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| Journal of the New Zealand Medical Association,
05-May-2006, Vol 119 No 1233
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Public views and use of antibiotics for the common cold
before and after an education campaign in New Zealand
Misty Curry, Linda Sung, Bruce Arroll, Felicity
Goodyear-Smith, Ngaire Kerse, Pauline Norris
The common cold is the most prevalent disease in humans and
is generally caused by a rhinovirus.1 In most cases, antimicrobial agents are
not needed. Indeed, there is no role for antibiotics in managing uncomplicated
colds2–4 nor preventing secondary bacterial infection.5
The common cold is associated with considerable costs in
terms of decreased productivity; time lost from work or school; visits to
healthcare providers; and the volume and cost of drugs prescribed.6 Despite the
lack of effectiveness of antibiotics for treating common cold symptoms
(rhinorrhoea, stuffiness, acute cough, sore throat, pharyngitis, and
laryngitis), general practitioners (GPs) frequently prescribe antibiotics for
patients with such symptoms in response to patients’ expectation or
doctors’ perceptions of these expectations.7,8
However, overuse and misuse of antibiotics for conditions
where there is no proven benefit of such therapy contributes to a number of
adverse events, as well as to the development of antimicrobial resistance and
unnecessary expense to patients and to the healthcare system as a whole.
The New Zealand (NZ) organisation PHARMAC (Pharmaceutical
Management Agency responsible for nationwide funding of pharmaceuticals)
launched the Wise Use of Antibiotics
campaign in 1999. This annual campaign aims to reduce antibiotic use by
educating the public that antibiotics are ineffective against viruses. The
campaign involves posters in family practice waiting-rooms and pharmacies and
leaflets given to patients in pharmacies and primary health care surgeries as
well as GP education.9
Between 1996 and 2003, PHARMAC reported a reduction in the
national antibiotic drug bill from $NZ36 million to 14.5 million. This resulted
from a combination of both decreased volume and price of the antibiotics
prescribed. From 1995 to 2002 there also was a national reduction in penicillin
resistance among pneumococci from 7% to 3.5% (p<0.05).10
The aim of our study was to assess change in public
attitudes, knowledge, and reported behaviour from 1998 to 2003 regarding
antibiotic use as a treatment for common colds and flu.
MethodsThe sample were adults aged 16 or over contacted by
telephone with their phone numbers randomly selected from the 1998 and
subsequently from the 2002 Auckland telephone book. A random sample of telephone
numbers was obtained from the telephone directory by randomising the page
number, the column number, and the number of private individuals represented per
column.
The University of Auckland Ethics Committee gave
ethical approval for both phases of the study. Participants were excluded if
they had a chronic condition such as chronic obstructive airways disease which
necessitated them having antibiotics on hand.
On contacting prospective participants, the
telephone-interviewers introduced themselves and asked respondents to
participate in ‘research into the use of antibiotics for the cold or
’flu (influenza)’. The confidentiality of all information gathered
was assured. No identifying details were retained other than the phone numbers
in case it was necessary to clarify any matter. To reduce bias, two call-backs
were made to respondents not initially available at varying times of the day and
week before replacement.
The interview consisted of a pre-prepared questionnaire
which covered the areas of personal management of colds/flu, utilisation of
health services, knowledge, attitudes, and reported behaviour regarding
antibiotic use in the management of the common cold. Respondents also were asked
about awareness of the Wise Use of
Antibiotics campaign. Results from the 1998 and 2003 interviews were
compared. Data were entered into a Microsorft Excel spreadsheet and analysed
using Stat-Sak and SPSS version 11 with Chi-squared statistical analysis.
ResultsIn 1998, 282 members of the public were approached of whom
206 agreed to participate. Six were excluded because they had chronic
respiratory disease, giving a 72% response rate. 387 members of the public were
approached in 2003 and 208 agreed to participate. Of these, 8 were ineligible (2
had chronic respiratory disease, 2 were terminally ill, and 4 had other chronic
illness that required them to have antibiotics readily available at all times).
The response rate was therefore 55% of eligible participants in 2003.
Table 1 shows the demographics of the members of the public
in both 1998 and 2003 surveys. There are no significant differences in the
demographic data between 1998 and 2003.
Table 2 shows the attitudes and behaviours reported by
patients regarding treatment of the common cold in the 1998 and 2003 surveys.
Significantly fewer people reported ever attending a doctor for a common cold in
2003 than in 1998 (45% vs 62%; p=0.0006). The number of people who would usually
see a doctor for a common cold decreased from 24% to 15% (p=0.026). However the
number who went to a doctor the last time they had a cold remained the same at
20% (p=0.86).
Table 1. Demographics of participants
*Chi-squared and
T-tests
Of those patients who had ever been to the doctor for a
common cold, the proportion who went specifically seeking antibiotics had risen
to 60% from 47% but this did not reach statistical significance (p=0.064). Those
who had ever visited a doctor for an upper respiratory tract infection (URTI)
were less likely to be prescribed antibiotics in 2003 (86% versus 74%; p=0.049).
There was also a significant increase in the reported giving of
“as-needed” prescriptions. An as-needed/delayed prescription is one
given at the time of consultation with instructions not to fill it unless
symptoms have not improved within a few days.
To evaluate people’s understanding of the function of
antibiotics, participants were first asked whether they thought antibiotics
cured bacterial infections, and then whether they cured viral infections. If
they answered yes to the first question
and no to the second question then they
were counted as understanding.
Members of the public had a similar understanding about the
function of antibiotics and the nature of the common cold (that it is viral, not
bacterial) in 2003 as in 1998 (38% versus 41%; p=0.9). However, they were
significantly less likely to feel positive about antibiotics in 2003 for the
treatment of a cold (16% versus 33%, p=0.00001). The perception (that
antibiotics were beneficial for fever, dry cough, coloured phlegm/nasal
discharge, runny nose, and to prevent complications) significantly reduced from
1998 to 2003. The perceived benefit of antibiotics for tonsillitis increased
from 83% to 91% in 2003 (p=0.014).
Only 30% of respondents were aware of the national
Wise Use of Antibiotics campaign; of
those who did recall it, 75% were unsure as to where, and in what format, they
had seen the information. Posters at the doctors had the highest recall (21% of
those who recalled the campaign).
Table 2. Patients’ reported behaviour and
attitudes
URTI=upper respiratory
tract infection.
DiscussionThis survey found no change since 1998 in the percentage of
the general public with a sound understanding that antibiotics are not effective
in the treatment of viral infections. There was, however, a reduction in those
wanting antibiotics for specific symptoms, and a reduction in positive feelings
towards antibiotics. There was also a reduction of 12% in patients getting
antibiotics. It is reassuring that doctors are using more
“as-needed” prescriptions (24% versus 7%). There was also a decrease
(from 62% to 45%) in the proportion of people who had ever consulted a doctor
about a cold or flu.
These findings may suggest that people are aware that that
they should not be using antibiotics to treat the cold or flu, even if they do
not know the reason. This assessment is supported by the number of respondents
who feel positive about antibiotic use for common colds falling dramatically
from 33% in 1998 to 16% in this study. If this assessment is correct then it may
form a base from which to launch further and better education programmes into
the wise use of antibiotics. However of those who had seen a GP, the proportion
wanting antibiotics had increased. Some of this may be due to a residue of
patients “keen” on antibiotics for common colds still consulting
GPs.
Another 1998 NZ study
found that the general public had poor understanding regarding the lack
of benefit of antibiotic treatment for the common cold and influenza (flu).11
Only 40% understood that antibiotics were unhelpful in viral infections and as
such would be of no use in treatment.
A US study evaluated patient contribution in antibiotic use
across nine countries (UK, France, Belgium, Turkey, Italy, Morocco, Colombia,
Spain, and Thailand).12 All had some degree of antibiotic misuse in the
community. Some patients exaggerated symptoms to get a prescription for
antibiotics, while others exerted pressure on doctors for a prescription.
Keeping leftover medication for future use and illegal sale of antibiotics
directly from the pharmacy was observed in all nine countries. The authors
concluded that the lack of knowledge in patients regarding antibiotic use and
the consequences of misuse made education a major priority in the primary care
setting.
An UK study examined the effect of giving an “as
needed” antibiotic prescription for sore throat management.13 Three groups
of patients were compared: one group was given a prescription for antibiotics,
one received no prescription for antibiotics, and the third group was asked to
come back to the practice in 3 days if not improved, to collect a prescription.
The use of antibiotics in these three groups was 99%, 13%, and 31% respectively.
Another study done by these authors found that it was more likely for patients
who received antibiotics previously to return for subsequent consultations for
sore throat, suggesting that giving antibiotics encourages patients to return
with subsequent illness.14
The reasons for visiting a doctor for the common cold show
that patients need re-education about antibiotics usage. This suggests that the
majority of patients who actually attend a doctor with symptoms of a cold do
want antibiotics. There was a general trend toward diminished perceived benefits
of antibiotics for various symptoms. On the other hand, for conditions such as
pharyngitis, tonsillitis, and sinusitis, patients had an increase in perceived
antibiotic benefits. From existing literature, it is controversial whether
antibiotics play a role in reducing symptoms of tonsillitis15 and purulent nasal
discharge.16, 17
Comparing our results to a US study,18 only 54% knew that a
virus is the usual cause of the common cold and 46% believed that antibiotics
kill viruses while 17% were not sure whether antibiotics kill viruses. Our
findings were more encouraging when compared to Swiss research of 5379
interviewees across nine countries showing that antibiotics were still perceived
as strong efficient drugs against viral illness.12 Interviewees believed that
most respiratory infections require antibiotic treatment and 11% of them had to
exaggerate their symptoms to get an antibiotic prescription from their doctor.
About one patient in four saved part of their antibiotic course for future
use.
Some commentators reflect that despite the excessive amounts
of antibiotics used, relatively minor attempts have been made to reduce
unnecessary or even improper use.7 This emphasises the importance of
reinforcement of education to both the public and GPs.
A study in the Netherlands found that fewer patients than
doctors endorsed the self-limiting character of cough, sore throat, and earache
(mean 3.1, 3.4 and 2.9 versus 4.1, 4.1 and 3.7). In addition, far more patients
than doctors rated antibiotics as necessary for cough and sore throat (mean 2.7
and 2.9 versus 1.7 and 1.7) and believed that antibiotics speed recovery (mean
3.7 versus 2.0).19
Educational material and prescribing feedback to physicians
has been shown to reduce their antibiotic prescribing.20–22 To a limited
degree patient education has been demonstrated to limit antibiotic use for viral
illness in some studies,23 but many patients still seek antibiotics despite
public education programmes.24
The strength of our study is that it reports on a random
selection of the public and compares two time periods between which there was a
campaign to reduce antibiotic use. We are not aware of any other study to do
this in the international literature. The response rate was 72% in 1998 and 55%
in 2003 which is acceptable for this type of study. There is no reason to
indicate that non-responders introduce a bias in the results in any particular
direction.
There is the possibility that the group who has seen a
doctor for a respiratory illness are a residue wanting antibiotics. This may not
be the case as the number of respondents who went to the doctor for their last
cold and flu remained constant at 20%. A limitation of this study is that it
relies on asking people what they do, rather than measuring what they do.
In conclusion, the results show that in 2003 the majority of
the general public believe that antibiotics are useful in the treatment of the
common cold, and that this belief has not changed since 1998. However, the
Wise Use of Antibiotics campaign may
have been successful in its goals since there appears to be a reduction in
patients seeking attention for common colds and a reduction in the number of
people receiving antibiotics from GPs. The campaign appears to have been less
successful in increasing public knowledge. The change in GP behaviour may be the
major factor in the reduction in antibiotic use from 1996 to 2003.
There are no conflicts of
interest in this study.
Author information:
Misty Curry, Medical Student, University of Auckland, Auckland; Linda Sung,
Medical Student, University of Otago, Dunedin; Bruce Arroll, Associate
Professor, Department of General Practice and Primary Health Care, School of
Population Health, University of Auckland, Auckland; Felicity Goodyear-Smith,
Senior Lecturer, Department of General Practice and Primary Health Care, School
of Population Health, University of Auckland, Auckland;; Ngaire Kerse, Associate
Professor, School of Population Health, University of Auckland, Auckland;
Pauline Norris, Senior Lecturer, School of Pharmacy, University of Otago,
Dunedin
Acknowledgments: We
thank the Charitable Trust of the Auckland Faculty of the Royal New Zealand
College of General Practitioners for their funding of this study.
Correspondence: Dr F
Goodyear-Smith, Dept of General Practice and Primary Health Care, School of
Population Health, University of Auckland, Private Bag 92019, Auckland. Fax:
(09) 373 7624; email: f.goodyear-smith@auckland.ac.nz
References:
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