GP CCE Cases · infectious-diseases
The patient who wants 'the strongest antibiotic' — CCE clinical encounter
CCE-style clinical encounter: a 38-year-old with 4 days of cough and a history of 'always needing antibiotics' demands a script before a work trip. The candidate must elicit the expectation, present natural history and harms, offer a delayed prescription with proper instructions or no antibiotic with safety-netting, and address a false penicillin allergy label.
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RACGP CCEFRACGP oralsCFPC SOOs
Prompt
A 38-year-old project manager attends at 4:50 pm: 'I fly to Perth tomorrow for three weeks and I can't be sick. Every time I get this it turns into a chest infection and I need antibiotics. Also — I'm allergic to penicillin, had a rash as a kid.' Observations normal. Chest clear. FeverPAIN 1. No comorbidities. Two prior 'chest infection' antibiotic courses in three years, both from after-hours clinics.
Objectives
- Elicit and reframe the expectation ('I can't be sick for the trip') without dismissing it. [4]
- Present natural history with exact numbers: cough mean 11.7 days, 25% beyond 17 days, unchanged by antibiotics. [3]
- Offer a delayed prescription with explicit activation instructions, or no antibiotic with safety-netting — patient choice within clinical limits. [1] [2]
- Assess the penicillin allergy label with PEN-FAST and explain why the label itself carries risk. [5] [6]
- Safety-net for travel: red flags, where to seek care in Perth, and when the delayed script must not be used. [1]
References8ShowHide
- [1]Spurling GK, Dooley L, Clark J, et al. Immediate versus delayed versus no antibiotics for respiratory infections Cochrane Database Syst Rev, 2023.PMID 37791590
- [2]Stuart B, Hounkpatin H, Becque T, et al. Delayed antibiotic prescribing for respiratory tract infections: individual patient data meta-analysis BMJ, 2021.PMID 33910882
- [3]Little P, Rumsby K, Kelly J, et al. Information leaflet and antibiotic prescribing strategies for acute lower respiratory tract infection: a randomized controlled trial JAMA, 2005.PMID 15972565
- [4]Coxeter P, Del Mar CB, McGregor L, et al. Interventions to facilitate shared decision making to address antibiotic use for acute respiratory infections in primary care Cochrane Database Syst Rev, 2015.PMID 26560888
- [5]Trubiano JA, Vogrin S, Chua KYL, et al. Development and Validation of a Penicillin Allergy Clinical Decision Rule JAMA Intern Med, 2020.PMID 32176248
- [6]Blumenthal KG, Lu N, Zhang Y, et al. Risk of meticillin resistant Staphylococcus aureus and Clostridium difficile in patients with a documented penicillin allergy: population based matched cohort study BMJ, 2018.PMID 29950489
- [7]Krishna MT, Huissoon AP, Li M, et al. Enhancing antibiotic stewardship by tackling "spurious" penicillin allergy Clin Exp Allergy, 2017.PMID 29028276
- [8]Gaarslev C, Yee M, Chan G, et al. A mixed methods study to understand patient expectations for antibiotics for an upper respiratory tract infection Antimicrob Resist Infect Control, 2016.PMID 27777760