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Open Access Research article

A decision aid to rule out pneumonia and reduce unnecessary prescriptions of antibiotics in primary care patients with cough and fever

Johann Steurer1*, Ulrike Held1, Anne Spaar1, Birke Bausch1, Marco Zoller2, Roger Hunziker3 and Lucas M Bachmann1

Author Affiliations

1 Horten Center for Patient-Oriented Research and Knowledge Transfer, University of Zurich, Zurich, Switzerland

2 Institute of General Practice and Health Services Research, University of Zurich, Zurich, Switzerland

3 Division of Diagnostic and Interventional Radiology, University Hospital of Zurich, CH-8091 Zurich, Switzerland

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BMC Medicine 2011, 9:56  doi:10.1186/1741-7015-9-56

Published: 13 May 2011

Abstract

Background

Physicians fear missing cases of pneumonia and treat many patients with signs of respiratory infection unnecessarily with antibiotics. This is an avoidable cause for the increasing worldwide problem of antibiotic resistance. We developed a user-friendly decision aid to rule out pneumonia and thus reduce the rate of needless prescriptions of antibiotics.

Methods

This was a prospective cohort study in which we enrolled patients older than 18 years with a new or worsened cough and fever without serious co-morbidities. Physicians recorded results of a standardized medical history and physical examination. C-reactive protein was measured and chest radiographs were obtained. We used Classification and Regression Trees to derive the decision tool.

Results

A total of 621 consenting eligible patients were studied, 598 were attending a primary care facility, were 48 years on average and 50% were male. Radiographic signs for pneumonia were present in 127 (20.5%) of patients. Antibiotics were prescribed to 234 (48.3%) of patients without pneumonia. In patients with C-reactive protein values below 10 μg/ml or patients presenting with C-reactive protein between 11 and 50 μg/ml, but without dyspnoea and daily fever, pneumonia can be ruled out. By applying this rule in clinical practice antibiotic prescription could be reduced by 9.1% (95% confidence interval (CI): 6.4 to 11.8).

Conclusions

Following validation and confirmation in new patient samples, this tool could help rule out pneumonia and be used to reduce unnecessary antibiotic prescriptions in patients presenting with cough and fever in primary care. The algorithm might be especially useful in those instances where taking a medical history and physical examination alone are inconclusive for ruling out pneumonia