[Appropriateness of treatment of acute pharyngotonsillitis according to the scientific evidence]

Antibiotic prescription pattern among Primary Healthcare General Practitioners in the South Batinah Governorate of Oman, 2019

BACKGROUND

Misuse and overuse of antibiotics comprise leading causes of antimicrobial resistance. The study aims to assess the pattern of antibiotic prescription among primary healthcare general practitioners in the South Batinah Governorate of Oman.

METHOD

A cross-sectional study of 600 antibiotic prescriptions issued in the South Batinah Governorate in 2019 was conducted to verify the triggering diagnoses and determine the appropriateness of the prescribed antibiotic. Logistic regression analysis was used to determine the association between predictors and inappropriate use.

RESULTS

Respiratory infections accounted for 62% of antibiotic prescriptions, of which 92.2% were inappropriately prescribed. Extended-spectrum antibiotics were inappropriately prescribed in 33.3% of cystitis cases, while 14.3% of gastroenteritis received incorrect spectrum of antibiotics. Amoxicillin represented 46.2% of antibiotic prescriptions, of which 84.4% were unnecessarily prescribed. Lower inappropriate antibiotic prescribing rate was linked to patients ≥ 18 years (OR = 0.46, 95% CI: [0.26, 0.82]), those who underwent laboratory tests (OR = 0.22, 95% CI: [0.12, 0.39]), and consultations at health centers (OR = 0.44, 95% CI: [0.24, 0.79]). Arabic-speaking physicians were more likely to prescribe antibiotics inappropriately.

CONCLUSION

Inappropriate antibiotic prescription was frequently observed in mild respiratory infections and associated with specific patient and physician characteristics. Appropriateness of antibiotic prescriptions issued can be improved through enhanced testing capacities as well as implementation of physician and community awareness campaigns.

[Introduction of rapid streptococcal antigen test: can its use improve adherence to antibiotic therapy?]

OBJECTIVE

To evaluate the influence of the result of a rapid streptococcal antigen test in paediatric pharyngotonsillitis infections, in terms of improvement of antibiotic therapy adherence.

DESIGN

Randomized community clinical trial with two study groups.

LOCATION

Primary Care Centers in Central Catalonia.

PARTICIPANTS

Patients aged from 3 to 15 years, who were attended at paediatric consultations on suspicion of pharyngotonsillitis caused by an infection between November 2010 and February 2011 (both included), were included in the study on a consecutive basis. 557 patients met the inclusion criteria and 519 were evaluated.

INTERVENTION

The control group received the usual diagnostic-therapeutic algorithm. Rapid streptococcal antigen test was additionally performed to experimental group participants and it was indicated the more convenient treatment.

MAIN MEASUREMENTS

Antibiotic adherence, non-adherence causes and socio-demographic risk factors were evaluated via telephone survey.

RESULTS

Antibiotics were prescribed to 65.6% and paediatricians of the control group were more likely to prescribe antibiotic than the ones in the intervention group (88.5% vs 45.5%, p< 0.0001). 64.8% followed doctor's treatment orders, being failure following medication scheduling the main cause of non-adherence (25.6%). Medication adherence was higher in the experimental group (68%) than in the control group (62.9%) but no significant differences were found.

CONCLUSION

Rapid strep test, complementing the use of Centor Criteria avoids unnecessary antibiotics prescriptions, but had not been proven to be effective in increasing medication adherence.

Survey of Spanish general practitioners' attitudes toward management of sore throat: an internet-based questionnaire study

Background

The management of sore throat varies widely in Europe. The objective of this study was to gain insight into clinicians’ perceptions on the current management of sore throat in Spain.

Methods

Cross-sectional, internet-based questionnaire study answered from July to September 2013. General practitioners (GPs) affiliated with the two largest scientific societies of primary care were invited to participate in the study. Questions were asked about physician knowledge, the use of current national guidelines for sore throat management, and management in two clinical scenarios, depicting a young adult with sore throat and: 1. cough, coriza with or without fever, and 2. fever without cough and coriza.

Results

The questionnaire was completed by 1476 GPs (5%) and 12.7% declared using rapid antigen detection tests. Antibiotics were considered by 18.8% of the GPs in the first scenario and by 32% in the second scenario (p < 0.001). The antibiotics most commonly mentioned by GPs were amoxicillin and amoxicillin + clavulanate (52.7 and 31.2%, respectively) whereas penicillin V was only prescribed in 11.9% of the cases. The drugs most commonly considered in both scenarios were analgesics and anti-inflammatory drugs. Antitussives, decongestants and expectorants were more commonly prescribed in cases of suspected viral infection (p < 0.001).

Conclusions

GPs have misconceptions as to the indications for using rapid antigen detection tests and prescribing drugs in the management of sore throat. These results suggest that guidelines are seldom followed since one in five GPs declared giving antibiotics for patients with a suspected viral infection and the use of second-choice antibiotics seems considerable.

[Consensus document on the diagnosis and treatment of acute tonsillopharyngitis]

Acute tonsillopharyngitis is one of the most common childhood diseases. Viruses are the most frequent origin. Group A Streptococcus (Streptococcus pyogenes) is the main bacterial cause. A culture or a rapid antigen-detection test of a throat-swab specimen should only be done on the basis of clinical scores, in order to avoid over-diagnosis of bacterial origin and unnecessary antibiotic prescription. The objectives of treatment are: the reduction of symptoms, reduce the contagious period, and prevent local suppurative and systemic complications. Ideally, only confirmed cases should receive antibiotics. If there is no possibility to perform a rapid antigen-detection test, or in some cases if the result is negative, it is recommended to perform a culture and, if there is high suspicious index, to prescribe antibiotics. Penicillin is the treatment of choice, although amoxicillin is also accepted as the first option. Amoxicillin/clavulanate is not indicated in any case as empirical treatment. Macrolides are not a first choice antibiotic, and should be reserved for those patients with immediate penicillin allergy reaction or for the treatment of streptococcal carriers. It is of primordial importance to adapt the prescribing of antibiotics to the scientific evidence.

Diagnosis and management of acute pharyngitis in a paediatric population: a cost-effectiveness analysis

Acute pharyngitis is one of the most frequent causes of primary care physician visits; however, there is no agreement about which is the best strategy to diagnose and manage acute pharyngitis in children. The aim of the current study was to evaluate the cost-effectiveness of the recommended strategies to diagnose and manage acute pharyngitis in a paediatric population. A decision tree analysis was performed to compare the following six strategies: "treat all", "clinical scoring", "rapid test", "culture", "rapid test + culture" and "clinical scoring + rapid test". The cost data came from the Spanish National Health Service sources. Cost-effectiveness was calculated from the payer's perspective. Effectiveness was measured as the proportion of patients cured without complications from the disease and did not have any reaction to penicillin therapy; a sensitivity analysis was performed. The findings revealed that the "clinical scoring + rapid test" strategy is the most cost-effective, with a cost-effectiveness ratio of 50.72 <euro>. This strategy dominated all others except "culture", which was the most effective but also the most costly. The sensitivity analysis showed that "rapid test" became the most cost-effective strategy when the clinical scoring sensitivity was <91% and its specificity was ≤9%. In conclusion, the use of a clinical scoring system to triage the diagnoses and performing a rapid antigen test for those with a high score is the most cost-effective strategy for the diagnosis and management of acute pharyngitis in children. When the clinical scoring system has a low diagnostic accuracy, testing all patients with rapid test becomes the most cost-effective strategy.

[Validation of a rapid antigenic test in the diagnosis of pharyngitis caused by group a beta-haemolytic Streptococcus]

OBJECTIVE

To determine the validity of the rapid antigen test (RAT) OSOM StrepA Genzyme for the diagnosis of acute pharyngitis caused by group A beta-haemolytic strep (GABHS).

DESIGN

Diagnostic techniques survey.

SETTING

Urban primary care centre, Spain.

PARTICIPANTS

All patients over 14 years old seen in 6 surgeries with sore throat and 2 or more Centor criteria: pharyngotonsillar exudate, tender laterocervical nodes, absence of coughing, and/or history or presence of fever.

PRINCIPAL MEASUREMENTS

Pharyngeal swabs were taken from all the patients, one for RAT and another to send for culture in the microbiology department.

RESULTS

A total of 182 patients were evaluable, with a mean age of 30.6 (12.1) years of which 116 were women (63.7%); 63 patients had 2 Centor criteria; 83 had 3 and 36, the 4 criteria. The culture was positive in 102 patients (56%), with GABHS showing infection in forty (22%; 95% confidence interval [CI], 21.2-22.8). Group C Streptococcus was isolated in 26 patients (14.3%). GABHS was higher among patients with four Centor criteria (38.9% vs 25.3% observed among those with 3 criteria and 7.9% with 2 criteria; P<.001). Sensitivity of RAT was 95%, with a specificity of 93%, a positive predictive value of 79.2% and a negative predictive value of 98.5%.

CONCLUSIONS

These results show the usefulness of RAT for diagnosing streptococcal pharyngitis. Its use should be spread to all primary care practices.

Variabilidad de la prescripción de antibióticos en la población pediátrica de Castilla y León durante los años 2001 a 2005 en el medio urbano o rural

OBJECTIVES

To compare systemic antibiotic prescribing in the pediatric population of Castile and Leon in relation to urban or rural setting.

MATERIAL AND METHODS

Data on non-hospital antibiotic consumption in the pediatric population were gathered from the database that processes the antibiotics billed in the Health Service of Castile and Leon. These data were analyzed according to the Anatomical Therapeutic Chemical Classification System (ATC) and the results were expressed as defined daily doses per 1000 inhabitants per day (DID).

RESULTS

Overall antibiotic consumption in the pediatric population was markedly higher in the rural setting (24.37 DID in rural areas vs. 19.54 DID in urban areas). Interannual variability was similar in both settings, with prescriptions reaching a peak in 2003. In the qualitative analysis, prescription of amoxicillin and, to a lesser extent, of cefixime and azithromycin was higher in rural areas. Differences in prescription in the urban and rural areas of the distinct health areas varied, the greatest differences being found in Segovia.

CONCLUSIONS

Wide quantitative and qualitative variability in antibiotic use was found between the various urban and rural zones of basic health areas. Although we suspected that the results for the urban setting would be underestimated due to the excessive use of emergency services, more detailed studies are required to better understand the determinants of antibiotic use in children.

Manejo racional de la antibioterapia en las infecciones otorrinolaringológicas en la infancia: revisión crítica de las mejores pruebas científicas

INTRODUCTION

Upper respiratory tract infections are the more prevalent infections in childhood and it is important to know the use and overuse of antibiotics. The objective of this article is to make a systematic and critical review of the best scientific evidence in bibliography in order to use antibiotics rationally in otorhinolaryngology (ORL) infections.

MATERIAL AND METHODS

Systematic and structured review of the articles regarding antibiotherapy in ORL infections (pharyngitis, tonsillitis, otitis, sinusitis and laryngitis) in childhood published in secondary (Cochrane Collaboration, clinical practice guidelines, health technology assessment database, etc) and primary (bibliographic databases, biomedical journals, books, etc.) publications and critical appraisal by means of methodology of the Evidence-Based Medicine Working Group. We selected the publications with the main scientific evidence in therapeutical articles (clinical trial, systematic review, meta-analysis and clinical practice guideline).

DATA SELECTION

study design, population, intervention, outcomes, main results and applicability in clinical practice.

RESULTS

The main secondary information is found in The Cochrane Library and in Clinical practice guideline clearinghouses. The documents in Cochrane Library are, basically, clinical trials, systematic reviews and/or meta-analysis, mainly about otitis (13 documents), sinusitis/rhinosinusitis (6), pharyngitis/tonsillitis (3) and nasopharyngitis (3). We found 17 guidelines, mainly for otitis (8 guidelines), pharyngitis/tonsillitis (5), sinusitis (3) and laryngitis (1). Also, we found some relevant articles in Pubmed database, complementary to secondary publications.

CONCLUSIONS

There are a high number of quality scientific studies who support an evidence-based decision making in clinical practice about the rational use of antibiotics in ORL infections in childhood, mainly in otitis, tonsillitis and sinusitis. Every decision in this field will have to be based on a systematic appraisal of the best evidence available in the context of the prevailing values and resources available. Doctor's knowledge (mainly in otorhinolaryngologists and pediatricians) of systematic and critical review of the current literature can help to modify prescribing habits about overuse and misuse of antibiotics in ORL infections.