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Daniels R, Miles E, Button K. Does the Addition of Point-of-Care Testing Alter Antibiotic Prescribing Decisions When Patients Present with Acute Sore Throat to Primary Care? A Prospective Test of Change. Diagnostics (Basel) 2024; 14:1104. [PMID: 38893631 PMCID: PMC11171997 DOI: 10.3390/diagnostics14111104] [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: 04/21/2024] [Revised: 05/23/2024] [Accepted: 05/24/2024] [Indexed: 06/21/2024] Open
Abstract
Accurate clinical diagnosis of patients presenting to primary care settings with acute sore throat remains challenging, often resulting in the over-prescribing of antibiotics. Using point-of-care tests (POCTs) to differentiate between respiratory infections is well-accepted, yet evidence on the application within primary care is sparse. We assessed the application of testing patients (n = 160) from three family practices with suspected Streptococcal infections using rapid molecular tests (ID NOW Strep A2, Abbott). In addition to comparing clinical evaluation and prescription rates with either usual care or testing, patients and staff completed a questionnaire about their experience of molecular POCT in primary care. The immediate availability of the result was important to patients (100%), and staff (≈90%) stated that molecular testing improved the quality of care. Interestingly, only 22.73% of patients with a Centor score > 2 tested positive for Strep A and, overall, less than 50% of Centor scores 3 and 4 tested positive for Strep A with the ID NOW testing platform. The addition of rapid molecular POCTs to clinical assessment resulted in a 55-65% reduction in immediate and deferred antibiotic prescriptions. The intervention was popular with patients and medical staff but was associated with increased cost and a longer appointment length.
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Affiliation(s)
- Rob Daniels
- Faculty of Health Care Professions, St Luke’s Campus, University of Exeter, Heavitree Road, Exeter EX1 2LU, UK
- TASC Primary Care Network, Townsend House Medical Centre, 49 Harepath Road, Seaton EX12 2RY, UK;
| | - Esther Miles
- Royal Devon University Hospital, Barrack Road, Exeter EX2 5DW, UK;
| | - Karen Button
- TASC Primary Care Network, Townsend House Medical Centre, 49 Harepath Road, Seaton EX12 2RY, UK;
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Taylor A, Webb R. Fifteen-minute consultation: Group A streptococcal pharyngitis, diagnosis and treatment in children. Arch Dis Child Educ Pract Ed 2024:edpract-2023-325755. [PMID: 38514137 DOI: 10.1136/archdischild-2023-325755] [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: 05/08/2023] [Accepted: 01/10/2024] [Indexed: 03/23/2024]
Abstract
Group A streptococcus (GAS) is the most common bacterial cause of pharyngitis in children. GAS causes significant suppurative and non-suppurative complications including invasive GAS disease and acute rheumatic fever. This article describes the current epidemiology and clinical presentation of GAS pharyngitis and explores how diagnostic and treatment decisions differ globally. Several key decision support tools are discussed including international guidelines, clinical decision scores and laboratory tests along with the evidence for treatment choice and duration. With recent international reports describing an increase in GAS infections, clinicians should be familiar with their local GAS pharyngitis guidelines and the rationale for diagnosis and treatment of this common childhood illness.
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Affiliation(s)
- Amanda Taylor
- Paediatrics: Child and Youth Health, The University of Auckland, Auckland, New Zealand
| | - Rachel Webb
- Paediatrics: Child and Youth Health, The University of Auckland, Auckland, New Zealand
- Paediatric Infectious Diseases, Starship Children's Health, Auckland, New Zealand
- Paediatrics, Kidz First Hospital, Counties Manukau, Auckland, New Zealand
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Mantzourani E, Ahmed H, Evans A, Gunnarsson R, Cannings-John R. A pharmacy-led sore throat test and treat (STTT) service: antigen testing and antibiotic supply rates during the period of heightened public awareness of Group A Streptococcus infections. J Antimicrob Chemother 2024; 79:354-359. [PMID: 38134314 PMCID: PMC10832601 DOI: 10.1093/jac/dkad388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 11/29/2023] [Indexed: 12/24/2023] Open
Abstract
BACKGROUND Community pharmacies in Wales delivered an NHS-funded sore throat test and treat (STTT) service during the period of increased invasive Group A Streptococcus (iGAS) incidents in winter 2022-23. Service users were screened using FeverPAIN/CENTOR scores, offered GAS rapid antigen detection tests (RADT) if appropriate, and antibiotics if indicated. OBJECTIVES To evaluate the service's response to a substantial rise in sore throat presentations during a period of heightened public anxiety. METHODS Cross-sectional study with anonymized individual-level data from electronic pharmacy records of all eligible STTT service users, between January 2022 and March 2023. RESULTS Antibiotics were supplied to 24% (95% CI: 23-24) of people who used the STTT service and 31% (95% CI: 31-32) of those who met the threshold for an RADT. Of 27 441 STTT consultations, 9308 (33.9%) occurred during December 2022. In the week commencing 2 December 2022, following the announcements of increased iGAS incidents, we observed a statistically significant increase of 1700 consultations (95% CI: 924-2476) and a statistically significant decrease in supply rate of 13.9 antibiotics per 100 RADT (95% CI: -18.40 to -9.40). Antibiotic supply rates increased thereafter to those observed before the announcements of iGAS incidents. Referral rates to other primary care or emergency settings remained below 10% throughout the study period. CONCLUSIONS Our findings suggest that, despite a dramatic increase in sore throat consultation rates in response to media reports, the pre-specified pathway followed by pharmacists ensured appropriate use of antibiotics, and absorbed a substantial workload that would otherwise end up in other healthcare settings.
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Affiliation(s)
- Efi Mantzourani
- Cardiff School of Pharmacy and Pharmaceutical Sciences, Cardiff University, Redwood Building, King Edward VII Avenue, Cardiff CF10 3NB, Wales, UK
- Clinical Informatics, Digital Health and Care Wales, NHS Wales, Cardiff, Wales, UK
| | - Haroon Ahmed
- Division of Population Medicine, Cardiff University, Cardiff, Wales, UK
| | - Andrew Evans
- Primary Care Services, Welsh Government, Cardiff, Wales, UK
| | - Ronny Gunnarsson
- School of Public Health and Community Medicine, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Research, Development, Education and Innovation, Primary Health Care, Gothenburg, Sweden
- Centre for Antibiotic Resistance Research (CARe) at University of Gothenburg, Gothenburg, Sweden
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Guntinas-Lichius O, Geißler K, Mäkitie AA, Ronen O, Bradley PJ, Rinaldo A, Takes RP, Ferlito A. Treatment of recurrent acute tonsillitis-a systematic review and clinical practice recommendations. Front Surg 2023; 10:1221932. [PMID: 37881239 PMCID: PMC10597714 DOI: 10.3389/fsurg.2023.1221932] [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: 05/13/2023] [Accepted: 09/11/2023] [Indexed: 10/27/2023] Open
Abstract
Background There is an ongoing debate on the indications for tonsil surgery in both children and adults with recurrent acute tonsillitis. The aim is to provide practical recommendations for diagnostics and treatment for recurrent acute tonsillitis including evidence-based decision making for tonsillectomy. Methods A systematic literature search in PubMed, Embase, Web of Science, and ScienceDirect from 2014 until April 2023 resulted in 68 articles. These were the basis for the review and a comprehensive series of consensus statements on the most important diagnostics and indications for both non-surgical and surgical therapy. A consensus paper was circulated among the authors and members of the International Head and Neck Scientific Group until a final agreement was reached for all recommendations. Results The differentiation between sore throat and tonsillitis patient episodes is mostly not feasible and hence is not relevant for diagnostic decision making. Diagnostics of a tonsillitis/sore throat episode should always include a classification with a scoring system (Centor, McIssac, FeverPAIN score) to estimate the probability of a bacterial tonsillitis, mainly due to group A streptococcus (GAS). In ambiguous cases, a point-of-care test GAS swab test is helpful. Consecutive counting of the tonsillitis/sore throat episodes is important. In addition, a specific quality of life score (Tonsillectomy Outcome Inventory 14 or Tonsil and Adenoid Health Status Instrument) should be used for each episode. Conservative treatment includes a combination of paracetamol and/or non-steroidal anti-inflammatory drugs. In case of high probability of bacterial tonsillitis, and only in such cases, especially in patients at risk, standard antibiotic treatment is initiated directly or by delayed prescription. Tonsillectomy is indicated and is highly effective if the patient has had ≥7 adequately treated episodes in the preceding year, ≥5 such episodes in each of the preceding 2 years, or ≥3 such episodes in each of the preceding 3 years. An essential part of surgery is standardized pain management because severe postoperative pain can be expected in most patients. Conclusion It is necessary to follow a stringent treatment algorithm for an optimal and evidence-based treatment for patients with recurrent acute tonsillitis. This will help decrease worldwide treatment variability, antibiotic overuse, and avoid ineffective tonsillectomy.
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Affiliation(s)
| | - Katharina Geißler
- Department of Otorhinolaryngology, Jena University Hospital, Jena, Germany
| | - Antti A. Mäkitie
- Department of Otorhinolaryngology-Head and Neck Surgery, Research Program in Systems Oncology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Ohad Ronen
- Department of Otolaryngology, Head and Neck Surgery, Galilee Medical Center, Affiliated with Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
| | - Patrick J. Bradley
- Department Otorhinolaryngology, Head and Neck Surgery, Nottingham University Hospitals, Queens Medical Centre Campus, Nottingham, United Kingdom
| | | | - Robert P. Takes
- Department of Otolaryngology, Head and Neck Surgery, Radboud University Medical Center, Nijmegen, Netherlands
| | - Alfio Ferlito
- International Head and Neck Scientific Group, Padua, Italy
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Cole J, Hughes C, Cadogan C, Vellinga A, Molloy G, Fahey T, Sheaf G, Maher A, Ryan C. Evidence for using point-of-care diagnostics in the management of respiratory tract infections in primary care: a scoping review protocol. HRB Open Res 2023; 6:59. [PMID: 38283945 PMCID: PMC10822039 DOI: 10.12688/hrbopenres.13770.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/14/2023] [Indexed: 01/30/2024] Open
Abstract
Background: Antimicrobial resistance (AmR) is widely considered a global health threat and is associated with significant morbidity, mortality and costs. Inappropriate antimicrobial use is the most important modifiable risk factor for AmR. Most human antimicrobial medicines use occurs in primary care [prescribed by general practitioners (GPs), dispensed by community pharmacists (CPs)]. However, up to 50% of use is deemed inappropriate. Point-of-care diagnostic tests are used as a basis for antimicrobial stewardship interventions to improve the diagnostic certainty of respiratory tract infections (RTIs), and therefore ensure prudent antimicrobial use. However, there is a lack of guidance on their use, and they are therefore not routinely used in clinical practice. Objective: A scoping review will be conducted to synthesise the available evidence to inform the development of best practice guidance for using point-of-care diagnostics in the management of RTIs in primary care. Methods: A scoping review will be conducted following guidance from the Joanna Briggs Institute (JBI) and reported using the PRISMA-ScR guidelines. Databases including Web of Science, MEDLINE, CINAHL, EMBASE, the International HTA database and the Cochrane Central Register of Controlled Trials, as well as grey literature, will be searched. Screening will be undertaken independently by two reviewers to identify studies and literature reporting the use of point-of-care diagnostics in the management of RTIs in primary care by GPs and/ or CPs. Findings will be described using narrative synthesis. Conclusion: The findings of this scoping review will be used to produce draft guidance on the use of point-of-care diagnostic tests in primary care, which will undergo further development using a Delphi consensus methodology involving experts in the field of RTIs, antimicrobial stewardship, point-of-care diagnostics and primary care.
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Affiliation(s)
- Judith Cole
- School of Pharmacy and Pharmaceutical Sciences, The University of Dublin, Trinity College, Dublin, Leinster, Ireland
| | - Carmel Hughes
- School of Pharmacy, Queen's University Belfast, Belfast, Northern Ireland, UK
| | - Cathal Cadogan
- School of Pharmacy and Pharmaceutical Sciences, The University of Dublin, Trinity College, Dublin, Leinster, Ireland
| | - Akke Vellinga
- School of Public Health, Physiotherapy and Sports Science, University College Dublin, Dublin, Leinster, Ireland
| | - Gerard Molloy
- School of Psychology, College of Arts, Social Sciences and Celtic Studies, University of Galway, Galway, County Galway, Ireland
| | - Tom Fahey
- Department of General Practice, Royal College of Surgeons in Ireland, Dublin, Leinster, Ireland
| | - Greg Sheaf
- The University of Dublin Trinity College, Dublin, Leinster, Ireland
| | - Anthony Maher
- School of Psychology, College of Arts, Social Sciences and Celtic Studies, University of Galway, Galway, County Galway, Ireland
| | - Cristin Ryan
- School of Pharmacy and Pharmaceutical Sciences, The University of Dublin, Trinity College, Dublin, Leinster, Ireland
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Hamilton RA, Courtenay M, Frost KJ, Harrison R, Root H, Allison DG, Tonna AP, Ashiru-Oredope D, Aldeyab MA, Shemilt K, Martin SJ. Implementation of the national antimicrobial stewardship competencies for UK undergraduate healthcare professional education within undergraduate pharmacy programmes: a survey of UK schools of pharmacy. JAC Antimicrob Resist 2023; 5:dlad095. [PMID: 37560542 PMCID: PMC10409409 DOI: 10.1093/jacamr/dlad095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 07/21/2023] [Indexed: 08/11/2023] Open
Abstract
BACKGROUND Pharmacists play a key role in antimicrobial stewardship (AMS). Consensus-based national AMS competencies for undergraduate healthcare professionals in the UK reflect the increasing emphasis on competency-based healthcare professional education. However, the extent to which these are included within undergraduate pharmacy education programmes in the UK is unknown. OBJECTIVES To explore which of the AMS competencies are delivered, including when and at which level, within UK undergraduate MPharm programmes. METHODS A cross-sectional online questionnaire captured the level of study of the MPharm programme in which each competency was taught, the method of delivery and assessment of AMS education, and examples of student feedback. RESULTS Ten institutions completed the survey (33% response rate). No institution reported covering all 54 AMS competencies and 5 of these were taught at half or fewer of the institutions. Key gaps were identified around taking samples, communication, outpatient parenteral antimicrobial therapy and surgical prophylaxis. The minimum time dedicated to AMS teaching differed between institutions (range 9-119 h), teaching was generally through didactic methods, and assessment was generally through knowledge recall and objective structured clinical examinations. Feedback from students suggests they find AMS and antimicrobial resistance (AMR) to be complex yet important topics. CONCLUSIONS UK schools of pharmacy should utilize the competency framework to identify gaps in their AMS, AMR and infection teaching. To prepare newly qualified pharmacists to be effective at delivering AMS and prescribing antimicrobials, schools of pharmacy should utilize more simulated environments and clinical placements for education and assessment of AMS.
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Affiliation(s)
- Ryan A Hamilton
- School of Pharmacy, De Montfort University, Leicester LE1 9BH, UK
| | - Molly Courtenay
- School of Healthcare Sciences, Cardiff University, Cardiff CF24 0AB, Wales
| | - Kevin J Frost
- Pharmacy Department, Airedale NHS Foundation Trust, Keighley BD20 6TD, UK
| | - Roger Harrison
- School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester M13 9PT, UK
| | - Helen Root
- School of Pharmacy, De Montfort University, Leicester LE1 9BH, UK
| | - David G Allison
- Division of Pharmacy & Optometry, The University of Manchester, Manchester M13 9PT, UK
| | - Antonella P Tonna
- School of Pharmacy and Life Sciences, Robert Gordon University, Aberdeen AB10 7AQ, UK
| | - Diane Ashiru-Oredope
- School of Pharmacy, University College London, London WC1N 1AX, UK
- UK Health Security Agency, London SW1P 3JR, UK
| | - Mamoon A Aldeyab
- Department of Pharmacy, University of Huddersfield, Huddersfield HD1 3DH, UK
| | - Katherine Shemilt
- School of Pharmacy and Biomolecular Sciences, Liverpool John Moores University, Liverpool L3 3AF, UK
| | - Sandra J Martin
- School of Pharmacy & Medical Sciences, University of Bradford, Bradford BD7 1DP, UK
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Affiliation(s)
- Michael Moore
- Primary Care Research Centre, Primary Care, Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton
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