title: A decision aid to rule out pneumonia and reduce unnecessary prescriptions of antibiotics in primary care patients with cough and fever.
abstract: BACKGROUND
  Physicians fear missing cases of pneumonia and treat many patients with signs of respiratory infection unnecessarily with antibiotics. This is an avoidable cause for the increasing worldwide problem of antibiotic resistance. We developed a user-friendly decision aid to rule out pneumonia and thus reduce the rate of needless prescriptions of antibiotics.
  
  
  METHODS
  This was a prospective cohort study in which we enrolled patients older than 18 years with a new or worsened cough and fever without serious co-morbidities. Physicians recorded results of a standardized medical history and physical examination. C-reactive protein was measured and chest radiographs were obtained. We used Classification and Regression Trees to derive the decision tool.
  
  
  RESULTS
  A total of 621 consenting eligible patients were studied, 598 were attending a primary care facility, were 48 years on average and 50% were male. Radiographic signs for pneumonia were present in 127 (20.5%) of patients. Antibiotics were prescribed to 234 (48.3%) of patients without pneumonia. In patients with C-reactive protein values below 10 μg/ml or patients presenting with C-reactive protein between 11 and 50 μg/ml, but without dyspnoea and daily fever, pneumonia can be ruled out. By applying this rule in clinical practice antibiotic prescription could be reduced by 9.1% (95% confidence interval (CI): 6.4 to 11.8).
  
  
  CONCLUSIONS
  Following validation and confirmation in new patient samples, this tool could help rule out pneumonia and be used to reduce unnecessary antibiotic prescriptions in patients presenting with cough and fever in primary care. The algorithm might be especially useful in those instances where taking a medical history and physical examination alone are inconclusive for ruling out pneumonia.
authors.affiliation: Horten Center for Patient-Oriented Research and Knowledge Transfer, University of Zurich, and University Hospital of Zurich, Zurich, Switzerland. johann.steurer@usz.ch
authors.forename: Johann
authors.initials: J
authors.lastname: Steurer
authors.forename: Ulrike
authors.initials: U
authors.lastname: Held
authors.forename: Anne
authors.initials: A
authors.lastname: Spaar
authors.forename: Birke
authors.initials: B
authors.lastname: Bausch
authors.forename: Marco
authors.initials: M
authors.lastname: Zoller
authors.forename: Roger
authors.initials: R
authors.lastname: Hunziker
authors.forename: Lucas M
authors.initials: LM
authors.lastname: Bachmann
mesh_terms: D000328:Adult; D000368:Aged; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D002097:C-Reactive Protein / Q000032:analysis; D015331:Cohort Studies; D003371:Cough / Q000188:drug therapy*; D003661:Decision Support Techniques; D004363:Drug Utilization / Q000706:statistics & numerical data*; D005260:Female; D005335:Fever of Unknown Origin / Q000188:drug therapy*; D006801:Humans; D008297:Male; D008875:Middle Aged; D018410:Pneumonia, Bacterial / Q000175:diagnosis*; D055656:Prescriptions / Q000706:statistics & numerical data; D011320:Primary Health Care / Q000379:methods*; D011446:Prospective Studies; D013902:Radiography, Thoracic
chemical_list: D000900:Anti-Bacterial Agents; D002097:C-Reactive Protein