Efficacy and safety of discontinuing antibiotic treatment for uncomplicated respiratory tract infections when deemed unnecessary. A multicentre, randomized clinical trial in primary care.

OBJECTIVES: To determine the benefits and harms of discontinuing unnecessary antibiotic therapy for uncomplicated respiratory tract infections (RTI) when antibiotics are considered no longer necessary. METHODS: Multicentre, open-label, randomized controlled clinical trial in primary care centres from 2017 to 2020 (ClinicalTrials.gov, NCT02900820). Adults with RTIs-acute rhinosinusitis, sore throat, influenza or acute bronchitis-who had previously taken any dose of antibiotic for less than 3 days, which physicians no longer deemed necessary were recruited. The patients were randomly assigned in a 1:1 ratio to discontinuing antibiotic therapy or the usual strategy of continuing antibiotic treatment. The primary outcome was the duration of severe symptoms (number of days scoring 5 or 6 on a six-item Likert scale). Secondary outcomes included days with symptoms, moderate symptoms (scores of 3 or 4), antibiotics taken, adverse events, patient satisfaction and complications within the first 3 months. RESULTS: A total of 467 patients were randomized, out of which 409 were considered valid for the analysis. The mean (SD) duration of severe symptoms was 3.0 (1.5) days for the patients assigned to discontinuation and 2.8 (1.3) days for those allocated to the control group (mean difference 0.2 days; 95% CI -0.1 to 0.4 days). Patients randomized to the discontinuation group used fewer antibiotics after the baseline visit (52/207 (25.1%) versus 182/202 (90.1%); p 0.001). Patients assigned to antibiotic continuation presented a relative risk of adverse events of 1.47 (95% CI 0.80-2.71), but the need for further health-care contact in the following 3 months was slightly lower (RR 0.61; 95% CI 0.28-1.37). CONCLUSIONS: Discontinuing antibiotic treatment for uncomplicated RTIs when clinicians consider it unnecessary is safe and notably reduces antibiotic consumption.

Effectiveness of antitussives, anticholinergics or honey versus usual care in adults with uncomplicated acute bronchitis: a study protocol of an open randomised clinical trial in primary care.

INTRODUCTION: Despite the frequent use of therapies in acute bronchitis, the evidence of their benefit is lacking, since only a few clinical trials have been published, with low sample sizes, poor methodological quality and mainly in children. The objective of this study is to compare the effectiveness of three symptomatic therapies (dextromethorphan, ipratropium or honey) associated with usual care and the usual care in adults with acute bronchitis. METHODS AND ANALYSIS: This will be a multicentre, pragmatic, parallel group, open randomised trial. Patients aged 18 or over with uncomplicated acute bronchitis, with cough for less than 3 weeks as the main symptom, scoring ≥4 in either daytime or nocturnal cough on a 7-point Likert scale, will be randomised to one of the following four groups: usual care, dextromethorphan 30 mg three times a day, ipratropium bromide inhaler 20 µg two puffs three times a day or honey 30 mg (a spoonful) three times a day, all taken for up to 14 days. The exclusion criteria will be pneumonia, criteria for hospital admission, pregnancy or lactation, concomitant pulmonary disease, associated significant comorbidity, allergy, intolerance or contraindication to any of the study drugs or admitted to a long-term residence. SAMPLE: 668 patients. The primary outcome will be the number of days with moderate-to-severe cough. All patients will be given a paper-based symptom diary to be self-administered. A second visit will be scheduled at day 2 or 3 for assessing evolution, with two more visits at days 15 and 29 for clinical assessment, evaluation of adverse effects, re-attendance and complications. Patients still with symptoms at day 29 will be called 6 weeks after the baseline visit. ETHICS AND DISSEMINATION: The study has been approved by the Ethical Board of IDIAP Jordi Gol (reference number: AC18/002). The findings of this trial will be disseminated through research conferences and peer-review journals. TRIAL REGISTRATION NUMBER: NCT03738917; Pre-results.

The STOP-AB trial protocol: efficacy and safety of discontinuing patient antibiotic treatment when physicians no longer consider it necessary.

INTRODUCTION: Since 2011, the Spanish Society of Family Medicine has recommended general practitioners (GPs) to ask their patients to stop taking antibiotics when they suspect a viral infection. However, this practice is seldom used because uncertainty about diagnosis, and fear of consequences of discontinuing antibiotic therapy, as well as perceived pressure to continue prescribing antibiotics and potential conflict with patients are more of a concern for GPs than antibiotic resistance. The main objective of this study is to determine whether discontinuation of antibiotic therapy when a GP no longer considers it necessary has any impact on the number of days with severe symptoms. METHODS AND ANALYSIS: This is a multicentre, open-label, randomised controlled clinical trial. The study was conducted in 10 primary care centres in Spain. We included patients from 18 to 75 years of age with uncomplicated acute respiratory tract infections-acute rhinosinusitis, acute sore throat, influenza or acute bronchitis-who had previously taken any dose of antibiotic for <3 days, which physicians no longer considered necessary. The patients were randomly assigned to the usual strategy of continuing antibiotic treatment or to discontinuing antibiotic therapy. A sample size of 240 patients per group was calculated on the basis of a reduction of 1 day in the duration of severe symptoms being a clinically relevant outcome. The primary outcome was the duration of severe symptoms, that is, symptoms scored 5 or 6 by means of validated symptom diaries. Secondary outcomes included antibiotics taken, adverse events, patient satisfaction and complications within the first 3 months. ETHICS AND DISSEMINATION: The study was approved by the Ethical Board of Fundació Jordi Gol i Gurina (reference number: 16/093). The findings of this trial will bedisseminated through research conferences and peer-reviewed journals. TRIAL REGISTRATION NUMBER: NCT02900820; pre-results.

Is C-reactive protein testing useful to predict outcome in patients with acute bronchitis?

BACKGROUND: A recent clinical trial could not find differences between anti-inflammatory drugs, antibiotics and placebo in shortening the duration of symptoms in acute bronchitis. OBJECTIVES: To investigate if C-reactive protein (CRP) concentrations at presentation are predictive of symptom resolution in these patients. METHODS: We performed a secondary analysis of the data from a placebo-controlled, randomized clinical trial carried out in primary care. Patients from 18 to 70 years of age presenting a respiratory tract infection of <1 week of evolution, with cough as the predominant symptom and the presence of discoloured expectoration, were enrolled in the study. On the baseline visit, CRP was determined in capillary blood and a five-item symptom diary was given. Patients were followed up to 30 days. The main outcome measure was the number of days with persistent cough. RESULTS: A total of 312 subjects fulfilled all the criteria for the efficacy analysis and had undergone the CRP test; of these, 56.4% presented a CRP value <8 mg/l and 76% presented <20 mg/l. There were no significant differences in the median duration of cough: 10 days among patients with CRP concentrations <8 mg/l [95% confidence interval (CI): 8-11 days], 11 days among those with concentrations ranging from 8 to 19 mg/l (95% CI: 8-16) and 11 days in those with CRP >20 mg/l (95% CI: 9-12) (P = 0.337). CONCLUSION: Among patients with uncomplicated acute bronchitis and discoloured sputum, the CRP concentrations at presentation are not helpful for predicting symptom resolution.

Efficacy of anti-inflammatory or antibiotic treatment in patients with non-complicated acute bronchitis and discoloured sputum: randomised placebo controlled trial.

OBJECTIVE: To evaluate the efficacy of oral anti-inflammatory or antibiotic treatment compared with placebo in the resolution of cough in patients with uncomplicated acute bronchitis and discoloured sputum. DESIGN: Multicentre, parallel, single blinded placebo controlled, randomised clinical trial. SETTING: Nine primary care centres in Spain. PARTICIPANTS: Adults aged 18 to 70 presenting symptoms associated with respiratory tract infection of less than one week's duration, with cough as the predominant symptom, the presence of discoloured sputum, and at least one other symptom of lower respiratory tract infection (dyspnoea, wheezing, chest discomfort, or chest pain). INTERVENTIONS: Patients were randomised to receive either ibuprofen 600 mg three times daily, amoxicillin-clavulanic acid 500 mg/125 mg three times daily, or placebo three times daily for 10 days. The duration of symptoms was measured with a diary card. MAIN OUTCOME MEASURE: Number of days with frequent cough after the randomisation visit. RESULTS: 416 participants were randomised (136 to ibuprofen, 137 to antibiotic, and 143 to placebo) and 390 returned their symptom diaries fully completed. The median number of days with frequent cough was slightly lower among patients assigned to ibuprofen (9 days, 95% confidence interval 8 to 10 days) compared with those receiving amoxicillin-clavulanic acid (11 days, 10 to 12 days) or placebo (11 days, 8 to 14 days), albeit without statistically significant differences. Neither amoxicillin-clavulanic acid nor ibuprofen increased the probability of cough resolution (hazard ratio 1.03, 95% confidence interval 0.78 to 1.35 and 1.23, 0.93 to 1.61, respectively) compared with placebo. Adverse events were observed in 27 patients, and were more common in the antibiotic arm (12%) than ibuprofen or placebo arms (5% and 3%, respectively; P<0.01). CONCLUSION: No significant differences were observed in the number of days with cough between patients with uncomplicated acute bronchitis and discoloured sputum treated with ibuprofen, amoxicillin-clavulanic acid, or placebo. TRIAL REGISTRATION: Current Controlled Trials ISRCTN07852892.

Is it possible to identify exacerbations of mild to moderate COPD that do not require antibiotic treatment?

BACKGROUND: Anthonisen criteria are widely used to guide the use of antibiotics in exacerbations of COPD. We evaluated the best predictors of outcomes in exacerbations of mild to moderate COPD not treated with antibiotics. METHODS: We used data from 152 patients of the placebo arm of a randomized trial of amoxicillin/clavulanate for exacerbations of mild to moderate COPD. Clinical response in relation to Anthonisen criteria and point-of-care serum C-reactive protein (CRP) tests (cutoff, 40 mg/L) was assessed with multivariate logistic regression analysis. RESULTS: Clinical failure without antibiotics was 19.9% compared with 9.5% with amoxicillin/clavulanate (P = .022). The only factors significantly associated with an increased risk of failure without antibiotics were the increase in sputum purulence (OR, 6.1; 95% CI, 1.5-25.0; P = .005) and a CRP concentration ≥ 40 mg/L (OR, 13.4; 95% CI, 4.6-38.8; P < .001). When both factors were present, the probability of failure without antibiotics was 63.7%. The Anthonisen criteria showed an area under the curve of 0.708 (95% CI, 0.616-0.801) for predicting clinical outcome. With the addition of CRP level, the area under the curve rose significantly to 0.842 (95% CI, 0.76-0.924; P < .001). CONCLUSIONS: Among the Anthonisen criteria, only an increase in sputum purulence is a significant predictor of failure without antibiotics. The use of a point-of-care CRP test significantly increases the predictive accuracy of failure. Both of these easy-to-obtain factors may help clinicians to identify patients with exacerbated mild to moderate COPD who can be safely treated without antibiotics in an ambulatory setting. TRIAL REGISTRY: ClinicalTrials.gov; No.: NCT00495586; URL: www.clinicaltrials.gov.

A study of adherence to antibiotic treatment in ambulatory respiratory infections.

OBJECTIVES: To assess the different types of antibiotic-taking behavior and to compare self-reported with objectively measured adherence to antibiotic regimens in respiratory infections. METHODS: This was a prospective study of patients with suspected bacterial pharyngitis and lower respiratory tract infections recruited from five primary care clinics in Catalonia. Adherence to various antibiotic regimens was assessed by the Medication Event Monitoring System (MEMS), which recorded every opening of the patient's bottle of tablets, and a self-reported adherence question. The outcome variables were antibiotic-taking adherence, correct dosing, and timing adherence. RESULTS: A total of 428 patients were included in the analysis. Five types of antibiotic use behavior were observed: excellent adherence (130 patients, 30.4%), acceptable adherence over time (53; 12.4%), declining adherence over time (123; 28.7%), non-adherence to correct dosing (108; 25.2%), and unacceptable adherence (14; 3.3%). Excellent adherence was significantly associated with the number of daily doses of antibiotic and antibiotic duration. A total of 254 patients reported never forgetting to take the antibiotic (59.3%), achieving a negative predictive value of 100% and a positive predictive value of 51.2%. CONCLUSIONS: Outpatients with respiratory infections treated with antibiotics showed poor adherence outcomes. Self-reported adherence was remarkably higher than that observed with the use of MEMS and failed to predict true patient adherence.

Efficacy of antibiotic therapy for acute exacerbations of mild to moderate chronic obstructive pulmonary disease.

RATIONALE: Antimicrobial therapy remains a controversial issue in nonsevere exacerbations of chronic obstructive pulmonary disease (COPD). OBJECTIVES: To evaluate the efficacy of antibiotic therapy in moderate exacerbations of mild-to-moderate COPD. METHODS: This study involved a multicenter, parallel, double-blind, placebo-controlled, randomized clinical trial. Patients aged 40 years or older, smokers, or ex-smokers of 10 pack-years or more with spirometrically confirmed mild-to-moderate COPD (FEV(1) > 50% predicted and FEV(1)/FVC ratio < 0.7) and diagnosed with an exacerbation were enrolled in the study. The patients were randomized to receive amoxicillin/clavulanate 500/125 mg three times a day or placebo three times a day for 8 days. MEASUREMENTS AND MAIN RESULTS: The primary outcome measure was clinical cure at end of therapy visit (EOT) at Days 9 to 11. A total of 310 subjects fulfilled all the criteria for efficacy analysis. A total of 117 patients with amoxicillin/clavulanate (74.1%) and 91 with placebo (59.9%) were considered cured at EOT (difference, 14.2%; 95% confidence interval, 3.7-24.3). The median time to the next exacerbation was significantly longer in patients receiving antibiotic compared with placebo (233 d [interquartile range, 110-365] compared with 160 d [interquartile range, 66-365]; P < 0.05). The best C-reactive protein serum cut-off for predicting clinical failure with placebo was 40 mg/L, with an area under the curve of 0.732 (95% confidence interval, 0.614-0.851). CONCLUSIONS: Treatment of ambulatory exacerbations of mild-to-moderate COPD with amoxicillin/clavulanate is more effective and significantly prolongs the time to the next exacerbation compared with placebo.

Comparison of adherence between twice- and thrice-daily regimens of oral amoxicillin/clavulanic acid.

BACKGROUND AND OBJECTIVE: Few studies have analysed adherence with antibiotic treatment in patients with respiratory tract infections. The aim of this study was to compare the compliance of patients taking a pharmacokinetically enhanced formulation of amoxicillin/clavulanic acid twice daily with that of patients taking the standard formulation thrice daily. METHODS: Patients with suspected bacterial lower respiratory tract infections, pharyngitis and dental infections were included. Adherence was assessed by electronic monitoring, which recorded every opening of the patient's bottle of pills. The outcome variables were compliance with taking the medication, taking the correct dose and with timing of the dose. RESULTS: A total of 240 patients were enrolled (167 in the thrice-daily group and 73 in the twice-daily group). The percentage of doses taken was greater with the twice-daily regimen (84.5 ± 22.8%) than with the thrice-daily regimen (72.7 ± 20.1%; P < 0.001). Forty patients in the twice-daily group opened the container every 12 ± 6 h during at least 80% of the course (54.8%), while only 19.6% of the patients assigned to the thrice-daily formulation did so every 8 ± 4 h (P < 0.001). The percentage of patients who opened the container a satisfactory number of times per day was significantly higher among those taking the twice-daily regimen on days three, four, five, six and seven. Moreover, the thrice-daily group more frequently forgot to take the afternoon dose. CONCLUSIONS: The rate of compliance with amoxicillin/clavulanic acid therapy was very low. However, compliance with the new formulation that is taken twice-daily was significantly better.

Effectiveness of anti-inflammatory treatment versus antibiotic therapy and placebo for patients with non-complicated acute bronchitis with purulent sputum. The BAAP Study protocol.

BACKGROUND: Acute bronchitis is one of the most prevalent respiratory infections in primary care, and in more than 90% of the cases antibiotics are prescribed, mainly when purulent expectoration is present. However, this process is usually viral in origin and the benefits of antibiotic treatment are marginal. On the other hand, in recent years bronchitis has been considered more as an inflammatory than an infectious process. Thus, the aim of this study is to evaluate the clinical effectiveness of a schedule of an oral anti-inflammatory compared with an antibiotic regimen and another group assigned to receive a placebo. METHODS AND DESIGN: A total of 420 patients from 15 to 70 years of age with no associated comorbidity, presenting respiratory tract infection of at least one week of evolution, with cough as the predominant symptom, the presence of purulent expectoration and at least one other symptom of the respiratory tract (dyspnoea, wheezing, chest discomfort or pain), with no alternative explanation such as pneumonia, will be included in a prospective, randomised and controlled, clinical trial with placebo. The patients will be randomised to receive one of three treatments: ibuprofen, amoxycillin and clavulanic acid or placebo for 10 days. The main outcome measure is the number of days with frequent cough defined by the symptom diary with a score of 1 or more. DISCUSSION: This trial is designed to evaluate the number of days with frequent cough with anti-inflammatory treatment compared with antimicrobial treatment and placebo in previously healthy patients with a clinical picture of acute bronchitis and purulent expectoration. It is hypothesized that anti-inflammatory treatment is more effective than antibiotic treatment to reduce cough, which is the most disturbing symptom for patients with this infection. TRIAL REGISTRATION: ISRCTN07852892.

Impact of C-reactive protein testing on adherence to thrice-daily antibiotic regimens in patients with lower respiratory tract infection.

BACKGROUND: Few studies have analysed adherence to antibiotic treatment in respiratory tract infections. OBJECTIVE: To evaluate the impact of C-reactive protein (CRP) testing on treatment adherence among patients aged 18 or over with lower respiratory tract infection (LRTI) treated with thrice-daily antibiotic regimens. DESIGN: Prospective study 2003 - 2008. SETTING: Office-based physician practices. METHODS: We compared patient adherence prior to the use of CRP testing (no CRP test was available prior to 2007) with adherence following CRP rapid testing for suspected bacterial infection in LRTIs. Patient adherence was assessed by electronic monitoring. RESULTS: 161 patients with LRTI were recruited. The percentage of container openings was 76.8 ± 17.4%. Adherence was significantly better when the CRP test was performed (83.3% vs. 74.4%; p < 0.01), as was 'good timing' adherence during at least 80% of the antibiotic course (32.6% vs. 16.9%; p < 0.05). CONCLUSION: Greater antibiotic treatment adherence is observed among patients with LRTI after CRP testing at the consultation prior to administration of antibiotic treatment.

Association between use of rapid antigen detection tests and adherence to antibiotics in suspected streptococcal pharyngitis.

OBJECTIVE: Few studies have analysed adherence to antibiotic treatment in pharyngitis. The aim of this study was to evaluate the association of rapid antigen detection tests (RADT) and treatment adherence among patients 18 years of age or over with pharyngitis treated with different antibiotic regimens. DESIGN: Prospective study from 2003 to 2008. SETTING: Office-based physician practices. Intervention. The adherence of patients prior to the use of RADTs - no test was available until mid-2006 - was compared with the adherence associated with the use of RADTs. SUBJECTS: Patients with suspected streptococcal pharyngitis. MAIN OUTCOME MEASURES: Patient adherence was assessed by electronic monitoring. The adherence outcomes considered were antibiotic-taking adherence, correct dosing, and good timing adherence during at least 80% of the antibiotic course. RESULTS: A total of 196 patients were recruited. The percentage of container openings was 77.9%+/-17.7%, being significantly higher for patients in whom the RADTs were performed compared with those in whom this test was not undertaken (80.1% vs. 70.8% for thrice-daily antibiotic regimens and 88.1% vs. 76.5% for twice-daily regimens; p < 0.01). The other variables of adherence were also better among patients undergoing RADT in both those who took at least 80% of the pills (71.3% vs. 42.2%; p < 0.001) as well as those with good timing adherence (52.5% vs. 32.8%; p < 0.01). Furthermore, correct dosing was always greater when the patient had undergone an RADT. CONCLUSION: Adherence to antibiotic treatment is higher when an RADT is carried out at the consultation prior to administration of antibiotic treatment.

Efficacy of amoxycillin versus amoxycillin/clavulanate in acute exacerbations of chronic pulmonary obstructive disease in primary care.

BACKGROUND: Amoxycillin/clavulanate is considered first-line treatment for ambulatory exacerbations of COPD. However, narrow-spectrum antibiotics may be as useful for mild to moderate patients. OBJECTIVE: To compare the clinical efficacy of amoxycillin versus amoxicyllin/clavulanate in exacerbations of COPD in primary care. METHODS: A randomized, double-blind, noninferiority clinical trial was carried out in eight primary care centers in Catalonia, Spain. Spirometrically-diagnosed patients older than 40 years with COPD, without criteria of hospitalization and Anthonisen's types I or II exacerbations were included. The main outcome was clinical cure at the end of treatment (EOT) visit on day 10. RESULTS: A total of 137 patients were enrolled in the study (68 assigned to amoxycillin and 69 to amoxycillin/clavulanate). The mean forced expiratory flow in one second was 61.6% and the mean age was 71.4 years. At EOT, 92.8% of patients in the amoxycillin/clavulanate and 90.9% in the amoxycillin group were considered clinically cured, a statistically non-significant difference. Adverse effects were observed in 11 subjects, 3 in the amoxycillin group and 8 in the amoxycillin/clavulanate group, 2 of whom required a change in treatment. CONCLUSIONS: Amoxycillin was at least as effective clinically and as safe as amoxycilin/ clavulanate in the treatment of acute exacerbations of COPD in mild to moderate patients in primary care.

The higher the number of daily doses of antibiotic treatment in lower respiratory tract infection the worse the compliance.

BACKGROUND: To assess the drug compliance observed among patients with lower respiratory tract infection treated with once-daily, twice-daily and thrice-daily antibiotic regimens. METHODS: We performed a prospective study in the primary care setting including patients with suspected bacterial lower respiratory tract infections, not allergic to beta-lactam antimicrobials, macrolides or quinolones, treated with several antibiotic regimens. Patient compliance was assessed by electronic monitoring. RESULTS: A total of 251 patients were enrolled (136 in the thrice-daily group, 70 in the twice-daily group and 45 in the once-daily group). The mean container openings ranged from 94.3 +/- 12.6% with once-daily antibiotics to 74.8 +/- 17.7% with thrice-daily drugs (P < 0.001). Seventy-five patients in the thrice-daily group took at least 80% of the medications (55.1%), being significantly less than those receiving twice-daily (71.4%) or once-daily (86.7%; P < 0.001) drugs. Only 20.6% of the patients assigned to the thrice-daily regimens opened the container every 8 +/- 4 h during at least 80% of the course. Among the patients assigned the same number of doses daily, compliance was better with the shortest antibiotic courses, being worse with schedules of 7 days or more. The percentage of patients who opened the MEMS container the satisfactory number of times a day was lower among the thrice-daily regimens. Moreover, the thrice-daily group more frequently forgot the afternoon dose. CONCLUSIONS: The rate of compliance was very low, mainly when antibiotics were administered thrice daily and in regimens of 7 days or more. New strategies addressed to improve antibiotic drug compliance are, therefore, necessary.

El formato del título en los resúmenes de comunicaciones influye en la aceptación final a congresos / Abstract title format influences its board aceptation in scientific meetings

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Indicadores cualitativos en la prescripción de antibióticos: ¿son los más adecuados? / Qualitative indicators in antibiotic prescription: are they the most appropriate ones?

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Spanish primary healthcare physicians' knowledge of resistance of respiratory germs and antimicrobial treatment in acute bronchitis.

OBJECTIVES: To determine what Spanish primary healthcare physicians consider the rates of pneumococcal resistance to be, the type of antimicrobial treatment they would prescribe on suspicion of high resistance and ascertain in which cases of acute bronchitis these physicians would initiate antibiotic treatment. METHODS: A cross-sectional, observational study was performed with a questionnaire distributed to 1368 physicians on their opinion on the degree of resistance of pneumococci to penicillins and macrolides in Spain. They were also asked which treatment they would recommend in penicillin-resistant pneumococcal infection and to indicate their degree of agreement regarding the use of antibiotics in different clinical situations of acute bronchitis. RESULTS: 843 physicians completed and returned the questionnaire, a response rate of 59.1%. Of the 750 physicians who answered the question concerning pneumococcal resistance, 312 stated resistance to be >30% (41.6%) while only 90 felt it to be <15% (12%). 153 physicians reported resistance to macrolides to be >30% (23%). In cases with suspicion of penicillin-resistant pneumococci, the clinicians stated they would prescribe quinolones (321, 40.3%) and macrolides (251, 31.5%). Of the 784 physicians who answered the questions on bronchitis, 662 preferred antibiotic therapy in acute bronchitis with purulent sputum (84.6%), 610 on uncertain diagnosis (77.8%), 569 in patients with fever over 38 degrees C (72.6%) and 210 on patient request (26.8%). CONCLUSION: Primary healthcare physicians in Spain are more concerned about pneumococcal resistance to penicillins than to macrolides although 35% of the strains isolated are resistant to the latter while only 10% are resistant to aminopenicillins. Furthermore, many physicians believe macrolides to be effective against pneumococcal infections. Despite their lack of efficacy in the treatment of acute bronchitis, many physicians prescribe antibiotics, mainly in cases with purulent expectoration, thus justifying the high consumption of antimicrobial agents in this disease.