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Christopher C. Winchester, DPhil; Tatiana Macfarlane, PhD; Mike Thomas, MBBS; David Price, MB BChir
Author and Funding Information

Affiliations: Drs. Winchester, Macfarlane, Thomas, and Price are affiliated with the University of Aberdeen.

Correspondence to: Christopher C. Winchester, DPhil, University of Aberdeen, Department of General Practice and Primary Care, Foresterhill Health Centre, Westburn Rd, Aberdeen AB25 2AY, UK; e-mail: c.winchester@abdn.ac.uk


Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/site/misc/reprints.xhtml).


© 2009 American College of Chest Physicians


Chest. 2009;136(4):1185-1186. doi:10.1378/chest.09-1449
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Our observational study1 of patients with lower respiratory tract infection (LRTI) presenting in the primary care setting showed a decrease in hospital admissions and mortality among patients who were prescribed an antibiotic on the day of consultation compared with those who did not receive such treatment. This association remained statistically significant after other potential factors influencing the outcomes of LRTI were taken into account in a multivariate model. These factors included comorbidity and its proxies, frequent health-care utilization and prior antibiotic use.

While it is not possible to assign causality unambiguously on the basis of an observed association, we believe that our data support the hypothesis that the prescription of antibiotics on the day of consultation can reduce the risk of adverse outcomes in patients with LRTI. Drawing on the Bradford Hill criteria of causality,2 we observed an association that has strength (hazard ratio, 0.31 [for the association of antibiotic prescribing with mortality]; 95% CI, 0.26 to 0.37), consistency (a significant benefit is also seen for hospitalization [hazard ratio, 0.73; 95% CI, 0.58 to 0.92]), temporality (the opportunity to prescribe antibiotics preceded the adverse outcome and could not have been influenced by it), and plausibility (antibiotics are known to be of benefit in patients with pneumonia,3 who cannot be separated reliably from the wider pool of patients with LRTI in primary care3). Researchers from the UK Health Protection Agency have also reached the same conclusion that antibiotics substantially reduce the risk of pneumonia after chest infection.4

A key message of our study was that many patients who are at the greatest risk of pneumonia are not prescribed antibiotics for an LRTI, including over one in four patients > 80 years of age and one in five patients with specific comorbidities, such as malignancy, congestive heart failure, hemiplegia, and dementia. If a reluctance to prescribe antibiotics is coupled with a reluctance to consult, it would not be surprising if patients who are at risk of pneumonia are admitted to the hospital or die unnecessarily as a result. We do not believe that the suggestion by Dr. Collignon of excluding from our analysis those patients who were at greatest risk of adverse outcomes would aid the interpretation of our results.

Finally, we would like to respond to the question regarding our motives. Our research was sponsored by the International Primary Care Respiratory Group, a large, impartial professional organization that has patient benefit as its aim. Two of us took part in the meeting at which this study was first discussed because our clinical experience suggested that initiatives to curb inappropriate antibiotic prescribing might be having unintended consequences; in a spirit of openness, this was disclosed 7 years after the event. Dr. Collignon declares that he has no conflicts of interest, yet conflicts of interest need not necessarily be financial. We feel entitled to ask whether his involvement in initiatives to curb antibiotic prescribing5,6 may have influenced his reaction to our article. We share the view of the CHEST editors and reviewers that a specialty medical journal is an appropriate forum for raising concerns regarding current health policy. All responsible clinicians and researchers need to consider the unintentional drawbacks of the interventions they advocate, as well as the intended benefits. While the correspondent may believe it to be irresponsible to discuss the potential for antibiotic prescribing policy to have unintended consequences, we believe that it would be irresponsible not to do so.

Financial/nonfinancial disclosures: Dr. Winchester is employed as a medical writer by Oxford PharmaGenesis Ltd. He and Oxford PharmaGenesis have received no industry funding for this research and are undertaking no industry-sponsored projects related to antibiotics or respiratory infection. Dr. Thomas received an honorarium for giving a lecture at an educational meeting arranged by Abbott Laboratories in 2007. Dr. Price is on the independent steering committee of a study looking at the treatment of lower respiratory tract infection in Europe sponsored by Bayer Healthcare; also, he chairs the Research Subcommittee of the International Primary Care Respiratory Group but was not involved in approving this study for funding. Dr. Macfarlane has reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Winchester CC, Macfarlane TV, Thomas M, et al. Antibiotic prescribing and outcomes of lower respiratory tract infection in UK primary care. Chest. 2009;135:1163-1172. [PubMed] [CrossRef]
 
Hill AB. The environment and disease: association or causation? Proc R Soc Med. 1965;58:295-300. [PubMed]
 
British Thoracic Society Standards of Care Committee. Guidelines for the management of community acquired pneumonia in adults. Thorax. 2001;56suppl:IV1-IV64. [PubMed]
 
Petersen I, Johnson AM, Islam A, et al. Protective effect of antibiotics against serious complications of common respiratory tract infections: retrospective cohort study with the UK General Practice Research Database. BMJ. 2007;335:982-984. [PubMed]
 
Australian Broadcasting Corp. Vital drugs useless if antibiotic abuse continues, expert warns.Accessed September 7, 2009 Available at:http://www.abc.net.au/news/features/antibiotics.htm.
 
Collignon P. Outbreak: Professor Peter Collignon, head of infectious diseases at Canberra Hospital.Accessed September 7, 2009 Available at:http://sixtyminutes.ninemsn.com.au/article.aspx?id=263847.
 

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References

Winchester CC, Macfarlane TV, Thomas M, et al. Antibiotic prescribing and outcomes of lower respiratory tract infection in UK primary care. Chest. 2009;135:1163-1172. [PubMed] [CrossRef]
 
Hill AB. The environment and disease: association or causation? Proc R Soc Med. 1965;58:295-300. [PubMed]
 
British Thoracic Society Standards of Care Committee. Guidelines for the management of community acquired pneumonia in adults. Thorax. 2001;56suppl:IV1-IV64. [PubMed]
 
Petersen I, Johnson AM, Islam A, et al. Protective effect of antibiotics against serious complications of common respiratory tract infections: retrospective cohort study with the UK General Practice Research Database. BMJ. 2007;335:982-984. [PubMed]
 
Australian Broadcasting Corp. Vital drugs useless if antibiotic abuse continues, expert warns.Accessed September 7, 2009 Available at:http://www.abc.net.au/news/features/antibiotics.htm.
 
Collignon P. Outbreak: Professor Peter Collignon, head of infectious diseases at Canberra Hospital.Accessed September 7, 2009 Available at:http://sixtyminutes.ninemsn.com.au/article.aspx?id=263847.
 
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