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The latest evidence for practice

Choice picks from the research journals, with some choice comment …

Una Adderley
Specialist Nurse
Team Leader

How should antibiotics be prescribed for upper respiratory tract infection?

The season of coughs, colds and sniffles brings a regular stream of patients to GP practices seeking antibiotics to relieve their symptoms. The majority of these illnesses will be due to viral infection for which antibiotics are ineffective. However, the weight of patient expectation can place pressure on independent nurse prescribers and GPs to issue prescriptions for antibiotics.
This patient expectation runs counter to the drive to reduce inappropriate antibiotic use because of the risks of increasing antibiotic resistance and drug-related adverse events. One strategy is to issue the patient with a prescription for antibiotics with the instruction that it should only be dispensed if symptoms fail to improve within a specified time frame, or worsen.

This Cochrane systematic review aimed to establish the relative effectiveness of delayed, immediate or no antibiotic prescriptions for acute respiratory infections. The review sought randomised, controlled trials that compared prescriptions of antibiotics for sore throat, otitis media or common cold in patients of any age. Nine trials met the inclusion criteria.

The review found evidence that delayed antibiotics reduced antibiotic use but made no significant difference in terms of clinical symptoms (fever, pain, malaise). Delayed antibiotics increased the use of antibiotics compared to no antibiotics.
A commentary notes that the results of this review must be interpreted with caution since the inclusion criteria meant that only a very limited number of trials could be included. However, the commentary supports the author's suggestion of a "no prescription" strategy when it is safe to do so, with the proviso that patients should be informed about other safe methods of controlling fever and pain, such as antipyretics.

Spurling GKP, Del Mar C, Dooley L, Foxlee R. Delayed antibiotics for respiratory infections. Cochrane Database of Systematic Reviews 2007; Issue 3. Art. No: CD004417.

Strickland S. Evid Base Nurs 2008;11(2):46.

Obesity and knee osteoarthritis
Obesity rates continue to increase and are now calculated to account for between 2–7% of healthcare costs in developed countries. Osteoarthritis of the knee is known to relate to weight; but although pharmacological treatment options can be effective, it is unclear whether weight loss may also be an effective approach for managing pain and disability.

This systematic review sought randomised, controlled trials that evaluated weight change interventions in obese patients with osteoarthritis of the knee. Four trials met the inclusion criteria. The results showed that moderate weight loss reduces the level of functional disability but does not reduce knee pain.
A commentary viewed the lack of evidence with regard to pain reduction as surprising, but suggested that this may be due to some of the included trials having relatively short follow-up periods. Despite this, it suggests that the results support primary care nurses and doctors continuing to encourage obese patients with knee arthritis to lose weight, since losing as little as 5% of body weight led to improved functional ability.

Christensen R, Bartels EM, Astrup A, Bliddal H. Effect of weight reduction in obese patients diagnosed with knee osteoarthritis: a systematic review and meta-analysis. Ann Rheum Dis 2007;66:433–9. 

Ciliska D. Evid Base Nurs 2008;11(1):17.