Journal of Antimicrobial Chemotherapy (1998) 41, 259266

JAC

Adult acute upper respiratory tract infections in Sicily: pattern of antibiotic drug prescription in primary care
G. Mazzaglia*, S. Greco, C. Lando, G. Cucinotta and A. P. Caputi
Institute of Pharmacology, School of Medicine, University of Messina, Piazza XX Settembre 4, I-98122 Messina, Italy
We performed an observational study of the antibiotic-prescribing behaviour of Sicilian general practitioners (GPs) in managing acute upper respiratory tract infections (URTIs). Seventy-six GPs from 25 towns, representing a patient population of 96,630, participated in the study between September 1995 and May 1996. These physicians issued 2038 antibiotic treatment courses for acute upper respiratory tract infections: 792 for acute pharyngitis, 531 for acute tonsillitis, 304 for acute laryngitis and tracheitis, 268 for suppurative and nonsuppurative acute otitis media, 124 for acute sinusitis and 19 for acute rhinitis. Forty-nine different antibiotics were prescribed. The most commonly used therapeutic groups were macrolides (38.6%), cephalosporins (27.1%), a combination of penicillins with -lactamase inhibitors (15.7%) and extended spectrum penicillins (13.5%). For each of the above diseases, except rhinitis, more than 30 different antibiotics were used. The choice of the route of administration appeared to be inuenced by the age of the patients and, signicantly, by a subjective clinical assessment of disease severity rather than by any consideration of epidemiological information or evidence from clinical trials. The rather marked variation in antibiotic-prescribing pattern for URTIs among Sicilian GPs reects lack of availability or knowledge of any local or national guidelines.

Introduction
Upper respiratory tract infections (URTIs) in children and adults are the commonest reason for consulting general practitioners (GPs). 1,2 The effectiveness of antibiotic prescriptions in many of these cases can be questioned,3,4 because URTIs can be caused by viruses, which are mainly self-limiting. Usually in general practice, therapy is started before a laboratory report is available and, consequently, antibiotic therapy has to be initiated on an empirical basis, guided by the physicians best guess of what aetiological agents are most likely to be involved. Various bacteria can cause URTIs; the most common pathogens involved are Streptococcus pneumoniae and Haemophilus inuenzae. Streptococcus pyogenes is more often associated with bacterial pharyngotonsillitis and Moraxella catarrhalis with middle ear infections. Both bacteria can be associated with sinus infections.5 Studies of drug use have shown great variability in the use of antibiotics for these diseases.6,7 Sometimes this variability is attributable to differences in the infecting organisms and in antimicrobial susceptibility, but other factors may also

be involved, such as differences in opinions among physicians, that may impede the selection of the most effective, safe and economic therapeutic antibiotic regimen. In Italy there are no guidelines for the management of infectious disease in general practice. The National Institute of Health (NIH) is responsible for approving drugs and specifying the recommended doses prior to marketing, but does not produce guidelines regarding the choice of a particular drug regimen. Thus, we carried out this study with the main aim of describing the antibiotic-prescribing pattern of Sicilian GPs in acute URTIs in order to develop a process that involves GPs in decisions regarding the choice of antibiotic.

Methods
The study was carried out from September 1995 to May 1996. A letter was sent in March 1995 to all Sicilian GPs whose names and addresses were obtained from a list supplied from the Regional Institute of Health. These doctors were invited to participate in our study and no nancial incentives were offered. They were told that all

*Tel:

39-90-712533; Fax:

39-90-661029.

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1998 The British Society for Antimicrobial Chemotherapy

G. Mazzaglia et al. practitioners who agreed to participate would be included in the study. Of 4749 Sicilian GPs approach, 76 physicians of 25 Sicilian towns, with a patient population of 96,630, agreed to participate (response rate 1.6%). Each participating GP was sent a questionnaire seeking information about gender, age, place and date of graduation in medicine, number of years in practice and size. A second questionnaire had to be completed for each consultation ending with an antibiotic prescription. This questionnaire enquired about patient demographics, the presence of comorbid diseases (e.g. diabetes, hypertension, etc.), any previous adverse drug reactions or allergies and an assessment of the present disease, including severity and proposed antibiotic management plan (drug type, route of administration, dosage, frequency, duration). The severity assessment was purely subjective and graded as slight, moderate, marked or severe. In the case of suspected adverse drug reaction due to the antibiotic, a second part of the questionnaire had to be completed. At the end of the course of treatment the GP had to re-evaluate subjectively the impact of treatment on the symptoms. This evidence has not been further assessed, because it did not fall directly within the remit of the study. The diagnoses and drugs were classied according to the International Classication of Diseases (ICD-10 three character categories; 10th revision) and to the Anatomical Therapeutic Chemical (ATC) classication system, respectively. To evaluate antibiotic utilization, all daily doses of antibacterial agents were standardized by using the prescribed daily dose (PDD). The PDD is the average daily dose prescribed by the physicians as obtained from a representative sample of prescriptions.8 In this study, of 9395 consultations ending with an antibiotic prescription, we selected 2038 (21.7%) classied as URTIs in adult patients. Data were analysed statistically with EPI-INFO version 6.0 (Centres for Disease Control and Prevention, USA, and WHO, Geneva) using the trend for quantitative data in order to analyse 2 of linearity and CIA (condence intervals analysis) version 1.0 to evaluate the 95% condence interval (CI), where appropriate.

Results
Prescriptions for acute URTIs accounted for 21.7% of all antibiotics prescribed by the physicians. Forty-nine different antibiotics were used, most commonly macrolides

Table I. Diagnosis and age of patients treated Age (years) 4660 6175 3 17 150 64 54 2 51 341 1 9 126 32 71 1 38 278

Disease (ICD-10 classication) Acute rhinitis (J00) Acute sinusitis (J01) Acute pharyngitis (J02) Acute tonsillitis (J03) Acute laryngitis and tracheitis (J04) Nonsuppurative otitis media (H65) Suppurative and unspecied otitis media (H66) Total

1530 5 44 251 237 67 3 71 678

3145 9 49 215 185 95 6 78 637

75 1 5 50 13 17 1 17 104

Total 19 124 792 531 304 13 255 2038

Table II. Therapeutic group (ATC classication) of patients treated Therapeutic group (ATC classicationa) J01DA J01CR J01CA J01MA J01FF 3 33 173 150 82 3 109 553 2 22 91 99 68 3 34 319 6 7 158 54 30 0 21 276 0 5 12 8 6 1 3 35 0 7 8 16 1 0 1 33

Disease (ICD-10 classication) Acute rhinitis (J00) Acute sinusitis (J01) Acute pharyngitis (J02) Acute tonsillitis (J03) Acute laryngitis and tracheitis (J04) Nonsuppurative otitis media (H65) Suppurative and unspecied otitis media (H66) Total
a

J01FA 8 44 342 197 104 6 85 786

Othersb 0 6 8 7 13 0 2 36

J01FA, macrolides; J01DA, cephalosporins; J01CR, combination of penicillins and -lactamase ihibitors; J01CA, extended spectrum penicillins; J01MA, uoroquinolones; J01FF, lincosamides. b Others: all other therapeutic groups, such as tetracyclines (J01AA), aminoglycosides (J01GB), which were used in 1% of all treatments.

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Antibiotic prescription and general practitioners Table III. The antibiotics prescribed for acute pharyngitis, in order of prescription frequency, with PDD and duration of treatment PDD (g/day) mean (median) S.E.M. 0.5 (0.5) 0.5 (0.5) 2.0 (2.0) 2.0 (2.0) 0.3 (0.3) 0.4 (0.4) 0.4 (0.4) 0.8 (0.8) 2.4 (2.4) 1.4 (1.5) 1.7 (2.0) 0.8 (1.0) 1.0 (1.0) 2.0 (2.0) 1.2 (1.2) 2.1 (2.0) 1.2 (1.2) 1.0 (1.0) 1.7 (2.0) 1.0 (1.0) 1.7 (2.0) 1.0 (1.0) 1.3 (1.2) 1.7 (2.0) 2.5 (2.0) 1.0 (1.0) 1.4 (2.0) 0.4 (0.4) 2.0 (2.0) 0.2 0.4 2.0 3.0 n.s. 1.9 n.s. 1.0 2.0 2.0 n.s. 0.8 n.s. 0.1 0.01 0.03 0.00 0.00 0.01 0.01 0.02 0.00 0.07 0.14 0.07 0.00 0.00 0.08 0.29 0.00 0.00 0.29 0.00 0.25 0.00 0.30 0.25 0.28 0.00 0.58 0.00 0.00 0.00 0.00 Length of treatment (days) mean (median) S.E.M. 3.4 (3) 5.0 (5) 5.7 (6) 5.6 (6) 5.7(6) 5.2 (5) 4.8 (5) 5.8 (6) 5.4 (6) 5.7 (5) 5.6 (6) 5.2 (5) 5.4 (5) 5.9 (6) 4.0 (4) 4.7 (4) 6.8 (6) 6.0 (6) 4.3 (4) 5.0 (6) 5.3 (5) 5.2 (5) 5.2 (5) 4.7 (5) 6.5 (6) 5.0 (6) 4.7 (5) 6.3 (5) 5.7 (6) 5.5 5.5 n.s. 4.0 11.0 4.0 4.0 7.0 7.0 5.0 n.s. 3.0 4.0 0.08 0.14 0.14 0.11 0.14 0.11 0.19 0.30 0.24 0.29 0.59 0.45 0.15 0.48 0.37 0.52 0.46 0.41 0.49 0.51 0.28 0.62 0.47 0.25 0.95 1.00 0.33 1.85 0.33 0.50 1.50

Antibiotic

No. of treatments 113 110 108 90 71 52 35 28 27 22 15 12 11 9 8 8 8 7 6 5 4 4 4 4 4 3 3 3 3 2 2 1 1 1 1 1 1 1 1 1 1 1 792

% of total 14.3 13.9 13.6 11.4 9.0 6.6 4.4 3.5 3.4 2.8 1.9 1.5 1.4 1.1 1.0 1.0 1.0 0.9 0.7 0.6 0.5 0.5 0.5 0.5 0.5 0.4 0.4 0.4 0.4 0.2 0.2 0.1 0.1 0.1 0.1 0.1 0.1 0.1 0.1 0.1 0.1 0.1 100.0

Azithromycin Clarithromycin Amoxycillin Co-amoxiclav Roxithromycin Cexime Ceftibuten Rokitamycin Bacampicillin Cefaclor Ampicillin Cefuroxime axetil Cefatrizine Cefadroxil Lincomycin Piperacillin Myocamicin Ciprooxacin Ceftazidime Cefonicid Cefotaxime Ceftriaxone Erythromycin Josamycin Spiramycin Cefodizime Cefuroxime Lomeoxacin Cefalexin Brodimoprim Ruoxacin Cephazolin Ampicillin sulbactam Tobramycin Co-trimoxazole Cephaloridine Tetracycline Cephradine Cephtezol Fusangine Rifaximine Trimethoprim Total
n.s.: not specied by GPs.

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G. Mazzaglia et al. (38.6%), cephalosporins (27.1%), a combination of penicillins and -lactamase inhibitors (15.7%) and extended spectrum penicillins (13.5%). Table I breaks down the GP prescribing by diagnosis group and age of the patient. The treatments given did not vary according to the gender of the patients. Table II shows the number of treatments prescribed by physicians divided into diagnostic group and therapeutic group. For acute pharyngitis, tonsillitis, laryngotracheitis and otitis media, 42, 34, 34 and 30 different compound, were used respectively. Data regarding PDD and duration of therapy are summarized in Tables IIIVI. For acute sinusitis, thirty different antibiotics were used. The seven most prescribed drugs were co-amoxiclav (17.7%), azithromycin (10.5%), clarithromycin (9.7%), cefuroxime axetil (8.9%), roxithromycin (8.9%), lincomycin (5.6%) and ceftibuten (4.8%). Analysis of the antibiotic prescription prole does not include the diagnosis of acute rhinitis because the number of treatments did not allow a signicant evaluation.

Table IV. The antibiotics prescribed for acute tonsillitis, in order of prescription frequency, together with PDD and duration of treatment PDD (g/day) mean (median) S.E.M. 0.5 (0.5) 2.1 (2.0) 0.5 (0.5) 0.4 (0.4) 2.2 (2.0) 1.0 (1.0) 2.0 (2.0) 0.4 (0.4) 1.2 (1.0) 1.1 (1.2) 0.3 (0.3) 2.3 (2.4) 2.0 (2.0) 1.1 (1.0) 1.6 (1.8) 3.7 (4.0) 0.9 (1.0) 2.8 (3.0) 0.9 (0.8) 2.0 (2.0) 1.7 (2.0) 1.8 (2.0) 1.0 2.0 1.9 0.2 2.0 1.2 2.0 1.0 1.0 n.s. 1.0 n.s. 0.00 0.03 0.01 0.00 0.06 0.06 0.00 0.00 0.06 0.04 0.00 0.06 0.00 0.10 0.17 0.25 0.08 0.14 0.10 0.00 0.25 0.16 0.00 0.00 0.66 0.12 Length of treatment (days) mean (median) S.E.M. 3.7 (3) 5.8 (6) 5.8 (6) 5.6 (5) 5.8 (6) 5.6 (6) 4.6 (4) 4.9 (5) 6.1 (6) 5.1 (5) 5.8 (6) 5.3 (5) 4.7 (4) 6.6 (6) 6.3 (6) 3.5 (3) 5.2 (5) 4.8 (5) 5.5 (5) 6.3 (6) 5.2 (6) 6.3 (6) 3.5 4.0 7.0 6.5 5.0 1.0 6.0 6.0 7.0 n.s. 4.0 n.s. 0.16 0.12 0.25 0.22 0.25 0.57 0.30 0.28 0.33 0.23 0.42 0.31 0.42 0.52 0.47 0.37 0.31 0.45 0.28 0.28 0.47 0.33 1.50 0.00 1.00 0.50

Antibiotic

No. of treatments 113 92 54 42 31 26 18 16 16 16 12 12 10 10 9 8 8 7 4 4 4 3 2 2 2 2 1 1 1 1 1 1 1 1 531

% of total 21.3 17.3 10.2 7.9 5.8 4.9 3.4 3.0 3.0 3.0 2.3 2.3 1.9 1.9 1.7 1.5 1.5 1.3 0.7 0.7 0.7 0.6 0.4 0.4 0.4 0.4 0.2 0.2 0.2 0.2 0.2 0.2 0.2 0.2 100.0

Azithromycin Co-amoxiclav Clarithromycin Cexime Amoxycillin Cefuroxime axetil Cefotaxime Ceftibuten Cefaclor Lincomycin Roxithromycin Bacampicillin Ceftazidime Ceftriaxone Erythromycin Piperacillin Ciprooxacin Ampicillin sulbactam Rokitamycin Josamycin Cefuroxime Ampicillin Cefatrizine Cefazolin Co-trimoxazole Netilmicin Cefadroxil Myocamycin Cephalexin Cefonicid Cefodizime Brodimoprim Tetracycline Benzylpenicillin Total
n.s.: not specied by GPs.

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Antibiotic prescription and general practitioners Table V. The antibiotics prescribed for acute laringitis and tracheitis, in order of prescription frequency, together with PDD and duration of treatment PDD (g/day) mean (median) S.E.M . 2.0 (2.0) 0.5 (0.5) 0.5 (0.5) 0.4 (0.4) 0.3 (0.3) 2.0 (2.0) 2.0 (2.0) 1.3 (1.5) 1.0 (1.0) 2.0 (2.0) 1.5 (1.5) 0.4 (0.4) 0.8 (0.8) 1.2 (1.0) 2.0 (2.0) 0.1 (0.1) 2.4 (2.4) 0.7 (0.5) 1.5 (2.0) 1.5 (1.2) n.s. 2.0 1.4 0.2 0.2 n.s. 1.2 n.s. 4.0 3.0 1.0 1.0 0.4 n.s. 0.00 0.00 0.02 0.05 0.01 0.05 0.00 0.29 0.00 0.00 0.12 0.00 0.00 0.25 0.00 0.00 0.00 0.16 0.50 0.26 0.00 0.00 0.00 0.00 Length of treatment (days) mean (median) S.E.M . 6.1 (6) 3.1 (3) 5.7 (6) 5.2 (5) 5.8 (6) 5.9 (6) 5.2 (5) 5.1 (5) 4.7 (4) 5.7 (5) 4.8 (5) 5.6 (6) 5.6 (6) 5.0 (5) 5.7 (6) 5.7 (6) 5.0 (5) 6.3 (5) 5.3 (5) 6.7 (6) n.s. 5.0 6.0 7.5 6.5 n.s. 6.0 n.s. 5.0 5.0 6.0 6.0 5.0 n.s. 0.10 0.08 0.20 0.14 0.32 0.21 0.44 0.12 0.74 0.42 0.16 0.50 0.50 0.40 0.62 0.47 0.57 1.33 0.33 0.66 0.00 0.00 0.50 0.50

Antibiotic

No. of treatments 67 41 34 31 20 18 10 8 7 7 6 5 5 4 4 4 3 3 3 3 3 2 2 2 2 2 1 1 1 1 1 1 1 1 304

% of total 22.0 13.5 11.2 10.2 6.6 5.9 3.3 2.6 2.3 2.3 2.0 1.6 1.6 1.3 1.3 1.3 1.0 1.0 1.0 1.0 1.0 0.7 0.7 0.7 0.7 0.7 0.3 0.3 0.3 0.3 0.3 0.3 0.3 0.3 100.0

Co-amoxiclav Azithromycin Clarithromycin Cexime Roxithromycin Amoxycillin Cefazolin Ampicillin Cefuroxime axetil Ceftazidime Cefaclor Ceftibuten Rokitamycin Ceftriaxone Cefadroxil Doxycycline Bacampicillin Ciprooxacin Cefuroxime Myocamycin Gentamicin Cefotaxime Co-trimoxazole Brodimoprim Ruoxacin Tobramycin Lincomycin Erythromycin Piperacillin Ampicillin sulbactam Cefonicid Cefodizime Lomeoxacin Cephaloridine Total
n.s.: not specied by GPs

Adverse drug reactions were reported in 28 cases (1.4% of total treatments). The combination of penicillins with -lactamase inhibitors was associated with the highest incidence (3.1%) of adverse drug reactions. The most commonly reported adverse reactions were gastrointestinal side-effects (diarrhoea and dyspepsia), as shown in Table VII. Table VIII relates the ages of patients and the subjective

symptom score observed by the GPs before the antibiotic prescription with the choice of the route (oral or injected) of antibiotic administration. Although not statistically signicant, there appears to be a correlation between use of parental route and increasing patient age ( 2 value of 2.18 with P 0.535). There is a signicant correlation between the choice of the parental route and the increased symptom score ( 2 value of 112.9).

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G. Mazzaglia et al. Table VI. The antibiotics prescribed for acute otitis media, in order of prescription frequency, together with PDD and duration of treatment PDD (g/day) mean (median) S.E.M. 0.5 (0.5) 2.0 (2.0) 0.5 (0.5) 0.4 (0.4) 0.9 (1.0) 1.2 (1.0) 2.1 (2.0) 2.0 (2.0) 0.4 (0.4) 0.3 (0.3) 1.8 (2.0) 4.3 (1.5) 1.4 (4.0) 1.0 (1.0) 0.8 (0.8) 1.0 (1.0) 2.0 2.4 2.0 0.6 2.0 n.s. 1.0 2.0 1.9 1.2 2.4 0.4 2.0 0.9 0.00 0.03 0.02 0.01 0.03 0.11 0.16 0.00 0.00 0.02 0.14 0.33 0.08 0.00 0.00 0.00 0.00 0.00 0.00 0.00 Length of treatment (days) mean (median) S.E.M. 3.1 (3) 6.9 (7) 6.4 (7) 6.1 (5) 6.0 (6) 6.1 (6) 6.4 (6) 6.0 (6) 5.4 (5) 6.0 (6) 4.8 (6) 7.2 (6) 6.0 (6) 7.5 (10) 5.5 (5) 5.0 (5) 6.5 4.5 9.0 6.0 4.0 n.s. 5.0 6.0 8.0 6.0 4.0 5.0 5.0 5.0 0.06 0.26 0.26 0.35 0.35 0.14 0.47 0.69 0.73 0.48 0.50 0.57 1.07 1.65 0.28 0.40 0.50 0.50 1.00 0.00

Antibiotic

No. of treatments 48 36 31 27 26 12 11 10 10 7 7 6 6 5 4 4 2 2 2 2 1 1 1 1 1 1 1 1 1 1 268

% of total 18.0 13.4 11.6 10.1 9.7 4.5 4.1 3.7 3.7 2.6 2.6 2.2 2.2 1.9 1.5 1.5 0.7 0.7 0.7 0.7 0.4 0.4 0.4 0.4 0.4 0.4 0.4 0.4 0.4 0.4 100.0

Azithromycin Co-amoxiclav Clarithromycin Cexime Cefuroxime axetil Ceftriaxone Amoxycillin Ceftazidime Ceftibuten Roxithromycin Cefotaxime Cefaclor Piperacillin Cefodizime Rokitamycin Cefonicid Ampicillin Bacampicillin Ceftizoxime Ooxacin Cefazolin Cefadroxil Ciprooxacin Cefuroxime Co-trimoxazole Lincomycin Ampicillin sulbactam Lomeoxacin Josamycin Rifampicin Total n.s.: not specied by GPs

Discussion
The place of antibiotic therapy in the management of the most common URTIs, such as sore throat or otitis media, has been the subject of great controversy.911 Ideally, antibacterial treatment should be prescribed once a microbiological diagnosis has been made. However, in the absence of ready available diagnostic aids in primary care, antibiotics are often prescribed before microbiological diagnosis has been made; these prescriptions are often inappropriate,12 and have resulted in development of resistance.13 There are no available data, in Sicily, to indicate the emergence of resistance among the most common bacteria

causing URTIs (S. pneumoniae, H. inuenzae and S. pyogenes)14 to amoxycillin and erythromycin, the rst-line choices. Furthermore, no randomized controlled trials, carried out in Sicily, have compared these antibiotics with newer but more expensive drugs. Despite this, our study indicates that GPs prescribe a very wide range of antibiotics, often choosing the most expensive ones (new macrolides, third-generation cephalosporins), and do not consider rst-line choices. This prescribing pattern is not based on any consideration of epidemiological information or evidence from clinical trials. There appears to be great concern regarding the efficacy of oral therapy in older patients and in those considered to be more sick. Indeed, most such patients were given injectable anti-

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Antibiotic prescription and general practitioners Table VII. Suspected adverse drug reactions following antibiotic treatment; antiiotics are divided by therapeutic group (ATC classication) J01CR No. of patients No. of adverse drug reactionsa Adverse reaction abdominal pain asthenia diarrhoea dyspepsia facial oedema atulence glossitis nausea oedema rash rash (erythematous) rigors stomatitis sweating increased syncope urticaria vertigo vomiting Total 319 10 0 1 6 1 0 0 1 0 0 1 0 0 0 1 0 0 1 1 13 J01FA 786 10 1 0 1 4 1 1 1 0 0 1 0 1 0 1 0 0 0 12 J01CA 276 3 0 0 0 0 0 0 0 0 0 2 1 0 0 0 0 0 0 0 3 J01DA 553 4 1 0 1 0 0 0 0 0 0 1 1 1 0 0 0 1 0 0 6 J01EE 7 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 1 Total 1941 28 2 1 8 5 1 1 1 1 1 4 3 1 1 1 1 1 1 1 35

J01CR, combination of penicillins and -lactamase inhibitors; J01FA, macrolides; J01CA, extended spectrum penicillins; J01DA, cephalosporins; J01EE, combination of sulphonamides and trimethoprim, including derivatives. a Multiple adverse drug reactions for a single antibiotic were considered.

Table VIII. Relationship between age or symptom score and route of delivery of prescribed antibiotics No. of treatments 675 632 341 276 104 2028 No. of treatments 74 912 736 70 1792 % of total 33.3 31.2 16.8 13.6 5.1 100.0 % of total 4.1 50.9 41.1 3.9 100.0 Oral (% of sample) 621 (92.0) 569 (90.0) 298 (87.4) 232 (84.1) 89 (85.6) 1809 (89.2) Oral (% of sample) 73 (98.6) 873 (95.7) 632 (85.9) 34 (48.6) 1612 (90.0) Injectable (% of sample) 54 (8.0) 63 (10.0) 43 (12.6) 44 (15.9) 15 (14.4) 219 (10.8) Injectable (% of sample) 1 (1.4) 39 (4.3) 104 (14.1) 36 (51.4) 180 (10.0)
2 2

Age (years) 1530 3145 4660 6175 75 Totala Symptoms score Slight Moderate Marked Severe Totalb
a b

95% CI for % injectable 6.110.3 7.712.6 9.116.1 11.620.3 7.721.2 : 2.18 with P 0.535

95% CI for % injectable 0.17.3 3.15.8 11.616.6 39.263.6 : 112.9 with P 0.000000

In ten cases GPs failed to indicate the route of administration. In 256 cases GPs failed to indicate the symptom score before starting the antibiotic therapy.

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G. Mazzaglia et al. biotics although a variety of clinical trials in outpatients have demonstrated that oral and parental therapy are equally effective.15 The reasons for this prescribing behaviour among Sicilian GPs are complex. The choice of antibiotic prescribed by the individual doctor could be inuenced by education, doctorpatient relationship, information, price of drugs government reimbursements and the activity of marketing groups from the pharmaceutical industry.16 It is clear that GPs in Sicily lack clear information about antibiotic prescribing related to URTIs. GPs who agreed to participate in this study are more receptive to supporting the notion of using the local guidelines for antimicrobial therapy. Therefore, an institutional and independent educational training programme is urgently needed in order to improve their knowledge, and enhance cost-effective prescribing. Institutions should encourage practitioners to examine their own prescribing and to compare the cost-effectiveness of alternative therapeutic regimes. Experience has also shown that, for guidelines to be effective in improving clinical practice, they should be constantly reinforced as a part of a continuing programme of improving quality.17 This should be part of an integrated strategy for improving antibiotic prescribing.
streptococcal tonsillopharyngitis. American Journal of Family Physicians 45, 199205. 5. Finch, R. (1987). Treatment of respiratory tract infections with cephalosporin antibiotics. In The cephalosporin antibiotics (Williams, J. D., Campoli-Richards, D. M. & Speight, T. M., Eds), pp. 1258. Adis Press Ltd, Auckland. 6. Grasela, T. H., Shentag, J. J., Boekenoogen, S. J., Crist, K. D., Lowes, W. L. & Lum, B. L. (1989). A clinical pharmacy-oriented drug surveillance network: results of a nationwide antibiotic utilization review of bacterial pneumonia1987. DICP Annals of Pharmacotherapy 23, 16270. 7. Hamilton-Miller, J. M. T. (1984). Use and abuse of antibiotics. British Journal of Clinical Pharmacology 18, 46974. 8. Bergman, U. & Sjoqvist, F. (1982). Measurement of drug utilization in Sweden: methodological and clinical implications. Acta Medica Scandinavica 683, Suppl., 1522. 9. Bain, J. (1990). Justication for antibiotic use in General Practice. British Medical Journal 300, 58286. 10. Del Mar, C., Glasziou, P. & Hayem, M. (1997). Are antibiotics indicated as initial treatment for children with acute otitis media? A meta-analysis. British Medical Journal 314, 15269. 11. Little, P. S. & Williamson, I. (1994). Are antibiotics appropriate for sore throat? British Medical Journal 309, 10102. 12. Joshi, N. & Milfred, D. (1995). The use and misuse of new antibiotics. Archives of Internal Medicine 155, 56977. 13. Medeiro, A. A. (1997). Evolution and dissemination of -lactamase accelerated by generations of -lactam antibiotics. Clinical Infectious Diseases 24, Suppl. 1, S1945. 14. Carroll, K. & Reimer, L. (1996). Microbiology and laboratory diagnosis of upper respiratory tract infections. Clinical Infectious Diseases 23, 4428. 15. Craig, W. A. & Andes, D. R. (1995). Parental versus oral antibiotic therapy. Medical Clinics of North America 79, 497508. 16. Bradley, C. P. (1992). Factors which inuence the decision whether or not to prescribe: the dilemma facing general practitioners. British Journal of General Practice 42, 4548. 17. Grimshaw, J. M. & Russell, I. T. (1993). Effect of clinical guidelines on medical practice: a systematic review of rigorous evaluations. Lancet 342, 131722.

Acknowledgements
Authors are very grateful to Dr Mario Cazzola for helpful comments on the manuscript and to Mr Nicholas Walsh for grammatical and stylistic revision of the manuscript.

References
1. Howie, J. G. R., Richardson, I. M., Gill, G. & Durno, D. (1971). Respiratory illness and antibiotic use in general practice. Journal of the Royal College of General Practitioners 21, 65763. 2. Dean, T. (1991). FHSA medical advisers: a survey of attitudes. Prescriber 2, 7980. 3. Irvine, D. A. (1986). The general practitioner and upper respiratory tract infection in childhood. Family Practice 3, 12631. 4. Pichichero, M. E. (1992). Culture and antigen detection tests for

Received 4 February 1997; returned 14 March 1997; revised 26 June 1997; accepted 14 August 1997

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