The Role of Antibiotics in Treating URTIs

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The Role of Antibiotics in Treating URTIs

• Or
• A small battle in the war against superbugs
• Or
• Tools to aid the modification of health seeking
  behaviour

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Wheres The Evidence?

• SIGN
• Clinical Evidence
• Tayside Formulary

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Presentation

• Most Patients with sore throat never attend GP
• UK study (1975) of women 20-44 years found that
  only 1 in 18 consulted.
• Estimated consultation rates of 0.1 per capita
  per annum 60 million
• Illness behaviour. Dutch Study 1994

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Diagnosis

• Clinical exam should not be relied upon to
  differentiate between bacterial and viral
  infection. (B)
• Throat swabs should not be carried out routinely
  in sore throat. (B)

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Antibiotics

• ACUTE
• Significance of presence of bacteria remains in
  doubt.
• Recent open study antibiotics vs. no script vs.
  delayed script no difference in main outcomes.
• Limited info is insufficient to support
  recommendation on the routine use of ABs.
• RECURRENT
• No evidence to support use of ABs in recurrent
  non-strep throat.
• If associated with GABHS limited evidence
  suggests 10 day course may ? no and freq of
  attacks.

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Questions

• What about Glomerulonephritis and RF?
• Incidence in UK very low.
• Most info on prevention is post war
• ABs should not be used specifically to prevent
  GN and RF (B)
• What about abscesses?
• The prevention of suppurative complications is
  not an indication for ABs (C)
• To relieve symptoms?
• Is evidence that better than placebo but not
  superior to simple analgaesics
• ABs should not be used for this purpose (A)

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What to Use
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Acute Otitis Media

• SIGN 66

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Diagnosis

• Signs and symptoms associated with purulent
  middle ear effusion in association with signs of
  systemic illness.
• Earache is most important
• May resolve with perforation
• Effusion may persist after resolution of acute
  symptoms.

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Antibiotics

• 8 studies of acceptable standard in 30 years
• Large proportion of exclusions - ? Why.? Ignore
  more severe cases
• Variable inclusion criteria
• Only 1 trial looked at ABs in under 2s
• Meta-analysis ABs v Placebo
• No influence on pain in 24hrs
• At 2-7 days only 14 control still have pain
• Early use of ABs ? risk of pain by 40
• ? risk of contralateral AOM but not recurrence or
  deafness.
• ? risk of vomiting, diarrhoea and rash with ABs

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Antibiotics 2

• Study of predictors of poor outcome
• In the absence of fever and vomiting ABs had
  little benefit
• Lack of AB did not lead to a poor outcome
• Simplest method to target minority at ? risk poor
  outcome is to select for systemically unwell.
• About 17 children need to be treated with broad
  spec AB to avoid 1 clinical failure
• Very few episodes of mastoiditis and suppurative
  complications.
• ABs may have modest benefit on symptom
  resolution and failure rates in over 2s
• Children diagnosed with AOM should not be
  routinely be prescribed ABs as initial
  treatment (B)

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Delayed Antibiotics

• 1 trial AB immediately vs. after 72 hours
• Immediate AB provided symptomatic benefit after
  72 hours
• Immediate ABs ? diarrhoea by 10
• Only 24 parents used delayed scripts
• Delayed antibiotic is an alternative approach
  which can be applied in Gen Practice. (B)

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What to Use
If ABs to be prescribed the conventional 5 day
course is recommended (B)
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Acute Sinusitis

• 1Systematic Review (6 RCTs)
• ABs effective in treating
• Symptoms improved in significantly fewer on
  placebo.
• No advantage of other ABs over Amoxycillin

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What to Use
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• Coughs and Colds

Systematic reviews found no significant
difference between ABs vs. placebo in cure or
general Improvement.
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Summary

• Sore Throat.
• Tonsillitis rather than pharyngitis
• No strong evidence either way. Routine use not
  recommended.
• Mainly guesswork.
• Throat swabs of little use
• Complications rare
• Pen V / Erythromycin
• AOM.
• ABs should not be routinely prescribed.
• Select for those systemically unwell.
• Use delayed scripts
• Complications rare
• Amoxycillin / Erythromycin
• Acute Sinusitis
• Minimal/modest effect of ABs
• Weigh against adverse effects.
• Pen V / Doxycycline