Many developing countries such as India, lack stringent regulations controlling the prescription and dispensation of antibiotic medications, as a result, these drugs are frequently being used. Despite the correlation between increased antibiotics and increased resistance of bacteria, antibiotic misuse is on the rise (1).
“The CDC estimates approximately 100 million courses of antibiotics are prescribed by office-based physicians each year, and approximately half of those are unnecessary” (2). “Studies show that nearly 50% of appointments made by patients for colds and URI and 80% of acute bronchitis visits are treated with antibiotics; however, multiple studies show that antibiotics do not significantly shorten the duration of illness in acute bronchitis” (3). “It is the uncertainty in the diagnosis of fevers, particularly the inability to distinguish a harmless viral fever from a debilitating salmonella, that compels many physicians in the developing world to blindly start antibiotics” (4), (6). Reasons found for the continued prescribing of antibiotics is simply that patients want antibiotics and are used to receiving prescriptions as a sort of receipt.
“Physicians tend to have a decreased amount of time to spend with patients, which also means a decreased amount of time to educate patients. The study concluded that prescribers need to work toward increased time to diagnose patients, educate patients, and evaluate the risk/benefit ratio of prescribing an antibiotic” (5).In this present study, we will use Temperature Charting and a Checklist in poorly localizable fevers to decrease antibiotic misuse and increase the patient’s prognosis and compliance to treatment with and without antibiotics.
A Fever Chart is a traditional, but inexpensive tool which is useful in analysing the different patterns of fever (Continuous fever, Remittent fever, etc.) thus distinguishing a harmless Viral fever from a potentially fatal Bacterial one. Our purpose is to make a Checklist which is simple and more familiar, which can be used by most of the Primary health care providers. Patients will be studied in two groups based on their encounters with physicians or investigators who are, and are not, blinded by patient’s inclusion status in the study.OBJECTIVES:1) To evaluate the Antibiotic requirement in the two groups by temperature monitoring and a Checklist.2) To find out the Duration of illness in the two groups at the end of the study.3) To assess the Patient Satisfaction Levels through Visual Analogue Scale (VAS).
METHODOLOGY:STUDY SETTING – Hospital-based study.STUDY DESIGN – It is a Prospective Observational Study.SAMPLING FRAME – Patients of age 15-50 years attending Medicine Department of a tertiary care Hospital in Narketpally, Nalgonda Rural District.STUDY PERIOD – 2 monthsSAMPLE SIZE – 500 patients presenting with fever to the OPD and IPD of the hospital within a span of 2 months.INCLUSION CRITERIA -1) Written informed consent from each patient or legal guardian prior to enrollment.
2) Patients aged 15-50 years.3) Recent-onset fever (within one to five days) when the diagnostic uncertainty is high.4) Symptoms commonly suggestive of self-limiting flu-like illnesses like myalgia, arthralgia with commonly known symptoms indicating involvement of upper respiratory tract such as cough, rhinorrhea, frontal headache, etc.EXCLUSION CRITERIA -1) Obvious clinical localization for fever such as Pneumonia, Meningitis, Urinary Tract Infection, etc.2) Clinical diagnosis suggesting important localizations.3) Elderly, underlying immunosuppression or any associated conditions predisposing to severe infections.
METHOD OF STUDY – Patients presenting with recent-onset fever to the hospital in Narketpally will be prospectively monitored for fever, duration of illness and satisfaction levels.A checklist will be used to allocate suitable patients to just antipyretics and/or antibiotics by temperature charting 4-hourly for 2 days by the patient himself/herself or the patient’s attenders or the hospital staff to study their health care outcomes. After monitoring for two days if the fever shows a progression, only then antibiotics will be instituted (depending on the judgment of the treating physician).Two groups will be studied:GROUP A – This group will comprise of patients encountered by investigators (not blinded by patient’s inclusion status in the study), waiting two days before taking a decision on antibiotics after selecting patients for the above on the basis of inclusion criteria and continue to encourage monitoring of their fever patterns over two days.GROUP B – This group will comprise of patients encountered by physicians delivering their usual care for fever (as per their prevailing clinical judgment). They remain blinded to the patient’s status in the study.A Visual Analogue Scale (VAS) will be used before and after the illness to access the satisfaction level of the patient with their current health.STUDY TOOLS -1) Mercury Thermometer2) A Checklist3) Visual Analogue ScaleSTATISTICAL ANALYSIS – Statistical analysis will be done using SPSS Software.
Average/median duration of fever will be ascertained. Dispersion in terms of range and standard deviation will be calculated. Antibiotic/Antipyretics consumptions will be associated/correlated by duration of fever by using Student T-test, and patient satisfaction through Mann-Whitney Test and appropriate statistical test.CONSENT – Written and informed consent in the local language will be obtained prior to enrollment in study and confidentiality of data will be maintained.
ETHICAL APPROVAL – Approval of Institutional Ethics Committee will be taken.IMPLICATIONS:1) The cost-effectiveness of fever charting would be an invaluable means to help differentiate viral and enteric fevers and thus help reduce unnecessary antibiotic prescriptions for viral fevers, which in turn would help in bringing the pandemic which is antimicrobial resistance, to a halt.2) To compare health care outcomes with those receiving currently prevalent care in our community of practice.
3) To institute good clinical practice in the physician community.REFERENCES:1. Ganguly NK, et al. Indian J Med Res. 2011. Rationalizing antibiotic use to limit antibiotic resistance in India.
in>ijmr2. Centers for Disease Control and Prevention, About Antimicrobial Resistance: A Brief Overview (2010)3. McCaig, L. F., & Hughes, J. M.
(1995). Trends in antimicrobial drug prescribing among office-based physicians in the United States. Journal of the American Medical Association, 273.4. Biswas R, Dhakal B, Das RN, Shetty KJ. Resolving diagnostic uncertainty in initially poorly-localizable-fevers: A prospective study.
Int J Clin Pract. January 2004;58(1):26–28.5.
Colgan, R., & Powers, J. H.
(2001). Appropriate antimicrobial prescribing: approaches that limit antibiotic resistance. American Family Physician, 479-486.6. Vineeth Dineshan, Rakesh Biswas, N.
S. Narasimhamurthy, A. S. Katherine. Integrating Hospital-Acquired Lessons into Community Health Practice: Optimizing Antimicrobial Use in Bangalore. Journal of continuing education in health professions – 27(2), 2007 DOI: 10.1002/chp7. Himanshu Jain.
Minimizing antibiotic usage for poorly localizable fevers of short duration in adults using a check list and temperature monitoring over SMS alerts (2014). Thesis.