There's a Lot of it About

v. 2, Private Life

Graham Worrall, Chris Del Mar, Sir Liam Donaldson

• Publisher: CRC Press
• Year: 2019
• Print ISBN:
  9781846190841
• eBook ISBN:
  9781315347332
• Topic: Medicine
• Subtopic: Infectious Diseases

This book contains forewords by Chris Del Mar and James Hutchinson respectively - Dean, Faculty of Health Sciences and Medicine, Bond University, Australia; Chief of Infectious Diseases Control, Memorial University of Newfoundland, Canada. Acute respiratory infections make up a quarter of all primary care consultations. This book is the ideal quick reference and teaching aid. In presenting best evidence on the epidemiology, causes and management of the most common acute respiratory infections, this book gathers together a wealth of previously scattered original research and information and offers solutions for practical application. It is concise, clear and easy to use. Primary care professionals, including doctors, nurses and health visitors will find it invaluable, as will general practitioners in training. 'There is much more to these diseases than most of us realise. It will not take you long to find fascinating and useful material here. It makes for a very interesting read. The evidence about management, as well as diagnosis, is very important. Acute respiratory infection is one of the famously important areas in which mistaken beliefs by not only our patients, but also us doctors, of the benefits of antibiotics makes to the contribution of bacterial resistance. Graham Worrall has highlighted new forms of treatment we often forget when we reach for the pad to write another 'safety' prescription for antibiotic. There is a wealth of information here.' - Chris Del Mar, in his Foreword. 'An objective, thoughtful treatment of a subject that accounts for a large part of a primary care physician's working life but inexplicably little of his or her training. Thorough evaluation of the literature, often exposing huge gaps in the study of these extremely common conditions, will serve as an impetus for study and a guide to rational decision-making. The straightforward approach with excellent practical distillations of the evidence and resulting recommendations is perfect for the busy physician or busy student. As someone who teaches medical students about infections I have longed for a concise resource to support my efforts at encouraging prudent antibiotic prescription for respiratory tract infections. I long no more.' - James Hutchinson, in his Foreword.

Chapter 1

Introduction

Next to hangovers, women and taxes, these [respiratory tract infections] are man’s most important affliction.

Prof. Alfred Evans

Diseases: the more common they are, the less they are studied.

Dr Robert de Melker

• • Acute respiratory infections are the most common conditions seen by family doctors and primary healthcare workers.
• • They account for one-quarter of adult visits.
• • They account for one-third of childhood visits.
• • They result in one-quarter of all prescriptions.
• • They are the leading cause of antibiotic prescriptions.

Like most young family doctors starting work in the community, I was at first surprised by the number of people who came to see me suffering from acute respiratory tract infections (ARIs). In winter, they represented up to a third of my patients, and even in summer they represented a fifth of all the people who visited me. Most of these people did not have the infectious diseases that I had seen and been taught about when I was a medical student and a house officer. There was little meningitis, pneumonia and hepatitis here – just a steady stream of people of all ages and colours, complaining of ‘flu’, colds, sore throat, earache, cough, sinuses and sniffles.

I rapidly realised that I needed help to manage these ARIs properly. My colleagues and mentors in general practice appeared unflappable in their ability to cope with them, but as time went by, I noticed that each general practitioner (GP) had a different approach to diagnosing and managing these illnesses. They called the same syndromes by different names, they prescribed different medications, they prescribed the same medicines for different durations, and they gave different advice about comfort measures, the prevention of disease spread, and preventive measures for the future. They rarely seemed to be able to explain their actions in a logical way. It seemed clear to me that most of the GPs I observed (both in teaching practices and in the more run-of-the-mill practices where I did locums) had established a treatment regime based upon their own personal experience and, as the ARIs are almost always self-limiting, most doctors found their own idiosyncratic regime entirely satisfactory for themselves and their patients.

Not only was it difficult to find out and understand why they acted as they did, but it soon became apparent to me that (at that time, during the 1970s) little research had been done on these infections, and very little of what had been published seemed relevant to the primary care physician. It was a paradox – the more common the disease, the less it appeared to have been studied.

Figure 1.1 Workload of British GPs (Hodgkin, 1978, p. 19).

In my darkness, some beacons shone, including a book entitled Common Diseases: Their Nature, Incidence and Care, written by Dr John Fry, a British general practitioner and researcher, who had worked in a suburban practice for over 2 5 years and built up a unique database of his experience of the common diseases of our communities. He observed that in any two-week period, around one-third of the general population will report experiencing symptoms suggestive of an acute respiratory infection. He also noted that although the majority of people did not consult the doctor about their illness, the minority that did resulted in between a quarter and a third of the general practitioner’s workload (Fry, 1974). Seven of the 21 chapters in his book concerned acute respiratory diseases. Soon afterwards, I discovered another seminal primary care research work, Towards Earlier Diagnosis in General Practice, by Dr Keith Hodgkin, another British GP who had kept long-term meticulous records of his encounters with all his patients. He gave important advice about the common nature of ARIs in primary care, with hints on how to distinguish self-limiting from serious conditions (see Figure 1.1) (Hodgkin, 1978). I was, and remain, profoundly grateful to Drs Fry and Hodgkin.

Figure 1.2 Office visits by patient’s reason for visit for children under 15 years of age in the USA. From US National Ambulatory Medical Care Survey, 1995–96.

I looked further, and discovered that ARIs (including ear infections) accounted for 35% of all office visits for children in the USA (see Figure 1.2). Five of the ten commonest diagnoses for children, and three of the top ten for adults in that country, were ARIs. Older textbooks of family medicine, such as Family Medicine: Principles and Practice (Taylor, 1988) and Textbook of Family Medicine (Rakel, 1984), confirmed the ubiquity of acute ARIs in primary care and devote considerable space to them.

It was striking to me that these traditional textbooks approached the common infectious diseases by stressing that untreated (or inappropriately treated) disease causes significant morbidity, and that the situation could be much improved if family doctors were better at identifying the responsible micro-organism and using the appropriate antibiotic agent. There was little consideration of the epidemiology, mild nature and self-limiting course of most such illness in primary care, and there was little emphasis on the use of watchful waiting and the principle of primum non nocere when using powerful pharmacological agents.

More recent texts, such as McWhinney’s A Textbook of Family Medicine (McWhinney, 1997), quote recent figures from the USA which indicate that sore throats, head colds and cough are the three commonest reasons for visits to primary care doctors (not necessarily all GPs), and from Canada and the UK, where cough, sore throats, colds and earache are all among the top ten most common presenting symptoms.

Since I entered practice, much more research has been done on the diagnosis and management of common conditions, and there is easy internet access to large research databases. There are still many gaps in our knowledge and many areas of controversy, but an increasing knowledge of the principles of research synthesis and evidence-based medicine (EBM) should put primary healthcare workers in a better position than ever to offer their patients with ARIs the best possible care.

Although an article in the Journal of Family Practice (de Melker, 1994) bemoaned the fact that ‘a scientific basis for the treatment of common diseases is lacking, there are very large gaps in our knowledge, and GP research and training should concentrate much more on these areas’, there is now in fact a very large literature on the ARIs.

Aims of this book

It is easier to buy books than to read them, and easier to read them than to absorb them.

Sir William Osier

First, I look at the epidemiology of ARIs in the developed world and, as a consequence, their impact on the daily work of primary care workers in those countries. This is not as easy as it seems, for two reasons.

• 1 The ARIs were classified in different ways in different surveys. For example, some surveys included influenza while others did not, some surveys included acute otitis media while others did not, and some studies included ‘common colds’ while others called them ‘non-specific upper respiratory infections.’
• 2 The healthcare worker of first contact was variously referred to as a ‘general practitioner’, ‘family physician’, ‘family doctor’ or ‘primary care physician.’ In some systems doctors were working with physician aides, family practice nurses and nurse practitioners.

For the sake of simplicity (and I apologise to all readers who are not doctors), I shall refer to such workers as ‘GPs’ in this book, except for a few studies (mostly from the USA) where it is clear that the first-contact physician was a paediatrician or an internal medicine specialist. If you work in primary care, this is the book for you.

Secondly, I look at the aetiology of the ARIs in the developed world. This involves more than a simple consideration of which ARI syndromes are likely to be bacterial and which are predominantly viral. It also involves consideration of how GPs can detect the small proportion of ARIs that are bacterial and, indeed, whether it is important for the GP to distinguish between them. I examine whether diagnostic tests for ARIs are available to GPs, and consider their usefulness. I also attempt to examine the natural history of the ARIs, both treated and untreated.

I follow with chapters on the six commonest ARIs in order of decreasing frequency, namely the common cold, acute sore throat, acute otitis media, acute sinusitis, acute bronchitis and influenza. Each chapter is structured in the same way. I look at the epidemiology and aetiology of each specific ARI in more detail, and I discuss the natural history of the illness, usually by looking at the control groups of randomised trials. Then I examine how effective clinical methods and laboratory tests are in helping GPs to diagnose the specific condition. Finally, I look at treatment (both symptomatic and curative) for the condition. Because there are two other ARIs – croup and bronchiolitis – which, although they are not as common, generate high levels of anxiety in both parents and physicians, I have also included chapters on these illnesses.

Because GPs are sometimes criticised for using their clinical judgement alone when diagnosing ARIs, and it has been suggested that more routine testing should be done, I examine what tests are available for the different ARIs. I look at how well clinical judgement compares with the tests, and I consider how feasible and expensive it would be for GPs to use some of the newer technologies and near-patient tests that are now being marketed. I then examine the evidence for the emergence of antibiotic resistance to the bacteria involved in some ARIs, and the effect that antibiotic prescribing by GPs (who prescribe 80% of all antibiotics) may be having on this phenomenon. Although it has been studied most in developed countries, bacterial resistance is a worldwide phenomenon.

Next, I discuss what we know about how GPs treat their patients who present with ARI symptoms. Although there are some differences between doctors in different countries, a surprising uniformity exists. GPs in most countries behave very similarly, and their behaviour has not changed much in the past 30 years. It is well known that GPs prescribe antibiotics more often than the microbial epidemiology dictates. This GP behaviour, which appears irrational at first sight, may be influenced by sensible considerations relating to the method by which the GP is paid, workload factors, diagnostic labelling, doctor-patient relationship factors, GP perceptions, patient expectations, and by the GP judging the potential benefit to the individual patient to be more important than the potential harm to society.

Finally, I consider whether there is evidence that GPs and their patients may benefit from changes in doctor diagnostic and prescribing behaviour. I discuss the literature on attempts to change GP and patient behaviour. If we should change, can we change? Can we persuade our patients to change? And how does the evidence concerning interventions that may cause change relate to the compliance of GPs and patients, and to management guidelines and course of medication?

In each chapter I review the increasing number (sometimes – for example, in sinusitis – almost an excess) of systematic reviews. I did not expect, but soon realised, that several systematic reviews on the same topic, apparently evaluating the same primary research literature, might reach different conclusions. However, as I had expected, many of the better reviews had been undertaken by members of the Cochrane Collaboration. As you probably know, this is an international virtual collaboration of people who seek out and evaluate the best evidence from a massive database of randomised trials of treatment. Not surprisingly, my work quotes heavily from the Cochrane Library of systemat...

Table of contents

• Cover
• Title Page
• Copyright Page
• Dedication Page
• Table of Contents
• Forewords
• About the author
• Acknowledgements
• 1 Introduction
• 2 The epidemiology and aetiology of acute respiratory infections seen by GPs in the developed world
• 3 The common cold
• 4 Acute sore throat
• 5 Acute otitis media
• 6 Acute sinusitis
• 7 Acute bronchitis
• 8 Influenza
• 9 Croup
• 10 Bronchiolitis
• 11 Clinical judgement versus diagnostic tests
• 12 Antibiotic prescribing and resistance
• 13 Strategies for promoting change
• Index