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Bayless S, Bihl T, Rohan CA, Travers JB, Whitney E. Inappropriate Testing of Streptococcal Pharyngitis in Children Aged Below 3 Years: Application of Statistical Process Control. Clin Pediatr (Phila) 2022; 62:309-315. [PMID: 36171730 DOI: 10.1177/00099228221125823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Group A strep tests in patients aged below 3 years are not recommended unless the patient has appropriate symptoms and a positive contact or signs of complications. The purpose of this quality improvement project was to increase the percentage of appropriately ordered strep tests among providers. Data were collected retrospectively and prospectively from 1163 patient visits. Providers were exposed to educational interventions, an electronic medical record order change, and provider feedback. Proportional control charts characterized the providers' behaviors and determined significant improvement among testing. The result was an increase in appropriate tests (13.7% to 37.8%), and the control charts showed sustainable results over time. This project demonstrates the efficacy of these methods to encourage antibiotic stewardship among providers. Furthermore, the interventions used here can be applied to other areas with low-value diagnostic testing. Future studies should investigate whether parental anxiety and educational programs influence testing and evaluate the efficacy of certain strategies.
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Affiliation(s)
- Sharlo Bayless
- Department of Pharmacology & Toxicology, Boonshoft School of Medicine, Wright State University, Dayton, OH, USA.,Dayton Veterans Administration Medical Center, Dayton, OH, USA
| | - Trevor Bihl
- Department of Pharmacology & Toxicology, Boonshoft School of Medicine, Wright State University, Dayton, OH, USA.,Department of Biomedical, Industrial and Human Factors Engineering, Wright State University, Dayton, OH, USA
| | - Craig A Rohan
- Department of Pharmacology & Toxicology, Boonshoft School of Medicine, Wright State University, Dayton, OH, USA.,Department of Dermatology, Boonshoft School of Medicine, Wright State University, Dayton, OH, USA
| | - Jeffrey B Travers
- Department of Pharmacology & Toxicology, Boonshoft School of Medicine, Wright State University, Dayton, OH, USA.,Dayton Veterans Administration Medical Center, Dayton, OH, USA.,Department of Dermatology, Boonshoft School of Medicine, Wright State University, Dayton, OH, USA
| | - Eric Whitney
- Department of Pediatrics, Boonshoft School of Medicine, Wright State University, Dayton, OH, USA.,Dayton Children's Hospital, Dayton, OH, USA
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Martel M, Negrín MA, Vázquez–Polo FJ. Bayesian heterogeneity in a meta-analysis with two studies and binary data. J Appl Stat 2022; 50:2760-2776. [PMID: 37720245 PMCID: PMC10503457 DOI: 10.1080/02664763.2022.2084719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 05/24/2022] [Indexed: 10/18/2022]
Abstract
The meta-analysis of two trials is valuable in many practical situations, such as studies of rare and/or orphan diseases focussed on a single intervention. In this context, additional concerns, like small sample size and/or heterogeneity in the results obtained, might make standard frequentist and Bayesian techniques inappropriate. In a meta-analysis, moreover, the presence of between-sample heterogeneity adds model uncertainty, which must be taken into consideration when drawing inferences. We suggest that the most appropriate way to measure this heterogeneity is by clustering the samples and then determining the posterior probability of the cluster models. The meta-inference is obtained as a mixture of all the meta-inferences for the cluster models, where the mixing distribution is the posterior model probability. We present a simple two-component form of Bayesian model averaging that is unaffected by characteristics such as small study size or zero-cell counts, and which is capable of incorporating uncertainties into the estimation process. Illustrative examples are given and analysed, using real sparse binomial data.
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Affiliation(s)
- M. Martel
- Dpt. of Quantitative Methods and TiDES Institute, U. of Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Canary Islands, Spain
| | - M. A. Negrín
- Dpt. of Quantitative Methods and TiDES Institute, U. of Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Canary Islands, Spain
| | - F. J. Vázquez–Polo
- Dpt. of Quantitative Methods and TiDES Institute, U. of Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Canary Islands, Spain
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3
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Baša M, Sovtić A. Treatment of the most common respiratory infections in children. ARHIV ZA FARMACIJU 2022. [DOI: 10.5937/arhfarm72-37857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
Acute respiratory infections are the most common group of infective diseases in the pediatric population. Although the improvement of health care and vaccination program has led to a significant reduction in the incidence of certain respiratory infections, the combination of a high prevalence in vulnerable pediatric categories and uncritical prescription of antibiotics, due to the inability to adequately distinguish between viruses and bacterial etiology, still represents a significant challenge for the public health system. In order to promote rational antibiotic therapy with an overall improvement of both diagnostic and therapeutic principles, acute respiratory diseases have been the subject of consideration in numerous publications and national guidelines. Nonspecific clinical manifestations with pathogen heterogeneity and both anatomical and physiological characteristics of the child's respiratory system during growth and development have created the need for individualized therapy. Since the guidelines emphasize the undoubtful and crucial benefits of symptomatic therapy (e.g. analgesics in acute otitis media, supplemental oxygen in lower respiratory tract infections with hypoxemia), the use of antibiotics and corticosteroids is indicated in selected cases with a severe clinical picture. The choice of antibiotic depends on the clinical condition, presumed causative agent, and local epidemiologic circumstances. Respiratory support (oxygen therapy and/or artificial ventilation) is reserved for inpatient treatment of cases with a particularly severe clinical picture and associated complications.
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Cannon JW, Jack S, Wu Y, Zhang J, Baker MG, Geelhoed E, Fraser J, Carapetis JR. An economic case for a vaccine to prevent group A streptococcus skin infections. Vaccine 2018; 36:6968-6978. [PMID: 30340879 DOI: 10.1016/j.vaccine.2018.10.001] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2018] [Revised: 07/22/2018] [Accepted: 10/01/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND Group A streptococcus (GAS) causes an exceptionally diverse range of diseases, raising questions about the optimal product characteristics of a commercially viable vaccine. The objectives of this study were to (1) estimate the current health and economic burdens caused by 24 diseases attributable to GAS each year in Australia and (2) use these estimates to explore the value of a GAS vaccine for different clinical indications, age schedules, and population groups. METHODS For objective 1, we estimated the population heath and economic burdens by synthesising data from administrative databases, nationally representative surveys, literature reviews, public reimbursement schedules, and expert opinion. For objective 2, we modelled the prospective lifetime burden of GAS for all infants from birth, for children from 5 years of age, and for adults from 65 years of age. A vaccine was assumed to reduce each GAS disease by 70% for a period of 10 years, and the difference in outcomes between vaccinated and non-vaccinated cohorts were used to calculate the cost-effective value of vaccination. RESULTS The annual health and economic burdens of GAS diseases totalled 23,528 disability-adjusted life years and AU$185.1 million in healthcare costs respectively; approximately half of each measure was due to cellulitis, followed by other skin infections and throat infections. Reducing the incidence of throat infections, skin infections, and cellulitis in non-Indigenous cohorts resulted in 30%, 33%, and 28% of the total vaccine value for an infant schedule (cost-effective vaccine price AU$260 per course); 47%, 26%, and 22% of the value for a child schedule (AU$289); and 2%, 15% and 74% for an adult schedule (AU$489). CONCLUSIONS A vaccine that prevents GAS cellulitis and other skin infections, in addition to throat infections, would maximise its value and commercial viability, with a cost-effective price in line with other recently-licensed and funded vaccines in Australia.
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Affiliation(s)
- Jeffrey W Cannon
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, WA, Australia
| | - Susan Jack
- Department of Preventive and Social Medicine, University of Otago, Dunedin, New Zealand
| | - Yue Wu
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, WA, Australia
| | - Jane Zhang
- Department of Public Health, University of Otago, Wellington, New Zealand
| | - Michael G Baker
- Department of Public Health, University of Otago, Wellington, New Zealand
| | - Elizabeth Geelhoed
- School of Population and Global Health, University of Western Australia, Perth, WA, Australia
| | - John Fraser
- Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Jonathan R Carapetis
- Telethon Kids Institute, University of Western Australia, and Perth Children's Hospital, 15 Hospital Avenue, Nedlands, Western Australia 6009, Australia.
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5
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Rheumatic Fever. Infect Dis (Lond) 2017. [DOI: 10.1016/b978-0-7020-6285-8.00052-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Elshout G, Kool M, Bohnen AM, Koes BW, Moll HA, Berger MY. Predicting prolonged duration of fever in children: a cohort study in primary care. Br J Gen Pract 2015; 65:e578-84. [PMID: 26324494 PMCID: PMC4540397 DOI: 10.3399/bjgp15x686485] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Accepted: 04/30/2015] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Fever in children in primary care is commonly caused by benign infections, but often worries parents. Information about the duration of fever and its predictors may help in reassuring parents, leading to diminished consultation of health care. AIM To determine which signs and symptoms predict a prolonged duration of fever in febrile children in primary care and evaluate whether C-reactive protein (CRP) measurement has an additive predictive value for these symptoms. DESIGN AND SETTING A prospective cohort study at a GPs' cooperative (GPC) out-of-hours service. METHOD Children (aged 3 months to 6 years) presenting with fever as stated by the parents were included. Exclusion criteria were no communication in Dutch possible, previous enrolment in the study within 2 weeks, referral to the hospital directly after visiting the GPC, or no informed consent. The main outcome measure was prolonged duration of fever (>3 days) after initial contact. RESULTS Four-hundred and eighty children were analysed, and the overall risk of prolonged duration was 13% (63/480). Multivariate analysis combined model of patient history and physical examination showed that 'sore throat' (OR 2.8; 95% CI = 1.30 to 6.01) and 'lymph nodes palpable' (OR 1.87; 95% CI = 1.01 to 3.49) are predictive for prolonged duration of fever. The discriminative value of the model was low (AUC 0.64). CRP had no additive value in the prediction of prolonged duration of fever (OR 1.00; 95% CI = 0.99 to 1.01). CONCLUSION The derived prediction model indicates that only a few signs and symptoms are related to prolonged duration of fever. CRP has no additional value in this model. Overall, because the discriminative value of the model was low, the duration of fever cannot be accurately predicted.
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Affiliation(s)
- Gijs Elshout
- Department of General Practice, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Marijke Kool
- Department of General Practice, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Arthur M Bohnen
- Department of General Practice, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Bart W Koes
- Department of General Practice, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Henriëtte A Moll
- Department of General Pediatrics, Erasmus MC - Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Marjolein Y Berger
- Department of General Practice, Erasmus MC, University Medical Center Rotterdam, Rotterdam; Department of General Practice, University Medical Center Groningen, Groningen, the Netherlands
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Thomas JP, Berner R, Zahnert T, Dazert S. Acute otitis media--a structured approach. DEUTSCHES ARZTEBLATT INTERNATIONAL 2015; 111:151-9; quiz 160. [PMID: 24661591 DOI: 10.3238/arztebl.2014.0151] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2013] [Revised: 11/05/2013] [Accepted: 11/05/2013] [Indexed: 01/22/2023]
Abstract
BACKGROUND Two-thirds of all children have an episode of acute otitis media (AOM) before their third birthday. Antibiotic treatment is often given immediately, even though adequate scientific evidence for this practice is lacking. METHOD This review is based on a selective literature search including previously published evidence-based recommendations, particularly those of the current American guidelines. RESULTS A purulent tympanic effusion, possibly associated with inflammation of the tympanic membrane, is indicative of AOM. Only some patients with AOM need immediate antibiotic treatment: children with severe otalgia and/or fever of 39.0°C or above, infants under 6 months of age, and children with certain specific risk factors, including immune deficiency and Down syndrome. In other cases, symptomatic treatment is appropriate. Antibiotic therapy (preferably with amoxicillin) should be initiated only if the symptoms and signs do not improve within two to three days. CONCLUSION As the currently available data are not fully consistent, there is still a need for controlled trials with well-defined endpoints to determine the relative benefits of immediate antibiotic treatment versus two to three days of watchful waiting.
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Affiliation(s)
- Jan Peter Thomas
- Department of Otorhinolaryngology and Head and Neck Surgery, Ruhr University of Bochum, Department of Child and Adolescent Medicine, Technical University of Dresden(Carl Gustav Carus University Hospital Dresden), Department of Otorhinolaryngology, Technical University of Dresden (Carl Gustav Carus University Hospital Dresden)
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8
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Bagger K, Nielsen ABS, Siersma V, Bjerrum L. Inappropriate antibiotic prescribing and demand for antibiotics in patients with upper respiratory tract infections is hardly different in female versus male patients as seen in primary care. Eur J Gen Pract 2015; 21:118-23. [PMID: 25712495 DOI: 10.3109/13814788.2014.1001361] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Unnecessary prescribing of antibiotics is a major public health concern. General practitioners (GPs) prescribe most antibiotics, often for upper respiratory tract infections (URTIs), and have in general been shown to prescribe antibiotics more often to women. No studies have examined the influence of patient gender on unnecessary antibiotic prescribing. OBJECTIVES To study a possible gender difference in unnecessary antibiotic prescriptions for URTIs in general practice; to assess whether a possible difference is explained by patient demand for antibiotics. METHODS Post-hoc analysis of a cross-sectional study including 15,022 patients with URTI (acute rhinitis, acute otitis media, acute sinusitis, acute pharyngotonsillitis) from Argentina, Denmark, Lithuania, Russia, Spain and Sweden (HAPPY AUDIT Project). The association between gender and unnecessary antibiotic prescriptions, unadjusted and adjusted for treatment demand, was analysed using logistic regression models. RESULTS A total of 25% of patients with URTI received antibiotics; in 45% of the cases, antibiotics were unnecessary. Overall, no gender difference for unnecessary prescribing of antibiotics for URTIs was found. Women with acute otitis media received an unnecessary antibiotic twice as often as men (14.4% versus 7.1%). In Danish patients with acute pharyngotonsillitis, there was a gender difference in unnecessary prescriptions for antibiotics (women 29.1% versus men 48.6%). Some 14% of patients receiving unnecessary antibiotics demonstrated a demand for antibiotics, but no gender difference was found in this group. CONCLUSION This study indicated a high rate of unnecessary antibiotic prescribing for URTIs in general practice, but overall found no gender differences in receiving unnecessary antibiotic prescriptions.
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Affiliation(s)
- Kathrine Bagger
- Section and Research Unit of General Practice, Department of Public Health, University of Copenhagen , Denmark
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9
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Passos SD. [Diagnosing streptococcal pharyngotonsillitis in children and adolescents: the limitations of the clinical features]. REVISTA PAULISTA DE PEDIATRIA : ORGAO OFICIAL DA SOCIEDADE DE PEDIATRIA DE SAO PAULO 2014; 32:283-4. [PMID: 25510989 PMCID: PMC4311779 DOI: 10.1016/j.rpped.2014.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
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Stelter K. Tonsillitis and sore throat in children. GMS CURRENT TOPICS IN OTORHINOLARYNGOLOGY, HEAD AND NECK SURGERY 2014; 13:Doc07. [PMID: 25587367 PMCID: PMC4273168 DOI: 10.3205/cto000110] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Surgery of the tonsils is still one of the most frequent procedures during childhood. Due to a series of fatal outcomes after hemorrhage in children in Austria in 2006, the standards and indications for tonsillectomy have slowly changed in Germany. However, no national guidelines exist and the frequency of tonsil surgery varies across the country. In some districts eight times more children were tonsillectomized than in others. A tonsillectomy in children under six years should only be done if the child suffers from recurrent acute bacterially tonsillitis. In all other cases (i.e. hyperplasia of the tonsils) the low risk partial tonsillectomy should be the first line therapy. Postoperative pain and the risk of hemorrhage are much lower in partial tonsillectomy (=tonsillotomy). No matter whether the tonsillotomy is done by laser, radiofrequency, shaver, coblation, bipolar scissor or Colorado needle, as long as the crypts are kept open and some tonsil tissue is left behind. Total extracapsular tonsillectomy is still indicated in severely affected children with recurrent infections of the tonsils, allergy to antibiotics, PFAPA syndrome (periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis) and peritonsillar abscess. With regard to the frequency and seriousness of the recurrent tonsillitis the indication for tonsillectomy in children is justified if 7 or more well-documented, clinically important, adequately treated episodes of throat infection occur in the preceding year, or 5 or more of such episodes occur in each of the 2 preceding years (according to the paradise criteria). Diagnosis of acute tonsillitis is clinical, but sometimes it is hard to distinguish viral from bacterial infections. Rapid antigen testing has a very low sensitivity in the diagnosis of bacterial tonsillitis and swabs are highly sensitive but take a long time. In all microbiological tests the treating physician has to keep in mind, that most of the bacterials, viruses and fungi belong to the healthy flora and do no harm. Ten percent of healthy children even bear strepptococcus pyogenes all the time in the tonsils with no clinical signs. In these children decolonization is not necessary. Therefore, microbiological screening tests in children without symptoms are senseless and do not justify an antibiotic treatment (which is sometimes postulated by the kindergartens). The acute tonsillitis should be treated with steroids (e.g. dexamethasone), NSAIDs (e.g. ibuprofene) and betalactam antibiotics (e.g. penicillin or cefuroxime). With respect to the symptom reduction and primary healing the short-term late-generation antibiotic therapy (azithromycin, clarithromycin or cephalosporine for three to five days) is comparable to the long-term penicilline therapy. There is no difference in the course of healing, recurrence or microbiological resistance between the short-term penicilline therapy and the standard ten days therapy. On the other hand, only the ten days antibiotic therapy has proven to be effective in the prevention of rheumatic fever and glomerulonephritic diseases. The incidence of rheumatic heart disease is currently 0.5 per 100,000 children of school age. The main morbidity after tonsillectomy is pain and the late haemorrhage. Posttonsillectomy bleeding can occur till the whole wound is completely healed, which is normally after three weeks. Life-threatening haemorrhages occur often after smaller bleedings, which can spontaneously cease. That is why every haemorrhage, even the smallest, has to be treated properly and in ward. Patients and parents have to be informed about the correct behaviour in case of haemorrhage with a written consent before the surgery. The handout should contain important addresses, phone numbers and contact persons. Almost all cases of fatal outcome after tonsillectomy were due to false management of haemorrhage. Haemorrhage in small children can be especially life-threatening because of the lower blood volume and the danger of aspiration with asphyxia. A massive haemorrhage is an extreme challenge for every paramedic or emergency doctor because of the difficult airway management. Intubation is only possible with appropriate inflexible suction tubes. All different surgical techniques have the risk of haemorrhage and even the best surgeon will experience a postoperative haemorrhage. The lowest risk of haemorrhage is after cold dissection with ligature or suturing. All "hot" techniques with laser, radiofrequency, coblation, mono- or bipolar forceps have a higher risk of late haemorrhage. Children with a hereditary coagulopathy have a higher risk of haemorrhage. It is possible, that these children were not identified before surgery. Therefore it is recommended by the Society of paediatrics, anaesthesia and ENT, that a standardised questionnaire should be answered by the parents before tonsillectomy and adenoidectomy. This 17-point-checklist questionnaire is more sensitive and easier to perform than a screening with blood tests (e.g. INR and PTT). Unfortunately, a lot of surgeons still screen the children preoperatively by coagulative blood tests, although these tests are inappropriate and incapable of detecting the von Willebrand disease, which is the most frequent coagulopathy in Europe. The preoperative information about the surgery should be done with the child and the parents in a calm and objective atmosphere with a written consent. A copy of the consent with the signature of the surgeon and both custodial parents has to be handed out to the parents.
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Affiliation(s)
- Klaus Stelter
- Dep. of Otorhinolaryngology, Head and Neck Surgery, Grosshadern Medical Centre, University of Munich, Munich, Germany
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Choi WS, Baek JH, Seo YB, Kee SY, Jeong HW, Lee HY, Eun BW, Choo EJ, Lee J, Kim YK, Song JY, Wie SH, Lee JS, Cheong HJ, Kim WJ. Severe influenza treatment guideline. Korean J Intern Med 2014; 29:132-47. [PMID: 24574848 PMCID: PMC3932389 DOI: 10.3904/kjim.2014.29.1.132] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2013] [Accepted: 12/17/2013] [Indexed: 01/20/2023] Open
Affiliation(s)
- Won Suk Choi
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Ji Hyeon Baek
- Department of Internal Medicine, Inha University School of Medicine, Incheon, Korea
| | - Yu Bin Seo
- Department of Internal Medicine, Hallym University College of Medicine, Seoul, Korea
| | - Sae Yoon Kee
- Department of Internal Medicine, Konkuk University School of Medicine, Chungju, Korea
| | - Hye Won Jeong
- Department of Internal Medicine, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Hee Young Lee
- Gachon University Gil Hospital Cancer Center, Gachon University Gil Medical Center, Incheon, Korea
| | - Byung Wook Eun
- Department of Pediatrics, Eulji University School of Medicine, Daejeon, Korea
| | - Eun Ju Choo
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Jacob Lee
- Department of Internal Medicine, Hallym University College of Medicine, Seoul, Korea
| | - Young Keun Kim
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Joon Young Song
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Seong-Heon Wie
- Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Jin Soo Lee
- Department of Internal Medicine, Inha University School of Medicine, Incheon, Korea
| | - Hee Jin Cheong
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Woo Joo Kim
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
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Ralph AP, Fittock M, Schultz R, Thompson D, Dowden M, Clemens T, Parnaby MG, Clark M, McDonald MI, Edwards KN, Carapetis JR, Bailie RS. Improvement in rheumatic fever and rheumatic heart disease management and prevention using a health centre-based continuous quality improvement approach. BMC Health Serv Res 2013; 13:525. [PMID: 24350582 PMCID: PMC3878366 DOI: 10.1186/1472-6963-13-525] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2012] [Accepted: 11/29/2013] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Rheumatic heart disease (RHD) remains a major health concern for Aboriginal Australians. A key component of RHD control is prevention of recurrent acute rheumatic fever (ARF) using long-term secondary prophylaxis with intramuscular benzathine penicillin (BPG). This is the most important and cost-effective step in RHD control. However, there are significant challenges to effective implementation of secondary prophylaxis programs. This project aimed to increase understanding and improve quality of RHD care through development and implementation of a continuous quality improvement (CQI) strategy. METHODS We used a CQI strategy to promote implementation of national best-practice ARF/RHD management guidelines at primary health care level in Indigenous communities of the Northern Territory (NT), Australia, 2008-2010. Participatory action research methods were employed to identify system barriers to delivery of high quality care. This entailed facilitated discussion with primary care staff aided by a system assessment tool (SAT). Participants were encouraged to develop and implement strategies to overcome identified barriers, including better record-keeping, triage systems and strategies for patient follow-up. To assess performance, clinical records were audited at baseline, then annually for two years. Key performance indicators included proportion of people receiving adequate secondary prophylaxis (≥80% of scheduled 4-weekly penicillin injections) and quality of documentation. RESULTS Six health centres participated, servicing approximately 154 people with ARF/RHD. Improvements occurred in indicators of service delivery including proportion of people receiving ≥40% of their scheduled BPG (increasing from 81/116 [70%] at baseline to 84/103 [82%] in year three, p = 0.04), proportion of people reviewed by a doctor within the past two years (112/154 [73%] and 134/156 [86%], p = 0.003), and proportion of people who received influenza vaccination (57/154 [37%] to 86/156 [55%], p = 0.001). However, the proportion receiving ≥80% of scheduled BPG did not change. Documentation in medical files improved: ARF episode documentation increased from 31/55 (56%) to 50/62 (81%) (p = 0.004), and RHD risk category documentation from 87/154 (56%) to 103/145 (76%) (p < 0.001). Large differences in performance were noted between health centres, reflected to some extent in SAT scores. CONCLUSIONS A CQI process using a systems approach and participatory action research methodology can significantly improve delivery of ARF/RHD care.
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Affiliation(s)
- Anna P Ralph
- Menzies School of Health Research, Darwin, Northern Territory (NT), Australia
- Division of Medicine, Royal Darwin Hospital, Darwin, NT, Australia
| | - Marea Fittock
- Menzies School of Health Research, Darwin, Northern Territory (NT), Australia
| | - Rosalie Schultz
- Nyangirru Piliyi-ngara Kurantta, Anyinginyi Health Aboriginal Corporation, Tennant Creek, NT, Australia
| | - Dale Thompson
- Menzies School of Health Research, Darwin, Northern Territory (NT), Australia
| | | | - Tom Clemens
- Northern Territory Department of Health and Community Services, Townsville, Australia
| | - Matthew G Parnaby
- Northern Territory Department of Health and Community Services, Townsville, Australia
| | - Michele Clark
- Queensland Health, Queensland Government, Townsville, Queensland, Australia
| | - Malcolm I McDonald
- School of Medicine and Dentistry, Cairns Campus, James Cook University, Townsville, QLD, Australia
| | - Keith N Edwards
- Northern Territory Department of Health and Community Services, Townsville, Australia
| | - Jonathan R Carapetis
- Telethon Institute for Child Health Research, Centre for Child Health Research, University of Western Australia, Perth, Western Australia, Australia
| | - Ross S Bailie
- Menzies School of Health Research, Darwin, Northern Territory (NT), Australia
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Abstract
BACKGROUND Sore throat is a common reason for people to present for medical care. Although it remits spontaneously, primary care doctors commonly prescribe antibiotics for it. OBJECTIVES To assess the benefits of antibiotics for sore throat for patients in primary care settings. SEARCH METHODS We searched CENTRAL 2013, Issue 6, MEDLINE (January 1966 to July week 1, 2013) and EMBASE (January 1990 to July 2013). SELECTION CRITERIA Randomised controlled trials (RCTs) or quasi-RCTs of antibiotics versus control assessing typical sore throat symptoms or complications. DATA COLLECTION AND ANALYSIS Two review authors independently screened studies for inclusion and extracted data. We resolved differences in opinion by discussion. We contacted trial authors from three studies for additional information. MAIN RESULTS We included 27 trials with 12,835 cases of sore throat. We did not identify any new trials in this 2013 update. 1. Symptoms Throat soreness and fever were reduced by about half by using antibiotics. The greatest difference was seen at day three. The number needed to treat to benefit (NNTB) to prevent one sore throat at day three was less than six; at week one it was 21. 2. Non-suppurative complications The trend was antibiotics protecting against acute glomerulonephritis but there were too few cases to be sure. Several studies found antibiotics reduced acute rheumatic fever by more than two-thirds within one month (risk ratio (RR) 0.27; 95% confidence interval (CI) 0.12 to 0.60). 3. Suppurative complications Antibiotics reduced the incidence of acute otitis media within 14 days (RR 0.30; 95% CI 0.15 to 0.58); acute sinusitis within 14 days (RR 0.48; 95% CI 0.08 to 2.76); and quinsy within two months (RR 0.15; 95% CI 0.05 to 0.47) compared to those taking placebo. 4. Subgroup analyses of symptom reduction Antibiotics were more effective against symptoms at day three (RR 0.58; 95% CI 0.48 to 0.71) if throat swabs were positive for Streptococcus, compared to RR 0.78; 95% CI 0.63 to 0.97 if negative. Similarly at week one the RR was 0.29 (95% CI 0.12 to 0.70) for positive and 0.73 (95% CI 0.50 to 1.07) for negative Streptococcus swabs. AUTHORS' CONCLUSIONS Antibiotics confer relative benefits in the treatment of sore throat. However, the absolute benefits are modest. Protecting sore throat sufferers against suppurative and non-suppurative complications in high-income countries requires treating many with antibiotics for one to benefit. This NNTB may be lower in low-income countries. Antibiotics shorten the duration of symptoms by about 16 hours overall.
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Affiliation(s)
- Anneliese Spinks
- Griffith UniversitySchool of MedicineUniversity DriveMeadowbrookQueenslandAustralia4031
| | - Paul P Glasziou
- Bond UniversityCentre for Research in Evidence‐Based Practice (CREBP)University DriveGold CoastQueenslandAustralia4229
| | - Chris B Del Mar
- Bond UniversityCentre for Research in Evidence‐Based Practice (CREBP)University DriveGold CoastQueenslandAustralia4229
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14
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Scaglione F, Bertazzoni Minelli E, De Sarro A, Esposito S, Legnani D, Mazzei T, Mini E, Passali D, Pea F, Stefani S, Viano I, Novelli A. TheChartaof Milan: Basic Criteria for the Appropriate and Accurate Use of Antibiotics: Recommendations of the Italian Society of Chemotherapy. J Chemother 2013; 21:475-81. [DOI: 10.1179/joc.2009.21.5.475] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Jefferis J, Perera R, Everitt H, van Weert H, Rietveld R, Glasziou P, Rose P. Acute infective conjunctivitis in primary care: who needs antibiotics? An individual patient data meta-analysis. Br J Gen Pract 2011; 61:e542-8. [PMID: 22152728 PMCID: PMC3162176 DOI: 10.3399/bjgp11x593811] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2011] [Revised: 02/21/2011] [Accepted: 03/29/2011] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Acute infective conjunctivitis is a common problem in primary care, traditionally managed with topical antibiotics. A number of clinical trials have questioned the benefit of topical antibiotics for patients with acute infective conjunctivitis. AIM To determine the benefit of antibiotics for the treatment of acute infective conjunctivitis in primary care and which subgroups benefit most. DESIGN An individual patient data meta-analysis. METHOD Relevant trials were identified and individual patient data gathered for meta-analysis and subgroup analysis. RESULTS Three eligible trials were identified. Individual patient data were available from all primary care trials and data were available for analysis in 622 patients. Eighty per cent (246/308) of patients who received antibiotics and 74% (233/314) of controls were cured at day 7. There was a significant benefit of antibiotics versus control for cure at seven days in all cases combined (risk difference 0.08, 95% confidence interval (CI) = 0.01 to 0.14). Subgroups that showed a significant benefit from antibiotics were patients with purulent discharge (risk difference 0.09, 95% CI = 0.01 to 0.17) and patients with mild severity of red eye (risk difference 0.10, 95% CI = 0.02 to 0.18), while the type of control used (placebo drops versus nothing) showed a statistically significant interaction (P=0.03). CONCLUSION Acute conjunctivitis seen in primary care can be thought of as a self-limiting condition, with most patients getting better regardless of antibiotic therapy. Patients with purulent discharge or a mild severity of red eye may have a small benefit from antibiotics. Prescribing practices need to be updated, taking into account these results.
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Murphy M, Byrne S, Bradley CP. Influence of patient payment on antibiotic prescribing in Irish general practice: a cohort study. Br J Gen Pract 2011; 61:e549-55. [PMID: 22152734 PMCID: PMC3162177 DOI: 10.3399/bjgp11x593820] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2011] [Revised: 03/28/2011] [Accepted: 04/13/2011] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Antibiotics are widely believed to be overused and misused. Approximately 80% of all prescriptions for antibiotics are written by GPs. There are many external factors that influence a GP's decision to prescribe, including patient pressure. Access to primary care services operates on a two-tier system in the Republic of Ireland: General Medical Service (GMS) card holders have free access to GPs and medications; and non-card holders (private patients) must pay a non-subsidised fee to visit their GP. AIM To ascertain whether there was a difference in antibiotic prescribing practice between those who pay a fee for their GP consultation and those who attend free of charge. DESIGN AND SETTING Cohort study in Irish general practice. METHOD All GPs attending continuing medical education (CME) groups nationwide were invited to participate from October 2008 until April 2010. GPs gathered data on 100 consecutive consultations including diagnosis and patient characteristics. RESULTS Data were collected from 171 GPs (distributed throughout Ireland), which resulted in 16 899 consultations. Antibiotics were prescribed at 3407 (20.16%) consultations. Nearly half of the prescriptions were for GMS card holders (n = 1669; 48.99%) and 1526 (44.79%) were for private patients; for 212 (6.22%) the payment status of the patient was unknown. Private patients were more likely to receive a prescription for antibiotics (odds ratio 1.23, 95% confidence interval = 1.14 to 1.33). CONCLUSION These results demonstrate that a GP's decision to provide a prescription for antibiotics may be influenced by whether or not the patient pays for their consultation at the GP interface. Private patients are more likely than GMS card holders to receive a prescription for antibiotics.
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Affiliation(s)
- Marion Murphy
- Department of General Practice, School of Medicine, University College Cork, Cork, Ireland
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Bin Abdulhak AA, Altannir MA, Almansor MA, Almohaya MS, Onazi AS, Marei MA, Aldossary OF, Obeidat SA, Obeidat MA, Riaz MS, Tleyjeh IM. Non prescribed sale of antibiotics in Riyadh, Saudi Arabia: a cross sectional study. BMC Public Health 2011; 11:538. [PMID: 21736711 PMCID: PMC3146870 DOI: 10.1186/1471-2458-11-538] [Citation(s) in RCA: 122] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2011] [Accepted: 07/07/2011] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Antibiotics sales without medical prescriptions are increasingly recognized as sources of antimicrobial misuse that can exacerbate the global burden of antibiotic resistance. We aimed to determine the percentage of pharmacies who sell antibiotics without medical prescriptions, examining the potential associated risks of such practice in Riyadh, Saudi Arabia, by simulation of different clinical scenarios. METHODS A cross sectional study of a quasi-random sample of pharmacies stratified by the five regions of Riyadh. Each pharmacy was visited once by two investigators who simulated having a relative with a specific clinical illness (sore throat, acute bronchitis, otitis media, acute sinusitis, diarrhea, and urinary tract infection (UTI) in childbearing aged women). RESULTS A total of 327 pharmacies were visited. Antibiotics were dispensed without a medical prescription in 244 (77.6%) of 327, of which 231 (95%) were dispensed without a patient request. Simulated cases of sore throat and diarrhea resulted in an antibiotic being dispensed in (90%) of encounters, followed by UTI (75%), acute bronchitis (73%), otitis media (51%) and acute sinusitis (40%). Metronidazole (89%) and ciprofloxacin (86%) were commonly given for diarrhea and UTI, respectively, whereas amoxicillin/clavulanate was dispensed (51%) for the other simulated cases. None of the pharmacists asked about antibiotic allergy history or provided information about drug interactions. Only 23% asked about pregnancy status when dispensing antibiotics for UTI-simulated cases. CONCLUSIONS We observed that an antibiotic could be obtained in Riyadh without a medical prescription or an evidence-based indication with associated potential clinical risks. Strict enforcement and adherence to existing regulations are warranted.
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Affiliation(s)
- Aref A Bin Abdulhak
- Internal Medicine Department, King Fahd Medical City, Aldabab Street, Riyadh, 11525, Saudi Arabia
| | - Mohamad A Altannir
- Research and Scientific Publication Center, King Fahd Medical City, Aldabab street, Riyadh, 11525, Saudi Arabia
| | - Mohammed A Almansor
- Internal Medicine Department, King Fahd Medical City, Aldabab Street, Riyadh, 11525, Saudi Arabia
| | - Mohammed S Almohaya
- Internal Medicine Department, King Fahd Medical City, Aldabab Street, Riyadh, 11525, Saudi Arabia
| | - Atallah S Onazi
- Internal Medicine Department, King Fahd Medical City, Aldabab Street, Riyadh, 11525, Saudi Arabia
| | - Mohammed A Marei
- Internal Medicine Department, King Fahd Medical City, Aldabab Street, Riyadh, 11525, Saudi Arabia
| | - Oweida F Aldossary
- Internal Medicine Department, King Fahd Medical City, Aldabab Street, Riyadh, 11525, Saudi Arabia
| | - Sadek A Obeidat
- Alfaisal University, Takhassusi Street, Riyadh, 11533, Saudi Arabia
| | | | - Muhammad S Riaz
- Research and Scientific Publication Center, King Fahd Medical City, Aldabab street, Riyadh, 11525, Saudi Arabia
| | - Imad M Tleyjeh
- Internal Medicine Department, King Fahd Medical City, Aldabab Street, Riyadh, 11525, Saudi Arabia
- Research and Scientific Publication Center, King Fahd Medical City, Aldabab street, Riyadh, 11525, Saudi Arabia
- Infectious Diseases Division, Mayo Clinic, 200 First Street S.W, Rochester, MN, 55905, USA
- Division of Epidemiology, Mayo Clinic, 200 First Street S.W, Rochester, MN, 55905, USA
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Høye S, Frich JC, Lindbæk M. Use and feasibility of delayed prescribing for respiratory tract infections: a questionnaire survey. BMC FAMILY PRACTICE 2011; 12:34. [PMID: 21592334 PMCID: PMC3114766 DOI: 10.1186/1471-2296-12-34] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/01/2010] [Accepted: 05/18/2011] [Indexed: 11/10/2022]
Abstract
BACKGROUND Delayed prescribing of antibiotics for respiratory tract infections (RTIs) lowers the amount of antibiotics consumed. Several national treatment guidelines on RTIs recommend the strategy. When advocating treatment innovations, the feasibility and credibility of the innovation must be taken into account. The objective of this study was to explore GPs use and patients uptake of wait-and-see prescriptions for RTIs, and to investigate the feasibility of the strategy from GPs' and patients' perspectives. METHODS Questionnaire survey among Norwegian GPs issuing and patients receiving a wait-and-see-prescription for RTIs. Patients reported symptoms, confidence and antibiotics consumption, GPs reported diagnoses, reason for issuing a wait-and-see-prescription and their opinion about the method. RESULTS 304 response pairs from consultations with 49 GPs were received. The patient response rate was 80%. The most common diagnosis for the GPs to issue a wait-and-see prescription was sinusitis (33%) and otitis (21%). 46% of the patients reported to consume the antibiotics. When adjusted for other factors, the diagnosis did not predict antibiotic consumption, but both being 16 years or more (p = 0,006) and reporting to have a fever (p = 0,012) doubled the odds of antibiotic consumption, while feeling very ill more than quadrupled the odds (p = 0,002). In 210 cases (69%), the GP found delayed prescribing a very reasonable strategy, and 270 patients (89%) would prefer to receive a wait-and-see prescription in a similar situation in the future. The GPs found delayed prescribing very reasonable most frequently in cases of sinusitis (79%, p = 0,007) and least frequently in cases of lower RTIs (49%, p = 0,002). CONCLUSION Most patients and GPs are satisfied with the delayed prescribing strategy. The patients' age, symptoms and malaise are more important than the diagnosis in predicting antibiotic consumption. The GP's view of the method as a reasonable approach depends on the patient's diagnosis. In our setting, delayed prescribing seems to be a feasible strategy, especially in cases of sinusitis and otitis. Educational efforts to promote delayed prescribing in similar settings should focus on these diagnoses.
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Affiliation(s)
- Sigurd Høye
- Antibiotic Center for Primary Care, Department of General Practice, Institute of Health and Society, University of Oslo, PO Box 1130 Blindern, N-0318 Oslo, Norway.
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19
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Rheumatic fever. Infect Dis (Lond) 2010. [DOI: 10.1016/b978-0-323-04579-7.00048-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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20
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Grammatikos AP, Mantadakis E, Falagas ME. Meta-analyses on Pediatric Infections and Vaccines. Infect Dis Clin North Am 2009; 23:431-57. [DOI: 10.1016/j.idc.2009.01.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Otitis Media and Sinusitis. ALLERGY FRONTIERS: CLINICAL MANIFESTATIONS 2009. [PMCID: PMC7121333 DOI: 10.1007/978-4-431-88317-3_7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Otitis media (OM) and sinusitis are common and costly maladies that are often preceded by the development of a viral upper respiratory infection (vURI). Although antibiotics have been shown to be somewhat effective in the treatment of these disorders, increasing concern over the emergence of pathogen resistence to these agents underscores the need for the development of other treatment options, including agents to treat and/or prevent vURIs. Earlier research implicated roles for cytopathology, cellular infiltration, and inflammatory mediators such as bradykinin, in the pathogenesis of vURIs and its complications, including OM and sinusitis, but these factors are now recognized as late events with specific and limited contributions to disease expression. Current therapies are relatively ineffective and aimed at reducing symptoms rather than moderating underlying mechanisms. Nasal elevations of proinflammatory cytokines and leukotrienes track symptom expression during vURIs, and it is hypothesized that these chemicals orchestrate a common response to infection with many different viruses causing vURIs. Moreover, recent evidence demonstrates that specific cytokine gene polymorphisms may modulate the severity of illness and incidence of complications during episodes of vURI. Additionally, other evidence supports a role for neurogenic inflammation in the development of complications. Future studies should dissect the role of proinflammatory cytokines, leukotrienes, and neuropeptides in the expression of symptoms, signs, pathophysiologies, and complications of vURIs.
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22
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Skoner DP. Delayed antibiotic therapy for acute otitis media in the emergency department. Curr Allergy Asthma Rep 2008. [DOI: 10.1007/s11882-008-0092-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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23
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Uijen JHJM, van Duijn HJ, Kuyvenhoven MM, Schellevis FG, van der Wouden JC. Characteristics of children consulting for cough, sore throat, or earache. Br J Gen Pract 2008; 58:248-54. [PMID: 18387228 PMCID: PMC2277110 DOI: 10.3399/bjgp08x279751] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2007] [Revised: 01/23/2007] [Accepted: 01/21/2008] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND GPs are often consulted for respiratory tract symptoms in children. AIM To explore characteristics of children, their parents, and their GPs that are correlated with consulting a GP for cough, sore throat, or earache. DESIGN OF STUDY Second Dutch National Survey of General Practice (DNSGP-2) with a health interview and an additional questionnaire. SETTING Children aged 0-17 years registered with 122 GPs in Dutch general practice. METHOD Characteristics of patients and their GPs were derived from the DNSGP-2 health interview and a questionnaire, respectively. Characteristics of the illness symptoms and GP consultation were acquired by means of an additional questionnaire. Data were analysed using multivariate logistic regression. RESULTS Of all children who completed the questionnaire, 550 reported cough, sore throat, or earache in the 2 weeks preceding the interview with 147 of them consulting their GP. Young children more frequently consulted the GP for respiratory symptoms, as did children with fever, longer duration of symptoms, those reporting their health to be 'poor to good', and living in an urban area. When parents were worried, and when a child or their parents were cued by someone else, the GP was also consulted more often. GP-related determinants were not associated with GP consultation by children. CONCLUSION This study emphasises the importance of establishing the reasons behind children with respiratory tract symptoms consulting their GP. When GPs are aware of possible determinants of the decision to consult a GP, more appropriate advice and reassurance can be given regarding these respiratory symptoms, which are generally self-limiting.
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Affiliation(s)
- Johannes H J M Uijen
- Department of General Practice, Erasmus MC, University Medical Center, Rotterdam, The Netherlands.
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Hrisos S, Eccles M, Johnston M, Francis J, Kaner EFS, Steen N, Grimshaw J. An intervention modelling experiment to change GPs' intentions to implement evidence-based practice: using theory-based interventions to promote GP management of upper respiratory tract infection without prescribing antibiotics #2. BMC Health Serv Res 2008; 8:10. [PMID: 18194526 PMCID: PMC2262061 DOI: 10.1186/1472-6963-8-10] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2007] [Accepted: 01/14/2008] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Psychological theories of behaviour may provide a framework to guide the design of interventions to change professional behaviour. Behaviour change interventions, designed using psychological theory and targeting important motivational beliefs, were experimentally evaluated for effects on the behavioural intention and simulated behaviour of GPs in the management of uncomplicated upper respiratory tract infection (URTI). METHODS The design was a 2 x 2 factorial randomised controlled trial. A postal questionnaire was developed based on three theories of human behaviour: Theory of Planned Behaviour; Social Cognitive Theory and Operant Learning Theory. The beliefs and attitudes of GPs regarding the management of URTI without antibiotics and rates of prescribing on eight patient scenarios were measured at baseline and post-intervention. Two theory-based interventions, a "graded task" with "action planning" and a "persuasive communication", were incorporated into the post-intervention questionnaire. Trial groups were compared using co-variate analyses. RESULTS Post-intervention questionnaires were returned for 340/397 (86%) GPs who responded to the baseline survey. Each intervention had a significant effect on its targeted behavioural belief: compared to those not receiving the intervention GPs completing Intervention 1 reported stronger self-efficacy scores (Beta = 1.41, 95% CI: 0.64 to 2.25) and GPs completing Intervention 2 had more positive anticipated consequences scores (Beta = 0.98, 95% CI = 0.46 to 1.98). Intervention 2 had a significant effect on intention (Beta = 0.90, 95% CI = 0.41 to 1.38) and simulated behaviour (Beta = 0.47, 95% CI = 0.19 to 0.74). CONCLUSION GPs' intended management of URTI was significantly influenced by their confidence in their ability to manage URTI without antibiotics and the consequences they anticipated as a result of doing so. Two targeted behaviour change interventions differentially affected these beliefs. One intervention also significantly enhanced GPs' intentions not to prescribe antibiotics for URTI and resulted in lower rates of prescribing on patient scenarios compared to a control group. The theoretical frameworks utilised provide a scientific rationale for understanding how and why the interventions had these effects, improving the reproducibility and generalisability of these findings and offering a sound basis for an intervention in a "real world" trial. TRIAL REGISTRATION Clinicaltrials.gov NCT00376142.
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Affiliation(s)
- Susan Hrisos
- Institute of Health and Society, Newcastle University, UK
| | - Martin Eccles
- Institute of Health and Society, Newcastle University, UK
| | | | - Jill Francis
- Health Services Research Unit, University of Aberdeen, UK
| | | | - Nick Steen
- Institute of Health and Society, Newcastle University, UK
| | - Jeremy Grimshaw
- Clinical Epidemiology Program, Ottawa Health Research Institute and Department of Medicine, University of Ottawa, Ottawa, Canada
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Hrisos S, Eccles M, Johnston M, Francis J, Kaner EFS, Steen N, Grimshaw J. Developing the content of two behavioural interventions: using theory-based interventions to promote GP management of upper respiratory tract infection without prescribing antibiotics #1. BMC Health Serv Res 2008; 8:11. [PMID: 18194527 PMCID: PMC2267186 DOI: 10.1186/1472-6963-8-11] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2007] [Accepted: 01/14/2008] [Indexed: 11/15/2022] Open
Abstract
UNLABELLED Evidence shows that antibiotics have limited effectiveness in the management of upper respiratory tract infection (URTI) yet GPs continue to prescribe antibiotics. Implementation research does not currently provide a strong evidence base to guide the choice of interventions to promote the uptake of such evidence-based practice by health professionals. While systematic reviews demonstrate that interventions to change clinical practice can be effective, heterogeneity between studies hinders generalisation to routine practice. Psychological models of behaviour change that have been used successfully to predict variation in behaviour in the general population can also predict the clinical behaviour of healthcare professionals. The purpose of this study was to design two theoretically-based interventions to promote the management of upper respiratory tract infection (URTI) without prescribing antibiotics. METHOD Interventions were developed using a systematic, empirically informed approach in which we: selected theoretical frameworks; identified modifiable behavioural antecedents that predicted GPs intended and actual management of URTI; mapped these target antecedents on to evidence-based behaviour change techniques; and operationalised intervention components in a format suitable for delivery by postal questionnaire. RESULTS We identified two psychological constructs that predicted GP management of URTI: "Self-efficacy," representing belief in one's capabilities, and "Anticipated consequences," representing beliefs about the consequences of one's actions. Behavioural techniques known to be effective in changing these beliefs were used in the design of two paper-based, interactive interventions. Intervention 1 targeted self-efficacy and required GPs to consider progressively more difficult situations in a "graded task" and to develop an "action plan" of what to do when next presented with one of these situations. Intervention 2 targeted anticipated consequences and required GPs to respond to a "persuasive communication" containing a series of pictures representing the consequences of managing URTI with and without antibiotics. CONCLUSION It is feasible to systematically develop theoretically-based interventions to change professional practice. Two interventions were designed that differentially target generalisable constructs predictive of GP management of URTI. Our detailed and scientific rationale for the choice and design of our interventions will provide a basis for understanding any effects identified in their evaluation. TRIAL REGISTRATION Clinicaltrials.gov NCT00376142.
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Affiliation(s)
- Susan Hrisos
- Institute of Health and Society, Newcastle University, UK
| | - Martin Eccles
- Institute of Health and Society, Newcastle University, UK
| | | | - Jill Francis
- Health Services Research Unit, University of Aberdeen, UK
| | | | - Nick Steen
- Institute of Health and Society, Newcastle University, UK
| | - Jeremy Grimshaw
- Clinical Epidemiology Program, Ottawa Health Research Institute and Department of Medicine, University of Ottawa, Ottawa, Canada
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Butler CC, Simpson S, Wood F. General practitioners' perceptions of introducing near-patient testing for common infections into routine primary care: a qualitative study. Scand J Prim Health Care 2008; 26:17-21. [PMID: 18297558 PMCID: PMC3406622 DOI: 10.1080/02813430701726285] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2007] [Indexed: 10/22/2022] Open
Abstract
OBJECTIVE Near-patient tests are promoted for guiding management of common infections in primary care with a view to enhancing the effectiveness of prescribing decisions and containing antimicrobial resistance. Changes in clinical practice should be based on appraisals of the factors that might influence change, viewed from the perspective of those expected to implement the change. We therefore explored the views of general practitioners concerning the possible introduction of near-patient tests for managing common infections. DESIGN Qualitative semi-structured interview study. Interviews were recorded and analysed using thematic content analysis. SETTING General practices in south-east Wales, UK. SUBJECTS A total of 26 general practitioners (GPs) from high fluroquinolone antibiotics prescribing practices and 14 GPs from practices that prescribed fluroquinolones close to the south-east Wales mean. RESULTS There was strong enthusiasm for a hypothetical near-patient, finger-prick blood tests that could distinguish viral from bacterial infections. Many GPs emphasized that such tests would be valuable in "selling" decisions not to prescribe antibiotics to patients. Concerns included limited additional useful information to guide prescribing above clinical diagnosis alone, that patients might deteriorate even if the tests correctly identified a viral aetiology, and that GPs would need to be convinced by research evidence supporting uptake. Several indicated that tests would be useful only for a limited number of patients and they were concerned by time pressures, apparatus maintenance and quality control, cost, and possible objections from patients, especially children. CONCLUSIONS Despite GP enthusiasm for the concept of a rapid test to distinguish viral from bacterial infection, strategies to promote uptake would be enhanced if concerns were addressed regarding the importance and feasibility of such tests in daily practice.
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Riordan T. Human infection with Fusobacterium necrophorum (Necrobacillosis), with a focus on Lemierre's syndrome. Clin Microbiol Rev 2007; 20:622-59. [PMID: 17934077 PMCID: PMC2176048 DOI: 10.1128/cmr.00011-07] [Citation(s) in RCA: 360] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Human infection with Fusobacterium necrophorum usually involves F. necrophorum subsp. funduliforme rather than F. necrophorum subsp. necrophorum, which is a common pathogen in animals. Lemierre's syndrome, or postanginal sepsis, is the most common life-threatening manifestation. Tonsillitis is followed by septic thrombophlebitis of the internal jugular vein and then a septicemia with septic emboli in lungs and other sites. Recent evidence suggests that F. necrophorum can be limited to the throat and cause persistent or recurrent tonsillitis. F. necrophorum is unique among non-spore-forming anaerobes, first for its virulence and association with Lemierre's syndrome as a monomicrobial infection and second because it seems probable that it is an exogenously acquired infection. The source of infection is unclear; suggestions include acquisition from animals or human-to-human transmission. Approximately 10% of published cases are associated with infectious mononucleosis, which may facilitate invasion. Recent work suggests that underlying thrombophilia may predispose to internal jugular vein thrombophlebitis. Lemierre's syndrome was relatively common in the preantibiotic era but seemed to virtually disappear with widespread use of antibiotics for upper respiratory tract infection. In the last 15 years there has been a rise in incidence, possibly related to restriction in antibiotic use for sore throat.
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Affiliation(s)
- Terry Riordan
- Microbiology Department, Royal Devon & Exeter Foundation Trust, Exeter, United Kingdom.
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McDonald M, Brown A, Edwards T, Hope A, Amu M, Morey F, Currie BJ, Carapetis JR. Apparent Contrasting Rates of Pharyngitis and Pyoderma in Regions where Rheumatic Heart Disease is Highly Prevalent. Heart Lung Circ 2007; 16:254-9. [PMID: 17581789 DOI: 10.1016/j.hlc.2007.02.087] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2006] [Revised: 12/18/2006] [Accepted: 02/07/2007] [Indexed: 11/26/2022]
Abstract
BACKGROUND The aim of the study was to describe the epidemiology of pharyngitis and pyoderma in a Central Australian Aboriginal community with a high prevalence of rheumatic heart disease (RHD) and compare it to communities in the Top End of the Northern Territory. METHODS Following ethics approval and community consultation, selected households were enrolled and visited over a 13-month period. People were asked if they had a sore throat and/or skin sores and asked about current or recent use of antibiotics; all throats and any pyoderma lesions were swabbed for bacterial culture. Beta-haemolytic streptococci (BHS), including group A streptococcus (GAS), were identified in the central laboratory using standard methods. Household crowding was also assessed. Results were then compared to those from the Top End study. RESULTS Sore throat was relatively common (480 episodes per 100 person years), although there was only one case of GAS pharyngitis in 326 consultations. Only 5.5% of children <15 years had pyoderma during the course of the study. This is the opposite picture to that reported in the Top End where symptomatic pharyngitis is rare and pyoderma is common. CONCLUSIONS Although the data are limited, the epidemiology of pharyngitis and pyoderma in this Central Australian Aboriginal community appears to be more akin to that seen in temperate climates rather than tropical Top End communities. In this community, RHD preventative measure should continue to include aggressive treatment of pharyngitis according to recommendations.
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Affiliation(s)
- Malcolm McDonald
- Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia.
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van Driel ML, Coenen S, Dirven K, Lobbestael J, Janssens I, Van Royen P, Haaijer-Ruskamp FM, De Meyere M, De Maeseneer J, Christiaens T. What is the role of quality circles in strategies to optimise antibiotic prescribing? A pragmatic cluster-randomised controlled trial in primary care. Qual Saf Health Care 2007; 16:197-202. [PMID: 17545346 PMCID: PMC2464984 DOI: 10.1136/qshc.2006.018663] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To evaluate the effect on antibiotic prescribing of an intervention in existing local quality circles promoting an evidence-based guideline for acute rhinosinusitis. DESIGN A pragmatic cluster-randomised controlled trial comparing standard dissemination of the guideline by mail with an additional strategy using quality circles. SETTING General practice in Flanders, Belgium. PARTICIPANTS General practitioners (GPs) in 18 local quality circles were randomly allocated to two study arms. All GPs received the guideline by mail. GPs in the nine quality circles allocated to the intervention arm received an additional group intervention, which consisted of one self-led meeting using material introduced to the group moderator by a member of the research team. MAIN OUTCOME MEASURES Adherence to the guideline was measured as differences in the proportion of antibiotic prescriptions, including the choice of antibiotic, between the two study arms after the intervention period. GPs registered their encounters with patients presenting with signs and symptoms of acute rhinosinusitis in a booklet designed for the study. RESULTS A total of 75 doctors (29% of GPs in the participating quality circles) registered 408 consultations. In the intervention group, 56.9% of patients received an antibiotic compared with 58.3% in the control group. First-choice antibiotics were issued in 34.5% of antibiotic prescriptions in the intervention group compared with 29.4% in the control group. After adjusting for patient and GP characteristics, the ORadj for antibiotics prescribed in the intervention arm compared with the control arm was 0.63 (95% CI 0.29 to 1.37). There was no effect on the choice of antibiotic (ORadj 1.07, 95% CI 0.34 to 3.37). CONCLUSION A single intervention in quality circles of GPs integrated in the group's normal working procedure did not have a significant effect on the quality of antibiotic prescribing. More attention to the context and structure of primary care practice, and insight into the process of self-reflective learning may provide clues to optimise the effectiveness of quality circles.
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Affiliation(s)
- M L van Driel
- Department of General Practice and Primary Health Care, Ghent University, Ghent, Belgium.
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Rovers MM, Glasziou P, Appelman CL, Burke P, McCormick DP, Damoiseaux RA, Little P, Le Saux N, Hoes AW. Predictors of pain and/or fever at 3 to 7 days for children with acute otitis media not treated initially with antibiotics: a meta-analysis of individual patient data. Pediatrics 2007; 119:579-85. [PMID: 17332211 DOI: 10.1542/peds.2006-2092] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE The goal was to determine the predictors of a prolonged course for children with acute otitis media. METHODS A meta-analysis of data with the observation groups of 6 randomized, controlled trials was performed. Participants were 824 children, 6 months to 12 years of age, with acute otitis media. The primary outcome was a prolonged course of acute otitis media, which was defined as fever and/or pain at 3 to 7 days. RESULTS Of the 824 included children, 303 had pain and/or fever at 3 to 7 days. Independent predictors of a prolonged course were age of < 2 years and bilateral acute otitis media. The absolute risk of pain and/or fever at 3 to 7 days for children < 2 years of age with bilateral acute otitis media (20% of all children) was 55%, and that for children > or = 2 years of age with unilateral acute otitis media (47% of all children) was 25%. CONCLUSIONS The risk of a prolonged course was 2 times higher for children < 2 years of age with bilateral acute otitis media than for children > or = 2 years of age with unilateral acute otitis media. Clinicians can use these features (ie, age of < 2 years and bilateral acute otitis media) to inform parents more explicitly about the expected course of their child's otitis media and to explain which features should prompt parents to contact their clinician for reexamination of the child.
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Affiliation(s)
- Maroeska M Rovers
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Stratenum 6.131, PO Box 85060, 3508 AB Utrecht, The Netherlands.
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Friedrich JO, Adhikari NKJ, Beyene J. Inclusion of zero total event trials in meta-analyses maintains analytic consistency and incorporates all available data. BMC Med Res Methodol 2007; 7:5. [PMID: 17244367 PMCID: PMC1783664 DOI: 10.1186/1471-2288-7-5] [Citation(s) in RCA: 350] [Impact Index Per Article: 20.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2006] [Accepted: 01/23/2007] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Meta-analysis handles randomized trials with no outcome events in both treatment and control arms inconsistently, including them when risk difference (RD) is the effect measure but excluding them when relative risk (RR) or odds ratio (OR) are used. This study examined the influence of such trials on pooled treatment effects. METHODS Analysis with and without zero total event trials of three illustrative published meta-analyses with a range of proportions of zero total event trials, treatment effects, and heterogeneity using inverse variance weighting and random effects that incorporates between-study heterogeneity. RESULTS Including zero total event trials in meta-analyses moves the pooled estimate of treatment effect closer to nil, decreases its confidence interval and decreases between-study heterogeneity. For RR and OR, inclusion of such trials causes small changes, even when they comprise the large majority of included trials. For RD, the changes are more substantial, and in extreme cases can eliminate a statistically significant effect estimate. CONCLUSION To include all relevant data regardless of effect measure chosen, reviewers should also include zero total event trials when calculating pooled estimates using OR and RR.
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Affiliation(s)
- Jan O Friedrich
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Canada
- Critical Care and Medicine Departments, St. Michael's Hospital, 30 Bond Street, 4Bond-015, Toronto, Ontario M5B 1W8, Canada
| | - Neill KJ Adhikari
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Canada
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue Toronto, Ontario M4N 3M5, Canada
| | - Joseph Beyene
- Department of Public Health Sciences, University of Toronto, Toronto, Canada
- Child Health Evaluative Sciences, Hospital for Sick Children Research Institute, 123 Edward Street, Room 1206, Toronto, Ontario M5G 1E2, Canada
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Pan Y, Henderson J, Britt H. Antibiotic prescribing in Australian general practice: How has it changed from 1990–91 to 2002–03? Respir Med 2006; 100:2004-11. [PMID: 16616483 DOI: 10.1016/j.rmed.2006.02.015] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2005] [Revised: 02/05/2006] [Accepted: 02/17/2006] [Indexed: 11/16/2022]
Abstract
There is increasing evidence that antibiotics have limited value for many respiratory illnesses. This study investigates changes in overall antibiotic prescribing rates, and rates for specific conditions, by Australian general practitioners (GPs) between 1990-91 and 2002-03. This is a comparative study of two cross-sectional surveys of general practice activity, the Australian Morbidity and Treatment Survey (AMTS) 1990-91 and Bettering Evaluation and Care of Health (BEACH) 2002-03. Both studies used random samples of GPs, each providing data about a cluster of patient encounters. Outcome measures are the antibiotic prescribing rate per 100 encounters or per 100 selected problems managed. Between 1990-91 and 2002-03, the overall antibiotic prescribing rate decreased 24.3% from 18.9 prescriptions per 100 encounters to 14.3 (P<0.001). For children, the decrease for acute upper respiratory tract infection (URTI) was from 39.0 per 100 URTI problems to 24.4 (P<0.001), while the antibiotic prescribing rate increased for acute otitis media, decreased for bronchitis/bronchiolitis, and remained unchanged for other respiratory problems analysed. For adults the antibiotic prescribing rate for URTI decreased from 58.2 per 100 URTI problems to 40.0 (P<0.001), increased significantly for sinusitis and remained unchanged for all other respiratory problems. Antibiotic prescribing decreased significantly between 1990-91 and 2002-03 but the decrease was selective. The decline has been more pronounced among children than adults, and particularly for URTI. While the message of educators may be achieving its goal for URTI, other approaches targeting specific respiratory problems may be required to reduce antibiotic prescribing in these areas.
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Affiliation(s)
- Ying Pan
- Australian General Practice Statistics and Classification Centre, University of Sydney, PO Box 533, Wentworthville 2145, Australia
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Rietveld RP, Bindels PJE, ter Riet G. Antibiotics for upper respiratory tract infections and conjunctivitis in primary care. BMJ 2006; 333:311-2. [PMID: 16902200 PMCID: PMC1539043 DOI: 10.1136/bmj.333.7563.311] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Van Limbergen J, Kalima P, Taheri S, Beattie TF. Streptococcus A in paediatric accident and emergency: are rapid streptococcal tests and clinical examination of any help? Emerg Med J 2006; 23:32-4. [PMID: 16373800 PMCID: PMC2564123 DOI: 10.1136/emj.2004.022970] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Rapid streptococcal tests (RSTs) for streptococcal pharyngitis have made diagnosis at once simpler and more complicated. The American Academy of Pediatrics recommends that all RSTs be confirmed by a follow up throat culture unless local validation has proved the RST to be equally sensitive. AIMS To evaluate (a) RST as a single diagnostic tool, compared with RST with or without throat culture; (b) clinical diagnosis and the relative contribution of different symptoms. METHODS The study included 213 patients with clinical signs of pharyngitis. Throat swabs were analysed using Quickvue+ Strep A Test; negative RSTs were backed up by throat culture. Thirteen clinical features commonly associated with strep throat were analysed using backward stepwise logistic regression. RESULTS Positive results (RST or throat culture) were obtained in 33 patients; RST correctly identified 21. Eleven samples were false negative on RST. At a strep throat prevalence of 15.9%, sensitivity of RST was 65.6% (95% CI 46.8% to 81.4%) and specificity 99.4% (96.7% to 99.9%). Sensitivity of clinical diagnosis alone was 57% (34% to 78%) and specificity 71% (61% to 80%). Clinically, only history of sore throat, rash, and pyrexia contributed to the diagnosis of strep throat (p<0.05). CONCLUSION The high specificity of RST facilitates early diagnosis of strep throat. However, the low sensitivity of RST does not support its use as a single diagnostic tool. The sensitivity in the present study is markedly different from that reported by the manufacturer. Clinical examination is of limited value in the diagnosis of strep throat. It is important to audit the performance of new diagnostic tests, previously validated in different settings.
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Affiliation(s)
- J Van Limbergen
- Department of Paediatric Emergency Care, Royal Hospital for Sick Children, Edinburgh, UK.
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Singh S, Dolan JG, Centor RM. Optimal management of adults with pharyngitis--a multi-criteria decision analysis. BMC Med Inform Decis Mak 2006; 6:14. [PMID: 16533386 PMCID: PMC1431519 DOI: 10.1186/1472-6947-6-14] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2005] [Accepted: 03/13/2006] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Current practice guidelines offer different management recommendations for adults presenting with a sore throat. The key issue is the extent to which the clinical likelihood of a Group A streptococcal infection should affect patient management decisions. To help resolve this issue, we conducted a multi-criteria decision analysis using the Analytic Hierarchy Process. METHODS We defined optimal patient management using four criteria: 1) reduce symptom duration; 2) prevent infectious complications, local and systemic; 3) minimize antibiotic side effects, minor and anaphylaxis; and 4) achieve prudent use of antibiotics, avoiding both over-use and under-use. In our baseline analysis we assumed that all criteria and sub-criteria were equally important except minimizing anaphylactic side effects, which was judged very strongly more important than minimizing minor side effects. Management strategies included: a) No test, No treatment; b) Perform a rapid strep test and treat if positive; c) Perform a throat culture and treat if positive; d) Perform a rapid strep test and treat if positive; if negative obtain a throat culture and treat if positive; and e) treat without further tests. We defined four scenarios based on the likelihood of group A streptococcal infection using the Centor score, a well-validated clinical index. Published data were used to estimate the likelihoods of clinical outcomes and the test operating characteristics of the rapid strep test and throat culture for identifying group A streptococcal infections. RESULTS Using the baseline assumptions, no testing and no treatment is preferred for patients with Centor scores of 1; two strategies--culture and treat if positive and rapid strep with culture of negative results--are equally preferable for patients with Centor scores of 2; and rapid strep with culture of negative results is the best management strategy for patients with Centor scores 3 or 4. These results are sensitive to the priorities assigned to the decision criteria, especially avoiding over-use versus under-use of antibiotics, and the population prevalence of Group A streptococcal pharyngitis. CONCLUSION The optimal clinical management of adults with sore throat depends on both the clinical probability of a group A streptococcal infection and clinical judgments that incorporate individual patient and practice circumstances.
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Affiliation(s)
- Sonal Singh
- Department of Medicine, Wake Forest University, Winston Salem, NC, USA
| | - James G Dolan
- Department of Medicine, Unity Health System and the University of Rochester, Rochester, New York, USA
| | - Robert M Centor
- Department of Medicine, University of Alabama-Birmingham, Birmingham, AL, USA
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Van Howe RS, Kusnier LP. Diagnosis and management of pharyngitis in a pediatric population based on cost-effectiveness and projected health outcomes. Pediatrics 2006; 117:609-19. [PMID: 16510638 DOI: 10.1542/peds.2005-0879] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Pharyngitis is a common childhood complaint. Current management for children and adolescents includes 1 of 6 strategies, ie, (1) observe without testing or treatment, (2) treat all suspected cases with an antibiotic, (3) treat those with positive throat cultures, (4) treat those with positive rapid tests, (5) treat those with positive rapid tests and those with positive throat cultures after negative rapid tests, or (6) use a clinical scoring measure to determine the diagnosis/treatment strategy. The sequelae of untreated group A hemolytic streptococcal (GAS) pharyngitis are rare, whereas antibiotic treatment may result in side effects ranging from rash to death. The cost-utility of these strategies for children has not been reported previously. METHODS A decision tree analysis incorporating the total cost and health impact of each management strategy was used to determine cost per quality-adjusted life-year ratios. Sensitivity analyses and Monte Carlo simulations assessed the accuracy of the estimates. RESULTS From a societal perspective with current Medicaid reimbursements for testing, performing a throat culture for all patients had the best cost-utility. For private insurance reimbursements, rapid antigen testing had the best cost-utility. Observing without testing or treatment had the lowest morbidity rate and highest cost from a societal perspective but the lowest cost from a payer perspective. The model was most sensitive to the incidence of acute rheumatic fever and peritonsillar abscess after untreated GAS pharyngitis. Monte Carlo simulations demonstrated considerable overlap among all of the options except for treating all patients and observing all patients. CONCLUSIONS Observing patients with pharyngitis had the lowest morbidity rate. The costs of this option were primarily from parental time lost from work. Before recommending observation rather than treatment of GAS pharyngitis, accurate estimates of the risk of developing acute rheumatic fever and peritonsillar abscess after GAS pharyngitis are needed.
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Affiliation(s)
- Robert S Van Howe
- Department of Pediatrics, Michigan State University College of Human Medicine, Marquette, Michigan, USA.
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Llor Vilà C. [The prescription of antibiotics for respiratory tract infections has to be reduced]. Aten Primaria 2005; 35:449-50. [PMID: 15919016 PMCID: PMC7669098 DOI: 10.1157/13075473] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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McAvoy BR. Primary care research--what in the world is going on? Med J Aust 2005; 183:110-2. [PMID: 16022629 DOI: 10.5694/j.1326-5377.2005.tb06944.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2005] [Accepted: 05/27/2005] [Indexed: 11/17/2022]
Abstract
Primary care research has been described as a "lost cause", and, although this claim has been strongly refuted, general practitioners publish less research than their colleagues in surgery, medicine and public health. Despite a fivefold increase in Australian general practice research papers from the 1980s to the 1990s, fewer than half of these focused on clinical topics. Trying to establish a global figure for expenditure on general practice and primary care research is difficult, but data show that public expenditure for primary care research is minimal in Australia, New Zealand, the Netherlands and the United Kingdom--fewer than 1.50 dollars per capita in 2002-2003. Compared with hospital- and laboratory-based research, primary care receives significantly fewer resources, ranging from 3.2% of total public expenditure on health and medical research in the Netherlands to 6.8% in New Zealand. Government-led investment in interventions such as strengthening primary care departments and colleges and supporting primary care academics, establishing practice-based networks, fostering international initiatives for cross-national efforts, and engaging individual primary care practitioners in research projects, are all required to build research capacity in primary care.
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Affiliation(s)
- Brian R McAvoy
- National Cancer Control Initiative, 1 Rathdowne Street, Carlton, VIC 3053.
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Akkerman AE, Kuyvenhoven MM, van der Wouden JC, Verheij TJM. Determinants of antibiotic overprescribing in respiratory tract infections in general practice. J Antimicrob Chemother 2005; 56:930-6. [PMID: 16155062 DOI: 10.1093/jac/dki283] [Citation(s) in RCA: 75] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES To assess determinants of antibiotic overprescribing in patients with sinusitis, tonsillitis and bronchitis in Dutch general practice. PATIENTS AND METHODS A total of 146 general practitioners (GPs) from The Netherlands included all patients with sinusitis, tonsillitis and bronchitis during a 4 week period in the winter of 2002/2003, and recorded patient characteristics, clinical presentation and management. Overprescribing of antibiotics was assessed using the recommendations of the Dutch national guidelines as a benchmark. RESULTS In almost 50% of all 1469 respiratory tract infection (RTI) consultations (694/1469), the antibiotic prescribing decisions were in accordance with the recommendations of the Dutch national guidelines. Overprescribing was highest in tonsillitis and bronchitis [71% (168/238) and 63% (415/656), respectively], while in sinusitis this was only 22% (128/575). Underprescribing was seen in 1% (3/238), 3% (17/656) and 8% (44/575), respectively. Patients who received an antibiotic prescription that was not in accordance with the guidelines had more inflammation signs such as fever (ORs 2.08, 2.18 and 3.04, for sinusitis, tonsillitis and bronchitis, respectively), were more severely ill according to their GP (ORs 2.37, 1.87 and 1.42, respectively), and their GP assumed more often that they expected an antibiotic (ORs 1.95, 1.70 and 2.11, respectively), compared with those who did not receive an antibiotic prescription. CONCLUSIONS GPs overestimate symptoms and probably patients' expectations when indicating antibiotic therapy in RTI cases in daily practice. Correct interpretation of combinations of symptoms for antibiotic treatment should be emphasized, combined with adopting more patient-centred consulting skills to rationalize the prescribing of antibiotics.
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Affiliation(s)
- Annemiek E Akkerman
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Location Stratenum, PO Box 85060, 3508 AB Utrecht, The Netherlands.
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Briel M, Christ-Crain M, Young J, Schuetz P, Huber P, Périat P, Bucher HC, Müller B. Procalcitonin-guided antibiotic use versus a standard approach for acute respiratory tract infections in primary care: study protocol for a randomised controlled trial and baseline characteristics of participating general practitioners [ISRCTN73182671]. BMC FAMILY PRACTICE 2005; 6:34. [PMID: 16107222 PMCID: PMC1190167 DOI: 10.1186/1471-2296-6-34] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/11/2005] [Accepted: 08/18/2005] [Indexed: 11/16/2022]
Abstract
BACKGROUND Acute respiratory tract infections (ARTI) are among the most frequent reasons for consultations in primary care. Although predominantly viral in origin, ARTI often lead to the prescription of antibiotics for ambulatory patients, mainly because it is difficult to distinguish between viral and bacterial infections. Unnecessary antibiotic use, however, is associated with increased drug expenditure, side effects and antibiotic resistance. A novel approach is to guide antibiotic therapy by procalcitonin (ProCT), since serum levels of ProCT are elevated in bacterial infections but remain lower in viral infections and inflammatory diseases. The aim of this trial is to compare a ProCT-guided antibiotic therapy with a standard approach based on evidence-based guidelines for patients with ARTI in primary care. METHODS/DESIGN This is a randomised controlled trial in primary care with an open intervention. Adult patients judged by their general practitioner (GP) to need antibiotics for ARTI are randomised in equal numbers either to standard antibiotic therapy or to ProCT-guided antibiotic therapy. Patients are followed-up after 1 week by their GP and after 2 and 4 weeks by phone interviews carried out by medical students blinded to the goal of the trial. Exclusion criteria for patients are antibiotic use in the previous 28 days, psychiatric disorders or inability to give written informed consent, not being fluent in German, severe immunosuppression, intravenous drug use, cystic fibrosis, active tuberculosis, or need for immediate hospitalisation. The primary endpoint is days with restrictions from ARTI within 14 days after randomisation. Secondary outcomes are antibiotic use in terms of antibiotic prescription rate and duration of antibiotic treatment in days, days off work and days with side-effects from medication within 14 days, and relapse rate from the infection within 28 days after randomisation. DISCUSSION We aim to include 600 patients from 50 general practices in the Northwest of Switzerland. Data from the registry of the Swiss Medical Association suggests that our recruited GPs are representative of all eligible GPs with respect to age, proportion of female physicians, specialisation, years of postgraduate training and years in private practice.
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Affiliation(s)
- Matthias Briel
- Basel Institute for Clinical Epidemiology, University Hospital Basel, CH-4031 Basel, Switzerland
| | - Mirjam Christ-Crain
- Clinic of Endocrinology, Diabetes & Clinical Nutrition, Department of Internal Medicine, University Hospital Basel, CH-4031 Basel, Switzerland
| | - Jim Young
- Basel Institute for Clinical Epidemiology, University Hospital Basel, CH-4031 Basel, Switzerland
| | - Philipp Schuetz
- Clinic of Endocrinology, Diabetes & Clinical Nutrition, Department of Internal Medicine, University Hospital Basel, CH-4031 Basel, Switzerland
| | - Peter Huber
- Department of Chemical Pathology, University Hospital Basel, CH-4031 Basel, Switzerland
| | - Pierre Périat
- General practice, In den Neumatten 63, CH-4125 Riehen, Switzerland
| | - Heiner C Bucher
- Basel Institute for Clinical Epidemiology, University Hospital Basel, CH-4031 Basel, Switzerland
| | - Beat Müller
- Clinic of Endocrinology, Diabetes & Clinical Nutrition, Department of Internal Medicine, University Hospital Basel, CH-4031 Basel, Switzerland
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Robertson KA, Volmink JA, Mayosi BM. Antibiotics for the primary prevention of acute rheumatic fever: a meta-analysis. BMC Cardiovasc Disord 2005; 5:11. [PMID: 15927077 PMCID: PMC1164408 DOI: 10.1186/1471-2261-5-11] [Citation(s) in RCA: 112] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2004] [Accepted: 05/31/2005] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Rheumatic fever continues to put a significant burden on the health of low socio-economic populations in low and middle-income countries despite the near disappearance of the disease in the developed world over the past century. Antibiotics have long been thought of as an effective method for preventing the onset of acute rheumatic fever following a Group-A streptococcal (GAS) throat infection; however, their use has not been widely adopted in developing countries for the treatment of sore throats. We have used the tools of systematic review and meta-analysis to quantify the effectiveness of antibiotic treatment for sore throat, with symptoms suggestive of group A streptococcal (GAS) infection, for the primary prevention of acute rheumatic fever. METHODS Trials were identified through a systematic search of titles and abstracts found in the Cochrane Central Register of Controlled Trials (Cochrane Library Issue 4, 2003), MEDLINE (1966-2003), EMBASE (1966-2003), and the reference lists of identified studies. The selection criteria included randomised or quasi-randomised controlled trials comparing the effectiveness of antibiotics versus no antibiotics for the prevention of rheumatic fever in patients presenting with a sore throat, with or without confirmation of GAS infection, and no history of rheumatic fever. RESULTS Ten trials (n = 7665) were eligible for inclusion in this review. The methodological quality of the studies, in general, was poor. All of the included trials were conducted during the period of 1950 and 1961 and in 8 of the 10 trials the study population consisted of young adult males living on United States military bases. Fixed effects, meta-analysis revealed an overall protective effect for the use of antibiotics against acute rheumatic fever of 70% (RR = 0.32; 95% CI = 0.21-0.48). The absolute risk reduction was 1.67% with an NNT of 53. When meta-analysis was restricted to include only trials evaluating penicillin, a protective effect of 80% was found (Fixed effect RR = 0.20, 95% CI = 0.11-0.36) with an NNT of 60. The marginal cost of preventing one case of rheumatic fever by a single intramuscular injection of penicillin is approximately USD 46 in South Africa. CONCLUSION Antibiotics appear to be effective in reducing the incidence of acute rheumatic fever following an episode of suspected GAS pharyngitis. This effect may be achieved at relatively low cost if a single intramuscular penicillin injection is administered.
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Affiliation(s)
- Katharine A Robertson
- Primary Health Care Directorate, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- The Cardiac Clinic, Department of Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
| | - Jimmy A Volmink
- Primary Health Care Directorate, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Bongani M Mayosi
- The Cardiac Clinic, Department of Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
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Arroll B. Antibiotics for upper respiratory tract infections: an overview of Cochrane reviews. Respir Med 2005; 99:255-61. [PMID: 15733498 DOI: 10.1016/j.rmed.2004.11.004] [Citation(s) in RCA: 93] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2004] [Accepted: 10/19/2004] [Indexed: 10/25/2022]
Abstract
OBJECTIVES The aim of this paper is to review the four Cochrane reviews of antibiotics for upper respiratory tract infections. METHODS Each Cochrane review was read and summarized, and results presented as odds ratios (as in the Internet version) and, where relevant, numbers needed to treat. RESULTS The reviews of antibiotics for acute otitis media have concluded that benefit is not great with a number needed to treat for a benefit (NNTB) of 15. Recent US guidelines are recommending a delay in prescriptions in children over the age of 6 months. For streptococcal tonsillitis, the Cochrane reviewers suggest that antibiotic use seems to be discretionary rather than prohibited or mandatory. This is because the benefit in terms of symptoms is only about 16h (NNTB from 2 to 7 at day 3 for pain) compared with placebo, and that serious complications, such as rheumatic fever and glomerulonephritis, are now rare in developed countries. The reviewers do, however, suggest that antibiotics are considered in populations in whom these complications are more common. This is an area of debate, as the Infectious Disease Society of America (2002) recommends routine treatment. [Clin. Infect. Dis. 35 (2002) 113] There is good evidence and consensus that there is no indication for antibiotics for the common cold. The situation with acute purulent rhinitis is less clear, as new evidence suggests that antibiotics may be effective for acute purulent rhinitis (NNTB from 6 to 8). However, as most people with acute purulent rhinitis improve without antibiotics, giving antibiotics is not justified as an initial treatment. For acute maxillary sinusitis, the evidence suggests that antibiotics are effective for people with radiologically confirmed sinusitis. The reviewers suggest that clinicians should weigh up the modest benefits (NNTB from 3 to 6) against the potential for adverse effects. CONCLUSION The use of antibiotics for acute otitis media, sore throat and streptococcal tonsillitis, common cold and acute purulent rhinitis, and acute maxillary sinusitis seems to be discretionary rather than prohibited or mandatory, at least for non-severe cases.
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Affiliation(s)
- B Arroll
- Department of General Practice and Primary Health Care, University of Auckland, Auckland New Zealand.
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