A systematic review of the public's knowledge and beliefs about antibiotic resistance.

OBJECTIVES: The objective of this study was to systematically review quantitative and qualitative studies on the public's knowledge and beliefs about antibiotic resistance. METHODS: We searched four databases to July 2014, with no language or study design restrictions. Two reviewers independently extracted data. We calculated the median (IQR) of the proportion of participants who agreed with each statement and synthesized qualitative data by identifying emergent themes. RESULTS: Of 3537 articles screened, 54 studies (41 quantitative, 3 mixed methods and 10 qualitative) were included (55 225 participants). Most studied adults (50; 93% studies) and were conducted in Europe (23; 43%), Asia (14; 26%) or North America (12; 22%). Some participants [median 70% (IQR 50%-84%); n = 8 studies] had heard of antibiotic resistance, but most [median 88% (IQR 86%-89%); n = 2 studies] believed it referred to changes in the human body. Many believed excessive antibiotic use [median 70% (IQR 59%-77%); n = 11 studies] and not completing antibiotic courses [median 62% (IQR 47%-77%); n = 8 studies] caused resistance. Most participants nominated reducing antibiotic use [median 74% (IQR 72%-85%); n = 4 studies] and discussing antibiotic resistance with their clinician (84%, n = 1 study) as strategies to reduce resistance. Qualitative data supported these findings and additionally identified that: participants believed they were at low risk from antibiotic resistance participants; largely attributed its development to the actions of others; and strategies to minimize resistance should be primarily aimed at clinicians. CONCLUSIONS: The public have an incomplete understanding of antibiotic resistance and misperceptions about it and its causes and do not believe they contribute to its development. These data can be used to inform interventions to change the public's beliefs about how they can contribute to tackling this global issue.

Not in my backyard: a systematic review of clinicians' knowledge and beliefs about antibiotic resistance.

OBJECTIVES: To systematically review clinicians' knowledge and beliefs about the importance and causes of antibiotic resistance, and strategies to reduce resistance. METHODS: Four databases were searched (until July 2014), without restrictions on language, setting or study design. Fixed responses (from surveys) were grouped into categories. The proportion of participants who agreed with each category was expressed as median, percentage and IQR. Qualitative data were coded into emergent themes. Quantitative categories and qualitative themes were grouped into four overarching categories that emerged from the data. RESULTS: There were 57 included studies (38 quantitative, 14 qualitative, 5 mixed methods) of 11593 clinicians. Most clinicians (69%, IQR 63%-72%, n=5 studies) had heard of antibiotic resistance and 98% (IQR 93%-99%, n=5 studies) believed it was serious. The proportion who believed it was a problem for their practice (67%, IQR 65%-74%, n=13 studies) was smaller than the proportion who believed it was a problem globally (89%, IQR 85%-97%, n=5 studies) or nationally (92%, IQR 88%-95%, n=21 studies). Most believed excessive antibiotic use (97%, IQR 91%-98%, n=12 studies) and patient non-adherence (90%, IQR 82%-92%, n=7 studies) caused resistance. Most knew of strategies to reduce resistance (e.g. clinician education, 90%, IQR 85%-96%, n=7 studies). Qualitative findings support these data: they attributed responsibility for antibiotic resistance to patients, other countries and healthcare settings; resistance was considered a low priority and a distant consequence of antibiotic prescribing. CONCLUSIONS: Clinicians believe antibiotic resistance is a serious problem, but think it is caused by others. This needs to be accommodated in interventions to reduce antibiotic resistance.

Body-site distribution of skin cancer, pre-malignant and common benign pigmented lesions excised in general practice.

BACKGROUND: Concern about skin cancer is a common reason for people from predominantly fair-skinned populations to present to primary care doctors. OBJECTIVES: To examine the frequency and body-site distribution of malignant, pre-malignant and benign pigmented skin lesions excised in primary care. METHODS: This prospective study conducted in Queensland, Australia, included 154 primary care doctors. For all excised or biopsied lesions, doctors recorded the patient's age and sex, body site, level of patient pressure to excise, and the clinical diagnosis. Histological confirmation was obtained through pathology laboratories. RESULTS: Of 9650 skin lesions, 57·7% were excised in males and 75·0% excised in patients ≥ 50 years. The most common diagnoses were basal cell carcinoma (BCC) (35·1%) and squamous cell carcinoma (SCC) (19·7%). Compared with the whole body, the highest densities for SCC, BCC and actinic keratoses were observed on chronically sun-exposed areas of the body including the face in males and females, the scalp and ears in males, and the hands in females. The density of BCC was also high on intermittently or rarely exposed body sites. Females, younger patients and patients with melanocytic naevi were significantly more likely to exert moderate/high levels of pressure on the doctor to excise. CONCLUSIONS: More than half the excised lesions were skin cancer, which mostly occurred on the more chronically sun-exposed areas of the body. Information on the type and body-site distribution of skin lesions can aid in the diagnosis and planned management of skin cancer and other skin lesions commonly presented in primary care.

Prospective study of skin surgery in smokers vs. nonsmokers.

BACKGROUND: Smoking may increase complications following minor surgery leading many clinicians to urge patients to refrain from smoking before and after surgery. OBJECTIVE: To study the association between smoking and complications following skin surgery. METHODS: In a 5-year prospective observational study 7224 lesions were excised on 4197 patients. Patients were not instructed regarding smoking. All complications were recorded. RESULTS: A total of 439 smokers (10.5%) underwent 646 procedures (9%), 3758 nonsmokers (89.5%) underwent 6578 procedures (91%). Smokers were younger (55 +/- 16 years) than nonsmokers (66 +/- 17 years) (P < 0.001). Infection incidence was not significantly different, 1.9% (12/646) in smokers compared with 2.2% (146/6578) in nonsmokers (P = 0.55). There were two bleeds with smokers (0.3%) vs. 50 in nonsmokers (0.8%) (P = 0.2). The incidence of wound dehiscence in nonsmokers (three) was not different from nonsmokers (21) (P = 0.54). However, the incidence of scar contour distortion in smokers (three) was greater than in nonsmokers (two) (odds ratio 15.3; 95% confidence interval 2.5-92). Total complication incidence was similar, 3.6% in smokers vs. 4.0% in nonsmokers (P = 0.58). Out of 2371 flaps there were 14 (0.6%) cases of end-flap necrosis but smokers were not at increased risk. The case-control analysis compared each smoker with two nonsmokers matched for age, sex, postal code and outdoor occupational exposure. This again demonstrated no difference in infection, scar complication, bleed, dehiscence, end-flap necrosis or total complication incidence. CONCLUSIONS: Smokers and nonsmokers suffer skin surgery complications similarly. The increased risk of contour distortion identified was difficult to interpret. Advice to cease smoking in the short term to improve outcomes with skin cancer surgery is not supported by these data.

Do case conferences between general practitioners and specialist palliative care services improve quality of life? A randomised controlled trial (ISRCTN 52269003).

Australian palliative care is delivered by general practitioners (GPs) and specialist palliative care teams. Patient outcomes should improve if they work in formal partnership. We conducted a multi-centred randomised controlled trial of specialist- GP case conferences, with the GP participating by teleconference, or usual care and communication methods. Primary outcome measure was global Quality of Life (QoL) scores at 3 weeks from intervention. Secondary measures included subscale QoL scores and carer burden. Two a priori intention-to-treat analyses were conducted using recruitment, and time of death, as fixed time points. There was no difference between groups in the magnitude of change in global QoL measures from baseline to any time point up to 9 weeks post-case conference, or at any time before death. The case conference group showed better maintenance of some physical and mental health measures of QoL in the 35 days before death. Case conferences may improve clinical relationships and care plans at referral, which are not implemented until severe symptoms develop. Case conferences between GPs and specialist palliative care services may be warranted for palliative care patients.

Delayed antibiotics for respiratory infections.

BACKGROUND: Modest benefits of antibiotics for acute upper respiratory tract infections have to be weighed against common adverse reactions, cost and antibacterial resistance. There has been interest in ways to reduce antibiotic prescribing. One strategy is to provide the prescription, but advise delay of more than 48 hours before use, in the hope symptoms resolve first. Advocates suggest this will preserve patient satisfaction. This review asks what effect delayed antibiotics have on clinical outcomes of respiratory infections, antibiotic use and patient satisfaction. OBJECTIVES: To evaluate the prescribing strategy of delayed antibiotics for acute respiratory tract infections compared to immediate or no antibiotics for clinical outcomes, antibiotic use and patient satisfaction. SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 4, 2006); MEDLINE (January 1966 to January Week 2, 2007), EMBASE (1990 to Week 2, 2007) and Current Contents - ISI Web of Knowledge (1998 to January 2007). SELECTION CRITERIA: Randomised controlled trials (RCTs) involving patients of all ages defined as having an acute respiratory infection were included in which delayed antibiotics were compared to antibiotics used immediately or no antibiotics. Outcomes measured included clinical outcomes, antibiotic use and patient satisfaction. DATA COLLECTION AND ANALYSIS: Data were collected and analysed by three review authors. MAIN RESULTS: Nine trials were eligible on the basis of design and relevant outcomes. For most clinical outcomes there was no difference between delayed, immediate and no antibiotics. Antibiotics prescribed immediately were more effective than delayed for fever, pain and malaise in some studies of patients with acute otitis media and sore throat but for other studies there was no difference. There was no difference for the common cold and bronchitis. Delaying antibiotic prescriptions reduced antibiotic use, and in three studies, reduced patient satisfaction compared to immediate antibiotics. In the other two studies comparing delayed and immediate antibiotics measuring satisfaction, there was no difference. Two studies also included a 'no antibiotics' arm for bronchitis and sore throat: there was no difference in symptom resolution nor patient satisfaction from antibiotic delay. In one study, but not the other, antibiotic use was significantly decreased with no, rather than delayed, antibiotics. AUTHORS' CONCLUSIONS: For most clinical outcomes there is no difference between the strategies. Immediate antibiotics was the strategy most likely to provide the best clinical outcomes in patients with sore throat and otitis media. Delaying or avoiding antibiotics, rather than providing them immediately, reduces antibiotic use for acute respiratory infections. Delay also reduced patient satisfaction in three trials, compared to immediate antibiotics with no difference in two other trials. Delaying antibiotics seems to have little advantage over avoiding them altogether where it is safe to do so.

Celecoxib compared with sustained-release paracetamol for osteoarthritis: a series of n-of-1 trials.

OBJECTIVE: To assess the use of n-of-1 trials for short-term choice of drugs for osteoarthritis, with particular reference to comparing the efficacy of sustained-release [SR] paracetamol with celecoxib in individual patients. METHODS: Evaluation of community-based patients undergoing n-of-1 trials which consisted of double-blind, crossover comparisons of celecoxib 200 or 400 mg/day with sustained-release paracetamol 1330 mg three times a day in three pairs of 2 week treatment periods per drug with random order of the drugs within pairs. Outcomes evaluated were pain and stiffness in sites nominated by the patient, functional limitation scores, preferred medication, side effects and changes in drug use after an n-of-1 trial. Participants were 59 patients with osteoarthritis in multiple sites (hip 6, knee 24, hand 6, shoulder/neck 8, back 14, foot 5), with pain for >or=1 month severe enough to warrant consideration of long-term use of celecoxib but for whom there was doubt about its efficacy. Forty-one n-of-1 trials were completed. RESULTS: Although on average, celecoxib showed better scores than SR paracetamol [0.2 (0.1) for pain, 0.3 (0.1) for stiffness and 0.3 (0.1) for functional limitation], 33 of the 41 individual patients (80%) failed to identify the differences between SR paracetamol and celecoxib in terms of overall symptom relief. Of the eight patients who were able to identify the differences, seven had better relief with celecoxib and one with SR paracetamol. In 25 out of 41 [61%] patients, subsequent management was consistent with their trial results. CONCLUSIONS: N-of-1 trials may provide a rational and effective method to best choose drugs for individuals with osteoarthritis. SR paracetamol is more useful than celecoxib for most patients of whom management is uncertain.

Antibiotics for sore throat.

BACKGROUND: Sore throat is a very common reason for people to present for medical care. Although it remits spontaneously, primary care doctors commonly prescribe antibiotics for it. OBJECTIVES: To assess the benefits of antibiotics for sore throat. SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) and the Database of Abstracts of Reviews of Effects (DARE) (The Cochrane Library, Issue 1, 2006), MEDLINE (January 1966 to March 2006) and EMBASE (January 1990 to December 2005). SELECTION CRITERIA: Trials of antibiotic against control with either measures of the typical symptoms (throat soreness, headache or fever), or suppurative or non-suppurative complications of sore throat. DATA COLLECTION AND ANALYSIS: Potential studies were screened independently by two authors for inclusion, with differences in opinion resolved by discussion. Data were then independently extracted from studies selected by inclusion by two authors. Researchers from three studies were contacted for additional information. MAIN RESULTS: There were 27 studies with 2835 cases of sore throat. 1. Non-suppurative complications: There was a trend for antibiotics to protect against acute glomerulonephritis, but there were insufficient cases to be sure. Several studies found antibiotics reduced acute rheumatic fever by more than two thirds (relative risk (RR) 0.22; 95% CI 0.02 to 2.08). 2. Suppurative complications: Antibiotics reduced the incidence of acute otitis media (RR 0.30; 95% CI 0.15 to 0.58); of acute sinusitis (RR 0.48; 95% CI 0.08 to 2.76); and of quinsy (peritonsillar abscess) compared to those taking placebo (RR 0.15; 95% CI 0.05 to 0.47). 3. SYMPTOMS: Throat soreness and fever were reduced by antibiotics by about one half. The greatest difference was seen at about 3 to 4 days (when the symptoms of about 50% of untreated patients had settled). By one week about 90% of treated and untreated patients were symptom-free. The overall number need to treat to prevent one sore throat at day 3 was just under six (95% CI 4.9 to 7.0); at week 1 it was 21 (95% CI 13.2 to 47.9). 4. Subgroup analyses of symptom reduction: Analysis by: age; blind versus unblinded; or use of antipyretics, found no significant differences. Analysis of results of throat swabs showed that antibiotics were more effective against symptoms at day 3, RR 0.58 (95% CI 0.48 to 0.71) if the swabs were positive for Streptococcus, compared to RR 0.78 (95% CI 0.63 to 0.97) if negative. Similarly at week 1, RRs 0.29 (95% CI 0.12 to 0.70) for positive, and 0.73 (95% CI 0.50 to 1.07) for negative swabs. AUTHORS' CONCLUSIONS: Antibiotics confer relative benefits in the treatment of sore throat. However, the absolute benefits are modest. Protecting sore throat sufferers against suppurative and non-suppurative complications in modern Western society can only be achieved by treating many with antibiotics, most of whom will derive no benefit. In emerging economies (where rates of acute rheumatic fever are high, for example), the number needed to treat may be much lower for antibiotics to be considered effective. Antibiotics shorten the duration of symptoms by about sixteen hours overall.

Advising patients to increase fluid intake for treating acute respiratory infections.

BACKGROUND: Acute respiratory infection is a common reason for people to present for medical care. Advice to increase fluid intake is a frequent treatment recommendation. Attributed benefits of fluids include replacing increased insensible fluid losses, correcting dehydration from reduced intake and reducing the viscosity of mucus. However, there are theoretical reasons for increased fluid intake to cause harm. Anti-diuretic hormone secretion is increased in lower respiratory tract infections of various aetiologies. This systematic examination of the evidence sought to determine the benefit versus harm from increasing fluid intake. OBJECTIVES: To answer the following questions. (1) Does recommending increased fluid intake as a treatment for acute respiratory infections improve duration and severity of symptoms? (2) Are there adverse effects from recommending increased fluids in people with acute respiratory infections? (3) Are any benefits or harms related to site of infection (upper or lower respiratory tract) or a different severity of illness? SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 2, 2005), MEDLINE (1966 to July Week 1, 2005), EMBASE (1974 to Week 29, 2005), Current Contents (current 5 years) and CINAHL (1982 to July week 3 2005). Reference lists of articles identified were searched, and experts in the relevant disciplines were contacted. SELECTION CRITERIA: Randomised controlled trials (RCTs) that examined the effect of increasing fluid intake in people with acute respiratory infections. DATA COLLECTION AND ANALYSIS: Each author assessed the identified studies to determine eligibility for inclusion. MAIN RESULTS: No RCTs assessing the effect of increasing fluid intake in acute respiratory infections were found. AUTHORS' CONCLUSIONS: There is currently no evidence for or against the recommendation to increase fluids in acute respiratory infections. The implications for fluid management in acute respiratory infections have not been studied in any RCTs to date. Some non-experimental (observational) studies report that increasing fluid intake in acute respiratory infections may cause harm. RCTs need to be done to determine the true effect of this very common medical advice.

Delayed antibiotics for symptoms and complications of respiratory infections.

BACKGROUND: The use of antibiotics for upper respiratory tract infections is controversial. Any benefits have to be weighed against common adverse reactions (including rash, abdominal pain, diarrhoea and vomiting), cost and antibacterial resistance. There has been interest in ways to reduce antibiotic prescribing for acute respiratory infections. One is delaying the use of prescribed antibiotics by more than 48 hours for acute upper respiratory tract infections. Such methods have been shown to reduce prescribing. This review asks what effect this practice has on the clinical course of the illness. OBJECTIVES: To evaluate the clinical effect of delayed antibiotic use in acute upper respiratory tract infections compared to immediate use of antibiotics SEARCH STRATEGY: The following electronic databases were searched: the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 1, 2004) which includes the Acute Respiratory Infection Groups' specialised register; MEDLINE (January 1966 to January Week 1 2004), EMBASE (1990 to September 2003) and Current Contents (1998 to 2003). The search was carried out by an expert librarian. Abstracts of identified articles were used to determine which studies were trials. SELECTION CRITERIA: Randomised controlled trials involving patients of all ages defined as having acute otitis media, acute pharyngitis, sore throat, common cold, a viral upper respiratory tract infection, acute sinusitis, and acute bronchitis were included in which delayed antibiotics are compared to antibiotics used immediately. Delayed antibiotic use was defined as the use of or advice to use antibiotics more than 48 hours after the initial consultation. 'Immediate antibiotic use' was defined as the immediate use of oral antibiotics given at the initial consultation. Clinical outcomes measured included: the presence or absence of fever, cough, pain, duration and severity of illness, complications of the disease, adverse effects from the antibiotics. Trial quality was assessed independently by two reviewers who were blinded to the author, journal and results of each study. DATA COLLECTION AND ANALYSIS: Data was collected by two reviewers who were blinded to the author and journal. Data were analysed and reported using RevMan. MAIN RESULTS: Seven trials were eligible on the basis of design and all reported patient-centred outcomes. Methodological quality of included trials was generally high. There was no difference between immediate and delayed antibiotic groups for symptoms on day one and day seven. For most symptom measures there was no significant difference between the immediate and delayed antibiotic groups. Missing data and marked heterogeneity between study outcomes prevented pooling of results as a meta-analysis. Three studies out of six reporting fever, all involving patients with sore throat, indicated that there was more fever in the delayed antibiotic group. The remaining three studies showed no difference. There was no significant symptom difference for patients with cough or the common cold between the two intervention groups. Pain and malaise severity scores at day three significantly favoured the immediate antibiotic group in children with acute otitis media (Little 2001). In this study by Little 2001 of children with otitis media proxies for other malaise related outcomes were reported, including 'last day of crying' which favoured the immediate antibiotic group by approximately 16 hours (0.69 days; 95% CI 0.31 to 1.07). In the same study, just over half a spoon of paracetamol a day less was used in the immediate antibiotic group (0.59; 95% CI 0.25 to 0.93). There was no significant difference between the intervention groups for the adverse outcome of rash. Two studies reported the outcome of vomiting which was reduced in the immediate antibiotic group in children with suspected streptococcal pharyngitis in El-Daher 1991 but there was no difference in children with sore throat in Little 1997. Diarrhoea was reported by three studies of which two showed no difference Little 1997; Arroll 2002a while Little 2001 reported less diarrhoea in the delayed antibiotic group in children with otitis media. REVIEWERS' CONCLUSIONS: When considering treatment options for upper respiratory tract infections, the option of delayed antibiotics has been used in an attempt to reduce the use of antibiotic prescriptions. This review shows that for all symptom scores the evidence varies between trials. Most symptom outcomes show no difference between immediate and delayed antibiotic groups. Three of the six studies, all involving patients with sore throat, indicated that patients in the delayed antibiotic group had significantly more fever that their counterparts in the immediate antibiotic group. The other three showed no difference for the outcome of fever. There is evidence indicating that for children with otitis media, pain and malaise scores are worse in the delayed antibiotic group compared to the immediate antibiotic group. This price must be weighed up against the benefits of reduced antibiotic prescribing. Future randomised controlled trials of delaying antibiotics as an intervention should fully report symptoms as well as changes of prescription rates.

Antibiotics for sore throat.

BACKGROUND: Sore throat is a very common reason for people to seek medical care. It is a disease that remits spontaneously, that is, 'cure' is not dependent on treatment. Nonetheless primary care doctors commonly prescribe antibiotics for sore throat and other upper respiratory tract infections. OBJECTIVES: To assess the benefits of antibiotics in the management of sore throat. SEARCH STRATEGY: Systematic search of the literature from 1945 to 2003, using electronic searches of the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, issue 2, 2003); MEDLINE (January 1966 to May 2003); EMBASE (January 1990 to March 2003), and the reference sections of the articles identified. We applied no language restrictions. We used abstracts of identified articles to identify trials. SELECTION CRITERIA: Trials of antibiotic against control with either measures of the typical symptoms (throat soreness, headache or fever), or suppurative complications (meaning: forming pus) and non-suppurative complications of sore throat. DATA COLLECTION AND ANALYSIS: Two reviewers independently screened potential studies for inclusion and resolved differences in opinion by discussion. The reviewers then independently extracted the data from the selected studies. We contacted the authors of three studies to acquire additional information not available in published articles. Potential studies were screened independently by two reviewers for inclusion, with differences in opinion resolved by discussion. Data was then independently extracted from studies selected by inclusion by two reviewers. Authors of three studies were contacted to acquire additional information not available in published articles. MAIN RESULTS: We included twenty-six studies, covering 12,669 cases of sore throat in the review.1. Non-suppurative complications There was a trend for protection against acute glomerulonephritis by antibiotics, but insufficient cases were recorded to be sure of this effect. Several studies found that antibiotics reduced acute rheumatic fever, to less than one third (odds ratio (OR) = 0.30; 95% confidence interval (CI) = 0.20 to 0.45). 2. Suppurative complications Antibiotics reduced the incidence of acute otitis media to about one quarter of that in the placebo group (OR = 0.22; 95% CI 0.11 to 0.43) and reduced the incidence of acute sinusitis to about one half of that in the placebo group (OR = 0.46; 95% CI 0.10 to 2.05). The incidence of quinsy was also reduced in relation to placebo group (OR = 0.16; 95% CI 0.07 to 0.35). 3. Symptoms Symptoms of headache, throat soreness and fever were reduced by antibiotics to about one half. The greatest time for this to be evident was at about three and a half days (when the symptoms of about 50% of untreated patients had settled). About 90% of treated and untreated patients were free of symptoms by one week. The overall number needed to treat to prevent one sore throat at day three was about 5.0 (95% CI 4.5 to 5.8); and at one week was 14.2 (95% CI 11.5 to 20.6). 4. Subgroup analyses of symptom reduction Subgroup analysis by age; blind versus unblinded; or use of antipyretics yielded no significant differences. The results of swabs of the throat for Streptococcus influenced the effect of antibiotics. If the swab was positive, antibiotics were more effective (the OR reduced to 0.16, 95% CI 0.09 to 0.26) than if it was negative (OR 0.65; 95% CI 0.38 to 1.12). REVIEWERS' CONCLUSIONS: Antibiotics confer relative benefits in the treatment of sore throat. However, the absolute benefits are modest. Protecting sore throat sufferers against suppurative and non-suppurative complications in modern Western society can be achieved only by treating with antibiotics many who will derive no benefit. In emerging economies where rates of for example acute rheumatic fever are high, the number needed to treat may be much lower. Antibiotics shorten the duration of symptoms by a mean of one day about half way through the illness (the time of maximal effect), and by about sixteen hours overall.

Antibiotics for acute otitis media in children.

BACKGROUND: Acute otitis media is one of the most common diseases in early infancy and childhood. Antibiotic use for acute otitis media varies from 31% in the Netherlands to 98% in the USA and Australia. OBJECTIVES: The objective of this review was to assess the effects of antibiotics for children with acute otitis media. SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE, Index Medicus (pre 1965), Current Contents and reference lists of articles from 1958 to January 2000. The search was updated in 2003. SELECTION CRITERIA: Randomised trials comparing antimicrobial drugs with placebo in children with acute otitis media. DATA COLLECTION AND ANALYSIS: Three reviewers independently assessed trial quality and extracted data. MAIN RESULTS: Ten trials were eligible based on design, only eight of the trials, with a total of 2,287 children, included patient-relevant outcomes. The methodological quality of the included trials was generally high. All trials were from developed countries. The trials showed no reduction in pain at 24 hours, but a 30% relative reduction (95% confidence interval 19% to 40%) in pain at two to seven days. Since approximately 80% of patients will have settled spontaneously in this time, this means an absolute reduction of 7% or that about 15 children must be treated with antibiotics to prevent one child having some pain after two days. There was no effect of antibiotics on hearing problems of acute otitis media, as measured by subsequent tympanometry. However, audiometry was done in only two studies and incompletely reported. Nor did antibiotics influence other complications or recurrence. There were few serious complications seen in these trials: only one case of mastoiditis occurred in a penicillin treated group. REVIEWER'S CONCLUSIONS: Antibiotics provide a small benefit for acute otitis media in children. As most cases will resolve spontaneously, this benefit must be weighed against the possible adverse reactions. Antibiotic treatment may play an important role in reducing the risk of mastoiditis in populations where it is more common.

Feasibility of an evidence-based literature search service for general practitioners.

OBJECTIVE: To test the feasibility of an evidence-based clinical literature search service to help answer general practitioners' (GPs') clinical questions. DESIGN: Two search services supplied GPs who submitted questions with the best available empirical evidence to answer these questions. The GPs provided feedback on the value of the service, and concordance of answers from the two search services was assessed. SETTING: Two literature search services (Queensland and Victoria), operating for nine months from February 1999. MAIN OUTCOME MEASURES: Use of the service; time taken to locate answers; availability of evidence; value of the service to GPs; and consistency of answers from the two services. RESULTS: 58 GPs asked 160 questions (29 asked one, 11 asked five or more). The questions concerned treatment (65%), aetiology (17%), prognosis (13%), and diagnosis (5%). Answering a question took a mean of 3 hours 32 minutes of personnel time (95% CI, 2.67-3.97); nine questions took longer than 10 hours each to answer, the longest taking 23 hours 30 minutes. Evidence of suitable quality to provide a sound answer was available for 126 (79%) questions. Feedback data for 84 (53%) questions, provided by 42 GPs, showed that they appreciated the service, and asking the questions changed clinical care. There were many minor differences between the answers from the two centres, and substantial differences in the evidence found for 4/14 questions. However, conclusions reached were largely similar, with no or only minor differences for all questions. CONCLUSIONS: It is feasible to provide a literature search service, but further assessment is needed to establish its cost effectiveness.

Research output of Australian general practice: a comparison with medicine, surgery and public health.

OBJECTIVES: To compare the productivity of Australian general practice in terms of research publications with the productivity of other medical disciplines. DESIGN: A survey of Australian general practice, medicine, surgery and public health publications carried out by manual searching of specific journals and an electronic search of the US National Library of Medicine's "PubMed" database. MAIN OUTCOME MEASURES: The number of original research publications by Australian general practitioners, physicians, surgeons and public health physicians during 1999; the relative publication rate of Australian general practice, medicine, surgery and public health over the period 1990-1999. RESULTS: Of original research articles published in 1999, GPs authored 65% (17/26) in Australian Family Physician and 3% (3/90) in the Medical Journal of Australia; physicians published 4% and 37%, respectively. The electronic search identified 54 research articles relating to Australian general practice published in 1999 in 21 different journals, only two of which were primary care journals. Over the period 1990-1999, there was a publication rate of one general practice [discipline] article per 1000 GPs in practice per year. Corresponding rates for medicine, surgery and public health were 105/1000, 61/1000 and 148/1000, respectively. CONCLUSIONS: There is considerable disparity between the level of research output of general practice and that of the disciplines of medicine, surgery and public health. If we are to have effective general practice research, we urgently need to develop research skills, a supportive infrastructure and a culture that nurtures research.

Ways of using evidence-based medicine in general practice.

General practitioners wanting to practise evidence-based medicine (EBM) are constrained by time factors and the great diversity of clinical problems they deal with. They need experience in knowing what questions to ask, in locating and evaluating the evidence, and in applying it. Conventional searching for the best evidence can be achieved in daily general practice. Sometimes the search can be performed during the consultation, but more often it can be done later and the patient can return for the "result". Case-based journal clubs provide a supportive environment for GPs to work together to find the best evidence at regular meetings. An evidence-based literature search service is being piloted to enhance decision-making for individual patients. A central facility provides the search and interprets the evidence in relation to individual cases. A request form and a "results" format make the service akin to pathology testing or imaging. Using EBM in general practice appears feasible. Major difficulties still exist before it can be practised by all GPs, but it has the potential to change the way doctors update their knowledge.