Antibiotic use by indication: a basis for active antibiotic policy in the community

Early exposure to environmental levels of sulfamethoxazole triggers immune and inflammatory response of healthy zebrafish larvae

Trace levels of antibiotics are increasingly being detected in aquatic environment and their potential toxicity to aquatic organisms is concerning. Sulfamethoxazole (SMX), a veterinary sulfonamide widely used across the globe, exists ubiquitously in aquatic environment with concentrations up to micrograms per liter. This study aims to investigate the effects of environmentally relevant levels (0.1, 1, 10, 100 μg/L) of SMX on the health of zebrafish during early development. Our results show that SMX delays the hatchment of embryos and reduces the body length. A dose-response relationship of oxidative stress indicators including total-antioxidant capacity (T-AOC), inducible nitric oxide synthase (iNOS) and total nitric oxide synthase (TNOS), catalase (CAT) has been observed. Additionally, SMX up-regulates the gene expression of several key proinflammatory cytokines and their corresponding proteins including interleukin-1β (IL-1β), interferon-γ (IFN-γ) and interleukin-11 (IL-11) and the expression of genes including interleukin-6 (il-6), tumor necrosis factor-α (tnf-α). This indicates that early exposure of SMX may evoke inflammation response in healthy fish. Inhibition of lysozyme and recombination-activating genes (rags) suggests that SMX suppresses the ability of zebrafish to resist pathogen. The reduction of the expression of Toll-like receptors (TLRs) related genes and significant correlations between TLRs and other immune-related genes reveal that TLRs might be an immunoregulator of SMX for zebrafish embryos and larvae. The novelty of this study lies in that early exposure to environmental levels of SMX not only affects the growth and development of zebrafish larvae, but also triggers oxidative stress and inflammation, resulting in a reduction in host immune defense via TLRs in healthy fish.

Comprehensive Identification of Fim-Mediated Inversions in Uropathogenic Escherichia coli with Structural Variation Detection Using Relative Entropy

UTI is a common ailment that affects more than half of all women during their lifetime. The leading cause of UTIs is UPEC, which relies on type 1 pili to colonize and persist within the bladder during infection. The regulation of type 1 pili is remarkable for an epigenetic mechanism in which a section of DNA containing a promoter is inverted. The inversion mechanism relies on what are thought to be dedicated recombinase genes; however, the full repertoire for these recombinases is not known. We show here that there are no additional targets beyond those already identified for the recombinases in the entire genome of two UPEC strains, arguing that type 1 pilus expression itself is the driving evolutionary force for the presence of these recombinase genes. This further suggests that targeting the type 1 pilus is a rational alternative nonantibiotic strategy for the treatment of UTI.

Most urinary tract infections (UTIs) are caused by uropathogenic Escherichia coli (UPEC), which depends on an extracellular organelle (type 1 pili) for adherence to bladder cells during infection. Type 1 pilus expression is partially regulated by inversion of a piece of DNA referred to as fimS, which contains the promoter for the fim operon encoding type 1 pili. fimS inversion is regulated by up to five recombinases collectively known as Fim recombinases. These Fim recombinases are currently known to regulate two other switches: the ipuS and hyxS switches. A long-standing question has been whether the Fim recombinases regulate the inversion of other switches, perhaps to coordinate expression for adhesion or virulence. We answered this question using whole-genome sequencing with a newly developed algorithm (structural variation detection using relative entropy [SVRE]) for calling structural variations using paired-end short-read sequencing. SVRE identified all of the previously known switches, refining the specificity of which recombinases act at which switches. Strikingly, we found no new inversions that were mediated by the Fim recombinases. We conclude that the Fim recombinases are each highly specific for a small number of switches. We hypothesize that the unlinked Fim recombinases have been recruited to regulate fimS, and fimS only, as a secondary locus; this further implies that regulation of type 1 pilus expression (and its role in gastrointestinal and/or genitourinary colonization) is important enough, on its own, to influence the evolution and maintenance of multiple additional genes within the accessory genome of E. coli.

IMPORTANCE UTI is a common ailment that affects more than half of all women during their lifetime. The leading cause of UTIs is UPEC, which relies on type 1 pili to colonize and persist within the bladder during infection. The regulation of type 1 pili is remarkable for an epigenetic mechanism in which a section of DNA containing a promoter is inverted. The inversion mechanism relies on what are thought to be dedicated recombinase genes; however, the full repertoire for these recombinases is not known. We show here that there are no additional targets beyond those already identified for the recombinases in the entire genome of two UPEC strains, arguing that type 1 pilus expression itself is the driving evolutionary force for the presence of these recombinase genes. This further suggests that targeting the type 1 pilus is a rational alternative nonantibiotic strategy for the treatment of UTI.

A national approach to medicines information research: A systematic review

BACKGROUND

The Finnish Medicines Agency Fimea published the first National Medicines Information (MI) strategy in 2012. For the purpose of implementing the MI strategy into practice by the national MI Network, a comprehensive inventory of MI research in Finland was needed.

OBJECTIVE

To systematically review literature on MI research conducted in Finland by analyzing and classifying the studies, and identifying the gaps in MI research.

METHODS

Medline, Scopus and Medic databases were searched for peer-reviewed MI publications by using key word screening criteria. The search and extraction process followed PRISMA Guidelines and covered the period from January 2000 to June 2016. Included studies were content analyzed according to MI practices identified, trends over time in research methodology and theory.

RESULTS

Included publications (n = 126) applied a variety of research methods, most often cross-sectional surveys (n = 51, 40% of all studies), but more than half of the studies were qualitative (n = 68, 54%). Twelve were intervention studies of which 6 were randomized and had a control group. Studies were categorized into: patient counseling in different settings (n = 45); MI sources and needs of medicine users (n = 25); healthcare professionals' (HCPs) competence in patient counseling and pharmacotherapy (n = 25); MI sources and needs of HCPs (n = 23); MI education and literacy (n = 13); and MI policies and strategies (n = 3). Most of the studies were descriptive, and only 6 studies applied a theory.

CONCLUSIONS

Regardless of some methodological pitfalls, MI research conducted in Finland since 2000 provides multifaceted understanding of MI practices and their development needs. Research should shift towards larger research lines having a stronger theory base and study designs to deepen the understanding of MI practices and behaviors, and effectiveness of MI in different healthcare settings. Future research should cover also the use of electronic MI sources and services which apply modern information technology to clinical decision making and medication reviews, national MI policy, MI literacy, MI needs of HCPs and consumers.

Alternative therapeutics for self-limiting infections-An indirect approach to the antibiotic resistance challenge

Alternative therapeutics for infectious diseases is a top priority, but what infections should be the primary targets? At present there is a focus on therapies for severe infections, for which effective treatment is most needed, but these infections are hard to manage, and progress has been limited. Here, we explore a different approach. Applying an evolutionary perspective to a review of antibiotic prescription studies, we identify infections that likely make a large contribution to resistance evolution across multiple taxa but are clinically mild and thus present easier targets for therapeutics development. Alternative therapeutics for these infections, we argue, would save lives indirectly by preserving the high efficacy of existing antibiotics for the patients who need them the most.

Antibiotic prescription and clinical management of common infections among general practitioners in Latvia, Lithuania, and Sweden: a pilot survey with a simple protocol

Comparative information on diagnosis-related antibiotic prescribing patterns are scarce from primary care within and between countries. To describe and compare antibiotic prescription and routine management of infections in primary care in Latvia (LV), Lithuania (LT) and two study sites in Sweden (SE), a cross-sectional observational study on patients who consulted due to sypmtoms compatible with infection was undetraken. Infection and treatment was detected and recorded by physicians only. Data was collected from altogether 8786 consecutive patients with infections in the three countries. Although the overall proportion of patients receiving an antibiotic prescription was similar in all three countries (LV and LT 42%, SE 38%), there were differences in the rate of prescription between the countries depending on the respective diagnoses. While penicillins dominated among prescriptions (LV 58%, LT 67%, SE 70%), phenoxymethylpenicillin was most commonly prescribed in Sweden (57% of all penicillins), while it was amoxicillin with or without clavulanic acid in Latvia (99%) and Lithuania (85%) respectively. Pivmecillinam and flucloxacillin, which accounted for 29% of penicillins in Sweden, were available neither in Latvia nor in Lithuania. The applied methodology was simple, and provided useful information on differences in treatment of common infections in ambulatory care in the absence of available computerized diagnosis-prescription data. Despite some limitations, the method can be used for assessment of intention to treat and compliance to treatment guidelines and benchmarking locally, nationally, or internationally, just as the point prevalence surveys (PPS) protocols have been used in hospitals all over Europe.

Antibiotic exposure in infancy and risk of being overweight in the first 24 months of life

OBJECTIVE

Antibiotics have direct effects on the human intestinal microbiota, particularly in infancy. Antibacterial agents promote growth in farm animals by unknown mechanisms, but little is known about their effects on human weight gain. Our aim was to evaluate the impact of antibiotic exposure during infancy on weight and height in healthy Finnish children.

METHODS

The population-based cohort comprised 6114 healthy boys and 5948 healthy girls having primary care weight and height measurements and drug purchase data from birth to 24 months. BMI and height, expressed as z-scores at the median age of 24 months (interquartile range 24 to 26 months), were compared between children exposed and unexposed to antibiotics using analysis of covariance with perinatal factors as covariates.

RESULTS

Exposed children were on average heavier than unexposed children (adjusted BMI-for-age z-score difference in boys 0.13 SD [95% confidence interval 0.07 to 0.19, P < .001] and in girls 0.07 SD [0.01 to 0.13, P < .05]). The effect was most pronounced after exposure to macrolides before 6 months of age (boys 0.28 [0.11 to 0.46]; girls 0.23 [0.04 to 0.42]) or >1 exposure (boys 0.20 [0.10 to 0.30]; girls 0.13 [0.03 to 0.22]).

CONCLUSIONS

Antibiotic exposure before 6 months of age, or repeatedly during infancy, was associated with increased body mass in healthy children. Such effects may play a role in the worldwide childhood obesity epidemic and highlight the importance of judicious use of antibiotics during infancy, favoring narrow-spectrum antibiotics.

Assessment of antibiotic prescribing in Latvian general practitioners

BACKGROUND

Though general antibiotic consumption data is available, information on the actual patterns of prescribing antibiotics locally is difficult to obtain. An easy to use methodology was designed to assess ambulatory management of infections by Latvian general practitioners (GPs).

METHODS

GPs were asked to record data in a patient data collection form for every patient that received antibiotics. Study period - (7 days) one week in November, 2008. Data recorded included the following details: an antibiotic, the prescribed dose, dosing interval, route of administration combined with the demographic factors of the patient and clinical diagnosis based on a pre-defined list.

RESULTS

Two hundred forty eight forms out of the 600 (41%) were returned by post. Antibiotics were prescribed in 6.4% (1711/26803) of outpatient consultations. In total, 1763 antibiotics were prescribed during the study period. Ninety seven percent of the patients received monotherapy and only 47 (2.7%) patients were prescribed two antibiotics. The most commonly prescribed antibiotics were amoxicillin (33.9% of prescribed), amoxicillin/clavulanate (18,7%) and clarithromycin (7.6%). The most commonly treated indications were pharyngitis (29.8%), acute bronchitis (25.3%) and rhinosinusitis (10.2%). Pneumonia was mostly treated with amoxicillin/clavulanate (25,7%), amoxicillin (15.7%) and clarithromycin (19.3%).

CONCLUSIONS

Methodology employed provided useful additional information on ambulatory practice of prescribing antibiotics and could be used in further assessment studies. Educational interventions should be focused on treatment of acute pharyngitis and bronchitis in children and unnecessary use of quinolones in adults for uncomplicated urinary tract infection.

Acoustic reflectometry in discrimination of otoscopic diagnoses in young ambulatory children

BACKGROUND

Studies concerning spectral gradient acoustic reflectometry (SG-AR) have analyzed middle ear effusion only as 1 entity. The usefulness of SG-AR to detect specific otoscopic diagnoses of otitis media in young children is unknown.

METHODS

Among 515 children aged 6-35 months, we compared SG-AR with pneumatic otoscopy and evaluated the proportions of 5 manufacturer-recommended SG-AR levels in relation to specific otoscopic diagnoses in 2802 and 1240 examinations at symptomatic and asymptomatic visits, respectively.

RESULTS

At symptomatic visits, when the angle value was >95° (level 1), healthy middle ear was diagnosed in 76% of otoscopic examinations and acute otitis media in 5%. Levels 2 (70-95°) and 3 (60-69°) did not relate to any otoscopic diagnosis. Levels 4 and 5 associated with acute otitis media in 50% and 64%, and otitis media with effusion in 33% and 32% of examinations, respectively. At asymptomatic visits, levels 1, 2 and 3 were associated with healthy middle ear in 87%, 71% and 54% of examinations, respectively. With levels 4 and 5, otitis media with effusion was diagnosed in 62% and 79% of examinations, respectively.

CONCLUSIONS

SG-AR is not useful in making specific otoscopic diagnoses. Although the extremities of 5 SG-AR levels are able to differentiate ears with and without effusion, SG-AR is not able to differentiate acute otitis media from otitis media with effusion. Therefore, SG-AR can aid in diagnostics, but careful pneumatic otoscopy is needed to determine accurate diagnoses.

A placebo-controlled trial of antimicrobial treatment for acute otitis media

BACKGROUND

The efficacy of antimicrobial treatment in children with acute otitis media remains controversial.

METHODS

In this randomized, double-blind trial, children 6 to 35 months of age with acute otitis media, diagnosed with the use of strict criteria, received amoxicillin-clavulanate (161 children) or placebo (158 children) for 7 days. The primary outcome was the time to treatment failure from the first dose until the end-of-treatment visit on day 8. The definition of treatment failure was based on the overall condition of the child (including adverse events) and otoscopic signs of acute otitis media.

RESULTS

Treatment failure occurred in 18.6% of the children who received amoxicillin-clavulanate, as compared with 44.9% of the children who received placebo (P<0.001). The difference between the groups was already apparent at the first scheduled visit (day 3), at which time 13.7% of the children who received amoxicillin-clavulanate, as compared with 25.3% of those who received placebo, had treatment failure. Overall, amoxicillin-clavulanate reduced the progression to treatment failure by 62% (hazard ratio, 0.38; 95% confidence interval [CI], 0.25 to 0.59; P<0.001) and the need for rescue treatment by 81% (6.8% vs. 33.5%; hazard ratio, 0.19; 95% CI, 0.10 to 0.36; P<0.001). Analgesic or antipyretic agents were given to 84.2% and 85.9% of the children in the amoxicillin-clavulanate and placebo groups, respectively. Adverse events were significantly more common in the amoxicillin-clavulanate group than in the placebo group. A total of 47.8% of the children in the amoxicillin-clavulanate group had diarrhea, as compared with 26.6% in the placebo group (P<0.001); 8.7% and 3.2% of the children in the respective groups had eczema (P=0.04).

CONCLUSIONS

Children with acute otitis media benefit from antimicrobial treatment as compared with placebo, although they have more side effects. Future studies should identify patients who may derive the greatest benefit, in order to minimize unnecessary antimicrobial treatment and the development of bacterial resistance. (Funded by the Foundation for Paediatric Research and others; ClinicalTrials.gov number, NCT00299455.).

Screening of urine samples by flow cytometry reduces the need for culture

Urine samples constitute a large proportion of samples tested in clinical microbiology laboratories. Culturing of the samples is fairly time- and labor-consuming, and most of the samples will yield no growth or insignificant growth. We analyzed the feasibility of the flow cytometry-based UF-500i instrument (Sysmex, Japan) to screen out urine samples with no growth or insignificant growth and reduce the number of samples to be cultured. A total of 1,094 urine specimens sent to our laboratory for culture during 4 months in the spring of 2009 in Lahti, Finland, were included in the study. After culture, all samples were analyzed with the Sysmex UF-500i for bacterial and leukocyte (white blood cell [WBC]) counts. Youden index and closest (0,1) methods were used to determine the cutoff values for bacterial and WBC counts in culture-positive and -negative groups. By flow cytometry, samples considered positive for UTI in culture had bacterial and WBC values that were significantly higher than those for samples considered negative. The flow cytometric screening worked best when both bacterial counts and WBC counts were used with age- and gender-specific cutoff values for all patient groups, excluding patients with urological disease or anomaly. By use of these cutoff values, 5/167 (3.0%) of culture-positive samples were missed by UF-500i and the percentage of samples that did not need to be cultured was 64.5%. Use of the UF-500i instrument is a reliable method for screening out a major part of the UTI-negative samples, significantly diminishing the amount of work required in the microbiology laboratory.

Parental experiences and attitudes regarding the management of acute otitis media--a comparative questionnaire between Finland and The Netherlands

BACKGROUND

Both treatment guidelines and the amount of antibiotics used for acute otitis media (AOM) vary across western countries. Parental expectations and their awareness of antimicrobial use and resistance, which may also be influenced by the guidelines, are not yet completely known.

OBJECTIVE

To compare parental experiences and opinions regarding the management of AOM in children with AOM in Finland and The Netherlands.

METHODS

We sent the questionnaires via public day care in Turku, Finland, and Utrecht, The Netherlands. We asked about family background, child's history of AOM and parental experiences and attitudes about AOM treatment and antimicrobial resistance.

RESULTS

Of 1151 participants, 83% in Finland and 49% in The Netherlands had had at least one episode of AOM. Antibiotics were used more frequently in Finland than in The Netherlands, 99% versus 78%, respectively. More Finnish parents reported to believe that antibiotics are necessary in the treatment of AOM as compared to Dutch parents. Use of analgesics for AOM was similar (80% in Finland and 86% in The Netherlands). One-third of the parents had discussed resistance with their doctor. According to parental experiences, antimicrobial resistance had caused more problems in Finland than in The Netherlands (20% versus 2%). Finally, 88% of parents in Finland and 65% in The Netherlands were worried that bacteria could become resistant to antibiotics.

CONCLUSIONS

Treatment practices and parental expectations seem to interact with each other. Therefore, if we aim to change AOM treatment practices, we have to modify both guidelines and parental expectations.

Association between antimicrobial consumption and resistance in Escherichia coli

During a 9-year study period from 1997 through 2005, the association between antimicrobial resistance rates in Escherichia coli and outpatient antimicrobial consumption was investigated in 20 hospital districts in Finland. A total of 754,293 E. coli isolates, mainly from urine samples, were tested for antimicrobial resistance in 26 clinical microbiology laboratories. The following antimicrobials were studied: ampicillin, amoxicillin-clavulanate, cephalosporins, fluoroquinolones, trimethoprim, trimethoprim-sulfamethoxazole, pivmecillinam, and nitrofurantoin. We applied a protocol used in earlier studies in which the level of antimicrobial consumption over 1 year was compared with the level of resistance in the next year. Statistically significant associations were found for nitrofurantoin use versus nitrofurantoin resistance (P < 0.0001), cephalosporin use versus nitrofurantoin resistance (P = 0.0293), amoxicillin use versus fluoroquinolone resistance (P = 0.0031), and fluoroquinolone use versus ampicillin resistance (P = 0.0046). Interestingly, we found only a few associations between resistance and antimicrobial consumption. The majority of the associations studied were not significant, including the association between fluoroquinolone use and fluoroquinolone resistance.

Connection between trimethoprim-sulfamethoxazole use and resistance in Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis

The association between trimethoprim-sulfamethoxazole use and resistance among the major respiratory tract pathogens was investigated by comparing regional consumption of the drug to regional resistance in the following year in 21 central hospital districts in Finland. A total of 23,530 Streptococcus pneumoniae isolates, 28,320 Haemophilus influenzae isolates, and 14,138 Moraxella catarrhalis isolates were tested for trimethoprim-sulfamethoxazole susceptibility during the study period (1998-2004). Among the S. pneumoniae isolates, a statistically significant connection was found between regional consumption and resistance. No statistically significant connection was found between regional trimethoprim-sulfamethoxazole use and resistance among H. influenzae and M. catarrhalis isolates. According to our results, it seems that only in pneumococci can the development of trimethoprim-sulfamethoxazole resistance be influenced by restricting its use. However, trimethoprim-sulfamethoxazole remains an important antimicrobial agent because of its reasonable price. Hence, resistance to trimethoprim-sulfamethoxazole among these pathogens needs continuous monitoring.

Three vs. 10 days of amoxycillin-clavulanic acid for type 1 acute exacerbations of chronic obstructive pulmonary disease: a randomised, double-blind study

The optimal duration of antibiotic treatment for acute exacerbations of chronic obstructive pulmonary disease (AECOPD) is unknown. This study compared the outcome of treatment for 3 vs. 10 days with amoxycillin-clavulanic acid of hospitalised patients with AECOPD who had improved substantially after initial therapy for 3 days. Between November 2000 and December 2003, 56 patients with AECOPD were enrolled in the study. Unfortunately, because of the low inclusion rate, the trial was discontinued prematurely. Patients were treated with oral or intravenous amoxycillin-clavulanic acid. Patients who showed improvement after 72 h were randomised to receive oral amoxycillin-clavulanic acid 625 mg or placebo, four times daily for 7 days. The primary outcome measure of the study was clinical cure after 3 weeks and 3 months. Of 46 patients included in the final analysis, 21 were in the 3-day treatment group and 25 were in the 10-day treatment group. After 3 weeks, 16 (76%) of 21 patients in the 3-day treatment group were cured, compared with 20 (80%) of 25 in the 10-day treatment group (difference -3.8%; 95% CI -28 to 20). After 3 months, 13 (62%) of 21 patients were cured, compared with 14 (56%) of 25 (difference 5.9%; 95% CI -23 to 34). Microbiological success, symptom recovery, the use of corticosteroids, the duration of oxygen therapy and the length of hospital stay were comparable for both treatment groups. It was concluded that 3-day treatment with amoxycillin-clavulanic acid can be a safe and effective alternative to the standard 10-day treatment for hospitalised patients with AECOPD who have improved after initial therapy for 3 days.

The Antimicrobial Treatment Strategies (MIKSTRA) Program: A 5-Year Follow-Up of Infection-Specific Antibiotic Use in Primary Health Care and the Effect of Implementation of Treatment Guidelines

BACKGROUND

A national 5-year follow-up study of infection-specific antibiotic use in primary care was conducted to see if prescribing practices change after implementing new treatment guidelines.

METHODS

The data were collected during 1 week of November each year from 1998 to 2002 from 30 health care centers that covered a total population of 819,777 persons and in 2002 from 20 control health care centers that covered a population of 545,098 persons. National guidelines for 6 major infections (otitis media, sinusitis, throat infection, acute bronchitis, urinary tract infection, and bacterial skin infection) were published in 1999-2000. Multifaceted interventions were performed by local trainers teaching his or her coworkers, supported by feedback and patient and public information.

RESULTS

The 6 infections targeted for intervention, together with unspecified upper respiratory tract infection constituted 80%-85% of all infections. The proportion of patients who received prescriptions for antibiotics did not change significantly. However, use of first-line antibiotics increased for all infections, and the change was significant for sinusitis (P<.001), acute bronchitis (P=.015), and urinary tract infections (P=.009). Also, the percentage of antibiotic treatments prescribed for the recommended duration increased significantly. Correct prescribing for respiratory tract infections improved by 6.4 percentage units (P<.001). However, there was no statistically significant difference in performance between study and control health care centers at follow-up.

CONCLUSIONS

Moderate qualitative improvements in antibiotic use were observed after multifaceted intervention, but prescribing for unjustified indications, mainly acute bronchitis, did not decrease. Obtained infection-specific information on management of patients with infections in primary health care is an important basis for planning targeted interventions in the future.

Analysis of the causes and consequences of decreased antibiotic consumption over the last 5 years in Slovenia

OBJECTIVES

Compared with European countries, the use of antibiotics in Slovenia is moderate. In the period 1999-2002 an 18.67% decrease in outpatient antibiotic consumption was noted. The aim of the present study was to analyse this decrease and its consequences.

METHODS

The data on outpatient antibiotic consumption were obtained from the Institute of Public Health and Health Insurance Institute of Slovenia and expressed in defined daily doses (DDD)/1000 inhabitant-days. The number of media publications on 'antibiotic drugs' and 'bacterial resistance' during the study period was obtained. In 2000, the prescription of co-amoxiclav and fluoroquinolones was restricted because of a constant increase in the consumption of these drugs. The data on incidence of acute mastoiditis and penicillin resistance among invasive pneumococci were obtained.

RESULTS

The total outpatient consumption of antibacterials increased from 15.21 DDD/1000 inhabitant-days in 1996 to 20.08 in 1999, and decreased to 16.97 in 2003. The consumption of restricted antibiotics decreased from 7.29 in 1999 to 5.25 DDD/1000 inhabitant-days in 2003. There was a positive correlation between antibiotic consumption and the number of newspaper articles (r=0.92), and a negative correlation between the number of diagnostic tests and antibiotic consumption (r=-0.73 for the C-reactive protein test and -0.68 for the streptococcal antigen detection test). Reduced antibiotic consumption was paralleled by a decrease in penicillin resistance among invasive pneumococci. No increase in mastoiditis cases was observed in spite of reduced antibiotic consumption.

CONCLUSION

Restriction of antibiotic prescription proved to be effective in reducing outpatient antibiotic consumption. The effect was prolonged and affected restricted antibiotics as well as non-restricted drugs.

Survey of condition-based prescribing of antimicrobial drugs for dogs at a veterinary teaching hospital

A database of the prescriptions of antimicrobial drugs for the treatment of common infectious diseases in dogs at the Finnish Veterinary Teaching Hospital was searched to determine to what extent national guidelines were being followed. Twenty-two per cent of 5918 dogs were treated orally with antimicrobial drugs. The most commonly used drugs were beta-lactams (49 per cent) of which cephalexin and amoxycillin-clavulanate were most widely prescribed. The usage of fluoroquinolones was only 2.8 per cent. The prescription of antimicrobials for pyoderma was contrary to Finnish guidelines, but the use of cephalexin or amoxycillin-clavulanate as first-line drugs instead of macrolides or lincosamides or trimethoprim-sulphonamides was acceptable because of the presence of resistance by canine staphylococci. The drug most commonly used to treat acute urinary tract infections was trimethoprim-sulphonamide, in agreement with the guidelines. Antimicrobial drugs were used excessively after surgical procedures, and for treating acute gastrointestinal disturbances and small wounds and traumas.

The seven-valent pneumococcal conjugate vaccine reduces tympanostomy tube placement in children

BACKGROUND

The novel pneumococcal conjugate vaccine, PncCRM, has been shown to prevent acute otitis media caused by vaccine serotypes and to reduce otitis surgery. Our aim was to assess long term efficacy of the vaccine on tympanostomy tube placements.

METHODS

Children with complete follow-up in the Finnish Otitis Media Vaccine Trial up to 24 months of age and still living in the study area (1490 of 1662 randomized at 2 months of age) were invited to a single visit at 4-5 years of age. The children had been vaccinated at 2, 4, 6 and 12 months of age with PncCRM or hepatitis B vaccine (control). Tympanostomy tube placements reported by parents at the visit were verified from hospital and private medical center records. Additionally, tympanostomy tube placements of all children were verified from the hospital discharge registry. Vaccine efficacy (VE) was estimated by comparing all events of tympanostomy tube placement between vaccine groups.

RESULTS

During the vaccine trial (2-24 months of age), VE (95% confidence interval) in preventing tympanostomy tube placement was only 4% (-19-23%). Altogether 756 children were enrolled for the follow-up study. After 24 months of age, the rate of surgery was 3.5 per 100 person-years in the PncCRM and 5.7 per 100 person-years in the control children, giving VE of 39% (4-61%). In the hospital-based data of all children (N = 1490), VE of 44% was obtained (19-62%).

CONCLUSIONS

Receipt of PncCRM vaccine at infancy was associated with a reduction in tympanostomy tube placement from 2 to 4-5 years of age.

Effect of Macrolide Consumption on Erythromycin Resistance in Streptococcus pyogenes in Finland in 1997-2001

The aim of this study was to investigate the association between regional macrolide resistance in Streptococcus pyogenes and macrolide use in Finland. During 1997-2001, a total of 50,875 S. pyogenes isolates were tested for erythromycin susceptibility in clinical microbiology laboratories throughout Finland. The local erythromycin resistance levels were compared with the regional consumption data of all macrolides pooled and, separately, with the use of azithromycin. The regional resistance rates of 1 year were compared with the regional consumption of the previous year and with the average rates of use for the 2 previous years. A linear mixed model for repeated measures was used in modeling the association. A statistically significant association existed between regional erythromycin resistance in S. pyogenes and consumption of macrolides; association with azithromycin use alone was not found.

Upper respiratory tract infections in general practice: diagnosis, antibiotic prescribing, duration of symptoms and use of diagnostic tests

A diagnosis/antibiotic prescribing study was performed in 5 counties in Sweden for 1 week in November 2000. As part of this study, the characteristics and clinical management of patients with upper respiratory tract infections (n = 2899) in primary care were analyzed. Almost half of the patients were aged < 15 y and one-fifth of the patients consulted out of hours. Of all patients seeking primary care for upper respiratory tract infections, 56.0% were prescribed an antibiotic. Almost all patients who were given the diagnoses streptococcal tonsillitis, acute otitis media or acute sinusitis were prescribed antibiotics, compared to 10% of patients with common cold or acute pharyngitis. The most frequently prescribed antibiotic was penicillin V (79.2%) and this was even more pronounced out of hours, when the diagnoses otitis media and streptococcal tonsillitis were more frequently used. In patients with common cold and acute pharyngitis, the percentage who received antibiotics increased with increasing length of symptoms and increasing CRP levels. In patients with acute pharyngitis or streptococcal tonsillitis, antibiotics were prescribed less frequently provided streptococcal tests were performed. The management of patients with upper respiratory tract infections in general practice seems to be in good agreement with current Swedish guidelines. However, the study indicates some areas for improvement. The diagnosis of acute sinusitis seems to have been overestimated and used only to justify antibiotic treatment.