March 13, 2014

DynaMed EBM Journal Volume 9, Issue 11

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Physicians: .25 AMA PRA Category ICreditsTM

Family Physicians: .25 Prescribed credits

Nurse Practitioners: .25 Contact hours

Release Date: March 13, 2014

Expiration Date: March 13, 2015

Estimated Completion Time: 15 minutes

There is no fee for this activity.

To Receive Credit

In order to receive your certificate of participation, you should read the information about this activity, including the disclosure statements, review the entire activity, take the post-test, and complete the evaluation form. You may then follow the directions to print your certificate of participation. To begin, click the CME icon at the end of the article.

Program Overview

Learning Objectives

Upon successful completion of this educational program, the reader should be able to:
1. Discuss the significance of this article as it relates to your clinical practice.
2. Be able to apply this knowledge to your patient's diagnosis, treatment and management.

Faculty Information

Alan Ehrlich, MD - Assistant Clinical Professor in Family Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, USA; Senior Deputy Editor, DynaMed, Ipswich, Massachusetts, USA

Michael Fleming, MD, FAAFP - Assistant Clinical Professor of Family Medicine and Comprehensive Care, LSU Health Science Center School of Medicine, Shreveport, Louisiana, USA; Assistant Clinical Professor of Family Medicine, Department of Family and Community Medicine, Tulane University Medical School, New Orleans, Louisiana, USA; Chief Medical Officer, Amedisys, Inc. & Antidote Education Company


Dr. Ehrlich, Dr. Fleming, DynaMed Editorial Team members, and the staff of Antidote Education Company have disclosed that they have no relevant financial relationships or conflicts of interest with commercial interests related directly or indirectly to this educational activity.

No commercial support has been received for this activity.

Accreditation Statements

ACCME: This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of Antidote EducationCompany and EBSCO Publishing. Antidote is accredited by the ACCME to provide continuing medical education for physicians. Antidote Education Company designates this enduring activity for a maximum of 0.25 AMA PRA Category 1 CreditsTM. Physicians should only claim credit commensurate with the extent of their participation in the activity.

AAFP: Enduring Material activity, DynaMed EBM Focus, has been reviewed and is acceptable for up to 13 Prescribed credits by the American Academy of Family Physicians. AAFP certification begins March 7, 2012. Term of approval is for one year from this date with the option of yearly renewal. Each EBM Focus is worth .25 Prescribed credits. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

AANP: This program is approved for 0.25 contact hour of continuing education by the American Academy of Nurse Practitioners.

Program ID: 1304159S


Last week 588 journal articles were evaluated via DynaMed's Systematic Literature Surveillance and summaries of 271 articles were added to DynaMed content.

Based on criteria for selecting "articles most likely to change clinical practice," one article was selected by the DynaMed Editorial Team.

Strategies Used to Avoid Antibiotic Prescription in Patients With Acute Respiratory Tract Infections May Not Result in Substantially Increased Antibiotic Use Compared to Not Prescribing Antibiotics at Initial Clinic Visit
Reference: BMJ 2014 Mar 6;348:g1606 (level 2 [mid-level] evidence)

Acute respiratory infections are commonly encountered in primary care, and symptom control is often the chief concern of patients. The American College of Physicians recommends against using antibiotics to treat nonspecific upper respiratory tract infections in previously healthy adults (Ann Intern Med. 2001 Mar 20;134(6):487), and a recent Cochrane review found that antibiotics do not reduce symptoms of the common cold or acute purulent rhinitis (Cochrane Database Syst Rev 2013 Jun 4;(6):CD000247). However, patient expectations for treating respiratory infections with antibiotics have helped fuel their use in primary care, even though they are not recommended and our best available evidence suggests they are ineffective for these conditions. A variety of methods for delaying use of antibiotics until symptoms resolve on their own have been proposed. A recent randomized trial evaluated several of these methods in patients with acute respiratory infection who were judged not to require antibiotic treatment.

A total of 889 patients aged 3 years or older with acute respiratory tract infection were assessed and followed for at least 1 month. Respiratory infections included acute cold, influenza, sore throat, otitis media, sinusitis, croup, or lower respiratory tract infection. After initial evaluation, 333 patients were judged to require antibiotics and immediately prescribed antibiotics for their use. The remaining 556 patients were judged not to need antibiotics, and were randomized to 1 of 5 strategies for avoiding antibiotics: requiring patients to recontact the clinic by phone to request a prescription (recontact), postdating the prescription (postdate), allowing patients to collect prescription from the clinic themselves (collection), giving patients a prescription but asking them to wait before use (patient led), and simply not prescribing antibiotics at all (no prescription).

The rate of antibiotic use was 26% among those not prescribed antibiotics, but the manner in which patients obtained antibiotics without initially having them prescribed was not addressed in the study. There were no significant differences in antibiotic use between any of the strategies to avoid antibiotics and the strategy of no prescription, but the confidence intervals for the observed differences cannot rule out clinically significant effects. The rates of antibiotic use were 37% with the recontact strategy, 37% with the postdate strategy, 33% with the collection strategy, and 39% with the patient-led strategy. There were no significant differences in comparisons of any groups to the no prescription group in mean symptom severity scores on days 2-4 or median duration of symptoms rated moderately bad or worse.

The use of antibiotics in common conditions like acute respiratory infection has been an important driver for the development of antibiotic resistance, and over time this may severely limit treatment options for serious infectious diseases. This randomized trial shows that several strategies for avoiding antibiotics can reduce their use by patients without any significant differences in symptom scores on days 2-4, when respiratory symptoms are typically at their worst. Any decrease in antibiotic use may help reduce growing rates of antibiotic resistance in the community. These findings reinforce current treatment guidelines and existing clinical evidence, and also support several different strategies to help reduce unnecessary antibiotic use in primary care. These data also reinforce messages about antibiotic prescribing for respiratory infections promoted by the Choosing Wisely initiative, which provides evidence-based recommendations for patients and healthcare professionals that can act as a basis for shared decision making in clinical practice. The Get Smart program from the Centers for Disease Control and Prevention provides similar information, along with a variety of patient-focused print materials.

For more information see the Upper respiratory infection (URI) topic in DynaMed.

Earn CME Credit for reading this e-Newsletter.
For more information on this educational activity, see the CME sidebar.

Call for Peer Reviews

We are currently seeking subspecialty reviewers for our Patient Education Resource Center (PERC). PERC provides fact sheets and discharge instructions for patients leaving the hospital or emergency room. These hand-outs fulfill the meaningful use requirements for the Medicare & Medicare Services Incentive Programs.

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DynaMed Careers

Looking for a change? The DynaMed editorial team is expanding and looking for talented and driven individuals. Visit the links below to learn about these exciting opportunities.

Deputy Editor of Oncology
Associate Managing Editor

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