Guidelines which care? Not yet for bronchiolitis

Writing on guidelines, the BMJ discussed how the “real challenge is to deal with illness and how it fragments, disarticulates, and renders uncertain the conduct and dignity of human lives”. But isn’t the same week’s Practice Update on bronchiolitis (1) an example of evidence-based medicine which “injects certainty” rather than doing justice to all the uncertainties that exist (2) – for clinicians and also for parents?

I agree strongly that children with viral infections do not benefit from, and may even be harmed by, antibiotics; and that a very large number of children with bronchiolitis do not need hospital admission.

But simply ‘reminding’ doctors of the bronchiolitis guidelines doesn’t really help the individual doctor faced with a child struggling to breathe. And many anxious parents will not be reassured if they are simply told that bronchiolitis is self limiting and their child’s “breathing and feeding will get better within five days” (3).

Improved evidence around admission avoidance does indeed need “to be done” [sic] (1), but surely if we were going to follow the more practical approaches suggested elsewhere in this week’s BMJ (4), it might be more useful to work on some more specific and practical ways forward for bronchiolitis?

Why aren’t there more evidence-based parent-friendly resources like whenshouldiworry.com? The trials of this showed a two-thirds reduction in antibiotic prescribing (5) and, in my experience as well as the trials, many parents really like it.
Are there any near-patient diagnostic tests that might help – like CRP, as used in a recent NHS Innovation award-winning project to reduce antibiotic prescribing in adults with a cough? (6) It’s good news that reminding higher antibiotic prescribers of their outlier status leads to reductions in antibiotic use (7).

But surely, with antimicrobial resistance flagged up as a potentially devastating global threat(8), we need to do more than wag fingers at doctors.

And developing more practical supports surely applies more widely than just bronchiolitis?

 

(1): p.29 in the hard copy 2 July edition – I cant find this electronically
(2): Caring with evidence based medicine BMJ 2016;353:i3530
(3): Bronchiolitis in children: NICE pathway
(4): Clinical encounters in the post-guidelines era BMJ 2016;353:i3200
(5): Effect of using an interactive booklet about childhood respiratory tract infections in primary care consultations on reconsulting and antibiotic prescribing: a cluster randomised controlled trial BMJ 2009;339:b2885
(6): Challenge Prize cash supporting GP surgery to fight antibiotic resistance. https://www.england.nhs.uk/2016/05/antibiotic-resistance-2/
(7): Provision of social norm feedback to high prescribers of antibiotics in general practice: a pragmatic national randomised controlled trial. Hallsworth M et al. Lancet 2016: 387; 10029: 1743–1752
(8): Tackling drug resistant infections globally. May 2016. amr-review.org/sites/default/files/160518_Final%20paper_with%20cover.pdf

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