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Cronberg O, Tyrstrup M, Ekblom K, Hedin K. Factors influencing antibiotic prescribing for respiratory tract infections in primary care - a comparison of physicians with different antibiotic prescribing rates. Scand J Prim Health Care 2024; 42:424-434. [PMID: 38625913 PMCID: PMC11332303 DOI: 10.1080/02813432.2024.2332757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 03/13/2024] [Indexed: 04/18/2024] Open
Abstract
BACKGROUND There has been a notable decrease in antibiotic prescribing in the last thirty years in Sweden. Little is known about factors influencing antibiotic prescribing over several years. OBJECTIVE To compare primary care physicians who, over time, reduced their antibiotic prescribing for respiratory tract infections with those who remained either high or low prescribers regarding potentially influencing factors. DESIGN AND SETTING A register-based study including all RTI visits in primary care in Region Kronoberg, Sweden 2006-2014. The data were divided into three 3-year periods. SUBJECTS The data comprised all physicians who had diagnosed at least one RTI for each of the three-year periods. The antibiotic prescribing rate adjusted for the patients' sex and age group was calculated for each physician and period, and based on the change between the first and the third period, the physicians were divided into three prescriber groups: The High Prescribing Group, the Decreasing Prescribing Group, and the Low Prescribing Group. MAIN OUTCOME MEASURES For the three prescriber groups, we compared factors influencing antibiotic prescribing such as the characteristics of the physicians, their use of point-of-care tests, their choice of diagnoses, and whether the patients returned and received antibiotics. RESULTS The High Prescribing Group ordered more point-of-care tests, registered more potential bacterial diagnoses, prescribed antibiotics at lower C-reactive protein levels, and prescribed antibiotics more often despite negative group A Streptococci test than in the Low Prescribing Group. The Decreasing Prescribing Group was between the High Prescribing Group and the Low Prescribing Group regarding these variables. The lower prescription rate in the Low Prescribing Group did not result in more return visits or new antibiotic prescriptions within 30 days. CONCLUSION Point-of-care testing and its interpretation differed between the prescriber groups. Focus on interpreting point-of-care test results could be a way forward in antibiotic stewardship.
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Affiliation(s)
- Olof Cronberg
- Växjöhälsan Primary Healthcare Center, Växjö, Sweden
- Department of Research and Development, Region Kronoberg, Växjö, Sweden
- Department of Clinical Sciences in Malmö, Family Medicine, Lund University, Malmö, Sweden
| | - Mia Tyrstrup
- Department of Clinical Sciences in Malmö, Family Medicine, Lund University, Malmö, Sweden
- Lundbergsgatan Primary Health Care Centre, Malmö, Sweden
| | - Kim Ekblom
- Department of Research and Development, Region Kronoberg, Växjö, Sweden
- Department of Medical Biosciences, Clinical Chemistry, Umeå University, Umeå, Sweden
| | - Katarina Hedin
- Department of Clinical Sciences in Malmö, Family Medicine, Lund University, Malmö, Sweden
- Futurum, Region Jönköping County, Sweden
- Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
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2
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Burvenich R, De Boodt S, Lowie L, Janssens A, Beerten SG, Vaes B, Toelen J, Verbakel JY. Temporal trends in antibiotic prescribing and serious and nonserious infections in children presenting to general practice: a registry-based longitudinal cohort study of 162 507 individuals. J Antimicrob Chemother 2024; 79:1397-1406. [PMID: 38714502 DOI: 10.1093/jac/dkae117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 04/02/2024] [Indexed: 05/10/2024] Open
Abstract
BACKGROUND It is crucial to understand the trends in paediatric antibiotic prescribing and serious and nonserious infections to improve antibiotic prescribing practices for children in ambulatory care. OBJECTIVES Assessing trends in paediatric antibiotic prescribing and infection incidence in general practice from 2002 to 2022. METHODS In this retrospective cohort study using INTEGO network data from 162 507 patients in Flanders (Belgium), we calculated antibiotic prescribing rates and proportions alongside incidence rates of serious and nonserious infections, stratified by age (0-1, 2-6, 7-12 years) and municipality. We performed autoregressive moving average time-series analyses and seasonality analyses. RESULTS From 2002 to 2022, antibiotic prescribing rate decreased significantly: 584/1000 person-years (PY) (95% CI 571-597) to 484/1000PY (95% CI 478-491); so did antibiotic overall prescribing proportion: 46.3% (95% CI 45.1-47.6) to 23.3% (95% CI 22.9-23.7) (59.3% amoxicillin and 17.8% broad spectrum). Prescribing proportions dropped significantly for nonserious (45.6% to 20.9%) and increased for serious infections (64.1% to 69.8%). Proportions significantly dropped for acute suppurative otitis media (74.7% to 64.1%), upper respiratory tract infections (44.9% to 16.6%), bronchitis/bronchiolitis (73.6% to 44.1%) and acute tonsillopharyngitis (59.5% to 21.7%), while significantly increasing for pneumonia (65.2% to 80.2%). Nonserious and serious infection incidence rates increased from 785/1000PY and 34.2/1000PY to 1223/1000PY and 64.1/1000PY, respectively. Blood and CRP testing proportions increased significantly. CONCLUSIONS Antibiotic prescribing in general practice for children declined from 2002 to 2022. Further targeted antibiotic stewardship initiatives are needed to reduce the use of broad-spectrum antibiotics and antibiotic prescribing for conditions such as otitis media and bronchitis/bronchiolitis.
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Affiliation(s)
- Ruben Burvenich
- Department of Public Health and Primary Care, Leuven Unit for Health and Technology Assessment Research (LUHTAR), KU Leuven, 7 Kapucijnenvoer, Leuven, 3000, Belgium
- Department of Public Health and Primary Care, Academic Centre for General Practice, KU Leuven, 7 Kapucijnenvoer, Leuven, 3000, Belgium
- Department of Family Medicine and Primary Healthcare, Ghent University, 10 Corneel Heymanslaan, Ghent, 9000, Belgium
- Menzies Institute for Medical Research, University of Tasmania, 17 Liverpool Street, Hobart, Tasmania, 7000, Australia
| | - Sien De Boodt
- Faculty of Medicine, KU Leuven, 49 Herestraat, Leuven, 3000, Belgium
| | - Lien Lowie
- Faculty of Medicine, KU Leuven, 49 Herestraat, Leuven, 3000, Belgium
| | - Arne Janssens
- Department of Public Health and Primary Care, Academic Centre for General Practice, KU Leuven, 7 Kapucijnenvoer, Leuven, 3000, Belgium
| | - Simon Gabriël Beerten
- Department of Public Health and Primary Care, Academic Centre for General Practice, KU Leuven, 7 Kapucijnenvoer, Leuven, 3000, Belgium
| | - Bert Vaes
- Department of Public Health and Primary Care, Academic Centre for General Practice, KU Leuven, 7 Kapucijnenvoer, Leuven, 3000, Belgium
| | - Jaan Toelen
- Woman and Child, Department of Development and Regeneration, KU Leuven, Leuven, Belgium
- Department of Pediatrics, University Hospitals Leuven, Leuven, Belgium
| | - Jan Yvan Verbakel
- Department of Public Health and Primary Care, Leuven Unit for Health and Technology Assessment Research (LUHTAR), KU Leuven, 7 Kapucijnenvoer, Leuven, 3000, Belgium
- Department of Public Health and Primary Care, Academic Centre for General Practice, KU Leuven, 7 Kapucijnenvoer, Leuven, 3000, Belgium
- Nuffield Department of Primary Care Health Sciences, NIHR Community Healthcare Medtech and IVD Cooperative, University of Oxford, Woodstock Road, Oxford, OX2 6GG, UK
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Plate A, Di Gangi S, Garzoni C, Selby K, Pichierri G, Senn O, Neuner-Jehle S. Patient leaflets on respiratory tract infections did not improve shared decision making and antibiotic prescriptions in a low-prescriber setting. Sci Rep 2024; 14:4978. [PMID: 38424442 PMCID: PMC10904372 DOI: 10.1038/s41598-024-55166-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Accepted: 02/21/2024] [Indexed: 03/02/2024] Open
Abstract
Patient information leaflets can reduce antibiotic prescription rates by improving knowledge and encouraging shared decision making (SDM) in patients with respiratory tract infections (RTI). The effect of these interventions in antibiotic low-prescriber settings is unknown. We conducted a pragmatic pre-/post interventional study between October 2022 and March 2023 in Swiss outpatient care. The intervention was the provision of patient leaflets informing about RTIs and antibiotics use. Main outcomes were the extent of SDM, antibiotic prescription rates, and patients' awareness/knowledge about antibiotic use in RTIs. 408 patients participated in the pre-intervention period, and 315 patients in the post- intervention period. There was no difference in the extent of SDM (mean score (range 0-100): 65.86 vs. 64.65, p = 0.565), nor in antibiotic prescription rates (no prescription: 89.8% vs. 87.2%, p = 0.465) between the periods. Overall awareness/knowledge among patients with RTI was high and leaflets showed only a small effect on overall awareness/knowledge. In conclusion, in an antibiotic low-prescriber setting, patient information leaflets may improve knowledge, but may not affect treatment decisions nor antibiotic prescription rates for RTIs.
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Affiliation(s)
- Andreas Plate
- Institute of Primary Care, University of Zurich and University Hospital Zürich, Pestalozzistrasse 24, 8091, Zurich, Switzerland.
| | - Stefania Di Gangi
- Institute of Primary Care, University of Zurich and University Hospital Zürich, Pestalozzistrasse 24, 8091, Zurich, Switzerland
| | - Christian Garzoni
- mediX Ticino and Clinic of Internal Medicine and Infectious Diseases, Clinica Luganese Moncucco, Lugano, Switzerland
| | - Kevin Selby
- Center for Primary Care and Public Health (Unisanté), Lausanne, Switzerland
| | - Giuseppe Pichierri
- Institute of Primary Care, University of Zurich and University Hospital Zürich, Pestalozzistrasse 24, 8091, Zurich, Switzerland
| | - Oliver Senn
- Institute of Primary Care, University of Zurich and University Hospital Zürich, Pestalozzistrasse 24, 8091, Zurich, Switzerland
| | - Stefan Neuner-Jehle
- Institute of Primary Care, University of Zurich and University Hospital Zürich, Pestalozzistrasse 24, 8091, Zurich, Switzerland
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Matta M, Gantzer L, Chakvetadze C, Moussiegt A, De Pontfarcy A, Lekens B, Diamantis S. Antibiotic prescription in ambulatory care for COVID-19 patients: a cohort analysis in four European countries. Eur J Clin Microbiol Infect Dis 2024; 43:115-119. [PMID: 37980300 DOI: 10.1007/s10096-023-04716-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 11/13/2023] [Indexed: 11/20/2023]
Abstract
OBJECTIVE To analyse antibiotic prescription rates in ambulatory care for COVID-19 patients by general practitioners (GPs) in four European countries. METHODS A total of 4,513,955 anonymised electronic prescribing records of 3656 GPs in four European countries were analysed. Diagnosis and prescriptions were retrieved. Antibiotic prescription rates during COVID-19 consultations were analysed and compared between France, the UK, Belgium and Romania. RESULTS Overall prescription rate was in France and Belgium (6.66 and 7.46%). However, analysing median GP prescribing rates, we found that 33.9% of the GPs in Belgium prescribed antibiotics with a median of 16 prescriptions per 100 COVID-19 consultations, while 55.21% of the GPs in France prescribed a median of 8 antibiotic prescriptions per 100 COVID-19 consultations. Overall antibiotic prescription rates were less in Romania than in the UK (22% vs 32%); however, 73% of the Romanian GPs vs 57% of the British GPs prescribed antibiotics. Depending on the country, the proportion of each type of antibiotic was statistically different, with the proportion of azithromycin being more than 50% of all antibiotics in each country except for the UK where it was less than 1%. CONCLUSION Both individual GPs prescribing patterns in addition to overall consumption patterns should be analysed in order to implement a tailored antimicrobial stewardship programme. Furthermore, antibiotic prescribing rates in COVID-19 are lower than other respiratory tract infections.
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Affiliation(s)
- Matta Matta
- Service de Maladies Infectieuses Et Tropicales, Centre Hospitalier de Melun, Melun, France.
| | | | - Catherine Chakvetadze
- Service de Maladies Infectieuses Et Tropicales, Centre Hospitalier de Melun, Melun, France
| | - Aurore Moussiegt
- Service de Maladies Infectieuses Et Tropicales, Centre Hospitalier de Melun, Melun, France
| | - Astrid De Pontfarcy
- Service de Maladies Infectieuses Et Tropicales, Centre Hospitalier de Melun, Melun, France
| | | | - Sylvain Diamantis
- Service de Maladies Infectieuses Et Tropicales, Centre Hospitalier de Melun, Melun, France
- Dynamic Research Unit, Université Paris Est Créteil, Créteil, France
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Miller KM, Barnett TC, Cadarette D, Bloom DE, Carapetis JR, Cannon JW. Antibiotic consumption for sore throat and the potential effect of a vaccine against group A Streptococcus: a systematic review and modelling study. EBioMedicine 2023; 98:104864. [PMID: 37950997 PMCID: PMC10663680 DOI: 10.1016/j.ebiom.2023.104864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 10/15/2023] [Accepted: 10/19/2023] [Indexed: 11/13/2023] Open
Abstract
BACKGROUND Antibiotic consumption can lead to antimicrobial resistance and microbiome imbalance. We sought to estimate global antibiotic consumption for sore throat, and the potential reduction in consumption due to effective vaccination against group A Streptococcus (Strep A). METHODS We reviewed and analysed articles published between January 2000 and February 2022, identified though Clarivate Analytics' Web of Science search platform, with reference to antibiotic prescribing or consumption, sore throat, pharyngitis, or tonsillitis. We then used those analyses, combined with assumptions for the effectiveness, duration of protection, and coverage of a vaccine, to calculate the estimated reduction in antibiotic prescribing due to the introduction of Strep A vaccines. FINDINGS We identified 101 studies covering 38 countries. The mean prescribing rate for sore throat was approximately 5 courses per 100 population per year, accounting for approximately 5% of all antibiotic consumption. Based on 2020 population estimates for countries with empiric prescribing rates, antibiotic consumption for sore throat was estimated to exceed 37 million courses annually, of which half could be attributable to treatment for Strep A. A vaccine that reduces rates of Strep A infection by 80%, with 80% coverage and 10 year's duration of protection, could avert 2.8 million courses of antibiotics prescribed for sore throat treatment among 5-14 year-olds in countries with observed prescribing rates, increasing to an estimated 7.5 million averted if an effective vaccination program also reduced precautionary prescribing. INTERPRETATION A vaccine that prevents Strep A throat infections in children may reduce antibiotic prescribing for sore throat by 32-87% depending on changes to prescribing and consumption behaviours. FUNDING The Wellcome Trust, grant agreement number 215490/Z/19/Z.
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Affiliation(s)
- Kate M Miller
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Nedlands, Western Australia, Australia; School of Population and Global Health, University of Western Australia, Nedlands, Western Australia, Australia
| | - Timothy C Barnett
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Nedlands, Western Australia, Australia; Marshall Centre for Infectious Diseases Research and Training, School of Biomedical Sciences, University of Western Australia, Nedlands, Western Australia, Australia
| | - Daniel Cadarette
- Harvard Kennedy School, Harvard University, Cambridge, MA, United States
| | - David E Bloom
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA, United States
| | - Jonathan R Carapetis
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Nedlands, Western Australia, Australia; Perth Children's Hospital, Nedlands, Western Australia, Australia
| | - Jeffrey W Cannon
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Nedlands, Western Australia, Australia; Centre for Child Health Research, Medical School, University of Western Australia, Nedlands, Western Australia, Australia.
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6
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Schmiemann G, Greser A, Maun A, Bleidorn J, Schuster A, Miljukov O, Rücker V, Klingeberg A, Mentzel A, Minin V, Eckmanns T, Heintze C, Heuschmann P, Gágyor I. Effects of a multimodal intervention in primary care to reduce second line antibiotic prescriptions for urinary tract infections in women: parallel, cluster randomised, controlled trial. BMJ 2023; 383:e076305. [PMID: 37918836 PMCID: PMC10620739 DOI: 10.1136/bmj-2023-076305] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/25/2023] [Indexed: 11/04/2023]
Abstract
OBJECTIVES To evaluate whether a multimodal intervention in general practice reduces the proportion of second line antibiotic prescriptions and the overall proportion of antibiotic prescriptions for uncomplicated urinary tract infections in women. DESIGN Parallel, cluster randomised, controlled trial. SETTING General practices in five regions in Germany. Data were collected between 1 April 2021 and 31 March 2022. PARTICIPANTS General practitioners from 128 randomly assigned practices. INTERVENTIONS Multimodal intervention consisting of guideline recommendations for general practitioners and patients, provision of regional data for antibiotic resistance, and quarterly feedback, which included individual first line and second line proportions of antibiotic prescribing, benchmarking with regional or supra-regional practices, and telephone counselling. Participants in the control group received no information on the intervention. MAIN OUTCOME MEASURES Primary outcome was the proportion of second line antibiotics prescribed by general practices, in relation to all antibiotics prescribed, for uncomplicated urinary tract infections after one year between the intervention and control group. General practices were randomly assigned in blocks (1:1), with a block size of four, into the intervention or control group using SAS version 9.4; randomisation was stratified by region. The secondary outcome was the prescription proportion of all antibiotics, relative within all cases (instances of UTI diagnosis), for the treatment of urinary tract infections after one year between the groups. Adverse events were assessed as exploratory outcomes. RESULTS 110 practices with full datasets identified 10 323 cases during five quarters (ie, 15 months). The mean proportion of second line antibiotics prescribed was 0.19 (standard deviation 0.20) in the intervention group and 0.35 (0.25) in the control group after 12 months. After adjustment for preintervention proportions, the mean difference was -0.13 (95% confidence interval -0.21 to -0.06, P<0.001). The overall proportion of all antibiotic prescriptions for urinary tract infections over 12 months was 0.74 (standard deviation 0.22) in the intervention and 0.80 (0.15) in the control group with a mean difference of -0.08 (95% confidence interval -0.15 to -0.02, P<0.029). No differences were noted in the number of complications (ie, pyelonephritis, admission to hospital, or fever) between the groups. CONCLUSIONS The multimodal intervention in general practice significantly reduced the proportion of second line antibiotics and all antibiotic prescriptions for uncomplicated urinary tract infections in women. TRIAL REGISTRATION German Clinical Trials Register (DRKS), DRKS00020389.
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Affiliation(s)
- Guido Schmiemann
- University of Bremen, Department of Health Services Research, Institute for Public Health and Nursing Research, Bremen, Germany
| | - Alexandra Greser
- University Hospital Wurzburg, Department of General Practice, Wurzburg, Germany
| | - Andy Maun
- Institute of General Practice/Primary Care, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg im Breisgau, Germany
| | - Jutta Bleidorn
- University Hospital Jena, Institute of General Practice, Jena, Thuringia, Germany
| | - Angela Schuster
- Charité-Universitätsmedizin Berlin, Institute of General Practice and Family Medicine, Berlin, Germany
| | - Olga Miljukov
- Clinical Trial Centre Wurzburg, University Hospital Wurzburg, Germany
- Institute for Medical Data Sciences, University Hospital Wurzburg, Germany
- Julius-Maximilians-University of Wurzburg, Institute for Clinical Epidemiology and Biometry (ICE-B), Wurzburg, Germany
| | - Viktoria Rücker
- Clinical Trial Centre Wurzburg, University Hospital Wurzburg, Germany
- Institute for Medical Data Sciences, University Hospital Wurzburg, Germany
- Julius-Maximilians-University of Wurzburg, Institute for Clinical Epidemiology and Biometry (ICE-B), Wurzburg, Germany
| | | | - Anja Mentzel
- Institute of General Practice/Primary Care, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg im Breisgau, Germany
| | - Vitalii Minin
- Institute of General Practice/Primary Care, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg im Breisgau, Germany
| | | | - Christoph Heintze
- Charité-Universitätsmedizin Berlin, Institute of General Practice and Family Medicine, Berlin, Germany
| | - Peter Heuschmann
- Clinical Trial Centre Wurzburg, University Hospital Wurzburg, Germany
- Institute for Medical Data Sciences, University Hospital Wurzburg, Germany
- Julius-Maximilians-University of Wurzburg, Institute for Clinical Epidemiology and Biometry (ICE-B), Wurzburg, Germany
| | - Ildikó Gágyor
- University Hospital Wurzburg, Department of General Practice, Wurzburg, Germany
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Shafrir A, Oster Y, Shauly-Aharonov M, Strahilevitz J. Real-Life Comparison of Fosfomycin to Nitrofurantoin for the Treatment of Uncomplicated Lower Urinary Tract Infection in Women. Biomedicines 2023; 11:biomedicines11041019. [PMID: 37189635 DOI: 10.3390/biomedicines11041019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 03/19/2023] [Accepted: 03/22/2023] [Indexed: 03/29/2023] Open
Abstract
In this study, we compared the failure rates of fosfomycin and nitrofurantoin for uncomplicated urinary tract infections. We used Meuhedet Health Services’ large database to collect data on all female patients, older than 18 years, who were prescribed either antibiotic during 2013–2018. Treatment failure was a composite endpoint of hospitalization, emergency-room visit, IV antibiotic treatment, or prescription of a different antibiotic, within seven days of the initial prescription. Reinfection was considered when one of these endpoints appeared 8–30 days following the initial prescription. We found 33,759 eligible patients. Treatment failure was more common in the fosfomycin group than the nitrofurantoin group (8.16% vs. 6.87%, p-value < 0.0001). However, reinfection rates were higher among patients who received nitrofurantoin (9.21% vs. 7.76%, p-value < 0.001). Among patients younger than 40 years, patients treated with nitrofurantoin had more reinfections (8.68% vs. 7.47%, p value = 0.024). Treatment failure rates were mildly higher in patients treated with fosfomycin, despite having less reinfections. We suggest that this effect is related to a shorter duration of treatment (one vs. five days) and encourage clinicians to be more patient before declaring fosfomycin failure and prescribing another antibiotic.
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Gunnarsson RK, Ebell M, Centor R, Little P, Verheij T, Lindbæk M, Sundvall PD. Best management of patients with an acute sore throat – a critical analysis of current evidence and a consensus of experts from different countries and traditions. Infect Dis (Lond) 2023; 55:384-395. [PMID: 36971650 DOI: 10.1080/23744235.2023.2191714] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/29/2023] Open
Abstract
BACKGROUND There is a very large body of publications discussing the management of patients with an acute sore throat. Advocates for a restrictive antibiotic policy and advocates for a more liberal use of antibiotics emphasise different and valid arguments and to date have not been able to unite in a consensus. Contradicting guidelines based on the same body of knowledge is not logical, may cause confusion and cause unwanted variation in clinical management. METHODS In multiple video meetings and email correspondence from March to November 2022 and finally in a workshop at the annual meeting for the North American Primary Care Group in November 2022, experts from different countries representing different traditions agreed on how the current evidence should be interpreted. RESULTS This critical analysis identifies that the problem can be resolved by introducing a new triage scheme considering both the acute risk for suppurative complications and sepsis as well as the long-term risk of developing rheumatic fever. CONCLUSIONS The new triage scheme may solve the long-standing problem of advocating for a restrictive use of antibiotics while also satisfying concerns that critically ill patients might be missed with severe consequences. We acknowledge that the perspective of this problem is vastly different between high- and low-income countries. Furthermore, we discuss the new trend which allows nurses and pharmacists to independently manage these patients and the increased need for safety netting required for such management.
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9
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Vellinga A, Luke-Currier A, Garzón-Orjuela N, Aabenhus R, Anastasaki M, Balan A, Böhmer F, Lang VB, Chlabicz S, Coenen S, García-Sangenís A, Kowalczyk A, Malania L, Tomacinschii A, van der Linde SR, Bongard E, Butler CC, Goossens H, van der Velden AW. Disease-Specific Quality Indicators for Outpatient Antibiotic Prescribing for Respiratory Infections (ESAC Quality Indicators) Applied to Point Prevalence Audit Surveys in General Practices in 13 European Countries. Antibiotics (Basel) 2023; 12:antibiotics12030572. [PMID: 36978439 PMCID: PMC10044809 DOI: 10.3390/antibiotics12030572] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 02/23/2023] [Accepted: 03/10/2023] [Indexed: 03/17/2023] Open
Abstract
Up to 80% of antibiotics are prescribed in the community. An assessment of prescribing by indication will help to identify areas where improvement can be made. A point prevalence audit study (PPAS) of consecutive respiratory tract infection (RTI) consultations in general practices in 13 European countries was conducted in January–February 2020 (PPAS-1) and again in 2022 (PPAS-4). The European Surveillance of Antibiotic Consumption quality indicators (ESAC-QI) were calculated to identify where improvements can be made. A total of 3618 consultations were recorded for PPAS-1 and 2655 in PPAS-4. Bacterial aetiology was suspected in 26% (PPAS-1) and 12% (PPAS-4), and an antibiotic was prescribed in 30% (PPAS-1) and 16% (PPAS-4) of consultations. The percentage of adult patients with bronchitis who receive an antibiotic should, according to the ESAC-QI, not exceed 30%, which was not met by participating practices in any country except Denmark and Spain. For patients (≥1) with acute upper RTI, less than 20% should be prescribed an antibiotic, which was achieved by general practices in most countries, except Ireland (both PPAS), Croatia (PPAS-1), and Greece (PPAS-4) where prescribing for acute or chronic sinusitis (0–20%) was also exceeded. For pneumonia in adults, prescribing is acceptable for 90–100%, and this is lower in most countries. Prescribing for tonsillitis (≥1) exceeded the ESAC-QI (0–20%) in all countries and was 69% (PPAS-1) and 75% (PPAS-4). In conclusion, ESAC-QI applied to PPAS outcomes allows us to evaluate appropriate antibiotic prescribing by indication and benchmark general practices and countries.
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Affiliation(s)
- Akke Vellinga
- School of Public Health, Physiotherapy and Sports Science, University College Dublin, D04 V1W8 Dublin, Ireland
- Correspondence:
| | - Addiena Luke-Currier
- School of Public Health, Physiotherapy and Sports Science, University College Dublin, D04 V1W8 Dublin, Ireland
| | - Nathaly Garzón-Orjuela
- School of Public Health, Physiotherapy and Sports Science, University College Dublin, D04 V1W8 Dublin, Ireland
| | - Rune Aabenhus
- Research Unit for General Practice, Department of Public Health, University of Copenhagen, DK-2200 Copenhagen, Denmark
| | - Marilena Anastasaki
- Department of Social Medicine, School of Medicine, University of Crete, 71003 Heraklion, Greece
| | - Anca Balan
- Balan Medfam Srl, 400064 Cluj Napoca, Romania
| | - Femke Böhmer
- Institute of General Practice, Rostock University Medical Center, 18057 Rostock, Germany
| | - Valerija Bralić Lang
- Department of Family Medicine, “Andrija Stampar” School of Public Health, School of Medicine, University of Zagreb, 10020 Zagreb, Croatia
| | - Slawomir Chlabicz
- Department of Family Medicine, Medical University of Bialystok, 15-089 Bialystok, Poland
| | - Samuel Coenen
- Department of Family Medicine & Population Health, University of Antwerp, 2610 Antwerp, Belgium
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute, University of Antwerp, 2610 Antwerp, Belgium
| | - Ana García-Sangenís
- Institut Universitari d’Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), 08007 Barcelona, Spain
- Centro de investigación Biomédica en Red Enfermedades Infecciosas (CIBERINFEC), 28029 Madrid, Spain
| | - Anna Kowalczyk
- Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Lodz, 92-213 Lodz, Poland
| | - Lile Malania
- National Center for Disease Control and Public Health, Tbilisi and Arner Science Management LLC, 0190 Tbilisi, Georgia
| | - Angela Tomacinschii
- University Clinic of Primary Medical Assistance, State University of Medicine and Pharmacy “Nicolae Testemițanu”, MD-2004 Chişinǎu, Moldova
| | - Sanne R. van der Linde
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Universiteitsweg 100, 3584 CG Utrecht, The Netherlands
| | - Emily Bongard
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX1 4BH, UK
| | - Christopher C. Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX1 4BH, UK
| | - Herman Goossens
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute, University of Antwerp, 2610 Antwerp, Belgium
| | - Alike W. van der Velden
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Universiteitsweg 100, 3584 CG Utrecht, The Netherlands
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10
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Rystedt K, Hedin K, Tyrstrup M, Skoog-Ståhlgren G, Edlund C, Giske CG, Gunnarsson R, Sundvall PD. Agreement between rapid antigen detection test and culture for group A streptococcus in patients recently treated for pharyngotonsillitis - a prospective observational study in primary care. Scand J Prim Health Care 2023; 41:91-97. [PMID: 36880344 PMCID: PMC10088972 DOI: 10.1080/02813432.2023.2182631] [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: 03/08/2023] Open
Abstract
OBJECTIVE The aim was to compare rapid antigen detection test (RADT) and throat culture for group A streptococci (GAS) among patients recently treated with penicillin V for GAS pharyngotonsillitis. DESIGN AND SETTING The study was a secondary analysis within a randomized controlled trial comparing 5 versus 10 days of penicillin V for GAS pharyngotonsillitis. Patients were recruited at 17 primary health care centres in Sweden. SUBJECTS We included 316 patients ≥ 6 years of age, having 3-4 Centor criteria, a positive RADT and a positive throat culture for GAS at inclusion, and also having a RADT and throat culture for GAS taken at a follow-up visit within 21 days. MAIN OUTCOME MEASURES RADT and conventional throat culture for GAS. RESULTS This prospective study showed 91% agreement between RADT and culture at follow-up within 21 days. Only 3/316 participants had negative RADT with a positive throat culture for GAS at follow-up, and 27/316 patients with positive RADT had a negative culture for GAS. Log rank test did not reveal any difference in the decline over time of positive tests between RADT and throat culture (p = 0.24). Agreement between RADT and throat culture for GAS at the follow-up was not associated with treatment duration, number of days from inclusion until follow-up, throat symptoms at follow-up, gender, or age. CONCLUSION RADT and culture for GAS agreed to a high extent also after recent penicillin V treatment. RADT for GAS means a low risk for missing the presence of GAS.KEY POINTSTesting for group A streptococci (GAS) before antibiotic treatment can reduce antibiotic prescription for pharyngotonsillitis. It has been proposed that rapid antigen detection tests (RADT) for group A streptococci after recent penicillin V treatment may be falsely positive due to possible persisting antigens from non-viable bacteria.The decline of the presence of GAS was similar between RADT and conventional throat culture in patients who had recently completed penicillin V treatment for GAS pharyngotonsillitisRADT for GAS is useful in identifying the presence of GAS after recent penicillin V treatment.
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Affiliation(s)
- Karin Rystedt
- Research, Education, Development & Innovation, Primary Health Care, Region Västra Götaland, Sweden
- General Practice/Family Medicine, School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Centre for Antibiotic Resistance Research (CARe) at University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Närhälsan Hentorp Health Care Center, Gröna vagen, Skövde, Sweden
| | - Katarina Hedin
- Futurum, Region Jönköping County, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
- Department of Clinical Sciences in Malmö, Family Medicine, Lund University, Malmö, Sweden
| | - Mia Tyrstrup
- Department of Clinical Sciences in Malmö, Family Medicine, Lund University, Malmö, Sweden
| | - Gunilla Skoog-Ståhlgren
- Unit for Antibiotics and Infection Control, the Public Health Agency of Sweden, Solna, Sweden
| | - Charlotta Edlund
- Unit for Antibiotics and Infection Control, the Public Health Agency of Sweden, Solna, Sweden
| | - Christian G Giske
- Division of Clinical Microbiology, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
- Department of Clinical Microbiology, Karolinska University Hospital, Stockholm, Sweden
| | - Ronny Gunnarsson
- Research, Education, Development & Innovation, Primary Health Care, Region Västra Götaland, Sweden
- General Practice/Family Medicine, School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Centre for Antibiotic Resistance Research (CARe) at University of Gothenburg, Gothenburg, Sweden
| | - Pär-Daniel Sundvall
- Research, Education, Development & Innovation, Primary Health Care, Region Västra Götaland, Sweden
- General Practice/Family Medicine, School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Centre for Antibiotic Resistance Research (CARe) at University of Gothenburg, Gothenburg, Sweden
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11
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Bentouhami H, Bungwa MK, Casas L, Coenen S, Weyler J. Asthma occurrence in children and early life systemic antibiotic use: an incidence density study. ALLERGY, ASTHMA, AND CLINICAL IMMUNOLOGY : OFFICIAL JOURNAL OF THE CANADIAN SOCIETY OF ALLERGY AND CLINICAL IMMUNOLOGY 2023; 19:18. [PMID: 36879341 PMCID: PMC9987135 DOI: 10.1186/s13223-023-00773-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 02/13/2023] [Indexed: 03/08/2023]
Abstract
BACKGROUND Results of studies evaluating the relationship between asthma occurrence and early life antibiotic use have been conflicting. The aim of this study was to investigate the relationship between occurrence of asthma in children and systemic antibiotic use in the first year of life based on an incidence density study with careful consideration of the temporal aspects of the determinant-outcome relationship. METHODS We conducted an incidence density study nested in a data collection project with information on 1128 mother-child pairs. Systemic antibiotic use in the first year of life was defined as excessive (≥ 4 courses) vs. non-excessive (< 4 courses) use based on information from weekly diaries. Events (cases) were defined as the first parent-reported occurrence of asthma in a child between 1 and 10 years of age. Population time 'at risk' was probed by sampling population moments (controls). Missing data were imputed. Multiple logistic regression was used to assess the association between current first asthma occurrence (incidence density) and systemic antibiotic use in the first year of life, to evaluate effect modification and adjust for confounding. RESULTS Forty-seven first asthma events and 147 population moments were included. Excessive systemic antibiotic use in the first year of life showed more than twice the incidence density of asthma compared to non-excessive use (adjusted IDR [95% CI]: 2.18 [0.98, 4.87], p = 0.06). The association was more pronounced in children who have had lower respiratory tract infections (LRTIs) in the first year of life compared to children who had no LRTIs in the first year of life (adjusted IDR [95% CI]: 5.17 [1.19, 22.52] versus 1.49 [0.54, 4.14]). CONCLUSIONS Excessive use of systemic antibiotics in the first year of life may play a role in the genesis of asthma in children. This effect is modified by the occurrence of LRTIs in the first year of life, with a stronger association observed in children experiencing LRTIs in the first year of life.
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Affiliation(s)
- Hayat Bentouhami
- Department of Family Medicine & Population Health (FAMPOP), Social Epidemiology and Health Policy (SEHPO), University of Antwerp, Antwerp, Belgium.
| | - Milcah Kahkelam Bungwa
- Department of Family Medicine & Population Health (FAMPOP), Social Epidemiology and Health Policy (SEHPO), University of Antwerp, Antwerp, Belgium
| | - Lidia Casas
- Department of Family Medicine & Population Health (FAMPOP), Social Epidemiology and Health Policy (SEHPO), University of Antwerp, Antwerp, Belgium
| | - Samuel Coenen
- Department of Family Medicine & Population Health (FAMPOP), Social Epidemiology and Health Policy (SEHPO), University of Antwerp, Antwerp, Belgium.,Department of Family Medicine & Population Health (FAMPOP), Primary Care & Interdisciplinary Care Antwerp (ELIZA), University of Antwerp, Antwerp, Belgium.,Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium
| | - Joost Weyler
- Department of Family Medicine & Population Health (FAMPOP), Social Epidemiology and Health Policy (SEHPO), University of Antwerp, Antwerp, Belgium.,StatUa Statistics Centre, University of Antwerp, Antwerp, Belgium
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12
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Johnston J, Wagner Mackenzie B, Biswas K, Waldvogel-Thurlow S, Clark ST, Radcliff F, Mahadevan M, Douglas RG. The Effect of Amoxicillin with Clavulanate on the Microbiota of Tonsillar Tissue in Disease: a Randomized Control Trial. Microbiol Spectr 2022; 10:e0123922. [PMID: 36318025 PMCID: PMC9769914 DOI: 10.1128/spectrum.01239-22] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 10/13/2022] [Indexed: 12/23/2022] Open
Abstract
Despite antibiotics being the primary medical treatment for recurrent tonsillitis, the impact of antibiotics on the tonsillar microbiome is not well understood. This study aimed to determine the effect of amoxicillin with clavulanate on the composition and quantity of bacteria in the tonsils of children with recurrent tonsillitis. A multicenter randomized clinical trial in Auckland, New Zealand was undertaken between August 1, 2017, and June 30, 2018. Sixty children undergoing tonsillectomy for the indication of recurrent tonsillitis were recruited for this study. Following random allocation, 30 participants were prescribed amoxicillin with clavulanate for the week before surgery. The remaining 30 received no antibiotics. Immediately following surgery, the crypts of the right and left tonsils were swabbed. Bacterial 16S rRNA gene-targeted amplicon sequencing and histological techniques were utilized. In the control group, there were significantly higher relative abundances of Haemophilus, Streptococcus, Neisseria, and Porphyromonas. Members from the genera Fusobacterium and Treponema were found to be significantly more abundant in the antibiotic group. There were no significant differences in the absolute quantities of bacteria between the groups. Microscopic examination found fewer bacterial microcolonies present in the tonsillar crypts of participants in the antibiotic group. Streptococcus pyogenes was not present in these bacterial microcolonies. These results suggest that a single course of antibiotics has a significant impact on the tonsil microbiota composition. The duration of this effect and the effect that the altered microbiome has on the course of the condition need to be determined. IMPORTANCE Several studies have identified the presence of multiple pathogenic bacteria in hyperplastic adenoids and palatine tonsils. However, there are currently no studies that utilize this technology to investigate the effect of oral antibiotics in children with recurrent tonsillitis on the tonsillar microbiome. This is the first study to investigate the effect of antibiotics on the microbiome of tonsillar tissue in children with recurrent tonsillitis using molecular techniques. This study has shown that participants who received amoxicillin with clavulanate immediately before tonsillectomy had a significantly reduced number of bacterial taxa commonly associated with recurrent tonsillitis, as well as the number of bacterial microcolonies observed in the tonsillar crypts. This novel finding suggests that either the effect of antibiotics is not sustained or that they are not an effective treatment for recurrent tonsillitis.
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Affiliation(s)
- James Johnston
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | | | - Kristi Biswas
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | | | - Sita Tarini Clark
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Fiona Radcliff
- Department of Molecular Medicine and Pathology, University of Auckland, Auckland, New Zealand
| | - Murali Mahadevan
- Department of Surgery, University of Auckland, Auckland, New Zealand
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13
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Saust LT, Siersma V, Lykkegaard J, Bjerrum L, Hansen MP. Diagnosis and Antibiotic Treatment of Urinary Tract Infections in Danish General Practice: A Quality Assessment. Antibiotics (Basel) 2022; 11:antibiotics11121759. [PMID: 36551416 PMCID: PMC9774586 DOI: 10.3390/antibiotics11121759] [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: 11/14/2022] [Revised: 11/28/2022] [Accepted: 12/03/2022] [Indexed: 12/12/2022] Open
Abstract
Rational antibiotic treatment of urinary tract infections (UTI) is important. To improve the quality of antibiotic treatment of UTI, it is essential to obtain insight into diagnostic approaches and prescribing patterns in general practice. The aim of this study was to investigate the quality of diagnostics and treatment of UTI in general practice by means of quality indicators (QIs). QIs provide a quantitative measure of quality and are defined by a numerator (the number of patients receiving a specific investigation or treatment) and a denominator (the number of patients included in the quality assessment). For adult patients with suspected UTI, practices registered the following: age, sex, risk factors, symptoms and signs, examinations, diagnosis and treatment. The levels of the QIs were compared with their corresponding standards. Half of the patients diagnosed with lower UTI or pyelonephritis fulfilled the diagnostic criteria for UTI: characteristic UTI symptoms and clear signs of bacteriuria, respectively. Urinalysis was performed for nearly all patients, including patients without characteristic symptoms of UTI. One-fourth of the patients with suspected lower UTI were treated with antibiotics despite no urinalysis and nearly half received antibiotics despite an inconclusive dipstick test. Pivmecillam was the preferred antibiotic. The findings of this study indicate that there is room for improvement in the management of UTI in Danish general practice.
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Affiliation(s)
- Laura Trolle Saust
- Center for General Practice, Department of Clinical Medicine, Aalborg University, 9220 Aalborg, Denmark
- Section of General Practice and Research Unit for General Practice, Department of Public Health, University of Copenhagen, 1353 Copenhagen, Denmark
- Correspondence:
| | - Volkert Siersma
- Section of General Practice and Research Unit for General Practice, Department of Public Health, University of Copenhagen, 1353 Copenhagen, Denmark
| | - Jesper Lykkegaard
- Audit Project Odense, Research Unit for General Practice, Department of Public Health, University of Southern Denmark, 5000 Odense, Denmark
| | - Lars Bjerrum
- Section of General Practice and Research Unit for General Practice, Department of Public Health, University of Copenhagen, 1353 Copenhagen, Denmark
| | - Malene Plejdrup Hansen
- Center for General Practice, Department of Clinical Medicine, Aalborg University, 9220 Aalborg, Denmark
- Audit Project Odense, Research Unit for General Practice, Department of Public Health, University of Southern Denmark, 5000 Odense, Denmark
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14
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Bel Haj Ali K, Sekma A, Messous S, Trabelsi I, Ben Youssef J, Maghraoui H, Razgallah R, walha A, Grissa MH, Beltaief K, Mezgar Z, Coubantini A, Bouida W, Msolli MA, Boukef R, Boubaker H, Nouira S. Appropriateness of antibiotic treatment of acute respiratory tract infections in Tunisian primary care and emergency departments: a multicenter cross-sectional study. BMC PRIMARY CARE 2022; 23:295. [PMID: 36418965 PMCID: PMC9682766 DOI: 10.1186/s12875-022-01904-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 07/13/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Little is known about the pattern and appropriateness of antibiotic prescriptions in patients with acute respiratory tract infections (ARTIs). OBJECTIVE Describe the antibiotics used to treat ARTIs in Tunisian primary care offices and emergency departments (EDs), and assess the appropriateness of their use. METHODS It was a prospective multicenter cross-sectional observational clinical study conducted at 63 primary care offices and 6 EDS during a period of 8 months. Appropriateness of antibiotic prescription was evaluated by trained physicians using the medication appropriateness index (MAI). The MAI ratings generated a weighted score of 0 to 18 with higher scores indicating low appropriateness. The study was conducted in accordance with the Declaration of Helsinki and national and institutional standards. The study was approved by the Ethics committee of Monastir Medical Faculty. RESULTS From the 12,880 patients screened we included 9886 patients. The mean age was 47.4, and 55.4% were men. The most frequent diagnosis of ARTI was were acute bronchitis (45.3%), COPD exacerbation (16.3%), tonsillitis (14.6%), rhinopharyngitis (12.2%) and sinusitis (11.5%). The most prescribed classes of antibiotics were penicillins (58.3%), fluoroquinolones (17.6%), and macrolides (16.9%). Antibiotic therapy was inappropriate in 75.5% of patients of whom 65.2% had bronchitis. 65% of patients had one or more antibiotic prescribing inappropriateness criteria as assessed by the MAI. The most frequently rated criteria were with expensiveness (75.8%) and indication (40%). Amoxicillin-clavulanic acid and levofloxacin were the most inappropriately prescribed antibiotics. History of cardiac ischemia ([OR] 3.66; 95% [CI] 2.17-10.26; p < 0.001), asthma ([OR] 3.29, 95% [CI] 1.77-6.13; p < 0.001), diabetes ([OR] 2.09, 95% [CI] 1.54-2.97; p = 0.003), history of COPD ([OR] 1.75, 95% [CI] 1.43-2.15; p < 0.001) and age > 65 years (Odds Ratio [OR] 1.35, 95% confidence interval [CI] 1.16-1.58; p < 0.001) were associated with a higher likelihood of inappropriate prescribing. CONCLUSION Our findings indicate a high inappropriate use of antibiotics in ARTIs treated in in primary care and EDs. This was mostly related to antibiotic prescription in acute bronchitis and overuse of expensive broad spectrum antibiotics. Future interventions to improve antibiotic prescribing in primary care and EDs is needed. TRIAL REGISTRATION the trial is registered at Clinicaltrials.gov registry (NCT04482231).
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Affiliation(s)
- Khaoula Bel Haj Ali
- grid.420157.5Emergency Department, Fattouma Bourguiba University Hospital, 5000 Monastir, Tunisia ,grid.411838.70000 0004 0593 5040Research Laboratory LR12SP18, Monastir University, 5019 Monastir, Tunisia
| | - Adel Sekma
- grid.420157.5Emergency Department, Fattouma Bourguiba University Hospital, 5000 Monastir, Tunisia ,grid.411838.70000 0004 0593 5040Research Laboratory LR12SP18, Monastir University, 5019 Monastir, Tunisia
| | - Selma Messous
- grid.411838.70000 0004 0593 5040Research Laboratory LR12SP18, Monastir University, 5019 Monastir, Tunisia
| | - Imen Trabelsi
- grid.411838.70000 0004 0593 5040Research Laboratory LR12SP18, Monastir University, 5019 Monastir, Tunisia
| | - Jalel Ben Youssef
- Vice-president of the Tunisian Society of Family Medicine, Tunis, Tunisia
| | - Hamida Maghraoui
- Emergency Department, Rabta University Hospital, 1007 Tunis, Tunisia
| | | | - Adel walha
- grid.420157.5Emergency Department, Fattouma Bourguiba University Hospital, 5000 Monastir, Tunisia ,grid.411838.70000 0004 0593 5040Research Laboratory LR12SP18, Monastir University, 5019 Monastir, Tunisia
| | - Mohamed Habib Grissa
- grid.420157.5Emergency Department, Fattouma Bourguiba University Hospital, 5000 Monastir, Tunisia ,grid.411838.70000 0004 0593 5040Research Laboratory LR12SP18, Monastir University, 5019 Monastir, Tunisia
| | - Kaouthar Beltaief
- grid.420157.5Emergency Department, Fattouma Bourguiba University Hospital, 5000 Monastir, Tunisia ,grid.411838.70000 0004 0593 5040Research Laboratory LR12SP18, Monastir University, 5019 Monastir, Tunisia
| | - Zied Mezgar
- grid.412791.80000 0004 0508 0097Emergency Department, Farhat Hached University Hospital, 4031 Sousse, Tunisia
| | - Ahmed Coubantini
- Department of Infectious Disease, Rabta University Hospital, 1007 Tunis, Tunisia
| | - Wahid Bouida
- grid.420157.5Emergency Department, Fattouma Bourguiba University Hospital, 5000 Monastir, Tunisia ,grid.411838.70000 0004 0593 5040Research Laboratory LR12SP18, Monastir University, 5019 Monastir, Tunisia
| | - Mohamed Amine Msolli
- grid.420157.5Emergency Department, Fattouma Bourguiba University Hospital, 5000 Monastir, Tunisia ,grid.411838.70000 0004 0593 5040Research Laboratory LR12SP18, Monastir University, 5019 Monastir, Tunisia
| | - Riadh Boukef
- grid.411838.70000 0004 0593 5040Research Laboratory LR12SP18, Monastir University, 5019 Monastir, Tunisia ,grid.412356.70000 0004 9226 7916Emergency Department, Sahloul University Hospital, 4011 Sousse, Tunisia
| | - Hamdi Boubaker
- grid.420157.5Emergency Department, Fattouma Bourguiba University Hospital, 5000 Monastir, Tunisia ,grid.411838.70000 0004 0593 5040Research Laboratory LR12SP18, Monastir University, 5019 Monastir, Tunisia
| | - Semir Nouira
- grid.420157.5Emergency Department, Fattouma Bourguiba University Hospital, 5000 Monastir, Tunisia ,grid.411838.70000 0004 0593 5040Research Laboratory LR12SP18, Monastir University, 5019 Monastir, Tunisia
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15
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Kusuma IY, Matuz M, Bordás R, Juhasz Haverinen M, Bahar MA, Hajdu E, Visnyovszki Á, Ruzsa R, Doró P, Engi Z, Csupor D, Benko R. Antibiotic use in elderly patients in ambulatory care: A comparison between Hungary and Sweden. Front Pharmacol 2022; 13:1042418. [PMID: 36467037 PMCID: PMC9714540 DOI: 10.3389/fphar.2022.1042418] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 10/27/2022] [Indexed: 11/23/2023] Open
Abstract
Background: The elderly use antibiotics frequently due to their increasing infection susceptibility. Given the high and increasing proportion of elderly in the population, their antibiotic use is substantial. Objective: This study aimed to compare antibiotic use in the elderly in the ambulatory care sector between Hungary and Sweden. Methods: This retrospective, descriptive, cross-national, comparative study included antibacterial use data from the Hungarian National Health Insurance Fund and the Swedish eHealth Agency. Antibiotic use (anatomical therapeutical chemical: J01) was expressed as the number of prescriptions/1000 inhabitants/year or month and was further stratified by age and sex. Results: Antibiotic exposure was higher in the Hungarian elderly population (649.8 prescriptions/1000 inhabitants/year) compared to its Swedish counterparts (545.0 prescriptions/1000 inhabitants/year). Hungary had a similar scale of antibacterial exposure across all elderly age subgroups, with different trends in males and females, while Sweden had a stepwise increase in antibiotic exposure by age in both sexes. The seasonal fluctuation was high in Hungary and reached a peak of 80.7 prescriptions/1000 inhabitants/month in January 2017, while even antibiotic use was detected throughout the year in Sweden. The pattern of antibiotic use in the elderly considerably differed between the two countries. Penicillin and beta-lactamase combinations, such as co-amoxiclav, were more frequently used in Hungary than in Sweden (19.08% vs 1.83% of corresponding total ambulatory antibiotic use). Likewise, quinolones were more commonly used in Hungary than in Sweden (34.53% vs. 9.98). The elderly in Sweden were mostly prescribed narrow spectra penicillins (26.71% vs. 0.29% in Hungary). Conclusion: This cross-national comparison revealed important differences in all aspects of antibiotic use in the elderly between the two countries. The identical scale and pattern of antibiotic use cannot be anticipated due to the poorer health status of the Hungarian elderly population. However, the substantial differences indicate some room for improvement in the antibiotic prescription for the Hungarian elderly.
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Affiliation(s)
- Ikhwan Yuda Kusuma
- Institute of Clinical Pharmacy, University of Szeged, Szeged, Hungary
- Pharmacy Study Program, Universitas Harapan Bangsa, Purwokerto, Indonesia
| | - Maria Matuz
- Institute of Clinical Pharmacy, University of Szeged, Szeged, Hungary
- Albert Szent-Györgyi Health Centre, Central Pharmacy, University of Szeged, Szeged, Hungary
| | - Réka Bordás
- Institute of Clinical Pharmacy, University of Szeged, Szeged, Hungary
| | | | - Muh. Akbar Bahar
- Institute of Clinical Pharmacy, University of Szeged, Szeged, Hungary
- Department of Pharmacy, Faculty of Pharmacy, Universitas Hasanuddin, Makassar, Indonesia
| | - Edit Hajdu
- Albert Szent-Györgyi Health Centre, Department of Internal Medicine Infectiology Unit, University of Szeged, Szeged, Hungary
| | - Ádám Visnyovszki
- Albert Szent-Györgyi Health Centre, Department of Internal Medicine Infectiology Unit, University of Szeged, Szeged, Hungary
| | - Roxána Ruzsa
- Institute of Clinical Pharmacy, University of Szeged, Szeged, Hungary
| | - Péter Doró
- Institute of Clinical Pharmacy, University of Szeged, Szeged, Hungary
| | - Zsófi Engi
- Institute of Clinical Pharmacy, University of Szeged, Szeged, Hungary
| | - Dezső Csupor
- Institute of Clinical Pharmacy, University of Szeged, Szeged, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Ria Benko
- Institute of Clinical Pharmacy, University of Szeged, Szeged, Hungary
- Albert Szent-Györgyi Health Centre, Central Pharmacy, University of Szeged, Szeged, Hungary
- Albert Szent-Györgyi Health Centre, Emergency Department, University of Szeged, Szeged, Hungary
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16
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Okubo Y, Nishi A, Michels KB, Nariai H, Kim-Farley RJ, Arah OA, Uda K, Kinoshita N, Miyairi I. The consequence of financial incentives for not prescribing antibiotics: a Japan's nationwide quasi-experiment. Int J Epidemiol 2022; 51:1645-1655. [PMID: 35353127 PMCID: PMC10233477 DOI: 10.1093/ije/dyac057] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 03/16/2022] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND For addressing antibiotic overuse, Japan designed a health care policy in which eligible medical facilities could claim a financial reward when antibiotics were not prescribed for early-stage respiratory and gastrointestinal infections. The policy was introduced in a pilot manner in paediatric clinics in April 2018. METHODS We conducted a quasi-experimental, propensity score-matched, difference-in-differences (DID) design to determine whether the nationwide financial incentives for appropriate non-prescribing of antibiotics as antimicrobial stewardship [800 JPY (≈7.3 US D) per case] were associated with changes in prescription patterns, including antibiotics, and health care use in routine paediatric health care settings at a national level. Data consisted of 9 253 261 cases of infectious diseases in 553 138 patients treated at 10 180 eligible or ineligible facilities. RESULTS A total of 2959 eligible facilities claimed 316 770 cases for financial incentives and earned 253 million JPY (≈2.29 million USD). Compared with ineligible facilities, the introduction of financial incentives in the eligible facilities was associated with an excess reduction in antibiotic prescriptions [DID estimate, -228.6 days of therapy (DOTs) per 1000 cases (95% CI, -272.4 to -184.9), which corresponded to a relative reduction of 17.8% (95% CI, 14.8 to 20.7)]. The introduction was also associated with excess reductions in drugs for respiratory symptoms [DID estimates, -256.9 DOTs per 1000 cases (95% CI, -379.3 to -134.5)] and antihistamines [DID estimate, -198.5 DOTs per 1000 cases (95% CI, -282.1 to -114.9)]. There was no excess in out-of-hour visits [DID estimate, -4.43 events per 1000 cases (95% CI, -12.8 to 3.97)] or hospitalizations [DID estimate, -0.08 events per 1000 cases (95% CI, -0.48 to 0.31)]. CONCLUSIONS Our findings suggest that financial incentives to medical facilities for not prescribing antibiotics were associated with reductions in prescriptions for antibiotics without adverse health care consequences. Japan's new health policy provided us with policy options for immediately reducing inappropriate antibiotic prescriptions by relatively small financial incentives.
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Affiliation(s)
- Yusuke Okubo
- Department of Social Medicine, National Center for Child Health and Development, Tokyo, Japan
- Department of Epidemiology, Fielding School of Public Health, University of California Los Angeles, Los Angeles, CA, USA
| | - Akihiro Nishi
- Department of Epidemiology, Fielding School of Public Health, University of California Los Angeles, Los Angeles, CA, USA
| | - Karin B Michels
- Department of Epidemiology, Fielding School of Public Health, University of California Los Angeles, Los Angeles, CA, USA
| | - Hiroki Nariai
- Department of Pediatrics, UCLA Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA, USA
| | - Robert J Kim-Farley
- Department of Epidemiology, Fielding School of Public Health, University of California Los Angeles, Los Angeles, CA, USA
| | - Onyebuchi A Arah
- Department of Epidemiology, Fielding School of Public Health, University of California Los Angeles, Los Angeles, CA, USA
| | - Kazuhiro Uda
- Department of Pediatrics, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
- Division of Infectious Diseases, Department of Medical Subspecialties, National Center for Child Health and Development, Tokyo, Japan
| | - Noriko Kinoshita
- Division of Infectious Diseases, Department of Medical Subspecialties, National Center for Child Health and Development, Tokyo, Japan
- Department of Infectious Diseases, National Center for Global Health and Medicine, Tokyo, Japan
| | - Isao Miyairi
- Division of Infectious Diseases, Department of Medical Subspecialties, National Center for Child Health and Development, Tokyo, Japan
- Department of Microbiology, Immunology, and Biochemistry, University of Tennessee Health Science Center, Knoxville, Tennessee, USA
- Department of Pediatrics, Hamamatsu University School of Medicine, Hamamatsu, Japan
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17
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Gunnarsson R, Orda U, Elliott B, Heal C, Del Mar C. What is the optimal strategy for managing primary care patients with an uncomplicated acute sore throat? Comparing the consequences of nine different strategies using a compilation of previous studies. BMJ Open 2022; 12:e059069. [PMID: 35487741 PMCID: PMC9058799 DOI: 10.1136/bmjopen-2021-059069] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVE Identifying optimal strategies for managing patients of any age with varying risk of acute rheumatic fever (ARF) attending for an apparently uncomplicated acute sore throat, also clarifying the role of point-of-care testing (POCT) for presence of group A beta-haemolytic Streptococcus (GABHS) in these settings. DESIGN We compared outcomes of adhering to nine different strategies for managing these patients in primary healthcare. SETTING AND PARTICIPANTS The nine strategies, similar to guidelines from several countries, were tested against two validation data sets being constructs from seven prior studies. MAIN OUTCOME MEASURES The proportion of patients requiring a POCT, prescribed antibiotics, prescribed antibiotics having GABHS and finally having GABHS not prescribed antibiotics, if different strategies had been adhered to. RESULTS In a scenario with high risk of ARF, adhering to existing guidelines would risk many patients ill from GABHS left without antibiotics. Hence, using a POCT on all of these patients minimised their risk. For low-risk patients, it is reasonable to only consider antibiotics if the patient has more than low pain levels despite adequate analgesia, 3-4 Centor scores (or 2-3 FeverPAIN scores or 3-4 McIsaac scores) and a POCT confirming the presence of GABHS. This would require testing only 10%-15% of patients and prescribing antibiotics to only 3.5%-6.6%. CONCLUSIONS Patients with high or low risk for ARF needs to be managed very differently. POCT can play an important role in safely targeting the use of antibiotics for patients with an apparently uncomplicated acute sore throat.
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Affiliation(s)
- Ronny Gunnarsson
- School of Public Health and Community Medicine - General Practice/Family Medicine, Göteborgs universitet Institutionen för medicin, Goteborg, Sweden
- Research, Development, Education and Innovation, Primary Health Care, Västra Götalandsregionen, Göteborg, Sweden
- Centre for Antibiotic Resistance Research (CARe), University of Gothenburg, Göteborg, Sweden
- The primary health care clinic for homeless people, Närhälsan, Region Västra Götaland, Göteborg, Sweden
| | - Ulrich Orda
- Mount Isa Hospital, North West Hospital and Health Service, Mount Isa, Queensland, Australia
| | | | - Clare Heal
- School of Medicine and Dentistry, James Cook University, Mackay, Queensland, Australia
| | - Chris Del Mar
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
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18
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Abstract
BACKGROUND Sore throat is a common reason for people to present for medical care and to be prescribed antibiotics. Overuse of antibiotics in primary medicine is a concern, hence it is important to establish their efficacy in treating sore throat and preventing secondary complications. OBJECTIVES: To assess the effects of antibiotics for reducing symptoms of sore throat for child and adult patients. SEARCH METHODS We searched CENTRAL 2021, Issue 2, MEDLINE (January 1966 to April week 1, 2021), Embase (January 1990 to April 2021), and two trial registries (searched 6 April 2021). SELECTION CRITERIA Randomised controlled trials (RCTs) or quasi-RCTs of antibiotics versus control assessing typical sore throat symptoms or complications amongst children and adults seeking medical care for sore throat symptoms. DATA COLLECTION AND ANALYSIS We used standard methodological procedures as recommended by Cochrane. Two review authors independently screened studies for inclusion and extracted data, resolving any differences in opinion by discussion. We contacted the trial authors from three studies for additional information. We used GRADE to assess the certainty of the evidence for the efficacy of antibiotics on our primary outcomes (sore throat at day three and one week) and secondary outcomes (fever and headache symptoms and incidence of acute rheumatic fever, acute glomerulonephritis, acute otitis media, acute sinusitis, and quinsy). MAIN RESULTS We included 29 trials with 15,337 cases of sore throat. The majority of included studies were conducted in the 1950s, during which time the rates of serious complications (especially acute rheumatic fever) were much higher than today. Although clinical antibiotic trials for sore throat and respiratory symptoms are still being conducted, it is unusual for them to include placebo or 'no treatment' control arms, which is a requirement for inclusion in the review. The age of participants ranged from younger than one year to older than 50 years, but most participants across all studies were adults. Although all studies recruited patients presenting with symptoms of sore throat, few of them distinguished between bacterial and viral aetiology. Bias may have been introduced through non-clarity in treatment allocation procedures and lack of blinding in some studies. Harms from antibiotics were poorly or inconsistently reported, and were thus not quantified for this review. 1. Symptoms Throat soreness and headache at day three were reduced by using antibiotics, although 82% of participants in the placebo or no treatment group were symptom-free by one week. The reduction in sore throat symptoms at day three (risk ratio (RR) 0.70, 95% confidence interval (CI) 0.60 to 0.80; 16 studies, 3730 participants; moderate-certainty evidence) was greater than at one week in absolute numbers (RR 0.50, 95% CI 0.34 to 0.75; 14 studies, 3083 participants; moderate-certainty evidence) due to many cases in both treatment groups having resolved by this time. The number needed to treat for an additional beneficial outcome (NNTB) to prevent one sore throat at day three was less than six; at week one it was 18. Compared with placebo or no treatment, antibiotics did not significantly reduce fever at day three (RR 0.75, 95% CI 0.53 to 1.07; 8 studies, 1443 participants; high-certainty evidence), but did reduce headache at day three (RR 0.49, 95% CI 0.34 to 0.70; 4 studies, 1020 participants; high-certainty evidence). 2. Suppurative complications Whilst the prevalence of suppurative complications was low, antibiotics reduced the incidence of acute otitis media within 14 days (Peto odds ratio (OR) 0.21, 95% CI 0.11 to 0.40; 10 studies, 3646 participants; high-certainty evidence) and quinsy within two months (Peto OR 0.16, 95% CI 0.07 to 0.35; 8 studies, 2433 participants; high-certainty evidence) compared to those receiving placebo or no treatment, but not acute sinusitis within 14 days (Peto OR 0.46, 95% CI 0.10 to 2.05; 8 studies, 2387 participants; high-certainty evidence). 3. Non-suppurative complications There were too few cases of acute glomerulonephritis to determine whether there was a protective effect of antibiotics compared with placebo against this complication (Peto OR 0.07, 95% CI 0.00 to 1.32; 10 studies, 5147 participants; low-certainty evidence). Antibiotics reduced acute rheumatic fever within two months when compared to the control group (Peto OR 0.36, 95% CI 0.26 to 0.50; 18 studies, 12,249 participants; moderate-certainty evidence). It should be noted that the overall prevalence of acute rheumatic fever was very low, particularly in the later studies. AUTHORS' CONCLUSIONS Antibiotics probably reduce the number of people experiencing sore throat, and reduce the likelihood of headache, and some sore throat complications. As the effect on symptoms can be small, clinicians must judge on an individual basis whether it is clinically justifiable to use antibiotics to produce this effect, and whether the underlying cause of the sore throat is likely to be of bacterial origin. Furthermore, the balance between modest symptom reduction and the potential hazards of antimicrobial resistance must be recognised. Few trials have attempted to measure symptom severity. If antibiotics reduce the severity as well as the duration of symptoms, their benefit will have been underestimated in this meta-analysis. Additionally, more trials are needed in low-income countries, in socio-economically deprived sections of high-income countries, as well as in children.
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Affiliation(s)
| | - Paul P Glasziou
- Institute for Evidence-Based Healthcare, Bond University, Gold Coast, Australia
| | - Chris B Del Mar
- Institute for Evidence-Based Healthcare, Bond University, Gold Coast, Australia
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19
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Ishida T, Hagiya H, Honda H, Nakano Y, Ogawa H, Obika M, Ueda K, Kataoka H, Hanayama Y, Otsuka F. Antimicrobial prescription practices for outpatients with acute respiratory tract infections: A retrospective, multicenter, medical record-based study. PLoS One 2021; 16:e0259633. [PMID: 34767587 PMCID: PMC8589193 DOI: 10.1371/journal.pone.0259633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Accepted: 10/25/2021] [Indexed: 11/19/2022] Open
Abstract
Antimicrobial stewardship for outpatients with acute respiratory tract infections (ARTIs) should be urgently promoted in this era of antimicrobial resistance. Previous large-sample studies were based on administrative data and had limited reliability. We aimed to identify current antimicrobial prescription practices for ARTIs by directly basing on medical records. This multicenter retrospective study was performed from January to December in 2018, at five medical institutes in Japan. We targeted outpatients aged ≥18 years whose medical records revealed International Classification of Diseases (ICD-10) codes suggesting ARTIs. We divided the eligible cases into three age groups (18-64 years, 65-74 years, and ≥75 years). We defined broad-spectrum antimicrobials as third-generation cephalosporins, macrolides, fluoroquinolones, and faropenem. Primary and secondary outcomes were defined as the proportion of antimicrobial prescriptions for the common cold and other respiratory tract infections, respectively. Totally, data of 3,940 patients were collected. Of 2,914 patients with the common cold, 369 (12.7%) were prescribed antimicrobials. Overall, compared to patients aged ≥75 years (8.5%), those aged 18-64 years (16.6%) and those aged 65-74 years (12.1%) were frequently prescribed antimicrobials for the common cold (odds ratio [95% confidential interval]; 2.15 [1.64-2.82] and 1.49 [1.06-2.09], respectively). However, when limited to cases with a valid diagnosis of the common cold by incorporating clinical data, no statistical difference was observed among the age groups. Broad-spectrum antimicrobials accounted for 90.2% of the antimicrobials used for the common cold. Of 1,026 patients with other respiratory infections, 1,018 (99.2%) were bronchitis, of which antimicrobials were prescribed in 49.9% of the cases. Broad-spectrum antimicrobials were the main agents prescribed, accounting for nearly 90% of prescriptions in all age groups. Our data suggested a favorable practice of antimicrobial prescription for outpatients with ARTIs in terms of prescribing proportions, or quantitative aspect. However, the prescriptions were biased towards broad-spectrum antimicrobials, highlighting the need for further antimicrobial stewardship in the outpatient setting from a qualitative perspective.
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Affiliation(s)
- Tomoharu Ishida
- Department of General Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Kitaku, Okayama, Japan
| | - Hideharu Hagiya
- Department of General Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Kitaku, Okayama, Japan
| | - Hiroyuki Honda
- Department of General Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Kitaku, Okayama, Japan
| | - Yasuhiro Nakano
- Department of General Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Kitaku, Okayama, Japan
| | - Hiroko Ogawa
- Department of General Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Kitaku, Okayama, Japan
| | - Mikako Obika
- Department of General Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Kitaku, Okayama, Japan
| | - Keigo Ueda
- Department of General Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Kitaku, Okayama, Japan
| | - Hitomi Kataoka
- Department of General Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Kitaku, Okayama, Japan
| | - Yoshihisa Hanayama
- Department of General Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Kitaku, Okayama, Japan
| | - Fumio Otsuka
- Department of General Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Kitaku, Okayama, Japan
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20
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Andersson M, Pallon J, Cronberg O, Sundqvist M, Hedin K. Seasonal variations in use and outcome of rapid antigen detection tests and cultures in pharyngotonsillitis: a register study in primary care. BMC Infect Dis 2021; 21:1104. [PMID: 34702170 PMCID: PMC8549259 DOI: 10.1186/s12879-021-06774-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Accepted: 09/27/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Diagnosis and treatment of pharyngotonsillitis are commonly focused on group A streptococci (GAS), although the disease is often associated with other pathogens. While the incidence of pharyngotonsillitis is known to vary with season, seasonal variations in the prevalence of potential pathogens are sparsely explored. The aim of this study was to explore any seasonal variations in the use and outcome of rapid antigen detection tests (RADTs) for GAS and throat cultures among patients diagnosed with pharyngotonsillitis in primary care. METHODS We retrieved and combined retrospective data from the electronic medical record system and the laboratory information system in Kronoberg County, Sweden. Primary care visits resulting in a diagnosis of tonsillitis or pharyngitis were included, covering the period 2013-2016. The monthly rate of visits was measured, along with the use and outcome of RADTs for GAS and throat cultures obtained on the date of diagnosis. The variations between calendar months were then analysed. RESULTS We found variations between calendar months, not only in the mean rate of visits resulting in a diagnosis of pharyngotonsillitis (p < 0.001), but in the mean proportion of RADTs being positive for GAS among the diagnosed (p < 0.001), and in the mean proportion of visits associated with a throat culture (p < 0.001). A lower mean rate of visits in August and September coincided with a lower proportion of RADTs being positive for GAS among them, which correlated with a higher proportion of visits associated with a throat culture. CONCLUSIONS This study suggests that the role of GAS in pharyngotonsillitis in Sweden is less prominent in August and September than during the rest of the year.
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Affiliation(s)
- Martin Andersson
- Department of Research and Development, Region Kronoberg, Växjö, Sweden.
| | - Jon Pallon
- Department of Research and Development, Region Kronoberg, Växjö, Sweden
- Department of Clinical Sciences in Malmö, Family Medicine, Lund University, Malmö, Sweden
| | - Olof Cronberg
- Department of Research and Development, Region Kronoberg, Växjö, Sweden
- Department of Clinical Sciences in Malmö, Family Medicine, Lund University, Malmö, Sweden
| | - Martin Sundqvist
- Department of Laboratory Medicine, Clinical Microbiology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Katarina Hedin
- Department of Clinical Sciences in Malmö, Family Medicine, Lund University, Malmö, Sweden
- Futurum, Region Jönköping County, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
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21
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Adriaenssens N, Bruyndonckx R, Versporten A, Hens N, Monnet DL, Molenberghs G, Goossens H, Weist K, Coenen S. Quality appraisal of antibiotic consumption in the community, European Union/European Economic Area, 2009 and 2017. J Antimicrob Chemother 2021; 76:ii60-ii67. [PMID: 34312656 PMCID: PMC8314110 DOI: 10.1093/jac/dkab178] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Objectives The quality of antibiotic consumption in the community can be assessed using 12 drug-specific quality indicators (DSQIs) developed by the European Surveillance of Antimicrobial Consumption (ESAC) project. We compared quality in 2009 and 2017 in the EU/European Economic Area (EEA) and evaluated the impact of using different DDD values (ATC/DDD indices 2011 and 2019) for the 2009 quality assessment using these DSQIs and a joint scientific opinion (JSO) indicator. Methods We calculated the 12 DSQIs and the JSO indicator for 2017 and for 2009 for EU/EEA countries able to deliver values. For each of the indicators we grouped the 2017 and 2009 indicator values into four quartiles. To evaluate changes in quality between 2009 and 2017, we used the quartile distribution of the 2009 indicator values in 30 EU/EEA countries as benchmarks. In addition, we compared the quality assessment for 2009 using the ATC/DDD indices 2011 and 2019. Results In 2017, a difference in the quality of antibiotic consumption in the community between northern and southern EU/EEA countries remained, but also several eastern EU/EEA countries shifted towards lower quality. Quality of antibiotic consumption decreased between 2009 and 2017 in particular indicator values for penicillin, quinolone, relative β-lactam and broad- versus narrow-spectrum antibiotic consumption, and seasonal variation. Using different ATC/DDD indices did not substantially change countries’ ranking based on their DSQI values. Conclusions The quality of antibiotic consumption in the community as measured by the DSQIs further decreased between 2009 and 2017, especially in Southern and Eastern European countries. A continuous effort to improve antibiotic consumption is essential to reduce antibiotic consumption in general and the use of broad-spectrum antibiotics in particular.
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Affiliation(s)
- Niels Adriaenssens
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium.,Centre for General Practice, Department of Family Medicine & Population Health (FAMPOP), University of Antwerp, Antwerp, Belgium
| | - Robin Bruyndonckx
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium.,Interuniversity Institute for Biostatistics and statistical Bioinformatics (I-BIOSTAT), Data Science Institute, Hasselt University, Hasselt, Belgium
| | - Ann Versporten
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium
| | - Niel Hens
- Interuniversity Institute for Biostatistics and statistical Bioinformatics (I-BIOSTAT), Data Science Institute, Hasselt University, Hasselt, Belgium.,Centre for Health Economic Research and Modelling Infectious Diseases, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium
| | - Dominique L Monnet
- Disease Programmes Unit, European Centre for Disease Prevention and Control, Stockholm, Sweden
| | - Geert Molenberghs
- Interuniversity Institute for Biostatistics and statistical Bioinformatics (I-BIOSTAT), Data Science Institute, Hasselt University, Hasselt, Belgium.,Interuniversity Institute for Biostatistics and statistical Bioinformatics (I-BIOSTAT), Catholic University of Leuven, Leuven, Belgium
| | - Herman Goossens
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium
| | - Klaus Weist
- Disease Programmes Unit, European Centre for Disease Prevention and Control, Stockholm, Sweden
| | - Samuel Coenen
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium.,Centre for General Practice, Department of Family Medicine & Population Health (FAMPOP), University of Antwerp, Antwerp, Belgium
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22
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Trinh NTH, Cohen R, Lemaitre M, Chahwakilian P, Coulthard G, Bruckner TA, Milic D, Levy C, Chalumeau M, Cohen JF. Community antibiotic prescribing for children in France from 2015 to 2017: a cross-sectional national study. J Antimicrob Chemother 2021; 75:2344-2352. [PMID: 32449915 DOI: 10.1093/jac/dkaa162] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2020] [Revised: 03/26/2020] [Accepted: 03/27/2020] [Indexed: 01/20/2023] Open
Abstract
OBJECTIVES To assess recent community antibiotic prescribing for French children and identify areas of potential improvement. METHODS We analysed 221 768 paediatric (<15 years) visits in a national sample of 680 French GPs and 70 community paediatricians (IQVIA's EPPM database), from March 2015 to February 2017, excluding well-child visits. We calculated antibiotic prescription rates per 100 visits, separately for GPs and paediatricians. For respiratory tract infections (RTIs), we described broad-spectrum antibiotic use and duration of treatment. We used Poisson regression to identify factors associated with antibiotic prescribing. RESULTS GPs prescribed more antibiotics than paediatricians [prescription rate 26.1 (95% CI 25.9-26.3) versus 21.6 (95% CI 21.0-22.2) per 100 visits, respectively; P < 0.0001]. RTIs accounted for more than 80% of antibiotic prescriptions, with presumed viral RTIs being responsible for 40.8% and 23.6% of all antibiotic prescriptions by GPs and paediatricians, respectively. For RTIs, antibiotic prescription rates per 100 visits were: otitis, 68.1 and 79.8; pharyngitis, 67.3 and 53.3; sinusitis, 67.9 and 77.3; pneumonia, 80.0 and 99.2; bronchitis, 65.2 and 47.3; common cold, 21.7 and 11.6; bronchiolitis 31.6 and 20.1; and other presumed viral RTIs, 24.1 and 11.0, for GPs and paediatricians, respectively. For RTIs, GPs prescribed more broad-spectrum antibiotics [49.8% (95% CI 49.3-50.3) versus 35.6% (95% CI 34.1-37.1), P < 0.0001] and antibiotic courses of similar duration (P = 0.21). After adjustment for diagnosis, antibiotic prescription rates were not associated with season and patient age, but were significantly higher among GPs aged ≥50 years. CONCLUSIONS Future antibiotic stewardship campaigns should target presumed viral RTIs, broad-spectrum antibiotic use and GPs aged ≥50 years.
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Affiliation(s)
- Nhung T H Trinh
- Université de Paris, Epidemiology and Statistics Research Center - CRESS, INSERM, Obstetrical, Perinatal and Pediatric Epidemiology research team, F-75004 Paris, France.,IQVIA, La Défense, France
| | - Robert Cohen
- Association Clinique et Thérapeutique Infantile du Val-de-Marne (ACTIV), Saint-Maur-des-Fossés, France.,Université Paris Est, IMRB-GRC GEMINI, Créteil, France
| | | | | | | | - Tim A Bruckner
- Program in Public Health, University of California, Irvine, CA, USA
| | | | - Corinne Levy
- Association Clinique et Thérapeutique Infantile du Val-de-Marne (ACTIV), Saint-Maur-des-Fossés, France.,Clinical Research Centre, Centre Hospitalier Intercommunal de Créteil, Créteil, France
| | - Martin Chalumeau
- Université de Paris, Epidemiology and Statistics Research Center - CRESS, INSERM, Obstetrical, Perinatal and Pediatric Epidemiology research team, F-75004 Paris, France.,Department of General Pediatrics and Pediatric Infectious Diseases, AP-HP, Hôpital Necker - Enfants malades, Université de Paris, Paris, France
| | - Jérémie F Cohen
- Université de Paris, Epidemiology and Statistics Research Center - CRESS, INSERM, Obstetrical, Perinatal and Pediatric Epidemiology research team, F-75004 Paris, France.,Department of General Pediatrics and Pediatric Infectious Diseases, AP-HP, Hôpital Necker - Enfants malades, Université de Paris, Paris, France
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23
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Haugom LEA, Ruths S, Emberland KE, Eliassen KER, Rortveit G, Wensaas KA. Consultations and antibiotic treatment for urinary tract infections in Norwegian primary care 2006-2015, a registry-based study. BMC FAMILY PRACTICE 2021; 22:127. [PMID: 34167484 PMCID: PMC8229743 DOI: 10.1186/s12875-021-01470-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 05/21/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Extensive use of antibiotics and the resulting emergence of antimicrobial resistance is a major health concern globally. In Norway, 82% of antibiotics is prescribed in primary care and one in four prescriptions are issued for the treatment of urinary tract infections (UTI). The aim of this study was to investigate time trends in antibiotic treatment following a consultation for UTI in primary care. METHODS For the period 2006-2015 we linked data from the Norwegian Registry for Control and Payment of Health Reimbursements on all patient consultations for cystitis and pyelonephritis in general practice and out-of-hours (OOH) services, and data from the Norwegian Prescription Database on all dispensed prescriptions of antibiotics. RESULTS Altogether 2,426,643 consultations by attendance for UTI took place in the study period, of these 94.5% for cystitis and 5.5% for pyelonephritis. Of all UTI consultations, 79.4% were conducted in general practice and 20.6% in OOH services. From 2006 to 2015, annual numbers of cystitis and pyelonephritis consultations increased by 33.9 and 14.0%, respectively. The proportion of UTI consultations resulting in an antibiotic prescription increased from 36.6 to 65.7% for cystitis, and from 35.3 to 50.7% for pyelonephritis. These observed changes occurred gradually over the years. Cystitis was mainly treated with pivmecillinam (53.9%), followed by trimethoprim (20.8%). For pyelonephritis, pivmecillinam was most frequently used (43.0%), followed by ciprofloxacin (20.5%) and sulfamethoxazole-trimethoprim (16.3%). For cystitis, the use of pivmecillinam increased the most during the study period (from 46.1 to 56.6%), and for pyelonephritis, the use of sulfamethoxazole-trimethoprim (from 11.4 to 25.5%) followed by ciprofloxacin (from 18.2 to 23.1%). CONCLUSIONS During the 10-year study period there was a considerable increase in the proportion of UTI consultations resulting in antibiotic treatment. Cystitis was most often treated with pivmecillinam, and this proportion increased during the study period. Treatment of pyelonephritis was characterized by more use of broader-spectrum antibiotics, use of both sulfamethoxazole-trimethoprim and ciprofloxacin increased during the study period. These trends, indicative of enduring changes in consultation and treatment patterns for UTIs, will have implications for future antibiotic stewardship measures and policy.
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Affiliation(s)
- Lars Emil Aga Haugom
- Research Unit for General Practice, NORCE Norwegian Research Centre, Postboks 22 Nygårdstangen, 5838, Bergen, Norway.
| | - Sabine Ruths
- Research Unit for General Practice, NORCE Norwegian Research Centre, Postboks 22 Nygårdstangen, 5838, Bergen, Norway
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Knut Erik Emberland
- Research Unit for General Practice, NORCE Norwegian Research Centre, Postboks 22 Nygårdstangen, 5838, Bergen, Norway
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | | | - Guri Rortveit
- Research Unit for General Practice, NORCE Norwegian Research Centre, Postboks 22 Nygårdstangen, 5838, Bergen, Norway
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Knut-Arne Wensaas
- Research Unit for General Practice, NORCE Norwegian Research Centre, Postboks 22 Nygårdstangen, 5838, Bergen, Norway
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24
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Beaurain C, Thibon P, Fiaux E, Piednoir E, Magnani C, Caron F, Verdon R. General practitioners' clinical practice on the management of cystitis in Normandy, France: A clinical vignettes-based study. J Eval Clin Pract 2021; 27:421-428. [PMID: 32929837 DOI: 10.1111/jep.13464] [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] [Received: 02/10/2020] [Revised: 07/23/2020] [Accepted: 07/24/2020] [Indexed: 11/29/2022]
Abstract
RATIONALE, AIMS, AND OBJECTIVES The objective was to measure the quality of clinical practice for the management of cystitis in adult women in general practice by collaborating with quality circles and the regional centre for antibiotic counsel. METHOD This descriptive cross-sectional study was performed in 2018 in Normandy, France. A questionnaire composed of clinical vignettes was used to evaluate practices of general practitioners (GPs) with regard to cystitis classified into four categories: simple, at risk of complication, recurrent, and caused by multidrug-resistant bacteria. The 2017 French Infectious Diseases Society's guidelines were used as a reference. RESULTS A total of 142 GPs participated in the study (45.5% of the solicited). Fosfomycin-trometamol and pivmecillinam were cited as first-line treatments for simple cystitis by 134 (94%) and 38 (27%) participants, respectively. For at risk of complication cystitis, the treatments cited were cefixime by 64 participants (45%), ofloxacin by 50 (35%), pivmecillinam by 49 (35%), fosfomycin-trometamol by 38 (27%), nitrofurantoin by 36 (25%), and amoxicillin-clavulanic acid by 28 (20%). Mean compliance rates were 85% for simple cystitis, 39% for at risk of complication cystitis, 60% for recurrent cystitis and 14% for cystitis caused by multidrug-resistant bacteria. Two criteria had less than 10% of the compliant answers: comprehensive knowledge of cystitis complication risk factors (9%) and positivity thresholds of urine cultures (10%). CONCLUSIONS In this study, diagnostic means, follow-up testing, and simple cystitis treatment (with fosfomycin predominantly mentioned) were broadly compliant. The use of critical antibiotics was too frequent for at risk of complication cystitis. There may be a need to improve the knowledge of professionals on antibiotic resistance and appropriate antibiotic use.
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Affiliation(s)
- Claire Beaurain
- Centre Régional de Conseil en Antibiothérapie NormAntibio, Caen-Rouen, France.,Université de Caen Normandie, Medical school, Caen, France
| | - Pascal Thibon
- Centre Régional de Conseil en Antibiothérapie NormAntibio, Caen-Rouen, France
| | - Elise Fiaux
- Centre Régional de Conseil en Antibiothérapie NormAntibio, Caen-Rouen, France
| | - Emmanuel Piednoir
- Centre Régional de Conseil en Antibiothérapie NormAntibio, Caen-Rouen, France
| | - Claude Magnani
- Union Régionale des Médecins Libéraux de Normandie, Caen, France
| | - François Caron
- Université de Rouen Normandie, Medical school, Rouen, France.,CHU de Rouen, Service Maladies infectieuses et tropicales, Rouen, France.,Groupe de Recherche sur l'Adaptation Microbienne (GRAM 2.0) Université de Normandie, UNIROUEN, UNICAEN, GRAM 2.0, Rouen, France
| | - Renaud Verdon
- Université de Caen Normandie, Medical school, Caen, France.,CHU de Caen, Service Maladies infectieuses et tropicales, Caen, France.,Groupe de Recherche sur l'Adaptation Microbienne (GRAM 2.0) Université de Normandie, UNICAEN, UNIROUEN, GRAM 2.0, Caen, France
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van Aerde KJ, de Haan L, van Leur M, Gerrits GP, Schers H, Moll HA, Hagedoorn NN, Herberg JA, Levin M, Rivero-Calle I, de Jonge MI, de Groot R, van der Flier M. Respiratory Tract Infection Management and Antibiotic Prescription in Children: A Unique Study Comparing Three Levels of Healthcare in The Netherlands. Pediatr Infect Dis J 2021; 40:e100-e105. [PMID: 33395212 DOI: 10.1097/inf.0000000000003019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Respiratory tract infections (RTIs) are common in children with febrile illness visiting the general practitioner (GP) or emergency department. We studied the management of children with fever and RTI at 3 different levels of healthcare in The Netherlands, focusing on antibiotic prescription. METHODS This prospective observational study is part of the Management and Outcome of Febrile children in Europe study. Data were used from face-to-face patient contacts of children with febrile illness in three healthcare settings in Nijmegen, The Netherlands during 2017. These settings were primary (GP), secondary (general hospital) and tertiary care (university hospital). RESULTS Of 892 cases with RTI without complex comorbidities, overall antibiotic prescription rates were 29% with no differences between the 3 levels of healthcare, leading to an absolute number of 5031 prescriptions per 100,000 children per year in primary care compared with 146 in secondary and tertiary care combined. The prescription rate in otitis media was similar in all levels: 60%. In cases with lower RTI who received nebulizations prescription rates varied between 19% and 55%. CONCLUSIONS Antibiotic prescription rates for RTIs in children were comparable between the 3 levels of healthcare, thus leading to a majority of antibiotics being prescribed in primary care. Relatively high prescription rates for all foci of RTIs were found, which was not in agreement with the national guidelines. Antibiotic stewardship needs improvement at all 3 levels of healthcare. Guidelines to prescribe small spectrum antibiotics for RTIs need to be better implemented in hospital care settings.
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Affiliation(s)
- Koen J van Aerde
- From the Pediatric Infectious Diseases and Immunology, Amalia Children's Hospital
- Section Pediatric Infectious Diseases, Laboratory of Medical Immunology, Department of Laboratory Medicine, Radboud Institute for Molecular Life Sciences
- Radboud Center for Infectious Diseases, Radboud University Medical Center
| | - Liza de Haan
- Department of Pediatrics, Canisius Wilhelmina Hospital
| | | | | | - Henk Schers
- Department of Primary and Community Care, Radboud Institute for Health Sciences, Radboud University Medical Center, FaME-Net, Nijmegen
| | - Henriette A Moll
- Department of General Pediatrics, Erasmus Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Nienke N Hagedoorn
- Department of General Pediatrics, Erasmus Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Jethro A Herberg
- Section of Pediatrics, Imperial College
- Pediatric Emergency Department, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Michael Levin
- Section of Pediatrics, Imperial College
- Pediatric Emergency Department, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Irene Rivero-Calle
- Genetics, Vaccines, Infections and Pediatrics Research group (GENVIP), Hospital Clinico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | - Marien I de Jonge
- Section Pediatric Infectious Diseases, Laboratory of Medical Immunology, Department of Laboratory Medicine, Radboud Institute for Molecular Life Sciences
- Radboud Center for Infectious Diseases, Radboud University Medical Center
| | - Ronald de Groot
- Section Pediatric Infectious Diseases, Laboratory of Medical Immunology, Department of Laboratory Medicine, Radboud Institute for Molecular Life Sciences
- Radboud Center for Infectious Diseases, Radboud University Medical Center
| | - Michiel van der Flier
- Section Pediatric Infectious Diseases, Laboratory of Medical Immunology, Department of Laboratory Medicine, Radboud Institute for Molecular Life Sciences
- Genetics, Vaccines, Infections and Pediatrics Research group (GENVIP), Hospital Clinico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
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Tapiala J, Hyvärinen A, Toppila-Salmi S, Suihko E, Penttilä E. Nasal saline irrigation: prescribing habits and attitudes of physicians and pharmacists. Scand J Prim Health Care 2021; 39:35-43. [PMID: 33569979 PMCID: PMC7971247 DOI: 10.1080/02813432.2021.1880123] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/30/2022] Open
Abstract
OBJECTIVES To explore the opinions, the usage and the patient education given on nasal saline irrigation by physicians and pharmaceutical personnel working in Finland. DESIGN An internet-based survey with predetermined, multiple-choice answers. SETTING Primary care centres, occupational health centres and private care centres in Eastern Finland as well as pharmacies in Finland. MAIN OUTCOME MEASURES Healthcare professionals views, practice and general knowledge of nasal irrigation for sinonasal symptoms and conditions. RESULTS We received 595 completed surveys (110 physicians, 485 pharmacists). The majority of the respondents recommended nasal saline irrigation for their patients either as a symptomatic treatment (98.0%) or to treat a specific condition (97.5%) such as acute rhinosinusitis, chronic rhinosinusitis and allergic rhinitis. Nasal saline irrigation was also often recommended as a prophylaxis for airway-infections (71.9%) and to enhance the health of the nasal mucosa (58.2%). In general, the possible adverse effects were recognised poorly by both professions. There was a clear difference between the two professions, as physicians were more conservative in recommending nasal saline irrigation and recognised possible adverse effects, such as epistaxis, pain, and dryness of the nose, better (75% vs. 59%, p = 0.002). CONCLUSIONS Nasal saline irrigation seems to be a popular treatment recommended by many health care professionals in Finland. Physicians and pharmaceutical personnel had variable opinions on the indications, utility and risks of nasal saline irrigation. There are also clear differences between physicians and pharmaceutical personnel's practices. There is a need to better educate professionals about nasal saline irrigation and to further study whether nasal saline irrigation is efficient and safe option for the different common sinonasal conditions.KEY POINTSLittle information is available on how physicians and pharmacists recommend nasal saline irrigation as a symptomatic treatment.Physicians and pharmacists seem to have variable opinions about the indications, utility and safety of nasal saline irrigation.The patient education given is in general very heterogenous.Both professions require more education to ensure that the usage remains as safe as possible for the patient.
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Affiliation(s)
- Jesse Tapiala
- Department of Otorhinolaryngology – Head and Neck Surgery, Kuopio University Hospital and University of Eastern Finland, Kuopio, Finland
- CONTACT Jesse Tapiala Department of Otorhinolaryngology, Kuopio University Hospital, P.O. Box 1777, Kuopio, FI-70211, Finland
| | - Antti Hyvärinen
- Department of Otorhinolaryngology – Head and Neck Surgery, Kuopio University Hospital, Kuopio, Finland
| | - Sanna Toppila-Salmi
- Skin and Allergy Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Eero Suihko
- Joensuun Uusi Apteekki and University of Eastern, Joensuu, Finland
| | - Elina Penttilä
- Department of Otorhinolaryngology – Head and Neck Surgery, Kuopio University Hospital and University of Eastern Finland, Kuopio, Finland
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Gong Y, Li H, Yang H, Tan K, Liu W, Li X, Wu J, Zhang G, Yin X. Evaluation of the Quality of Antibiotic Prescribing in Primary Care: A Multicenter Longitudinal Study From Shenzhen, China. Front Pharmacol 2021; 11:617260. [PMID: 33679389 PMCID: PMC7933578 DOI: 10.3389/fphar.2020.617260] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 11/30/2020] [Indexed: 12/27/2022] Open
Abstract
Background: Currently, there is no comprehensive evaluation of the quality of antibiotic prescribing in China's primary care facilities based on longitudinal data. Methods: We randomly selected 11 community health centers in Shenzhen, China, and collected all outpatient prescriptions of these centers from 2010 to 2015. To evaluate the quality of antibiotic prescribing, we used six quality indicators for analysis, including number of antibiotics per 100 consultations, ratio between broad-spectrum and narrow-spectrum antibiotics (B/N ratio), percentage of first-line antibiotics recommended by guidelines, percentage of oral antibiotics with a duration exceeding the guideline recommendation, and new pediatric-specific indicators such as percentage of antibiotics with amoxicillin (A index) and ratio between amoxicillin and broad-spectrum antibiotics (A/B ratio). Results: During the study period, 571,362 outpatient consultations resulted in antibiotic prescriptions, which contained 706,411 antibiotics. The overall number of antibiotics per 100 consultations decreased significantly from 93.50 in 2010 to 19.98 in 2015 (p = 0.004), but the B/N ratio showed an upward trend over time (p = 0.009). In different populations and different common infections, the number of antibiotics used decreased to varying degrees, while the B/N ratio increased to varying degrees, with the most obvious change in children <5 years. The percentage of first-line antibiotics for common infections was not high, ranging from 3.45 to 44.25% during 2014-2015. The percentage of oral antibiotics with an exceeded duration ranged from 0.70 to 19.39%. Moreover, the A index and A/B ratio in children remained low for a long time, which was 0.76% and 0.01 in 2015. Conclusion: A review of antibiotic prescribing in Shenzhen, China, showed a substantial reduction in antibiotic use in primary care. However, problems such as widespread use of broad-spectrum antibiotics, insufficient use of first-line antibiotics and low use of amoxicillin were prevalent. Improving and optimizing the quality of antibiotic prescribing, particularly in children prescriptions, will be the focus of future antibiotic stewardship in China.
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Affiliation(s)
- Yanhong Gong
- Department of Social Medicine and Health Management, School of Public Health, Huazhong University of Science and Technology, Wuhan, China
| | - Hui Li
- Department of Social Medicine and Health Management, School of Public Health, Huazhong University of Science and Technology, Wuhan, China
| | - Heping Yang
- School of Nursing, Wuchang University of Technology, Wuhan, China
| | - Kun Tan
- Department of Infection Control, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Wei Liu
- Department of Public Health, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiaotong Li
- Department of Social Medicine and Health Management, School of Public Health, Huazhong University of Science and Technology, Wuhan, China
| | - Jianxiong Wu
- Department of Social Medicine and Health Management, School of Public Health, Huazhong University of Science and Technology, Wuhan, China
| | - Guopeng Zhang
- Department of Nuclear Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiaoxv Yin
- Department of Social Medicine and Health Management, School of Public Health, Huazhong University of Science and Technology, Wuhan, China
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Hendi SB, Malik ZA, Khamis AH, Al-Najjar FYA. High diagnostic accuracy of automated rapid Strep A test reduces antibiotic prescriptions for children in the United Arab Emirates. BMC Pediatr 2021; 21:52. [PMID: 33494718 PMCID: PMC7831179 DOI: 10.1186/s12887-021-02516-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 01/20/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Diagnosis of Group A Streptococcus (GAS) pharyngitis in children is hindered by variable sensitivity of clinical criteria and rapid Strep A tests (SAT), resulting in reliance on throat cultures as the gold standard for diagnosis. Delays while awaiting culture reports result in unnecessary antibiotic prescriptions among children, contributing to the spread of antimicrobial resistance (AMR). METHODS Diagnostic accuracy study of an automated SAT (A-SAT) in children up to 16 years of age presenting to an emergency room with signs and symptoms of pharyngitis between March and June 2019. Paired throat swabs for A-SAT and culture were collected. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for A-SAT were calculated. RESULTS Two hundred and ninety-one children were included in this study. 168 (57.7%) were boys and the mean age was 4.2 years. A-SAT was positive in 94 (32.3%) and throat culture was positive in 90 (30.9%) children. A-SAT and throat culture results showed a high level of consistency in our cohort. Only 6 (2%) children had inconsistent results, demonstrating that the A-SAT has a high sensitivity (98.9%), specificity (97.5%), PPV (94.7%) and NPV (99.5%) for the diagnosis of GAS pharyngitis in children. Only 92 (32%) children were prescribed antibiotics while the vast majority (68%) were not. CONCLUSIONS A-SAT is a quick and reliable test with diagnostic accuracy comparable to throat culture. Its widespread clinical use can help limit antibiotic prescriptions to children presenting with pharyngitis, thus limiting the spread of AMR.
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Affiliation(s)
- Salama Bin Hendi
- College of Medicine, Mohamed Bin Rashid University of Medicine and Health Sciences, Dubai Healthcare City, Building 14, Dubai, 505005, United Arab Emirates
| | - Zainab A Malik
- College of Medicine, Mohamed Bin Rashid University of Medicine and Health Sciences, Dubai Healthcare City, Building 14, Dubai, 505005, United Arab Emirates.
- Department of Pediatrics, Mediclinic City Hospital. Dubai Healthcare City, Building 37, Dubai, 505004, United Arab Emirates.
- Pediatric Infectious Diseases, Mediclinic City Hospital. Dubai Healthcare City, Building 37, Dubai, 505004, United Arab Emirates.
| | - Amar Hassan Khamis
- College of Medicine, Mohamed Bin Rashid University of Medicine and Health Sciences, Dubai Healthcare City, Building 14, Dubai, 505005, United Arab Emirates
- Department of Biostatistics, Mohamed Bin Rashid University of Medicine and Health Sciences. Dubai Healthcare City, Building 14, Dubai, 505005, United Arab Emirates
| | - Fadil Y A Al-Najjar
- College of Medicine, Mohamed Bin Rashid University of Medicine and Health Sciences, Dubai Healthcare City, Building 14, Dubai, 505005, United Arab Emirates
- Department of Pediatrics, Mediclinic City Hospital. Dubai Healthcare City, Building 37, Dubai, 505004, United Arab Emirates
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29
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Meskina ER, Stashko TV. [How to reduce the antibacterial load in the treatment of acute tonsillitis and pharyngitis? Possible tactics and practical approaches]. Vestn Otorinolaringol 2021; 85:90-99. [PMID: 33474925 DOI: 10.17116/otorino20208506190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Acute tonsillopharyngitis is one of the most frequent reasons for visiting a doctor and prescribing inappropriate antibiotic therapy (ABT). There are several reasons for this - from the difficulties of etiological diagnosis and the development of relapses and possible severe complications to the personal attitude of doctors and patients to the choice of treatment. At the same time, the issue of antibiotic resistance and other aspects associated with the prescription of ABT is one of the most important problems of modern healthcare worldwide. The purpose of this review is to demonstrate the best practical approaches to the choice of treatment tactics for acute tonsillitis (AT) in the treatment of children and adults, with an emphasis on reducing the load of ABT. The review examines the indications and disadvantages of clinical and laboratory diagnosis of AT. There are no highly sensitive clinical and laboratory instruments that differentiate viral and bacterial AT. Exudativeis AT in children is not an underlying symptom of streptococcal etiology. Despite the limitations, the modified Centor/McIsaac score ≥3 (taking into account age and the presence of respiratory symptoms) should be used as an indication for ABT in conjunction with a rapid streptotest and subsequent bacteriological culture for S. pyogenes if the screening test is negative. Additional examinations (determination of leukocytosis, CRP and procalcitonin test) are not required for most patients. ABT should not be given to low-risk patients for the treatment and prevention of rheumatic fever and acute glomerulonephritis. Prevention of purulent complications (paratonsillitis and retropharyngeal abscess, acute otitis media, cervical lymphadenitis, mastoiditis, or acute sinusitis) is not a specific indication for ABT in AT and is not required in most patients. The strategy of «delayed antibiotic prescriptions» with monitoring the patient's condition for 2-3 days is appropriate and highly effective in doubtful cases. The drugs of choice for treatment of AT are amoxicillin and oral forms of I and II generation cephalosporins. Macrolides are not indicated as first-line treatment for AT. The course of ABT for streptococcal AT is 10 days, which reduces the risk of recurrent episode. Topical drugs can be the only means of etiopathogenetic treatment with viral AT, or additional for bacterial AT. Their use not only relieves sore throat, but also shortens the duration of the disease, and also improves the patients prognosis. Benzalkonium chloride + tyrothricin + benzocaine (Dorithyrcin) may be a rational drug of choice for topical therapy due to the available clinical evidence. There is a significant reserve for reducing the load of ABT during AT. Further clinical trials are needed to assess the efficacy of short courses of ABT in the treatment of AT in high-income countries and provide a basis for strong recommendations for topical drug use. This can reduce the frequency of ABT prescribing and increase the level of interaction between specialists and patients.
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Affiliation(s)
- E R Meskina
- Moscow Regional Research and Clinical Institute (MONIKI), Moskow, Russia
| | - T V Stashko
- Moscow Regional Research and Clinical Institute (MONIKI), Moskow, Russia
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30
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Blaser MJ, Melby MK, Lock M, Nichter M. Accounting for variation in and overuse of antibiotics among humans. Bioessays 2021; 43:e2000163. [PMID: 33410142 DOI: 10.1002/bies.202000163] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Revised: 10/04/2020] [Accepted: 10/06/2020] [Indexed: 01/10/2023]
Abstract
Worldwide, antibiotic use is increasing, but many infections against which antibiotics are applied are not even caused by bacteria. Over-the-counter and internet sales preclude physician oversight. Regional differences, between and within countries highlight many potential factors influencing antibiotic use. Taking a systems perspective that considers pharmaceutical commodity chains, we examine antibiotic overuse from the vantage point of both sides of the therapeutic relationship. We examine patterns and expectations of practitioners and patients, institutional policies and pressures, the business strategies of pharmaceutical companies and distributors, and cultural drivers of variation. Solutions to improve antibiotic stewardship include practitioners taking greater responsibility for their antibiotic prescribing, increasing the role of caregivers as diagnosticians rather than medicine providers, improving their communication to patients about antibiotic treatment consequences, lessening the economic influences on prescribing, and identifying antibiotic alternatives.
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Affiliation(s)
- Martin J Blaser
- Center for Advanced Biotechnology and Medicine, Rutgers University, Piscataway, New Jersey, USA
| | - Melissa K Melby
- Department of Anthropology, University of Delaware, Newark, Delaware, USA
| | - Margaret Lock
- Department of Social Studies of Medicine and Department of Anthropology, McGill University, Montreal, Quebec, Canada
| | - Mark Nichter
- School of Anthropology, Mel and Enid Zuckerman College of Public Health, Department of Family Medicine, University of Arizona, Tucson, Arizona, USA
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Applicability of Outpatient Quality Indicators for Appropriate Antibiotic Use in a Primary Health Care Area: a Point Prevalence Survey. Antimicrob Agents Chemother 2020; 64:AAC.01266-20. [PMID: 32839215 DOI: 10.1128/aac.01266-20] [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: 06/18/2020] [Accepted: 08/11/2020] [Indexed: 11/20/2022] Open
Abstract
The ability to measure the quality of antibiotic prescriptions is a critical element in all antimicrobial stewardship programs. The aims of the present study were to evaluate the clinimetric properties of 32 recently developed outpatient quality indicators (OQIs) and to identify potential room for improvement in antibiotic use in a primary health care (PHC) area. The study was performed in a PHC area in Barcelona, Spain with 260,657 inhabitants, nine PHC centers, and a 400-bed acute-care teaching hospital. We selected 9 of the 32 OQIs that were applicable to our PHC area and evaluated them for measurability, adherence, and room for improvement. Nonmeasurable OQIs, OQIs without room for improvement, and OQIs beyond the scope of the PHC antimicrobial stewardship program were excluded. Data from 260,561 registered patients were assessed. Measurability was high for all OQIs except those that required manual recording of the clinical diagnosis (OQIs on group A streptococcal diagnostic testing). Adherence to guidelines was poor for most OQIs, but particularly for the indicator on the avoidance of antibiotics for viral or self-limiting bacterial infections, where we observed more than 60% room for improvement for both acute tonsillitis and sinusitis. The QIs evaluated were applicable to clinical practice and proved useful for identifying areas with room for improvement in our setting and for guiding the design of future interventions with specific objectives.
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Structural Antibiotic Surveillance and Stewardship via Indication-Linked Quality Indicators: Pilot in Dutch Primary Care. Antibiotics (Basel) 2020; 9:antibiotics9100670. [PMID: 33023009 PMCID: PMC7601107 DOI: 10.3390/antibiotics9100670] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 09/25/2020] [Accepted: 10/02/2020] [Indexed: 01/21/2023] Open
Abstract
Insight into antibiotic prescribing quality is key to general practitioners (GPs) to improve their prescribing behavior and to national antibiotic surveillance and stewardship programs. Additionally to numbers of prescribed antibiotics, quality indicators (QIs) linked to the clinical indication for prescribing are urgently needed. The aim of this proof of concept study was to define indication-linked QIs which can be easily implemented in Dutch primary care by collaborating with data-extraction/processing companies that routinely process patient data for GP practices. An expert group of academic and practicing GPs defined indication-linked QIs for which outcomes can be derived from routine care data. QI outcomes were calculated and fed back to GPs from 44 practices, associations between QI outcomes were determined, and GPs’ opinions and suggestions with respect to the new set were captured using an online questionnaire. The new set comprises: (1) total number of prescribed antibiotics per 1000 registered patients and percentages of generally non-1st choice antibiotics; (2) prescribing percentages for episodes of upper and lower respiratory tract infection; (3) 1st choice prescribing for episodes of tonsillitis, pneumonia and cystitis in women. Large inter-practice variation in QI outcomes was found. The validity of the QI outcomes was confirmed by associations that were expected. The new set was highly appreciated by GPs and additional QIs were suggested. We conclude that it proved feasible to provide GPs with informative, indication-linked feedback of their antibiotic prescribing quality by collaborating with established data extraction/processing companies. Based on GPs’ suggestions the set will be refined and extended and used in the near future as yearly feedback with benchmarking for GPs and for national surveillance and stewardship purposes.
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Lampi E, Carlsson F, Sundvall PD, Torres MJ, Ulleryd P, Åhrén C, Jacobsson G. Interventions for prudent antibiotic use in primary healthcare: an econometric analysis. BMC Health Serv Res 2020; 20:895. [PMID: 32967662 PMCID: PMC7510320 DOI: 10.1186/s12913-020-05732-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 09/11/2020] [Indexed: 01/21/2023] Open
Abstract
Background Rational antibiotic prescribing is crucial to combat antibiotic resistance. Optimal strategies to improve antibiotic use are not known. Strama, the Swedish strategic program against antibiotic resistance, has been successful in reducing antibiotic prescription rates. This study investigates whether two specific interventions directed toward healthcare centers, an informational visit and a self-evaluation meeting, played a role in observed reduction in rates of antibiotic prescriptions in primary healthcare. Methods The study was a retrospective, observational, empirical analysis exploiting the variation in the timing of the interventions and considering past prescriptions through use of estimations from dynamic panel data models. Primary healthcare data from 2011 to 2014 were examined. Data were from public and private primary healthcare centers in western Sweden. The key variables were prescription of antibiotics and indicator variables for the two interventions. Results The first intervention, an educational information intervention, decreased the number of prescriptions among public healthcare centers, but this effect was only temporary. We found no proof that the second intervention, a self-evaluation meeting at the healthcare center, had an impact on the reduction of prescriptions. Conclusions Single educational interventions aimed at influencing rates of antibiotic prescriptions have limited impact. A multifaceted approach is needed in efforts to reduce the use of antibiotics in primary health care.
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Affiliation(s)
- Elina Lampi
- Department of Economics, University of Gothenburg, Vasagatan 1, SE-411 24, Gothenburg, Sweden.,Center for Antibiotic Resistance Research (CARe), University of Gothenburg, Guldhedsgatan 10, 405 30, Gothenburg, SE, Sweden
| | - Fredrik Carlsson
- Department of Economics, University of Gothenburg, Vasagatan 1, SE-411 24, Gothenburg, Sweden.,Center for Antibiotic Resistance Research (CARe), University of Gothenburg, Guldhedsgatan 10, 405 30, Gothenburg, SE, Sweden
| | - Pär-Daniel Sundvall
- Region Västra Götaland, Research and Development Primary Health Care, Research and Development Centre Södra Älvsborg, Sven Eriksonsplatsen 4, SE-503 38, Borås, Sweden.,Department of Public Health and Community Medicine/Primary Health Care, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Box 454, SE-405 30, Gothenburg, Sweden
| | - Marcela Jaime Torres
- School of Management and Business, Research Nucleus on Environmental and Natural Resource Economics (NENRE), Universidad de Concepción, Victoria 471, Barrio Universitario, Concepción, Chile
| | - Peter Ulleryd
- Department of Communicable Disease Control and Prevention, Region Västra Götaland, Kaserntorget 11B, SE-411 18, Gothenburg, Sweden.,Swedish Strategic Program against Antimicrobial Resistance (Strama), Region Västra Götaland, Bergslagsgatan 2, SE-411 04, Gothenburg, Sweden
| | - Christina Åhrén
- Center for Antibiotic Resistance Research (CARe), University of Gothenburg, Guldhedsgatan 10, 405 30, Gothenburg, SE, Sweden.,Swedish Strategic Program against Antimicrobial Resistance (Strama), Region Västra Götaland, Bergslagsgatan 2, SE-411 04, Gothenburg, Sweden.,Department of Infectious Diseases, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Medicinaregatan 9 A-B, SE-413 90, Gothenburg, Sweden
| | - Gunnar Jacobsson
- Center for Antibiotic Resistance Research (CARe), University of Gothenburg, Guldhedsgatan 10, 405 30, Gothenburg, SE, Sweden. .,Swedish Strategic Program against Antimicrobial Resistance (Strama), Region Västra Götaland, Bergslagsgatan 2, SE-411 04, Gothenburg, Sweden. .,Department of Infectious Diseases, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Medicinaregatan 9 A-B, SE-413 90, Gothenburg, Sweden. .,Department of Infectious Diseases, Skaraborg Hospital, Lövängsvägen, SE-541 42, Skövde, Sweden.
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Gunnarsson R, Ebell MH, Wächtler H, Manchal N, Reid L, Malmberg S, Hawkey S, Hay AD, Hedin K, Sundvall PD. Association between guidelines and medical practitioners' perception of best management for patients attending with an apparently uncomplicated acute sore throat: a cross-sectional survey in five countries. BMJ Open 2020; 10:e037884. [PMID: 32948565 PMCID: PMC7500311 DOI: 10.1136/bmjopen-2020-037884] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE To investigate the relationship between guidelines and the medical practitioners' perception of optimal care for patients attending with an apparently uncomplicated acute sore throat in five countries (Australia, Germany, Sweden, UK and USA). DESIGN International cross-sectional survey. SETTING Primary healthcare (PHC). PARTICIPANTS Medical practitioners working in PHC. MAIN OUTCOME MEASURES ORs for: (A) perception of throat swabs as important, (B) perception of blood tests (C reactive protein, B-ESR and B-leucocytes) as important and (C) antibiotic prescriptions if no pathogenic bacteria isolated on throat swab. RESULTS Guidelines differed significantly; those recommending throat swabs (Sweden and USA) were associated with practitioners perceiving them as important. The UK guideline was the only one actively discouraging the use of throat swabs. Hence, compared with the USA (reference), a throat swab showing no pathogenic bacteria increased the probability of antibiotic prescribing in the UK with OR 3.2 (95% CI 1.7 to 6.1) for adults, whereas it reduced the probability in Sweden for adults OR 0.35 (95% CI 0.13 to 0.96) and children 0.19 (95% CI 0.069 to 0.50). CONCLUSIONS The differences between practitioners' perceptions of best management were associated with their guidelines. It remains unclear if guidelines influenced medical practitioners' perception or if guidelines merely reflect the consensus of current practice. A larger effort should be made to reach an international consensus in high-income countries about the best management of patients attending for an uncomplicated acute sore throat.
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Affiliation(s)
- Ronny Gunnarsson
- General Practice / Family Medicine, School of Public Health and Community Medicine, Institute of Medicine at University of Gothenburg, Gothenburg, Sweden
- Research, Development, Education and Innovation, Primary Health Care, Region Västra Götaland, Gothenburg, Sweden
- Centre for Antibiotic Resistance Research (CARe), University of Gothenburg, Gothenburg, Sweden
| | - Mark H Ebell
- Department of Epidemiology and Biostatistics, University of Georgia, Athens, Georgia, USA
| | - Hannelore Wächtler
- Faculty of Medicine, Institute for General Practice, Christian-Albrechts-Universität zu Kiel, Kiel, Germany
| | - Naveen Manchal
- Cairns Clinical School, James Cook University College of Medicine and Dentistry, Cairns, Queensland, Australia
| | - Lynne Reid
- Cairns Clinical School, James Cook University College of Medicine and Dentistry, Cairns, Queensland, Australia
| | - Stefan Malmberg
- General Practice / Family Medicine, School of Public Health and Community Medicine, Institute of Medicine at University of Gothenburg, Gothenburg, Sweden
| | - Sean Hawkey
- Centre for Academic Primary Care, NIHR School for Primary Care Research, Population Health Sciences, University of Bristol Medical School, Bristol, UK
| | - Alastair D Hay
- Centre for Academic Primary Care, University of Bristol, Bristol, UK
| | - Katarina Hedin
- Linköpings universitet Institutionen för medicin och hälsa, Linkoping, Sweden
- Futurum Academy of Health and Care, Jonkoping, Sweden
| | - Pär-Daniel Sundvall
- General Practice / Family Medicine, School of Public Health and Community Medicine, Institute of Medicine at University of Gothenburg, Gothenburg, Sweden
- Research, Development, Education and Innovation, Primary Health Care, Region Västra Götaland, Gothenburg, Sweden
- Centre for Antibiotic Resistance Research (CARe), University of Gothenburg, Gothenburg, Sweden
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35
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Cronberg O, Tyrstrup M, Ekblom K, Hedin K. Diagnosis-linked antibiotic prescribing in Swedish primary care - a comparison between in-hours and out-of-hours. BMC Infect Dis 2020; 20:616. [PMID: 32819280 PMCID: PMC7441551 DOI: 10.1186/s12879-020-05334-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 08/10/2020] [Indexed: 12/28/2022] Open
Abstract
Background The rise in antibiotic resistance is a global public health concern, and antibiotic overuse needs to be reduced. Earlier studies of out-of-hours care have indicated that antibiotic prescribing is less appropriate than that of in-hours care. However, no study has compared the out-of-hours treatment of infections to in-hours treatment within the same population. Methods This retrospective, descriptive study was based on data retrieved from the Kronoberg Infection Database in Primary Care (KIDPC), which consists of all visits to primary care with an infection diagnosis or prescription of antibiotics during 2006–2014. The purpose was to study the trends in antibiotic prescribing and to compare consultations and prescriptions between in-hours and out-of-hours. Results The visit rate for all infections was 434 visits per 1000 inhabitants per year. The visit rate was stable during the study period, but the antibiotic prescribing rate decreased from 266 prescriptions per 1000 inhabitants in 2006 to 194 prescriptions in 2014 (mean annual change − 8.5 [95% CI − 11.9 to − 5.2]). For the out-of-hours visits (12% of the total visits), a similar reduction in antibiotic prescribing was seen. The decrease was most apparent among children and in respiratory tract infections. When antibiotic prescribing during out-of-hours was compared to in-hours, the unadjusted relative risk of antibiotic prescribing was 1.37 (95% CI 1.36 to 1.38), but when adjusted for age, sex, and diagnosis, the relative risk of antibiotic prescribing was 1.09 (95% CI 1.08 to 1.10). The reduction after adjustment was largely explained by a higher visit rate during out-of-hours for infections requiring antibiotics (acute otitis media, pharyngotonsillitis, and lower urinary tract infection). The choices of antibiotics used for common diagnoses were similar. Conclusions Although the infection visit rate was unchanged over the study period, there was a significant reduction in antibiotic prescribing, especially to children and for respiratory tract infections. The higher antibiotic prescribing rate during out-of-hours was small when adjusted for age, sex, and diagnosis. No excess prescription of broad-spectrum antibiotics was seen. Therefore, interventions selectively aiming at out-of-hours centres seem to be unmotivated in a low-prescribing context.
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Affiliation(s)
- Olof Cronberg
- Växjöhälsan Primary Healthcare Center, VC Växjöhälsan, Hjortvägen 1, 352 45, Växjö, Sweden. .,Department of Research and Development, Region Kronoberg, Växjö, Sweden. .,Department of Clinical Sciences in Malmö, Family Medicine, Lund University, Malmö, Sweden.
| | - Mia Tyrstrup
- Department of Clinical Sciences in Malmö, Family Medicine, Lund University, Malmö, Sweden.,Lundbergsgatan Primary Health Care Centre, Malmö, Sweden
| | - Kim Ekblom
- Department of Research and Development, Region Kronoberg, Växjö, Sweden.,Department of Medical Biosciences, Clinical Chemistry, Umeå University, Umeå, Sweden
| | - Katarina Hedin
- Department of Clinical Sciences in Malmö, Family Medicine, Lund University, Malmö, Sweden.,Futurum, Region Jönköping County and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
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36
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Palin V, Mölter A, Belmonte M, Ashcroft DM, White A, Welfare W, van Staa T. Antibiotic prescribing for common infections in UK general practice: variability and drivers. J Antimicrob Chemother 2020; 74:2440-2450. [PMID: 31038162 PMCID: PMC6640319 DOI: 10.1093/jac/dkz163] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Revised: 03/14/2019] [Accepted: 03/19/2019] [Indexed: 01/08/2023] Open
Abstract
Objectives To examine variations across general practices and factors associated with antibiotic prescribing for common infections in UK primary care to identify potential targets for improvement and optimization of prescribing. Methods Oral antibiotic prescribing for common infections was analysed using anonymized UK primary care electronic health records between 2000 and 2015 using the Clinical Practice Research Datalink (CPRD). The rate of prescribing for each condition was observed over time and mean change points were compared with national guideline updates. Any correlation between the rate of prescribing for each infectious condition was estimated within a practice. Predictors of prescribing were estimated using logistic regression in a matched patient cohort (1:1 by age, sex and calendar time). Results Over 8 million patient records were examined in 587 UK general practices. Practices varied considerably in their propensity to prescribe antibiotics and this variance increased over time. Change points in prescribing did not reflect updates to national guidelines. Prescribing levels within practices were not consistent for different infectious conditions. A history of antibiotic use significantly increased the risk of receiving a subsequent antibiotic (by 22%–48% for patients with three or more antibiotic prescriptions in the past 12 months), as did higher BMI, history of smoking and flu vaccinations. Other drivers for receiving an antibiotic varied considerably for each condition. Conclusions Large variability in antibiotic prescribing between practices and within practices was observed. Prescribing guidelines alone do not positively influence a change in prescribing, suggesting more targeted interventions are required to optimize antibiotic prescribing in the UK.
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Affiliation(s)
- Victoria Palin
- Greater Manchester Connected Health Cities, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Oxford Road, Manchester M13 9PL, UK
| | - Anna Mölter
- Greater Manchester Connected Health Cities, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Oxford Road, Manchester M13 9PL, UK
| | - Miguel Belmonte
- Greater Manchester Connected Health Cities, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Oxford Road, Manchester M13 9PL, UK
| | - Darren M Ashcroft
- Greater Manchester Connected Health Cities, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Oxford Road, Manchester M13 9PL, UK.,NIHR Greater Manchester Patient Safety Translational Research Centre, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Oxford Road, Manchester M13 9PL, UK
| | - Andrew White
- NHS Greater Manchester Shared Service, Ellen House, Waddington Street, Oldham OL9 6EE, UK
| | - William Welfare
- Public Health England North West, 3 Piccadilly Place, London Road, Manchester M1 3BN, UK
| | - Tjeerd van Staa
- Greater Manchester Connected Health Cities, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Oxford Road, Manchester M13 9PL, UK.,Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute of Pharmaceutical Sciences, Utrecht University, Utrecht, Netherlands
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37
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Nygren D, Holm K. Invasive infections with Fusobacterium necrophorum including Lemierre's syndrome: an 8-year Swedish nationwide retrospective study. Clin Microbiol Infect 2020; 26:1089.e7-1089.e12. [DOI: 10.1016/j.cmi.2019.12.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 12/06/2019] [Accepted: 12/08/2019] [Indexed: 10/25/2022]
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D'Atri F, Arthur J, Blix HS, Hicks LA, Plachouras D, Monnet DL. Targets for the reduction of antibiotic use in humans in the Transatlantic Taskforce on Antimicrobial Resistance (TATFAR) partner countries. ACTA ACUST UNITED AC 2020; 24. [PMID: 31311620 PMCID: PMC6636213 DOI: 10.2807/1560-7917.es.2019.24.28.1800339] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Unnecessary and inappropriate use of antibiotics in human healthcare is a major driver for the development and spread of antimicrobial resistance; many countries are implementing measures to limit the overuse and misuse of antibiotics e.g. through the establishment of antimicrobial use reduction targets. We performed a review of antimicrobial use reduction goals in human medicine in Transatlantic Taskforce on Antimicrobial Resistance partner countries. On 31 March 2017, the European Centre for Disease Prevention and Control sent a questionnaire to National Focal Points for Antimicrobial Consumption and the National Focal Points for Antimicrobial Resistance in 28 European Union countries, Iceland and Norway. The same questionnaire was sent to the TATFAR implementers in Canada and the United States. Thirty of 32 countries replied. Only nine countries indicated that they have established targets to reduce antimicrobial use in humans. Twenty-one countries replied that no target had been established. However, 17 of these 21 countries indicated that work to establish such targets is currently underway, often in the context of developing a national action plan against antimicrobial resistance. The reported targets varied greatly between countries and can be a useful resource for countries willing to engage in the reduction of antibiotic use in humans.
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Affiliation(s)
- Fabio D'Atri
- European Commission, Directorate General for Health and Food Safety, Brussels, Belgium.,European Centre for Disease Prevention and Control (ECDC), Stockholm, Sweden
| | - Jacqueline Arthur
- Centre for Communicable Diseases and Infection Control, Public Health Agency of Canada, Ottawa, Canada
| | | | - Lauri A Hicks
- Office of Antibiotic Stewardship, Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, United States
| | | | - Dominique L Monnet
- European Centre for Disease Prevention and Control (ECDC), Stockholm, Sweden
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Fuertes M, Gonçalves JL, Faria A, Lopes-Dos-Santos P, Conceição IC, Dionisio F. Maternal sensitivity and mother-infant attachment are associated with antibiotic uptake in infancy. J Health Psychol 2020; 27:2197-2210. [PMID: 32660278 DOI: 10.1177/1359105320941245] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Attachment security has been associated with health status and symptom reporting. In this longitudinal study, we investigated the association between antibiotics uptake by infants at 9-months and mother-infant attachment at 12-months. Logistic regression analyses indicated that lower maternal sensitivity was associated with increased odds of antibiotic uptake. Furthermore, 89.7% of insecure-ambivalent infants consumed antibiotics, which contrasted with 32.5% of avoidant infants and 21.5% of secure infants. This study suggests that maternal behavior and mother-infant attachment impact on antibiotic consumption, which is worrying because antibiotics may lead to several health problems later in life and antibiotic-resistance.
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Affiliation(s)
- Marina Fuertes
- Centro de Psicologia, University of Porto, Portugal.,Escola Superior de Educação de Lisboa, Portugal
| | | | - Anabela Faria
- Hospital de Santo Espírito, Terceira, Azores, Portugal
| | | | - Inês C Conceição
- Serviço de Patologia Clínica, Hospital Nossa Senhora do Rosário, Barreiro, Setúbal, Portugal
| | - Francisco Dionisio
- cE3c -Centre for Ecology, Evolution and Environmental Changes, and Departamento de Biologia Vegetal, Faculdade de Ciências, Universidade de Lisboa, Portugal
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40
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Aslan Kayıran M, Karadağ AS, Mutlu HH, Goldust M, Sarıcaoğlu H. Comparison of dermatologists and family physicians in terms of prescribing antibiotics for the treatment of acne vulgaris. Dermatol Ther 2020; 33:e13973. [PMID: 32621767 DOI: 10.1111/dth.13973] [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: 05/27/2020] [Revised: 06/28/2020] [Accepted: 07/02/2020] [Indexed: 11/28/2022]
Abstract
Acne vulgaris (AV) is a common skin disease that is treated both with dermatologists and family physicians (FPs) with different strategies. To assess the antibiotics that are frequently preferred in AV treatment, and the differences between the FPs and dermatologists in treatment were investigated. The physicians were informed about the study, and sent over the internet a multiple-choice questionnaire that consists of 29 questions in total. Afterwards, the answers provided were compared. 201 dermatologists and 147 FPs participated in the study. Dermatologists were found to have preferred topical erythromycin, nadifloxacin, clindamycin, and tetracycline, and systematically doxycycline and azithromycin in adult patients, whereas the FPs were found to have preferred mupirocin, fusidic acid (FA), and oxytetracycline, and systematically tetracycline. Dermatologists were found to have recommended topical clindamycin and erythromycin in pregnant/breastfeeding AV patients, whereas the FPs were found to have recommended FA. Dermatologists were found to have continued the antibiotics for 8 to 12 weeks, whereas the FPs were found to have continued for 1 to 4 weeks. The dermatologists preferred systemic antibiotics in cases with back involvement, moderate to severe AV, and that the FPs preferred them in severe AV. The dermatologists considered that the use of antibiotics alone or long-term were important factors causing antibiotic resistance. There were significant differences between the approaches of dermatologists and FPs to AV treatment. FPs were found to have insufficient information about prevention of antibiotic resistance. Therefore, we think that the continuous training of FPs on dermatology will be beneficial.
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Affiliation(s)
- Melek Aslan Kayıran
- Department of Dermatology and Venereology, Istanbul Medeniyet University, School of Medicine, Goztepe Training and Research Hospital, Istanbul, Turkey
| | - Ayşe Serap Karadağ
- Department of Dermatology and Venereology, Istanbul Medeniyet University, School of Medicine, Goztepe Training and Research Hospital, Istanbul, Turkey
| | - Hacer Hicran Mutlu
- Department of Family Medicine, Istanbul Medeniyet University, School of Medicine, Goztepe Training and Research Hospital, Istanbul, Turkey
| | - Mohamad Goldust
- Department of Dermatology, University of Rome G. Marconi, Rome, Italy.,Department of Dermatology, University Hospital Basel, Switzerland
| | - Hayriye Sarıcaoğlu
- Department of Dermatology and Venereology, Uludag University, School of Medicine, Bursa, Turkey
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Plate A, Kronenberg A, Risch M, Mueller Y, Di Gangi S, Rosemann T, Senn O. Treatment of urinary tract infections in Swiss primary care: quality and determinants of antibiotic prescribing. BMC FAMILY PRACTICE 2020; 21:125. [PMID: 32611320 PMCID: PMC7329427 DOI: 10.1186/s12875-020-01201-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 06/18/2020] [Indexed: 11/29/2022]
Abstract
Background Urinary tract infections are one of the most common reasons for prescribing antibiotics in primary care. Current guidelines recommend fosfomycin, nitrofurantoin, or trimethoprim - sulfamethoxazol as empiric first line antimicrobial agents in uncomplicated infections. However, there is evidence that the use of fluoroquinolones, which are no longer recommended, is still inappropriate high. We determined antibiotic prescription patterns, quality and factors affecting antibiotic prescriptions in urinary tract infections in primary care in Switzerland. Methods From June 2017 to August 2018, we conducted a cross-sectional study in patients suffering from a urinary tract infection (UTI). Patient and general practitioners characteristics as well as antibiotic prescribing patterns were analysed. Results Antibiotic prescribing patterns in 1.352 consecutively recruited patients, treated in 163 practices could be analysed. In 950 (84.7%) patients with an uncomplicated UTI the prescriptions were according to current guidelines and therefore rated as appropriate. Fluoroquinolones were prescribed in 13.8% and therefore rated as inappropriate. In multivariable analysis, the age of the general practitioner was associated with increasing odds of prescribing a not guideline recommended antibiotic therapy. Conclusions We found a high degree of guideline conform antibiotic prescriptions in patients with an uncomplicated urinary tract infection in primary care in Switzerland. However, there is still a substantial use of fluoroquinolones in empiric therapy.
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Affiliation(s)
- Andreas Plate
- Institute of Primary Care, University and University Hospital of Zurich, Pestalozzistrasse 24, 8071, Zurich, Switzerland.
| | - Andreas Kronenberg
- Swiss Center for Antibiotic Resistance, Institute for Infectious Diseases, University Bern, Bern and Medix General Practice Network, Bern, Switzerland
| | - Martin Risch
- labormedizinisches zentrum Dr Risch Ostschweiz AG, Buchs, St. Gallen, Switzerland
| | - Yolanda Mueller
- Department of Family Medicine, Center for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland
| | - Stefania Di Gangi
- Institute of Primary Care, University and University Hospital of Zurich, Pestalozzistrasse 24, 8071, Zurich, Switzerland
| | - Thomas Rosemann
- Institute of Primary Care, University and University Hospital of Zurich, Pestalozzistrasse 24, 8071, Zurich, Switzerland
| | - Oliver Senn
- Institute of Primary Care, University and University Hospital of Zurich, Pestalozzistrasse 24, 8071, Zurich, Switzerland
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Koyama T, Hagiya H, Teratani Y, Tatebe Y, Ohshima A, Adachi M, Funahashi T, Zamami Y, Tanaka HY, Tasaka K, Shinomiya K, Kitamura Y, Sendo T, Hinotsu S, Kano MR. Antibiotic prescriptions for Japanese outpatients with acute respiratory tract infections (2013–2015): A retrospective Observational Study. J Infect Chemother 2020; 26:660-666. [DOI: 10.1016/j.jiac.2020.02.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 01/16/2020] [Accepted: 02/03/2020] [Indexed: 10/24/2022]
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Saliba-Gustafsson EA, Dunberger Hampton A, Zarb P, Borg MA, Stålsby Lundborg C. Antibiotic prescribing for respiratory tract complaints in Malta: a 1 year repeated cross-sectional surveillance study. J Antimicrob Chemother 2020; 74:1116-1124. [PMID: 30624733 DOI: 10.1093/jac/dky544] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Revised: 11/26/2018] [Accepted: 11/28/2018] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES To determine the 1 year antibiotic prescribing patterns by GPs for acute respiratory tract complaints (aRTCs) in Malta. METHODS In this repeated cross-sectional surveillance study, GPs collected data for patients seen for aRTCs during a designated 1 week period each month, between May 2015 and April 2016. GPs received three text reminders during surveillance weeks and were contacted by phone at most four times during the year. GPs also received 3 monthly individual- and aggregate-level feedback reports on their antibiotic prescribing patterns. Descriptive statistics were used to examine patient, consultation and clinical characteristics, and to describe GPs' prescribing patterns. RESULTS Participating GPs (n = 33) registered 4641 patients with an aRTC, of whom 2122 (45.7%) received an antibiotic prescription. The majority (99.6%) of antibiotics prescribed were broad-spectrum and the most commonly prescribed antibiotics were macrolides (35.5%), followed by penicillins with a β-lactamase inhibitor (33.2%) and second-generation cephalosporins (14.2%). Specifically, co-amoxiclav (33.2%), clarithromycin (19.6%), azithromycin (15.1%) and cefuroxime axetil (10.9%) represented 78.8% of all antibiotics prescribed. Patients with tonsillar exudate (99.1%), purulent sputum (84%), otorrhoea (78%), tender cervical nodes (74.4%) and fever (73.1%) received most antibiotics. The diagnoses that received the highest proportion of antibiotic treatment were tonsillitis (96.3%), otitis media (92.5%) and bronchitis (87.5%). Wide variation in the choice of antibiotic class by diagnosis was observed. CONCLUSIONS GP antibiotic prescribing in Malta is high. The abundant use of broad-spectrum antibiotics, particularly macrolides, is of particular concern and indicates that antibiotics are being used inappropriately. Efforts must be made to improve GP awareness of appropriate antibiotic prescribing.
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Affiliation(s)
- Erika A Saliba-Gustafsson
- Department of Public Health Sciences, Global Health - Health Systems and Policy (HSP): Improving Use of Medicines, Karolinska Institutet, Tomtebodavägen 18A, Stockholm, Sweden
| | - Alexandra Dunberger Hampton
- Department of Public Health Sciences, Global Health - Health Systems and Policy (HSP): Improving Use of Medicines, Karolinska Institutet, Tomtebodavägen 18A, Stockholm, Sweden
| | - Peter Zarb
- Department of Infection Prevention and Control, Mater Dei Hospital, Msida MSD, Malta
| | - Michael A Borg
- Department of Infection Prevention and Control, Mater Dei Hospital, Msida MSD, Malta.,Faculty of Medicine and Surgery, University of Malta, Msida MSD, Malta
| | - Cecilia Stålsby Lundborg
- Department of Public Health Sciences, Global Health - Health Systems and Policy (HSP): Improving Use of Medicines, Karolinska Institutet, Tomtebodavägen 18A, Stockholm, Sweden
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Dyar OJ, Yang D, Yin J, Sun Q, Stålsby Lundborg C. Variations in antibiotic prescribing among village doctors in a rural region of Shandong province, China: a cross-sectional analysis of prescriptions. BMJ Open 2020; 10:e036703. [PMID: 32487580 PMCID: PMC7265041 DOI: 10.1136/bmjopen-2019-036703] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES To assess variation in antibiotic prescribing practices among village doctors in a rural region of Shandong province, China. DESIGN, SETTING AND PARTICIPANTS Almost all outpatient encounters at village clinics result in a prescription being issued. Prescriptions were collected over a 2.5-year period from 8 primary care village clinics staffed by 24 doctors located around a town in rural Shandong province. A target of 60 prescriptions per clinic per month was sampled from an average total of around 300. Prescriptions were analysed at both aggregate and individual-prescriber levels, with a focus on diagnoses of likely viral acute upper respiratory tract infections (AURIs), defined as International Classification of Diseases, 10th Revision codes J00 and J06.9. MAIN OUTCOME MEASURES Proportions of prescriptions for AURIs containing (1) at least one antibiotic, (2) multiple antibiotics, (3) at least one parenteral antibiotic; classes and agents of antibiotics prescribed. RESULTS In total, 14 471 prescriptions from 23 prescribers were ultimately included, of which 5833 (40.3%) contained at least 1 antibiotic. Nearly two-thirds 62.5% (3237/5177) of likely viral AURI prescriptions contained an antibiotic, accounting for 55.5% (3237/5833) of all antibiotic-containing prescriptions. For AURIs, there was wide variation at the individual level in antibiotic prescribing rates (33.1%-88.0%), as well multiple antibiotic prescribing rates (1.3%-60.2%) and parenteral antibiotic prescribing rates (3.2%-62.1%). Each village doctor prescribed between 11 and 21 unique agents for AURIs, including many broad-spectrum antibiotics. Doctors in the highest quartile for antibiotic prescribing rates for AURI also had higher antibiotic prescribing rates than doctors in the lowest quartile for potentially bacterial upper respiratory tract infections (pharyngitis, tonsillitis, laryngopharyngitis; 89.1% vs 72.4%, p=0.002). CONCLUSIONS All village doctors overused antibiotics for respiratory tract infections. Variations in individual prescriber practices are significant even in a small homogenous setting and should be accounted for when developing targets and interventions to improve antibiotic use.
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Affiliation(s)
- Oliver James Dyar
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Ding Yang
- School of Health Care Management, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
- NHC Key Laboratory of Health Economics and Policy Research, Shandong University, Jinan, Shandong, China
| | - Jia Yin
- School of Health Care Management, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
- NHC Key Laboratory of Health Economics and Policy Research, Shandong University, Jinan, Shandong, China
| | - Qiang Sun
- School of Health Care Management, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
- NHC Key Laboratory of Health Economics and Policy Research, Shandong University, Jinan, Shandong, China
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Tyrstrup M, André M, Brorsson A, Gröndal H, Strandberg EL, Hedin K. A study of guidelines for respiratory tract infections and their references from Swedish GPs: a qualitative analysis. Scand J Prim Health Care 2020; 38:83-91. [PMID: 32031035 PMCID: PMC7054917 DOI: 10.1080/02813432.2020.1717073] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background: National guidelines are important instruments in reducing inappropriate antibiotic prescriptions. Low adherence to guidelines is an acknowledged problem that needs to be addressed.Method: We evaluated established characteristics for guidelines in the guidelines for lower respiratory tract infection, acute otitis media and pharyngotonsillitis in primary care. We studied how doctors used these guidelines by analysing interviews with 29 general practitioners (GPs) in Sweden.Results: We found important between-guidelines differences, which we believe affects adherence. The GPs reported persistent preconceptions about diagnosis and treatment, which we believe reduces their adherence to the guidelines.Conclusion: To increase adherence, it is important to consider doctors' preconceptions when creating new guidelines.
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Affiliation(s)
- M. Tyrstrup
- Department of Clinical Sciences, Family Medicine, Lund University, Malmö, Sweden;
- CONTACT M. Tyrstrup Department of Clinical Sciences, Malmö, Family Medicine, Lund University, Malmö, Sweden
| | - M. André
- Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine, Uppsala University, Uppsala, Sweden;
- Department of Medicine and Health Sciences, Family Medicine, Linköping University, Linköping, Sweden;
| | - A. Brorsson
- Department of Clinical Sciences, Family Medicine, Lund University, Malmö, Sweden;
- Center for Primary Health Care Research, Malmö, Sweden;
| | - H. Gröndal
- Department of Sociology, Uppsala University, Uppsala, Sweden;
| | - E.-L. Strandberg
- Department of Clinical Sciences, Family Medicine, Lund University, Malmö, Sweden;
| | - K. Hedin
- Department of Clinical Sciences, Family Medicine, Lund University, Malmö, Sweden;
- Fururum, Jönköping, Sweden;
- Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
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46
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Benko R, Matuz M, Juhasz Z, Bognar J, Bordas R, Soos G, Hajdu E, Peto Z. Treatment of Cystitis by Hungarian General Practitioners: A Prospective Observational Study. Front Pharmacol 2020; 10:1498. [PMID: 31920676 PMCID: PMC6931317 DOI: 10.3389/fphar.2019.01498] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Accepted: 11/19/2019] [Indexed: 11/13/2022] Open
Abstract
Background: Lower urinary tract infections (LUTIs) are amongst the most common community acquired infections with frequent antibiotic prescribing. Objectives: To assess empiric antibiotic choice in different types of lower urinary tract infections. We also aimed to identify determinants of fluoroquinolone prescribing, as well as to determine the rate of short antibiotic courses. The frequencies of executing laboratory tests and recommending analgesics/anti-inflammatory drugs were also assessed. Methods: A prospective observational study was performed in 19 different Hungarian primary care practices. Participating general practitioners (GPs) filled out data sheets for each patient with a suspected urinary tract infection. Details of drug use were evaluated. Comparison of different LUTI groups were made by descriptive statistics and univariate analysis. Possible determinants of fluoroquinolone prescribing were assessed by logistic regression. Results: Data sheets of 372 patients were analyzed. The majority of patients (68.82%) had acute uncomplicated cystitis. While antibiotics were prescribed for almost every patient (uncomplicated cases: 92.58%, complicated cases: 94.83%), analgesics/anti-inflammatory drugs were recommended at a rate of 7.81% in uncomplicated, and 13.79% in complicated cystitis cases. Ciprofloxacin was the most commonly prescribed antibacterial agent in both types of cystitis. Short-term antibiotic therapy was prescribed in one third of relevant cases. Logistic regression found a weak association between fluoroquinolone use and patient’s age and presence of complicating factors. Conclusions: Many aspects of suboptimal cystitis management were identified (e.g. unnecessarily broad spectra agents, too long antibiotic courses). In this study, patient characteristics has weakly influenced fluoroquinolone prescribing. Based on these results there is considerable room for improvement in primary care antibiotic therapy of cystitis in Hungary.
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Affiliation(s)
- Ria Benko
- Department of Clinical Pharmacy, University of Szeged, Szeged, Hungary
| | - Maria Matuz
- Department of Clinical Pharmacy, University of Szeged, Szeged, Hungary
| | - Zoltan Juhasz
- First Department of Internal Medicine, Infectology Unit, University of Szeged, Szeged, Hungary
| | | | - Reka Bordas
- Department of Clinical Pharmacy, University of Szeged, Szeged, Hungary
| | - Gyongyver Soos
- Department of Clinical Pharmacy, University of Szeged, Szeged, Hungary
| | - Edit Hajdu
- First Department of Internal Medicine, Infectology Unit, University of Szeged, Szeged, Hungary
| | - Zoltan Peto
- Emergency Department, University of Szeged, Szeged, Hungary
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47
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Colliers A, Adriaenssens N, Anthierens S, Bartholomeeusen S, Philips H, Remmen R, Coenen S. Antibiotic Prescribing Quality in Out-of-Hours Primary Care and Critical Appraisal of Disease-Specific Quality Indicators. Antibiotics (Basel) 2019; 8:antibiotics8020079. [PMID: 31212871 PMCID: PMC6628021 DOI: 10.3390/antibiotics8020079] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 06/05/2019] [Accepted: 06/07/2019] [Indexed: 12/25/2022] Open
Abstract
Outpatient antibiotic use in Belgium is among the highest in Europe. The most common reason for an encounter in out-of-hours (OOH) primary care is an infection. In this study, we assessed all consultations from July 2016 to June 2018 at five OOH services. We described antibiotic prescribing by diagnosis, calculated disease-specific antibiotic prescribing quality indicators’ (APQI) values and critically appraised these APQI. We determined that 111,600 encounters resulted in 26,436 (23.7%) antibiotic prescriptions. The APQI diagnoses (i.e., bronchitis, upper respiratory infection, cystitis, tonsillitis, sinusitis, otitis media, and pneumonia) covered 14,927 (56.7%) antibiotic prescriptions. Erysipelas (1344 (5.1%)) and teeth/gum disease (982 (3.7%)) covered more prescriptions than sinusitis or pneumonia. Over 75% of patients with tonsillitis and over 50% with bronchitis, sinusitis, and otitis media were prescribed an antibiotic. Only for otitis media the choice of antibiotic was near the acceptable range. Over 10% of patients with bronchitis or pneumonia and over 25% of female patients with an acute cystitis received quinolones. The APQI cover the diagnoses for only 57% of all antibiotic prescriptions. As 5.1% and 3.7% of antibiotic prescriptions are made for erysipelas and teeth/gum disease, respectively, we propose to add these indications when assessing antibiotic prescribing quality in OOH primary care.
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Affiliation(s)
- Annelies Colliers
- Department of Primary and Interdisciplinary Care (ELIZA)-Centre for General Practice, University of Antwerp, Faculty of Medicine and Health Sciences, Doornstraat 331, B-2610 Antwerp, Belgium.
| | - Niels Adriaenssens
- Department of Primary and Interdisciplinary Care (ELIZA)-Centre for General Practice, University of Antwerp, Faculty of Medicine and Health Sciences, Doornstraat 331, B-2610 Antwerp, Belgium.
| | - Sibyl Anthierens
- Department of Primary and Interdisciplinary Care (ELIZA)-Centre for General Practice, University of Antwerp, Faculty of Medicine and Health Sciences, Doornstraat 331, B-2610 Antwerp, Belgium.
| | - Stephaan Bartholomeeusen
- Department of Primary and Interdisciplinary Care (ELIZA)-Centre for General Practice, University of Antwerp, Faculty of Medicine and Health Sciences, Doornstraat 331, B-2610 Antwerp, Belgium.
| | - Hilde Philips
- Department of Primary and Interdisciplinary Care (ELIZA)-Centre for General Practice, University of Antwerp, Faculty of Medicine and Health Sciences, Doornstraat 331, B-2610 Antwerp, Belgium.
| | - Roy Remmen
- Department of Primary and Interdisciplinary Care (ELIZA)-Centre for General Practice, University of Antwerp, Faculty of Medicine and Health Sciences, Doornstraat 331, B-2610 Antwerp, Belgium.
| | - Samuel Coenen
- Department of Primary and Interdisciplinary Care (ELIZA)-Centre for General Practice, University of Antwerp, Faculty of Medicine and Health Sciences, Doornstraat 331, B-2610 Antwerp, Belgium.
- Department of Epidemiology and Social Medicine (ESOC), University of Antwerp, Faculty of Medicine and Health Sciences, Universiteitsplein 1, B-2610 Antwerp, Belgium.
- Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Faculty of Medicine and Health Sciences, Universiteitsplein 1, B-2610 Antwerp, Belgium.
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48
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Smieszek T, Pouwels KB, Dolk FCK, Smith DRM, Hopkins S, Sharland M, Hay AD, Moore MV, Robotham JV. Potential for reducing inappropriate antibiotic prescribing in English primary care. J Antimicrob Chemother 2019; 73:ii36-ii43. [PMID: 29490058 DOI: 10.1093/jac/dkx500] [Citation(s) in RCA: 143] [Impact Index Per Article: 28.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Objectives To identify and quantify inappropriate systemic antibiotic prescribing in primary care in England, and ultimately to determine the potential for reduction in prescribing of antibiotics. Methods Primary care data from 2013-15 recorded in The Health Improvement Network (THIN) database were used. Potentially inappropriate prescribing events in the database were identified by: (i) comparing prescribing events against treatment guidelines; (ii) comparing actual proportions of consultations resulting in prescription for a set of conditions with the ideal proportions derived from expert opinion; and (iii) identifying high prescribers and their number of prescriptions above an age- and body-system-specific benchmark. Results Applying the most conservative assumptions, 8.8% of all systemic antibiotic prescriptions in English primary care were identified as inappropriate, and in the least conservative scenario 23.1% of prescriptions were inappropriate. All practices had non-zero reduction potentials, ranging from 6.4% to 43.5% in the middle scenario. The four conditions that contributed most to inappropriate prescribing were sore throat (23.0% of identified inappropriate prescriptions), cough (22.2%), sinusitis (7.6%) and acute otitis media (5.7%). One-third of all antibiotic prescriptions lacked an informative diagnostic code. Conclusions This work demonstrates (i) the existence of substantial inappropriate antibiotic prescribing and (ii) poor diagnostic coding in English primary care. All practices (not just the high prescribers) should engage in efforts to improve antimicrobial stewardship. Better diagnostic coding, more precise prescribing guidelines and a deeper understanding of appropriate long-term uses of antibiotics would allow identification of further potential for reductions.
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Affiliation(s)
- Timo Smieszek
- Modelling and Economics Unit, National Infection Service, Public Health England, London, UK.,MRC Centre for Outbreak Analysis and Modelling, Department of Infectious Disease Epidemiology, Imperial College School of Public Health, London, UK
| | - Koen B Pouwels
- Modelling and Economics Unit, National Infection Service, Public Health England, London, UK.,MRC Centre for Outbreak Analysis and Modelling, Department of Infectious Disease Epidemiology, Imperial College School of Public Health, London, UK.,PharmacoTherapy, -Epidemiology & -Economics, Department of Pharmacy, University of Groningen, Groningen, The Netherlands
| | - F Christiaan K Dolk
- Modelling and Economics Unit, National Infection Service, Public Health England, London, UK.,PharmacoTherapy, -Epidemiology & -Economics, Department of Pharmacy, University of Groningen, Groningen, The Netherlands
| | - David R M Smith
- Modelling and Economics Unit, National Infection Service, Public Health England, London, UK
| | - Susan Hopkins
- Antimicrobial Resistance and Stewardship and Healthcare-Associated Infections Programme, Public Health England, London, UK.,Directorate of Infection, Royal Free London NHS Foundation Trust, London, UK
| | - Mike Sharland
- Paediatric Infectious Diseases Research Group, St George's University of London, London, UK
| | - Alastair D Hay
- Centre for Academic Primary Care, NIHR School for Primary Care Research, Population Health Sciences, Bristol Medical School, University of Bristol, UK
| | - Michael V Moore
- Academic Unit for Primary Care and Population Sciences, University of Southampton, Southampton, UK
| | - Julie V Robotham
- Modelling and Economics Unit, National Infection Service, Public Health England, London, UK
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Dal Negro RW, Zanasi A, Turco P, Povero M. Acute cough in Italian children: parents' beliefs, approach to treatment, and the family impact. Multidiscip Respir Med 2019; 14:16. [PMID: 30988950 PMCID: PMC6448239 DOI: 10.1186/s40248-019-0180-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Accepted: 03/18/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Acute cough is the most common symptom among children in primary care, but the impact of cough episodes was never investigated in Italian families. METHODS A cross-sectional telephone survey was conducted on a representative sample of Italian families, randomly selected from general population; a specific and validated questionnaire was used. RESULTS The sample (604 calls) was uniform by geographical distribution, and by children age and gender. Mean cough episode was 3.1/year, they were short lasting (only 4.7% > 2 weeks). Independent predictors of children cough episodes were parents' active smoking habit and work (p < 0.05). The mean nursery/school absenteeism was mostly < 7 days, but of a 7-15-day duration in near 30% of cases. The pediatrician was contacted immediately only by 25% of parents and a second consultation (mostly a lung physician) usually occurred after 2-3 weeks of cough. Meanwhile, home/pharmacist suggested remedies were adopted in 50-70% of cases. Usual prescriptions were mucolytics (85.8%), antitussive agents (55.6%), non-steroideal anti-inflammatory drugs (33.8%), antibiotics (regularly or episodically 80%), and corticosteroids (systemic steroids in less than 50%, but via aerosol in more than 80% of cases). Moreover, pediatricians claimed to use homeopathic drugs regularly or episodically in almost 50%. The respondents' willingness to spend out-of-pocket for an "effective remedy" against cough was of € 20 (>€ 30 in 18.4% of cases). CONCLUSIONS Parents' actions against cough episodes were variable, depending on their beliefs, smoking habit, and occupational status. The parents' perceived efficacy of usual prescriptions is poor, and their willingness to pay out-of-pocket for an "effective remedy" against cough is high. The interest for alternative treatments is not negligible in these circumstances.
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Affiliation(s)
- Roberto W. Dal Negro
- National Centre for Respiratory Pharmacoeconomics and Pharmacoepidemiology, Verona, Italy
| | | | - Paola Turco
- Research & Clinical Governance, Verona, Italy
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50
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van Uum RT, Venekamp RP, Schilder AGM, Damoiseaux RAMJ, Anthierens S. Pain management in acute otitis media: a qualitative study of parents' views and expectations. BMC FAMILY PRACTICE 2019; 20:18. [PMID: 30674279 PMCID: PMC6343236 DOI: 10.1186/s12875-019-0908-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Accepted: 01/15/2019] [Indexed: 11/10/2022]
Abstract
BACKGROUND For unclarified reasons, parents tend to be cautious about administering analgesics to their children, potentially leading to suboptimal management of AOM symptoms. We aim to understand parents' views and expectations of pain management in acute otitis media (AOM) in children. METHODS Qualitative study alongside a cluster-randomised controlled trial (PIM-POM study) aimed at optimising pain management in childhood AOM. We purposefully sampled 14 parents of children diagnosed with AOM by their GP, who were recruited to the trial between November 2017 and May 2018. Semi-structured interviews were held at home in the first two weeks after trial enrollment. Interviews were audio-recorded, transcribed and analyzed thematically. RESULTS Parents experienced difficulties in recognising earache and other symptoms of an ear infection. They consulted the GP for a diagnosis, for reassurance and for management advice. Parents shared that, prior to consultation, they had insufficient knowledge of the benefits of correctly dosed pain medication at regularly scheduled intervals. Parents valued the GP's advice on pain management, and were happy to accept pain medication as standalone therapy, provided that the GP explained why antibiotics would not be needed. Parents' views and expectations of pain management in AOM were shaped by previous experiences of AOM within their family; those with a positive experience of pain medication are more likely to use it in subsequent AOM episodes. CONCLUSIONS Parents of children with AOM consult the GP to help cope with uncertainties in recognising symptoms of AOM, and to receive management advice. It is important that GPs are aware of parents' lack of understanding of the role of pain medication in managing AOM, and that they address this during the consultation. TRIAL REGISTRATION Netherlands Trial Register, identifier NTR4920 (registration date: 19 December 2014).
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Affiliation(s)
- Rick T. van Uum
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, University Utrecht, Office number FAC 5.09, P.O. Box 85500, 3508 GA Utrecht, The Netherlands
| | - Roderick P. Venekamp
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, University Utrecht, Office number FAC 5.09, P.O. Box 85500, 3508 GA Utrecht, The Netherlands
| | - Anne G. M. Schilder
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, University Utrecht, Office number FAC 5.09, P.O. Box 85500, 3508 GA Utrecht, The Netherlands
- evidENT, Ear Institute, University College London, London, UK
| | - Roger A. M. J. Damoiseaux
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, University Utrecht, Office number FAC 5.09, P.O. Box 85500, 3508 GA Utrecht, The Netherlands
| | - Sibyl Anthierens
- Department of Primary Care and Interdisciplinary Care, University of Antwerp, Antwerp, Belgium
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