Infectious diseases in primary care; managing the interface between the person and the community

Abstract

Respiratory infections are still among the most common new diagnoses in primary care. The most frequent reason for encounter is acute cough. General practitioners have to make antibiotic prescribing decisions in a context of diagnostic uncertainty, patient preferences and antimicrobial resistance. There is a causal link between antimicrobial resistance and antibiotic prescribing in primary care. GRACE observational studies (www.grace-lrti.org), show that variation in clinical presentation does not explain the considerable variation in antibiotic prescribing in Europe for adults presenting in primary care with acute cough and that recovery is similar between those treated with any antibiotic, a particular antibiotic class, or no antibiotic. A GRACE randomized controlled trial (RCT) of the effect of antibiotics for acute cough has recruited more patients than all RCTs combined in the current Cochrane Review and will have the power to identify subgroups of patients who will (not) benefit from amoxicillin. Another multi-country GRACE RCT assessing the effect on antibiotic prescribing of largely web-based versions of successful interventions including a C-reactive protein point-of-care test, a communication skill training and an interactive patient booklet is awaited. Given potential long-term cost-effectiveness, the GRACE suite of observational and interventional studies are enhancing the evidence base for reducing diagnostic uncertainty and managing patient expectations in a patient-centred way to achieve greater evidence-based antibiotic prescribing that is likely to help containing antimicrobial resistance.

Key words::

• Infectious diseases
• quality of care
• antibiotics
• antimicrobial resistance
• primary care

Acknowledgements

This paper builds upon the work of many others, including those presenting their work at the EGPRN Meeting held in Krakow, Poland, 13–16 October 2011, the CHAMP, ESAC and GRACE project groups and their participants. The author acknowledges Sibyl Anthierens, Chris Butler, Herman Goossens, Stefan Heytens, Paul Little and Theo Verheij for critically reviewing the manuscript.

Declaration of interest: The author reports no conflicts of interest. The author alone is responsible for the content and writing of the paper.