10.1 Lifestyle

The reasons for prescription of antibiotics in respiratory illness are complex.¹⁷⁴ Many patients with non-pneumonic LRTI believe that their symptoms are due to an infection which can be cured by antibiotics and such beliefs can significantly influence a general practitioner's prescribing. A primary care study showed a correlation between a patient's expectations of receiving an antibiotic and a physician prescribing it. Physicians prescribed antibiotics 77% of the time when they believed that the patients wanted antibiotics, but only 29% of the time when they believed the patients did not want antibiotics; however, in only 47% of patients was the physician's perception correct. Patient satisfaction in this study was most strongly associated with the physician spending enough time explaining the illness and the choice of treatment.¹⁷⁵ Evidence level 3

GPs can reduce a patient's expectations of being prescribed an antibiotic and reduce unnecessary reconsultations by addressing four issues at consultation: The natural course of the illness The lack of effectiveness of antibiotics The problems of antibiotic resistance The side effects of antibiotics.

Time constraints are often a difficulty in general practice, and this may influence prescribing habits. However, it has been shown that a decrease in antibiotic prescribing need not lead to an increase in the reconsultation rate,¹⁷⁶ that the reconsultation rate in a single illness episode seems independent of antibiotic prescribing,¹⁷⁷ and furthermore that antibiotic prescriptions may increase the likelihood of future consultations if the patient perceived that the drug had helped in the past.¹⁷⁸ Previous consultation habit, underlying chronic disease and dyspnoea were positively associated with reconsultation. Evidence level 2+

Attempts to solve this problem are likely to be largely behavioural, multifactorial and multidisciplinary in nature, requiring education of both patients and medical staff. No single intervention is likely to produce a high degree of change. Nevertheless, intervention strategies adopting a multidimensional approach (educational patient mailings, clinician education in communication and disease management, and surgery based literature) have shown a reduction in antibiotic prescribing of up to 40%.¹⁷⁶ Evidence level 2+

The provision of patient education alone has been successful in recent studies.^179,180,181 These studies have shown that the use of an information leaflet for patients (similar to that below) significantly reduces reconsultation rates. In addition, using terms such as "chest cold" with patients, rather than "bronchitis" or "chest infection", may reduce their expectations for an antibiotic. Evidence level 1+,3

GPs should give non-pneumonic LRTI patients written information to help explain the illness, to explain the decision not to prescribe an antibiotic and to reduce reconsultation rates.

The example patient information leaflet shown below may be copied freely and adapted for use locally. A sample copy of a patient leaflet is also available from the BMJ website:
http://bmj.com/cgi/content/full/324/7329/91

Example information leaflet for patients with a cough

Dear Patient, We hope you find this information sheet will help you understand why your cough is troublesome and what you can expect to happen. What does a cough mean? A cough is not a "bad" thing: it is there for a reason. It helps defend your lungs by making sure that any secretions are coughed up, rather than settling in the lower lungs where they would cause trouble. Similarly, "phlegm" or "sputum" is there to act as a barrier to catch the dust and germs that we breathe in. Because your cough is part of your body's defence mechanisms, it is likely to be the last symptom of your current illness to go back to normal. Do I have a chest infection? No microbes (the organisms that cause infection) can be detected in around half of the patients with a cough. When patients do have an infection, it is caused by either virus germs or bacteria germs. Should I be treated with antibiotics? Antibiotics are only effective against bacteria and do not kill viruses. Antibiotics are not needed in most people who normally have healthy chests. They do not usually speed up recovery and can cause unpleasant side effects, such as feeling or being sick, and lead to resistance in future infections. In some cases, however, an antibiotic may be useful. For example, for people who have had previous chest problems or are vulnerable to severe chest infections for other reasons. If you are prescribed antibiotics, you must ensure that you complete the full course. What will help relieve my symptoms? Paracetamol or aspirin, taken regularly, will help with fever and mild chest pains and it is advisable to stop smoking. Remember to drink plenty of fluids. There is no good evidence that cough mixtures work. Is there anything I should look out for? Should you find that you develop any new or worsening symptoms, or if you start to cough up any blood or feel breathless, it is important to telephone the surgery and make an appointment for a further check. The process of recovery, even with any treatment that your doctor may have prescribed is likely to take up to two to three weeks to complete. Assuming you are otherwise feeling well, you need not worry if your cough and phlegm take time to settle, especially if you are getting gradually better every day. Further information: This surgery telephone number is ______________ when closed ______________ You can also contact NHS 24 for telephone advice at any time on: A lot of the information is also available on the NHS Direct web site: http://www.nhsdirect.nhs.uk or visit the British Lung Foundation web site: http://www.lunguk.org

10.2 Sources of further information

NHS 24
http://www.nhs24.com

NHS Direct
http://www.nhsdirect.nhs.uk

The British Lung Foundation Scotland
The Royal College of Physicians and Surgeons
234-242 St Vincent Street Glasgow G2 5PA
Tel: 0141 204 4110
Email:redballoon@blfscotland.org.uk
http://www.lunguk.org

Chest, Heart & Stroke Scotland
65 North Castle Street Edinburgh EH2 3LT
Advice Line: 0845 077 6000
Tel: 0131 225 6963
Fax: 0131 220 6313
E-mail:admin@chss.org.uk
http://www.chss.org.uk