Symptoms, signs, and prescribing for acute lower respiratory tract illness

Most patients who consult with acute lower respiratory symptoms receive antibiotics, usually without evidence of significant infection. The physical signs at presentation of acute lower respiratory tract illness and the rate at which symptoms resolve and normal activities recover is not well documented.

To examine in patients with lower respiratory tract infection (LRTi), their physical signs at presentation, their relationship to antibiotic prescribing, and symptom resolution and resumption of normal activities.

Analysis of data collected prospectively during presentation of acute LRTi in primary care and from patient symptom diary cards.

Forty GPs who were members of an informal Community Respiratory Infection Interest Group recruited 391 patients to the study.

Information was collected on pulse, oral temperature, respiratory rate, abnormalities on auscultation, and details of any antibiotic prescription. Patients completed symptom diary cards for the following 10 days.

Of the 391 patients who consulted 71% received antibiotics. A minority had abnormal physical signs: 17% had a pulse greater than 90 bpm, 15% a respiratory rate greater than 20 breaths per minute, 4% had a temperature greater than 38 degrees C, and 25% had an abnormality on auscultation. Antibiotic prescribing was more common in the presence of abnormal chest signs (odds ratio = 8.71, 95% confidence interval = 3.69-20.61) or discoloured sputum (OR = 2.67, 95% CI = 1.57-4.56). Ten days after consultation, 58% of patients were still coughing and 29% had not returned to normal activities.

Abnormal physical signs at presentation do not explain the high rates of antibiotic prescribing nor do they predict persisting cough and functional impairment at 10 days. Reconsultation for the same symptoms within a month is common and is strongly related to persisting cough, but not abnormalities at presentation.