Subject: Journal Watch General Medicine Alert for September 13, 2007

From: [email-masked]
Date: Thu, 13 Sep 2007 16:42:18 -0700

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GENERAL MEDICINE for September 13, 2007

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Overuse of Antibiotics for URI   Still a Problem
[Summary and Comment | Free]

New studies look at an educational intervention to reduce unnecessary 
antibiotic use and the influence of perceived patient expectations on 
antibiotic prescribing.
   By Allan S. Brett, MD
   September 13, 2007
   Covering: Metlay JP et al. Ann Emerg Med 2007 Sep 50:221-30
   Ong S et al. Ann Emerg Med 2007 Sep 50:213-20
   http://general-medicine.jwatch.org/cgi/content/full/2007/913/1?q=etoc_jwgenmed

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Recommendations for Management of COPD
[Clinical Practice Guideline Watch | Subscription Required]

Highlights for primary care clinicians include spirometric classification 
of four stages of COPD and recommendations for introducing medications 
according to disease stage.
   By Allan S. Brett, MD
   September 13, 2007
   Covering: Rabe KF et al. Am J Respir Crit Care Med 2007 Sep 15; 
   176:532-55
   http://general-medicine.jwatch.org/cgi/content/full/2007/913/2?q=etoc_jwgenmed

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How Common Is ADHD in U.S. Children?
[Summary and Comment | Subscription Required]

The overall prevalence translates to 2.4 million children, and the poorest 
are at greatest risk.
   By Robert A. Dershewitz, MD, MSc
   September 13, 2007
   Covering: Froehlich TE et al. Arch Pediatr Adolesc Med 2007 Sep 
   161:857-64
   http://general-medicine.jwatch.org/cgi/content/full/2007/913/3?q=etoc_jwgenmed

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Shortening N-Acetylcysteine Therapy for Acetaminophen Overdose
[Summary and Comment | Subscription Required]

None of 205 selected patients treated with a shortened course of 
<i>N</i>-acetylcysteine therapy developed liver injury.
   By Allan S. Brett, MD
   September 13, 2007
   Covering: Betten DP et al. Ann Emerg Med 2007 Sep 50:272-9
   Dart RC and Rumack BH. Ann Emerg Med 2007 Sep 50:280-1
   http://general-medicine.jwatch.org/cgi/content/full/2007/913/4?q=etoc_jwgenmed

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FREE FULL-TEXT ARTICLE

Summary and Comment

Overuse of Antibiotics for URI  Still a Problem
New studies look at an educational intervention to reduce unnecessary 
antibiotic use and the influence of perceived patient expectations on 
antibiotic prescribing.

Two new studies conducted in U.S. emergency departments (EDs) address the 
ongoing issue of overuse of antibiotics for upper respiratory infections 
(URIs).

In one study conducted at 15 EDs, eight hospitals were randomized to 
receive an elaborate educational intervention, involving both clinicians 
and patients, aimed at reducing antibiotic prescribing for nonspecific URIs
and acute bronchitis (in patients without chronic bronchitis); the other 
seven served as controls. In a comparison between the year before and the 
year after the intervention, antibiotic prescribing for presumed viral URIs
decreased significantly from 52% to 42% at intervention EDs. Antibiotic 
prescribing remained unchanged at control EDs.

In a study conducted at 10 EDs, researchers interviewed patients and their 
treating physicians involved in 272 visits for URI or acute bronchitis. 
Before seeing the physician, about half the patients stated that they 
expected an antibiotic. Physicians' decisions to prescribe antibiotics were
significantly associated with their perception that the patient expected an
antibiotic, but not with the patient's actual expectation; thus, physicians
inaccurately assessed patients' expectations. Patient satisfaction with the
visit did not correlate with receipt of an antibiotic. Physicians 
prescribed antibiotics to 68% of bronchitis patients and 9% of other URI 
patients.

Comment: In the first study, an education initiative reduced prescribing of
unnecessary antibiotics, but almost half the patients still received 
antibiotics. In the second study, physicians seemed to be influenced by 
their perceptions  often incorrect  of patient expectations. It is 
intriguing that physicians are so quick to "give in" to perceived patient 
expectations for antibiotics, given that clinical trials, clinical 
guidelines, and common sense point in the opposite direction.

 Allan S. Brett, MD

Published in Journal Watch General Medicine September 13, 2007 Citation(s):

Metlay JP et al. Cluster-randomized trial to improve antibiotic use for 
adults with acute respiratory infections treated in emergency departments. 
Ann Emerg Med 2007 Sep; 50:221-30. (Free)

Ong S et al. Antibiotic use for emergency department patients with upper 
respiratory infections: Prescribing practices, patient expectations, and 
patient satisfaction. Ann Emerg Med 2007 Sep; 50:213-20. (Free)

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