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A cute respiratory infections (ARIs) are a major burden on healthcare systems. ARIs—including non-specific upper respiratory infections (the common cold), otitis media, sinusitis, pharyngitis, acute bronchitis, influenza, and pneumonia—are the number-one symptomatic reason for seeking medical care. In the United States, ARIs account for about 10 % of all ambulatory visits. Among ARIs, the diagnosis and management of acute bronchitis should be particularly straightforward. Acute bronchitis is a cough-predominant respiratory infection of less than 3 weeks’ duration in a patient without chronic cardiopulmonary disease who has normal vital signs and a normal lung examination. Forty years of randomized controlled trials, as well as more recent guidelines and performance measures, indicate that antibiotics are not beneficial for acute bronchitis and that the right antibiotic prescribing rate is zero. Despite clear evidence, guidelines, and measures indicating that physicians should avoid prescribing antibiotics for acute bronchitis, doctors and patients remain anxious about withholding them. The Centers for Disease Control and Prevention and other organizations have implemented broad educational efforts, but the antibiotic prescribing rate for acute bronchitis in the United States is 70 %, and actually increased between 1996 and 2010. There are many possible reasons that doctors continue to prescribe antibiotics for acute bronchitis despite the clear contravening evidence. Physicians and patients are confused by differences among “chest colds,” “chest infections,” “acute bronchitis,” “lower respiratory tract infections,” and “pneumonia.” Even if diagnostic definitions were perfect, in the real world, physicians are faced with uncertainty. Where does a cold stop and acute bronchitis start? Am I really sure my patient does not have pneumonia? Sinusitis? Undetected, underlying chronic lung disease? Acute bronchitis is anxiety-provoking for both doctors and patients, in part because it has a long course. Patients and physicians are anxious about an illness that, on average, resolves over the course of 3 weeks. Physicians are also anxious about keeping patients satisfied, and feel they have to do something in an effort to help patients feel better. Merely providing reassurance feels inadequate, and physicians have a difficult time conveying reassurance without trivializing patients’ concerns. Finally, a few patients with acute bronchitis have complications, and a very small proportion of patients initially diagnosed with acute bronchitis will develop pneumonia. To address this anxiety and reduce inappropriate antibiotic prescribing, the GRACE INTRO investigators have conducted a pragmatic multinational implementation tour de force. The investigators performed a 6-country controlled factorial cluster randomized trial of C-reactive protein (CRP) testing in comparison to communication training and the use of a patient booklet for patients with ARIs, most of whom probably had acute bronchitis. They evaluated CRP testing, given that prior studies had revealed that patients and physicians expressed a strong interest in testing that would reduce uncertainty and would clarify the need for antibiotics. The investigators evaluated communication through the use of an educational booklet, which had been found effective in prior studies. However, beyond measuring whether the interventions worked, they conducted a suite of adjunctive quantitative and qualitative studies in order to understand why the interventions worked and whether they were likely to continue working after the trial. The trial included 228 practices, 372 physicians, and 4,264 patients, and found that CRP testing and communication training interventions were effective in reducing antibiotic prescribing. The antibiotic prescribing rate decreased in the CRP group from 48 % to 33 % and decreased in the communication and booklet group from 45 % to 36 %. Each intervention had a downside: patients in the CRP had a low, but slightly higher rate of hospitalization; patients in the communication group reported 1 additional day of rating their symptoms “moderately bad or worse,” perhaps because the patients had newly reset expectations about the duration of illness. Some advantages of the communication and booklet intervention began to emerge in quantitative surveys of physicians. Published online January 22, 2015

journal of general internal medicine

Comparative Effectiveness of Three Anxiolytics for Acute Respiratory Infections: Antibiotics, C-Reactive Protein Point-of-Care Testing, and Improved Communication