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BMJ 2002;324:1099 ( 4 May )

Letters

GPs should reduce antibiotic use with alternative treatments

EDITORIncreasing evidence accumulating from the Cochrane Database of Systematic Reviews suggests that the benefits of antibiotics in upper respiratory tract illnesses in childhood are modest. Nasrin et al have shown that the use of antibiotics in such cases increases the prevalence of antimicrobial resistance in the children.¹ Their study provides yet more urgency to reduce the use of antibiotics in general practice for acute respiratory infections.

But how can this be achieved? Doctors do not necessarily share a sceptical approach to the use of antibiotics. The barriers to the implementation of best evidence are being explored and described.² For example, general practitioners are more influenced by certain clinical signs and symptoms to use antibiotics for acute respiratory infections than the evidence suggests is effective.³

Are the public campaigns run in Belgium and the United Kingdom to reduce use of antibiotics the best approach? Doctors may be placed in an ethical dilemma to choose between what they think is best for their individual patient and what is deemed best for the community, now or in the future. Another problem is the replacement of "something that can be done for the patient" by a sort of nihilism: "Antibiotics provide such a weak benefit that they are hardly worth the bother. And then there's all the resistance worry."

Other treatments for acute respiratory infections exist that are just as effective, but they do not have the same ring to them as curative ones: killing bacteria has a more satisfying sounding objective than the palliative alternatives, but does this matter? For spontaneously remitting diseases, anything that reduces the symptoms is just as effective as anything else, bactericidal or not. We therefore suggest wider dissemination and greater promotion of alternative treatments (evidence based, of course). These include short acting agents such as analgesics, non-steroidal anti-inflammatory drugs, and steroids; vaccination against the pneumococcus and influenza; xylitol liquid and chewing gum; and better communication skills. ^{4 5}

Michael Nissen, director of infectious diseases. 
Department of Paediatrics and Child Health, University of Queensland, Royal Children's Hospital-Brisbane, Herston, Queensland 4029, Australia theniss@mailbox.uq.edu.au

Chris Del Mar, professor. 
Centre for General Practice, University of Queensland Medical School, Herston, Queensland 4006

1.	Nasrin D, Collignon PJ, Roberts R, Wilson EJ, Pilotto LS, Douglas RM. Effect of  lactam antibiotic use in children on pneumococcal resistance to penicillin: prospective cohort study. BMJ 2002; 324: 28-30[Abstract/Full Text]. (5 January.)
2.	Freeman AC, Sweeney K. Why general practitioners do not implement evidence: qualitative study. BMJ 2001; 323: 1100-1102[Abstract/Full Text].
3.	Murray S, Del Mar C, O'Rourke P. Predictors of an antibiotic prescription by GPs for respiratory tract infections: a pilot. Fam Pract 2000; 17: 386-388[Medline].
4.	Thomas M, Del Mar C, Glasziou P. How effective are treatments other than antibiotics for acute sore throat? Br J Gen Pract 2000; 50: 817-820[Medline].
5.	O'Neill P. Acute otitis media. In: Barton S, ed. Clinical evidence. Issue 6. London: BMJ Publishing Group, 2001:211-218.

© BMJ 2002
 

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PRIMARY CARE
Effect of lactam antibiotic use in children on pneumococcal resistance to penicillin: prospective cohort study.

Dilruba Nasrin, Peter J Collignon, Leslee Roberts, Eileen J Wilson, Louis S Pilotto, and Robert M Douglas
BMJ 2002 324: 28. [Abstract] [Abridged text] [Full text]  

 

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