by name projects a comforting aura of diagnostic certainty. The recognition that this is based on a statewide surveillance provides the added consolation of shared experience: “There's a lot of that going around.” The astoundingly low 3.3 percent URI antibiotic prescription rate achieved by the Wisconsin group apparently confirms the results of Barden's study1: parents and patients will accept not receiving a prescription for antibiotics if physicians take the time to explain why they're not being given one.

Although access to a respiratory virus surveillance system will vary from state to state, validating the effectiveness of Dr. Temte's program with a controlled study and an analysis of its cost-benefit could provide a stimulus for making such information more widely and readily available. His data suggest that an informed physician, particularly one able to educate the patients and parents under his or her care, represents our best hope for promoting rational use of antimicrobial therapy.2,3

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This series is coordinated by Kenny Lin, MD, MPH, deputy editor.

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