1. Antibiotics shorten duration of acute cough? A cohort study. Teng CL, Efendie B, Lee VKM, Tey KK, Selvakumari S, Sarghunan P, Rafidah B, Bong YK, Shafiq Ali JS, Lee WH, Anuja K, Chen WS, Kennedy C. International Medical University, Malaysia tengcl@gmail.com WONCA Asia Pacific Region, Hong Kong, 4 – 7 June 2009 Oral Presentation, 7 June 2009

2. INTRODUCTION Systematic review on upper respiratory tract infections (URTI) did not support antibiotic use. In Malaysian primary care practices, antibiotic use is still commonly prescribed for URTI. –28.7% in public clinics (Med J Malaysia 2003) –68.4% in private clinics (Asia Pacific Family Medicine 2004)

3. INTRODUCTION Rationale of study: we hope to show to primary care doctors that the antibiotics they prescribe did not alter the course of the illness

4. METHODS: patients & settings 23 July to 25 September 2008. 9 private clinics (16 doctors), 2 public clinics (14 doctors) Adult patients (  16 years) with acute URTI: cough or runny nose or sore throat with a duration of  7 days.

5. Data collection form for doctor Antibiotic data

6. Patient diary Return via self-addressed enveloped Text messaging and telephone calls

7. RESULTS & DISCUSSION 503 patients were enrolled Mean age 34 yrs (range 16-80, SD=12.5) 47 (9.3%) defaulted (unable to contact and/or diary not returned)

8. RESULTS & DISCUSSION Cough before presentation = 413 (82.1%) Cough before/after presentation = 424 (84.3%)

9. RESULTS: Cough duration in URTI 37% remained coughing at 7 th day 5.4% remained coughing at 14 th day

10. Cough duration Antibiotics = 7.2 days No antibiotics = 8.7 days p=0.004 Antibiotics shorten duration of cough?

11. Cough duration Private clinic (GP) = 6.9 days Public clinic (KK) = 10.3 days P<0.001 “Milder” URTI were seen in private clinics? (Private) (Public)

12. RESULTS & DISCUSSION Cough duration (Private) Antibiotics = 6.9 days No antibiotics = 6.7 days P>0.05 Cough duration (Public) Antibiotics =10.2 days No antibiotics = 10.3 days P>0.05 Differences in cough duration between those given antibiotic and not given antibiotic disappeared when clinic setting is taken into account

13. CONCLUSION This cohort study reaffirms the lack of effectiveness of antibiotic for cough in URTI. Caution need to be exercised when combining data on symptom presentation and prescribing in public and private primary care.

14. ACKNOWLEDGEMENT We wish to thank the following: –International Medical University for providing the funding. –Ministry of Health Malaysia for allowing this study in the public clinics –Doctors in private and public primary care clinics (and their patients) for their participation –Prof James Dickinson (University of Calgary) for his insightful comments

15. Teng CL, Efendie B, Lee VKM, et al. Antibiotics shorten duration of acute cough? A cohort study. WONCA Asia Pacific Regional Conference, Hong Kong, 4-7 June 2009 [Oral Presentation, 7 June 2009] Background. Systematic review on upper respiratory tract infections (URTI) did not support antibiotic use. However, in Malaysian primary care practices, antibiotic use is still commonly prescribed for URTI. Objectives. We conducted a cohort study to verify the ineffectiveness of antibiotic therapy in primary care practices in Malaysia. Methods. Adult patients (age 16 years) presenting with upper respiratory tract symptoms from public and private primary care clinics were followed up until symptoms resolved or up to 28 days. The participating doctors were advised to manage their patients in the usual way. The clinical details of patients were collected at recruitment and by patient diary (reminders given by text messaging and telephone call). Results/Key Message. 503 patients with URTI were enrolled (74.8% from private clinics). Patients presented earlier in private clinic compared to public clinics (mean cough duration before presentation: 2.42 days vs 3.11 days, p<0.001). Cough lasted shorter in private clinics (mean total cough duration: 6.9 days vs 10.3 days, p<0.001). Antibiotic prescribing rates were higher in private clinics (80.9% vs 29.1%). Cough duration was found to be shorter in patients given antibiotics (7.2 days vs 8.7 days, p=0.004), but this statistical difference disappeared when analysis was made separately by clinic setting. Conclusion. The earlier presentation of URTI in private clinic, acting together with the overwhelmingly high antibiotic prescribing rate, explains the apparent reduction of cough duration by antibiotic in this cohort study. This study finding reaffirms the lack of effectiveness of antibiotic for URTI symptoms. Throat culture taken =230, result available=229; Group A beta-haemolytic streptococcus isolated 4/229=1.7%].