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71 Preventing antimicrobial resistance. General practitioners’ views about tailoring antibiotic duration for respiratory tract infections based on clinical stability criteria and C-reactive protein concentration when patients are afebrile and feel better
  1. Carl Llor1,2,3,
  2. Ana Moragas4,
  3. Lars Bjerrum5
  1. 1University Institute in Primary Care Research Jordi Gol, Barcelona, Spain
  2. 2CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain
  3. 3Research Unit for General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
  4. 4University Rovira i Virgili, Reus, Spain
  5. 5Department of Public Health and Primary Care. University of Copenhagen, Copenhagen, Denmark


Objectives The optimization of antimicrobial therapy remains a challenge that requires an intelligent utilization of all tools and resources at our disposal. Unnecessary antibiotic use significantly contributes to increasing bacterial resistance, medical costs, and the risk of drug-related adverse events. Studies have showed strong evidence of correlation between prescription of antibiotics and selection of resistant bacteria. Ensuring prudent antimicrobial utilisation is key to an effective response to this problem, mainly in primary care, in which nearly 80% of all antibiotics are issued. A strategy to reduce the selection of antimicrobial resistance is by reducing the use of antibiotics or by shortening the length of antibiotic treatments by individualizing duration. More than half of the antibiotics prescribed are for respiratory tract infections (RTI). We explored general practitioners’ (GP) views on stopping antibiotics as soon as clinical stability criteria and C-reactive protein (CRP) values are normal when patients feel better.

Method We are planning to carry out a randomised clinical trial to assess the feasibility of measuring clinical stability criteria and CRP values as soon as patients are afebrile and feel better after completing two days of antibiotic therapy for a bacterial RTI, but first we wished to explore what clinicians thought about this. We recruited GPs in Catalonia from two large cities and one rural primary care centre, covering clinicians with both low and high antibiotic prescribing rates. We conducted one-to-one interviews. Two researchers collected the data using semi-structured topic guides. We asked doctors about their experiences of managing RTIs, advising patients on these infections and antibiotic therapy, and views on tailoring the antibiotic course based on monitoring of the clinical stability criteria and CRP concentrations after a given number of days of antibiotic course. Data were audio-recorded, transcribed, and analysed thematically.

Results We included 12 GPs, six of which were high antibiotic prescribers. All participants considered tailoring antibiotic therapy based on clinical criteria and CRP when patients feel better contradictory to well-known advice to complete antibiotic courses for RTIs and they all were concerned about the burden related to re-visiting patients but were also interested in shortening antibiotic courses if this is not associated with an increased risk of complications and hospitalization, as long as they have completed some days of antibiotic course. GPs stressed the need for unambiguous evidence based on randomized clinical trials showing that tailoring antibiotic duration is safe and beneficial. Participants would be more confident with stopping the antibiotic courses based on monitoring of clinical stability and CRP values rather than using delayed antibiotic prescribing. Although most GPs were amenable in most of the RTIs, they were averse to it in case of a radiologically-confirmed pneumonia.

Conclusions Despite being unfamiliar, general practitioners showed interest in shortening antibiotic courses for RTIs if this does not lead to a major number of complications. However, they were reluctant to tailor antibiotic therapy in case of pneumonia. They all agreed that stopping antibiotics when feeling better, clinical stability criteria are normal and CRP values are low could reduce exposure to antibiotics and risks of antimicrobial resistance, but they asked for more evidence before this strategy could be implemented, and if evidence supports this approach, patients need to be offered a clear explanation as to why the advice is different from the long-standing dogma of ‘completing the course’. Curiously, GPs preferred tailoring antibiotic courses for RTIs rather than using the delayed antibiotic prescribing as they ensure a minimal antibiotic exposure when they consider antibiotic therapy is warranted.

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