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Amoxicillin for acute lower respiratory tract infection in primary care: subgroup analysis by bacterial and viral aetiology

Amoxicillin for acute lower respiratory tract infection in primary care: subgroup analysis by bacterial and viral aetiology
Amoxicillin for acute lower respiratory tract infection in primary care: subgroup analysis by bacterial and viral aetiology

Objective: We aimed to assess the effects of amoxicillin treatment in adult patients presenting to primary care with a lower respiratory tract infection (LRTI) who were infected with a potential bacterial, viral, or mixed bacterial/viral infection. 

Methods: This multicentre randomized controlled trial focused on adults with LRTI not suspected for pneumonia. Patients were randomized to receive either antibiotic (amoxicillin 1 g) or placebo three times daily for 7 consecutive days using computer-generated random numbers (follow-up 28 days). In this secondary analysis of the trial, symptom duration (primary outcome), symptom severity (scored 0-6), and illness deterioration (reconsultation with new or worsening symptoms, or hospital admission) were analysed in pre-specified subgroups using regression models. Subgroups of interest were patients with a (strictly) bacterial, (strictly) viral, or combined infection, and patients with elevated values of procalcitonin, C-reactive protein, or blood urea nitrogen. 

Results: 2058 patients (amoxicillin n = 1036; placebo n = 1022) were randomized. Treatment did not affect symptom duration (n = 1793). Patients from whom a bacterial pathogen only was isolated (n = 207) benefited from amoxicillin in that symptom severity (n = 804) was reduced by 0.26 points (95% CI -0.48 to -0.03). The odds of illness deterioration (n = 2024) was 0.24 (95% CI 0.11 to 0.53) times lower from treatment with amoxicillin when both a bacterial and a viral pathogen were isolated (combined infection; n = 198). 

Conclusions: Amoxicillin may reduce the risk of illness deterioration in patients with a combined bacterial and viral infection. We found no clinically meaningful benefit from amoxicillin treatment in other subgroups.

Aetiology, Amoxicillin, Illness deterioration, Lower respiratory tract infection, Symptom duration, Symptom severity
1198-743X
Bruyndonckx, R.
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Stuart, B.
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Little, P.
1bf2d1f7-200c-47a5-ab16-fe5a8756a777
Hens, N.
ae31e0dd-2c9b-47b7-91b8-814f44ea6de8
Ieven, M.
c138048d-d838-4c8e-848d-a43e309f4cf0
Butler, C.C.
736f78ad-3e18-4c63-900f-c2249577b645
Verheij, T.
cc355b92-ba85-4102-98a0-cee55f0504f6
Goossens, H.
533640f7-b568-4d95-a7c1-28158d154ba8
Coenen, S.
9afe2a52-9f4f-45bb-b8e5-c6ee3eeb3498
The GRACE project group
Bruyndonckx, R.
f4de37c8-5255-4d22-936b-62a7c900c81a
Stuart, B.
626862fc-892b-4f6d-9cbb-7a8d7172b209
Little, P.
1bf2d1f7-200c-47a5-ab16-fe5a8756a777
Hens, N.
ae31e0dd-2c9b-47b7-91b8-814f44ea6de8
Ieven, M.
c138048d-d838-4c8e-848d-a43e309f4cf0
Butler, C.C.
736f78ad-3e18-4c63-900f-c2249577b645
Verheij, T.
cc355b92-ba85-4102-98a0-cee55f0504f6
Goossens, H.
533640f7-b568-4d95-a7c1-28158d154ba8
Coenen, S.
9afe2a52-9f4f-45bb-b8e5-c6ee3eeb3498

Bruyndonckx, R., Stuart, B., Little, P., Hens, N., Ieven, M., Butler, C.C., Verheij, T., Goossens, H. and Coenen, S. , The GRACE project group (2017) Amoxicillin for acute lower respiratory tract infection in primary care: subgroup analysis by bacterial and viral aetiology. Clinical Microbiology and Infection. (doi:10.1016/j.cmi.2017.10.032).

Record type: Article

Abstract

Objective: We aimed to assess the effects of amoxicillin treatment in adult patients presenting to primary care with a lower respiratory tract infection (LRTI) who were infected with a potential bacterial, viral, or mixed bacterial/viral infection. 

Methods: This multicentre randomized controlled trial focused on adults with LRTI not suspected for pneumonia. Patients were randomized to receive either antibiotic (amoxicillin 1 g) or placebo three times daily for 7 consecutive days using computer-generated random numbers (follow-up 28 days). In this secondary analysis of the trial, symptom duration (primary outcome), symptom severity (scored 0-6), and illness deterioration (reconsultation with new or worsening symptoms, or hospital admission) were analysed in pre-specified subgroups using regression models. Subgroups of interest were patients with a (strictly) bacterial, (strictly) viral, or combined infection, and patients with elevated values of procalcitonin, C-reactive protein, or blood urea nitrogen. 

Results: 2058 patients (amoxicillin n = 1036; placebo n = 1022) were randomized. Treatment did not affect symptom duration (n = 1793). Patients from whom a bacterial pathogen only was isolated (n = 207) benefited from amoxicillin in that symptom severity (n = 804) was reduced by 0.26 points (95% CI -0.48 to -0.03). The odds of illness deterioration (n = 2024) was 0.24 (95% CI 0.11 to 0.53) times lower from treatment with amoxicillin when both a bacterial and a viral pathogen were isolated (combined infection; n = 198). 

Conclusions: Amoxicillin may reduce the risk of illness deterioration in patients with a combined bacterial and viral infection. We found no clinically meaningful benefit from amoxicillin treatment in other subgroups.

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Accepted/In Press date: 31 October 2017
e-pub ahead of print date: 3 November 2017
Keywords: Aetiology, Amoxicillin, Illness deterioration, Lower respiratory tract infection, Symptom duration, Symptom severity

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Local EPrints ID: 416996
URI: https://eprints.soton.ac.uk/id/eprint/416996
ISSN: 1198-743X
PURE UUID: 17df8cc7-7ceb-4672-9fa3-eda335fae3fc

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Date deposited: 16 Jan 2018 17:30
Last modified: 14 Mar 2019 05:20

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Contributors

Author: R. Bruyndonckx
Author: B. Stuart
Author: P. Little
Author: N. Hens
Author: M. Ieven
Author: C.C. Butler
Author: T. Verheij
Author: H. Goossens
Author: S. Coenen

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