Primary Care/Managed Care

Erythromycin reduces time off work but not symptoms in patients with acute bronchitis

Antibiotics are generally not recommended for bouts of acute bronchitis because bronchitis is usually caused by viruses that don't respond to antibiotics as bacteria do. Nevertheless, physicians treat 70 to 93 percent of all such episodes with antibiotics. A recent study, supported by the Agency for Health Care Policy and Research (HS07192), shows that the antibiotic erythromycin substantially reduced the time out of work for patients receiving it compared with a placebo, even though the patients continued to cough, have chest congestion, use cough medicine, and feel just as sick as placebo-treated patients. This was true whether or not the cause of the bronchitis was Mycoplasma pneumoniae bacteria.

Acute bronchitis can be caused by rhinovirus, coronavirus, adenovirus, or influenza virus, in addition to M. pneumoniae, explains Dana E. King, M.D., of the East Carolina University School of Medicine, the study's lead investigator. Using a rapid M. pneumoniae antibody test to detect patients who would be more likely to respond to antibiotic therapy, his team conducted a prospective, double-blind trial (neither physician nor patient knows what the patient is receiving) that randomized patients with acute bronchitis at three different primary care sites in North Carolina to receive erythromycin or a placebo for 10 days.

Patients treated with erythromycin, whether they tested positive for M. pneumonia or not, missed fewer days of work than patients treated with placebo (average of 0.81 vs. 2.16 days). This may be due to treatment of other organisms susceptible to erythromycin treatment, such as Chlamydia pneumoniae, which causes 3 to 10 percent of cases of acute bronchitis. On the other hand, returning to work may be a better indicator of improved health status than individual symptoms, which stayed the same for treated and untreated patients.

For more details, see "Effectiveness of erythromycin in the treatment of acute bronchitis," by Dr. King, William Cameron Williams, M.D., M.S.P.H., Lynn Bishop, M.T., and Aaron Shechter, in the June 1996 issue of The Journal of Family Practice 42(6), pp. 601-605.

Less than two-thirds of family physicians follow recommendations to routinely vaccinate infants against hepatitis B

Vaccinating all infants against hepatitis B virus has been recommended by the U.S. Public Health Service since 1991 and the American Academy of Pediatrics and American Academy of Family Physicians since 1992. However, as of 1994, a significantly larger number of pediatricians than family physicians had adopted the practice. Also, more physicians had adopted it than actually agreed with it, concludes a study supported by the Agency for Health Care Policy and Research (HS07286).

Physicians' reluctance to provide the hepatitis B vaccine was due partly to doubt about the vaccine's long-term protection and to concerns about perceived parental resistance to the vaccine. Physician hesitance has resulted in lower levels of adoption than other vaccines in the primary immunization series, which includes polio and measles, mumps, and rubella, explains Thomas R. Konrad, Ph.D., of the University of North Carolina at Chapel Hill, one of the study's principal investigators.

Gary L. Freed, M.D., M.P.H., Dr. Konrad, Donald E. Pathman, M.D., M.P.H., and their colleagues surveyed 3,014 family physicians and pediatricians in select metropolitan and nonmetropolitan areas of nine States. Analysis of the 1,421 responses showed that pediatricians were more likely than family physicians to state that they "knew a lot" about the vaccine recommendation (95 percent vs. 84 percent), agree with it (83 percent vs. 57 percent), and adopt it into practice (90 percent vs. 64 percent). More family physicians than pediatricians believed it appropriate to limit hepatitis B vaccination to high-risk patients (24 percent vs. 10 percent), with 69 percent of family physicians and 55 percent of pediatricians considering their patients at low risk for hepatitis B infection.

Family physicians felt parents were more likely to resist this vaccination for their children than did pediatricians (33 percent vs. 22 percent). One-third of respondents expressed concern that the vaccine may not provide long-term protection. There were no differences in adoption rates by percentage of patients enrolled in managed care plans or Medicaid, or by practice type or location for both types of physicians, according to the researchers.

They also concluded from this study that accurate comparative immunization rates cannot be obtained across medical practices without substantial research investments, major restructuring of physicians' office information systems, or both. Their review of 1,900 children's medical records in both pediatric and family practice offices in eight States showed that recordkeeping problems made it difficult to calculate a clinic's childhood immunization rate. Often patient records were dense, with immunization notations on several different forms; some records were in disarray; and immunization data were not consistently recorded on a grid or other central location. Moreover, recordkeeping in practices varied widely in content, location of demographic and insurance information, and level of detail about immunization referrals or deferrals.

For more information, see "Pediatrician and family physician agreement with and adoption of universal hepatitis B immunization," by Gary L. Freed, M.D., M.P.H., Victoria A. Freeman, R.N., Dr.P.H., Sarah J. Clark, M.P.H., and others, in the June 1996 issue of The Journal of Family Practice 42(6), pp. 587-592, and "Calculating a clinic's childhood immunization rate: Costs and returns [letter]," by Catherine Stevens, M.S.P.H., Victoria Freeman, R.N., Dr.P.H., Dr. Konrad, and others, in the June 1996 Archives of Family Medicine 5, p. 323.

Lyme disease may occur much more often than reported

Lyme disease (LD) is the second most prevalent emerging infectious disease in the United States and the most common vector-borne infection. A recent study shows that LD is underreported 10- to 12-fold in Maryland and is a much greater public health problem than official State Department of Health (SDH) surveillance data suggest. About 80 percent of LD cases are managed by primary care physicians, and actual treatment does not always coincide with the recommended approach. These are the findings of G. Thomas Strickland, M.D., Ph.D., of the University of Maryland School of Medicine, and colleagues, who were supported in part by the Agency for Health Care Policy and Research (HS07813).

They surveyed 1,200 Maryland physicians, a 1 in 15 random sample, and found that 1,900 to 2,400 cases of LD are being diagnosed each year, a dramatically greater number than the 180 to 340 cases reported annually by the Maryland SDH. Also, over 4,000 (or twice as many) patients were treated for presumptive LD and another 23,000 were seen for tick bites only; 5,500 to 6,000 of the latter group were given prophylactic antibiotics in both 1992 and 1993.

Antibiotic prophylaxis for tick bites has not been recommended, even in areas with high numbers of endemic ticks. However, this policy remains controversial. Some areas of Maryland—for example, the Eastern Shore—may actually have incidence rates at levels that make administration of preventive antibiotics for well-documented black-legged tick bites cost effective. In any event, many primary care physicians in Maryland are managing patients with presumptive LD and tick-bite exposures differently from the current recommendations. Another concern is that almost 15 percent (or one of every six) patients receiving prophylaxis for tick bites were treated with drugs more costly and potentially more toxic than the recommended drugs (oral doxycycline, tetracycline, and amoxicillin). The much greater number of patients treated for presumptive LD, seen and given preventive antibiotics for tick bites, and receiving diagnostic tests indicate that LD also accounts for significantly more medical resources than official surveillance data suggest.

For more details on this study and the case study, see "The public health impact of Lyme disease in Maryland," by Bonnie S. Coyle, M.D., Dr. Strickland, Yale Y. Liang, M.D., and others, in The Journal of Infectious Diseases 173, pp. 1260-1262, and "Cluster of Lyme disease cases at a summer camp in Kent County, Maryland," by Dr. Strickland, Leena Trivedi, Ph.D., Stanley Watkins, B.S., and others, in Emerging Infectious Diseases 2(1), pp. 44-46.

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