Control of antimicrobial resistance: time for action. The essentials of control are already well known

Approach to the Control of Antimicrobial Resistance: Are We Missing the Plot?

How to cite this article: Peter JV. Approach to the Control of Antimicrobial Resistance: Are We Missing the Plot? Indian J Crit Care Med 2020;24(10):899-900.

Indirect Impact of Ten-valent Pneumococcal Conjugate Vaccine Program on Reducing Antimicrobial Use and Tympanostomy Tube Placements in Finland

BACKGROUND

Acute otitis media (AOM) is the most common reason for antimicrobial use, and tympanostomy tube placement (TTP) is the most common reason for surgery requiring general anesthesia in children. Ten-valent pneumococcal conjugate vaccine (PCV10) was introduced in Finland in 2010 for infants. We evaluated the indirect impact of PCV10 on these surrogate otitis outcomes in unvaccinated children.

METHODS

Using before-after design, unvaccinated children ineligible for National Vaccination Program (born January 2006 to May 2010) were followed-up during 2012-2016 (target cohort, age 1.5-7 years). The target cohort was compared with an age- and season-matched unvaccinated reference cohort (born January 2000 to May 2004) during 2006-2010. Antimicrobial purchase data were obtained from the Social Insurance Institution of Finland benefits register. We assessed the relative reduction by generalized Cox regression for outpatient purchases of antibiotics recommended for treatment of AOM in the Finnish guidelines. Data on all TTP procedures were obtained from national hospital discharge register and Social Insurance Institution benefits register.

RESULTS

The rate of outpatient purchases of antimicrobials recommended for AOM was 51 in the unvaccinated reference cohort and 44/100 person-years in the unvaccinated target cohort; relative rate reduction was 14.7% [95% confidence interval: 14.0-15.3] and absolute rate reduction 7/100 person-years. The rates of TTP in the reference and target cohorts were 1.66/100 and 1.61/100 person-years, respectively. The relative rate reduction was 3.6% (0.7-6.5).

CONCLUSIONS

Antimicrobial use and TTP procedures reduced in unvaccinated children after PCV10 introduction in infants. These indirect effects contribute to the savings in health care resource use for otitis and may also help in combating antimicrobial resistance.

An evaluation of nurses' record-keeping skills and knowledge of using patient group directions for antibiotics at a walk-in centre

Patient group directions (PGDs) are now an integral feature of walk-in centres (WiCs), enabling nurses to supply and administer drugs to the generalised direction of a doctor rather than by means of a patient-specific prescription. The aims of the study described here were to assess nurses' record-keeping and knowledge with regard to PGDs for antibiotics implemented at a local WiC.

The study methods included undertaking a clinical audit of patient records between October 2000 and March 2001 and an assessment of nurses' knowledge using multiple-choice questionnaires, vignettes and shadowing consultations. A total of 1,169 patients was supplied antibiotics, 72% of which were provided by nurses using a PGD. Nearly 100% of patients were supplied antibiotics correctly according to drug and dose; however, in only 63% of cases was there recorded evidence that allergy or contraindications were checked before the antibiotic was supplied. The study found that 51% of the required assessment criteria were recorded on the computer records. Nurses' knowledge at baseline resulted in a median score of 70%, which rose to 79% following educational interventions.

The study suggests that nurses are knowledgeable and supply antibiotics judiciously in terms of drug and dose, but that in terms of clinical governance there is room for improvement in record-keeping.

Clostridium perfringens: Comparative effects of heat and osmotic stress on non-enterotoxigenic and enterotoxigenic strains

Clostridium perfringens isolates associated with food poisoning carries a chromosomal cpe gene, while non-foodborne human gastrointestinal disease isolates carry a plasmid cpe gene. The enterotoxigenic strains tested produced vegetative cells and spores with significantly higher resistance than non-enterotoxigenic strains. These results suggest that the vegetative cells and spores have a competitive advantage over non-enterotoxigenic strains. However, no explanation has been provided for the significant associations between chromosomal cpe genotypes with the high resistance, which could explain the strong relationship between chromosomal cpe isolates and C. perfringens type A food poisoning. Here, we analyse the action of physical and chemical agent on non-enterotoxigenic and enterotoxigenic regional strains. And this study tested the relationship between the sensitivities of spores and their levels SASPs (small acid soluble proteins) production in the same strains examined.

A review of complications of odontogenic infections

Life-threatening infections of odontogenic or upper airway origin may extend to potential spaces formed by fascial planes of the lower head and upper cervical area. Complications include airway obstruction, mediastinitis, necrotizing fascitis, cavernous sinus thrombosis, sepsis, thoracic empyema, Lemierre's syndrome, cerebral abscess, orbital abscess, and osteomyelitis. The incidence of these "space infections" has been greatly reduced by modern antibiotic therapy. However, serious morbidity and even fatalities continue to occur. This study reviews complications of odontogenic infections. The search done was based on PubMed and Google Scholar, and an extensive published work search was undertaken. Advanced MEDLINE search was performed using the terms "odontogenic infections," "complications," and "risk factors."

Antibiotic prescription patterns among Swedish dentists working with dental implant surgery: adherence to recommendations

OBJECTIVES

To investigate antibiotic prophylaxis prescription behaviors among Swedish dentists working with dental implant surgery and the influence of scientific reviews.

MATERIAL AND METHODS

An observational questionnaire study was conducted in 2008 and 2012. Dental clinic addresses were found through online search services of Swedish telephone directories. The questionnaires were posted to eligible dentists (120 in 2008, 161 in 2012) in the Stockholm region, Sweden. Absolute frequencies were used to describe the data. Chi-square tests were applied to assess statistically significant differences.

RESULTS

The response rate was 75% in 2008 and 88% in 2012. In 2008, 88% of the dentists routinely prescribed antibiotic prophylaxis when performing implant surgery and 74% in 2012 (P = 0.01). There was a significant reduction in the dentists prescription patterns as 65% prescribed a single dose in 2012, compared to 49% in 2008 (P = 0.04). Amoxicillin was the drug of choice for 47% of the respondents in 2012, and 21% in 2008 (P = 0.01). Dentists without postgraduate clinical training were significantly more prone to extend antibiotic administration after surgery (P < 0.009).

CONCLUSIONS

There is a wide variation in the choice of compound and prescription patterns of prophylactic antibiotic prior to implant insertion. A reduction in antibiotic prescription to a single dose was observed comparing 2008 and 2012, probably influenced by scientific reviews. Dentists with postgraduate education are more likely to limit antibiotic usage.

Update on the clinical utility and optimal use of cefditoren

This article reviews and updates published data on cefditoren. The in vitro activity of cefditoren and its potential pharmacokinetic/pharmacodynamic adequacy to cover emerging resistance phenotypes in the present decade is reviewed. Cefditoren’s in vitro activity against most prevalent bacterial respiratory pathogens in the community and its pharmacokinetic/pharmacodynamic profile suggests a significant role for cefditoren in the treatment of respiratory tract infections. Clinical trials (in acute exacerbations of chronic bronchitis, community-acquired pneumonia, pharyngotonsillitis, and sinusitis) performed during clinical development outside Japan, mainly in adults, are reviewed, together with new clinical studies in the treatment of pharyngotonsillitis, sinusitis, and otitis media in children, mainly in Japan, for efficacy and safety assessment. The results of these studies support the adequacy of cefditoren for the treatment of community-acquired respiratory tract infections with a safety profile similar to previous oral antibiotics. From the data reviewed, it is concluded that cefditoren is an adequate option for the treatment of mild-to-moderate community-acquired respiratory infections, especially in geographical areas with a reported prevalence of phenotypes exhibiting nonsusceptibility to common oral antibiotics.

Risk factors for fluoroquinolone resistance in Gram-negative bacilli causing healthcare-acquired urinary tract infections

The prevalence of urinary tract infections caused by fluoroquinolone-resistant Gram-negative bacilli (FQ-resistant GNB-UTIs) has been increasing. Previous studies that explored risk factors for FQ resistance have focused only on UTIs caused by Escherichia coli and/or failed to distinguish colonisation from infection. We conducted a case-control study at two medical centres within the University of Pennsylvania Health System to identify risk factors for FQ resistance among healthcare-acquired GNB-UTIs. Subjects with positive urine cultures for GNB and who met Centers for Disease Control and Prevention criteria for healthcare-acquired UTI were eligible. Cases were subjects with FQ-resistant GNB-UTI and controls were subjects with FQ-susceptible GNB-UTI matched to cases by month of isolation and species of infecting organism. In total, 251 cases and 263 controls were included from 1 January 2003 to 31 March 2005. Independent risk factors (adjusted odds ratio; 95% confidence interval) for FQ resistance included male sex (2.03; 1.21-3.39; P=0.007), African-American race (1.80; 1.10-2.94; P=0.020), chronic respiratory disease (2.58; 1.18-5.62; P=0.017), residence in a long term care facility (4.41; 1.79-10.88; P=0.001), hospitalisation within the past two weeks (2.19; 1.31-3.64; P=0.003), hospitalisation under a medical service (2.72; 1.63-4.54; P<0.001), recent FQ exposure (15.73; 6.15-40.26; P<0.001), recent cotrimoxazole exposure (2.49; 1.07-5.79; P=0.033), and recent metronidazole exposure (2.89; 1.48-5.65; P=0.002).

Cefditoren in upper and lower community-acquired respiratory tract infections

This article reviews and updates published data on cefditoren in the evolving scenario of resistance among the most prevalent isolates from respiratory tract infections in the community (Streptococcus pyogenes, Haemophilus influenzae, and Streptococcus pneumoniae). By relating the in vitro activity of cefditoren (in national and multinational surveillance and against isolates with emerging resistant genotypes/phenotypes) to its pharmacokinetics, the cefditoren pharmacodynamic activity predicting efficacy (in humans, animal models, and in vitro simulations) is analyzed prior to reviewing clinical studies (tonsillopharyngitis, sinusitis, acute exacerbations of chronic bronchitis, and community-acquired pneumonia) and the relationship between bacterial eradication and clinical efficacy. The high in vitro activity of cefditoren against the most prevalent respiratory isolates in the community, together with its pharmacokinetics (enabling a twice daily regimen) leading to adequate pharmacodynamic indexes covering all S. pyogenes, H. influenzae, and at least 95% S. pneumoniae isolates, makes cefditoren an antibiotic that will play a significant role in the treatment of respiratory tract infections in the community. In the clinical setting, studies carried out with cefditoren showed that treatments with the 400 mg twice daily regimen were associated with high rates of bacteriological response, even against penicillin-nonsusceptible S. pneumoniae, with good correlation between bacteriological efficacy/response and clinical outcome.

Drug resistance in community-acquired respiratory tract infections: role for an emerging antibacterial

The nasopharynx is the ecological niche where evolution towards resistance occurs in respiratory tract isolates. Dynamics of different bacterial populations in antibiotic-free multibacterial niches are the baseline that antibiotic treatments can alter by shifting the competitive balance in favor of resistant populations. For this reason, antibiotic resistance is increasingly being considered to be an ecological problem. Traditionally, resistance has implied the need for development of new antibiotics for which basic efficacy and safety data are required prior to licensing. Antibiotic development is mainly focused on demonstrating clinical efficacy and setting susceptibility breakpoints for efficacy prediction. However, additional information on pharmacodynamic data predicting absence of selection of resistance and of resistant subpopulations, and specific surveillance on resistance to core antibiotics (to detect emerging resistances and its link with antibiotic consumption in the community) are valuable data in defining the role of a new antibiotic, not only from the perspective of its therapeutic potential but also from the ecologic perspective (countering resistances to core antibiotics in the community). The documented information on cefditoren gleaned from published studies in recent years is an example of the role for an emerging oral antibacterial facing current antibiotic resistance in community-acquired respiratory tract infections.

Socioeconomic factors and antibiotic use in relation to antimicrobial resistance in the Amazonian area of Peru

Our objective was to correlate antibiotic resistance in gut E. coli flora of children, aged 6-72 months, with use of antibiotics, socioeconomic status (SES) and household characteristics in the urban communities of Yurimaguas and Moyobamba in the Amazonian area of Peru. Caregivers of 1598 children were interviewed using a structured questionnaire in a cross-sectional survey. Faecal samples were collected from the children and the antimicrobial susceptibility of E. coli was analysed by a rapid resistance screening method. Significantly higher odds for resistance were seen for children who had used antibiotics, both during the last 2 weeks and the last 6 months. Children from wealthier families had significantly higher odds for resistance to a number of antibiotics than children from the least wealthy families (Yurimaguas: nalidixic acid, OR = 2.13; ciprofloxacin, OR = 2.09; chloramphenicol, OR = 1.98. Moyobamba: nalidixic acid, OR = 1.59; ciprofloxacin, OR = 1.69). Thus, the children of wealthier families had a significantly increased odds ratio for resistance, also when controlling for the family's antibiotic use. Unknown factors related to socioeconomic status seem to contribute to the results seen in the study area.

The British Society for Antimicrobial Chemotherapy Resistance Surveillance Project: a successful collaborative model

The British Society for Antimicrobial Chemotherapy (BSAC) Resistance Surveillance Project was initiated in light of the need for UK-wide surveillance of antibacterial resistance in key clinical pathogens. The Project comprises two defined-protocol programmes that cover a range of important pathogens and antibacterials related to community-acquired respiratory tract infection and bloodstream infection, respectively. The Respiratory Programme has reported quantitative susceptibility data for Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis collected from across the UK and Ireland since 1999. The Bacteraemia Programme has reported the susceptibility of a wide range of Gram-positive and -negative organisms since 2001. The sustainability of the Programmes relies on a unique collaborative funding model: sponsorship is provided by a number of pharmaceutical companies in return for the inclusion of their investigational or marketed agents in the study alongside a core panel of established antibacterials. The sponsors have changed over time according to their interest in participating. Results for marketed agents are communicated in a timely manner through the BSAC web site and by presentation and publication, and for investigational agents with the agreement of their sponsors. The Project satisfies the requirement for sustainable defined-protocol high-quality resistance surveillance across the UK and Ireland.

The withdrawal of antimicrobial treatment as a mechanism for defeating resistant microorganisms

Antimicrobial resistance is a major concern in health care and farming settings throughout the world. The level of antimicrobial resistance continues to increase and the requirement for a novel and possibly dramatic change in therapy choices is required. One possible mechanism for overcoming resistance is the actual removal of antimicrobial treatment from the therapeutic armoury. This review examines the potential for success of a policy advocating the reduction of antimicrobial use and additionally the withdrawal of such treatments. Evidence from agriculture suggests that the removal of certain drugs from animal husbandry can result in concomitant falls in certain drug resistances in human patients.

The efficacy of cefditoren pivoxil in the treatment of lower respiratory tract infections, with a focus on the per-pathogen bacteriologic response in infections caused by Streptococcus pneumoniae and Haemophilus influenzae: a pooled analysis of seven clinical trials

BACKGROUND

Community-acquired pneumonia (CAP) and acute exacerbations of chronic bronchitis (AECB) are frequently caused by Streptococcus pneumoniae, Haemopbilus influenzae, and Moraxella catarrbalis; thus, these are the target pathogens for antibiotic treatment.

OBJECTIVES

This pooled analysis was performed to evaluate the efficacy of cefditoren pivoxil (CDN) in patients with lower respiratory tract infections (CAP or AECB). A particular focus was the per-pathogen bacteriologic response rate among the most common causative pathogens, S pneumoniae, H influenzae, and M catarrbalis.

METHODS

The final reports of all clinical trials of CDN in the treatment of community-acquired lower respiratory tract infection were reviewed. Microbiologic outcome data for CDN 200 and 400 mg and comparator treatments were pooled from 4 CAP studies (3 randomized and 1 noncomparative) and 3 AECB studies. The comparators were the standard oral treatments clarithromycin 500 mg BID, cefuroxime 250 mg BID, cefpodoxime 200 mg BID, and amoxicillin/clavulanate 500/125 mg TID or 875/125 mg BID. Microbiologic response was defined as eradication of the initial pathogen or presumed eradication (absence of sputum for culture in a patient with a clinical response).

RESULTS

The bacteriologically evaluable population contained 654 patients in the CDN 200-mg group, 592 in the CDN 400-mg group, and 664 in the comparator group. A total of 1223 target pathogens were isolated before treatment: 406 isolates of S pneumoniae (including 56 penicillin-nonsusceptible [intermediate + resistant] strains), 595 isolates of H influenzae, and 222 isolates of M catarrbalis. The microbiologic response ranged from 84.1% to 88.8% in the CAP studies and from 75.1% to 77.1% in the AECB studies, with no differences between the CDN 200-mg, CDN 400-mg, and comparator groups. In the analysis of per-pathogen bacteriologic response, similar response rates were found for S pneumoniae (range, 88.5%-92.0%), H influenzae (range, 82.7%-86.6%), and M catarrbalis (range, 84.1%-95.2%), with no significant differences between groups. Focusing on penicillin-nonsusceptible (MIC >or=0.12 microg/mL) strains of S pneumoniae, CDN (both doses pooled) was associated with a response rate of 92.3% (36/39 isolates); all nonresponders were in the CDN 200-mg group. When only penicillin-resistant (MIC >or=2 microg/mL) strains were considered, there was only 1 nonresponder, again in the CDN 200-mg group. Thus, the overall response rate to CDN (both doses pooled) was 94.4% (17/18 isolates).

CONCLUSIONS

In this pooled analysis, CDN was associated with high rates of per-pathogen bacteriologic response among the main causative pathogens in lower respiratory tract infection. The rates of response were approximately 85% against H influenzae and approximately 90% against S pneumoniae, including penicillin-intermediate and penicillin-resistant strains.

Molecular graphics approach to bacterial AcrB protein–β-lactam antibiotic molecular recognition in drug efflux mechanism

AcrAB-TolC is the most important multidrug efflux pump system of Gram-negative bacteria, responsible for their resistance to lipophilic and amphiphilic drugs. In this work, a molecular graphics study of the pump components AcrB and TolC, 16 beta-lactam antibiotics and 7 other substrates, as well as of AcrB-substrate complexes, was performed in order to give a mechanistic proposal for the efflux process at molecular level. AcrAB-TolC is a proton-dependent electromechanical device which opens to extrude drugs from the bacterial periplasm and perhaps cytoplasm, by means of a series of structural changes within the complex and its components AcrA, AcrB and TolC. These changes are initiated by protonation and disruption of salt bridges and certain hydrogen bonds, and are followed by conformational changes in which a number of intra- and interchain interactions are rearranged. Molecular properties of beta-lactams accounting for their lipophilicity, shape/conformation and other sterical features, polar/charge group distribution and other electronic properties, and hydrogen bonding potency determine their interaction with polar headpieces of the inner membrane, recognition and binding to receptors of AcrB and TolC. The orientation of the beta-lactam molecular dipoles with respect the efflux system is maintained during the drug efflux. Elongated cylinder-like beta-lactam antibiotics with lipophylic side chains, a significantly negative component of the dipole moment and low hydrogen bonding capacity seem to be good substrates of AcrAB-TolC.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Is there cross-reactivity between penicillins and cephalosporins?

BACKGROUND

We sought to determine the risk of an allergic reaction to a cephalosporin exposure in those with prior penicillin reactions.

METHODS

We conducted a retrospective cohort study using the United Kingdom General Practice Research Database. We selected all patients receiving a prescription for penicillin followed by a prescription for a cephalosporin and identified allergic-like events within 30 days after each prescription. Allergic events were defined by 2 sets of codes: 1 more restrictive, 1 more inclusive. Comparison was made with a population of patients receiving a prescription for a penicillin followed by a prescription for a sulfonamide antibiotic.

RESULTS

A total of 3,375,162 patients received a penicillin; 506,679 (15%) received a subsequent cephalosporin. Among patients receiving a penicillin followed by a cephalosporin, the unadjusted risk ratio of an allergic-like event for those who had a prior event, compared with those who had no such prior event, narrowly defined, was 10.1 (confidence interval 7.4-13.8). The absolute risk of anaphylaxis after a cephalosporin was less than 0.001%. The unadjusted risk ratio for sulfonamide antibiotic, rather than cephalosporin after penicillin allergic-like events was 7.2 (confidence interval 3.8-13.5).

CONCLUSION

Patients with allergic-like events after penicillin had a markedly increased risk of events after either subsequent cephalosporins or sulfonamide antibiotics. Cross-reactivity is not an adequate explanation for this increased risk, and the risk of anaphylaxis is very low. Thus, our data indicate that cephalosporins can be considered for patients with penicillin allergy.

Antibiotic prophylaxis for dentoalveolar surgery: is it indicated?

Usually dentists in Australia give patients oral antibiotics after dentoalveolar surgery as a prophylaxis against wound infection. When this practice is compared to the principle of antibiotic prophylaxis in major surgery it is found to be at variance in a number of ways. In major surgery, the risk of infection should be high, and the consequences of infection severe or catastrophic, before antibiotic prophylaxis is ordered. If it is provided then a high dose of an appropriate spectrum antibiotic must be present in the blood prior to the first incision. Other factors which need to be considered are the degree of tissue trauma, the extent of host compromise, other medical comorbidities and length of hospitalization. Standardized protocols of administration have been determined and evaluated for most major surgical procedures. Dentoalveolar surgery is undoubtedly a skilled and technically challenging procedure. However, in contrast to major surgical procedures, it has a less than five per cent infection rate and rarely has severe adverse consequences. Dentoalveolar surgery should be of short duration with minimal tissue damage and performed in the dental chair under local anaesthesia. Controlled studies for both mandibular third molar surgery and placement of dental implants show little or no evidence of benefit from antibiotic prophylaxis and there is an adverse risk from the antibiotic. This review concludes that there is no case for antibiotic prophylaxis for most dentoalveolar surgery in fit patients. In the few cases where it can be considered, a single high preoperative dose should be given.

Problem-based, peer-facilitated education about antibiotic prescribing

AIMS

To assess the feasibility and acceptability of a problem-based, peer-facilitated educational workshop about antibiotic prescribingfor GPs.

METHOD

PARTICIPANTS

All 39 GPs working in an average sized Local Health Care Co-operative (LHCC) in Glasgow.

INTERVENTION

Prospective collection of information about 10 prescriptions for antibiotics to assess learning needs in relation to antibiotic prescribing. Two and a half hour workshop involving problem-based group work based on the needs assessment and discussions with a consultant microbiologist, prescribing adviser and academic GP.

EVALUATION

Written feedback about the process of the educational intervention immediately after the workshop and outcome feedback collected after four weeks. Telephone interviews with non-participants.

RESULTS

Twenty-four GPs agreed to participate in the study. 19 of these completed the Needs Assessment and 14 of these completed the workshop. The method of learning needs assessment and the educational workshop were highly acceptable. "No time, too busy" was the main reason given for not taking part in the study.

CONCLUSION

Some GPs are unable to participate as fully as they would like in continuing professional learning activities due to competing workload pressures. Further research is required to investigate the necessary type and balance of learning activities and the barriers to engagement to ensure the most effective use of clinician time available for continuing educational activities.

Treatment of acute exacerbation of severe-to-very severe COPD with azithromycin in patients vaccinated against Streptococcus pneumoniae

Sixty-five consecutive eligible adult patients, who were treated as outpatients for stable severe-to-very severe COPD, were enrolled in the study. All of them received 23-valent pneumococcal capsular polysaccharide vaccine intramuscularly. Patients were seen monthly, as well as whenever they had symptoms suggestive of an exacerbation, at our outpatient clinic. Eighteen out of 65 patients suffered from acute exacerbation (AECOPD). Three of these patients presented two episodes of AECOPD. Patients with an acute exacerbation of COPD received azithromycin 500 mg/day once daily for 3 days and a short course of oral prednisolone 25 mg/die. In 16 cases, a single species was isolated, while in the remaining 5 cases at least two species were recovered. Clinical cure or improvement at the end of therapy (3-5 days post-therapy) was reported in 17 episodes of AECOPD with no relapse at the late post-therapy (10-14 days after the completion of treatment). Bacteriologic eradication or presumptive eradication rates at the end of therapy were 86% (24 out of 28 isolates). Azithromycin eradicated all isolates of Haemophilus influenzae, Moraxella catarrhalis, H. parainfluenzae, Klebsiella pneumoniae, and Klebsiella spp. isolated at baseline. Eradication of Sta aureus occurred in 1 of 3 isolates whereas azithromycin was unable to eradicate Pseudomonas aeruginosa isolates. Our data seem to indicate that pneumococcal vaccination reduces the possibility that an AECOPD is caused by Streptococcus pneumoniae. This finding allows the use of antibiotics such as azithromycin, which, otherwise, should be avoided because of resistances.

Antibiotic Resistance Pattern Among Aerobic Gram Negative Bacilli Isolated from Patients in Intensive Care Units

To study the antimicrobial resistance pattern of aerobic Gram-negative bacilli isolated from patients in intensive care units in Hamad Medical Corporation, 108 non-duplicate isolates from 60 patients with nosocomial infections were determined by Vitek machine. The minimal inhibitory concentration of 14 antimicrobials was determined by E-test and results were interpreted according to the National Committee for Clinical Laboratory Standards guidelines. The most common species was Pseudomonas aeruginosa High levels of resistance were seen to second and third generation cephalosporins, piperacillin, fi-lactam Ji-lactamase inhibitors combinations, and gentamicin. The most active agents were amikacin, meropenem and imipenem (resistance 19%, 19%, 20% respectively). We conclude that second and third generation cephalosporins, piperacillin, fi-lactam/fi-lactamase inhibitors combinations and gentamicin are not suitable drugs for empirical monotherapy for aerobic Gram-negative infections in intensive care units in Qatar.

An investigation of therapeutic antibiotic prescribing for children referred for dental general anaesthesia in three community national health service trusts

OBJECTIVE

To investigate antibiotic prescribing for paediatric dental patients requiring general anaesthesia.

DESIGN

A prospective clinical study of children referred for dental treatment under general anaesthesia.

METHOD

Information was collected by way of a two-stage questionnaire for children attending three community NHS trusts for dental extractions under general anaesthesia between July 2001 and January 2003.

RESULTS

A total of 360 questionnaires were analysed. There was wide variation in the waiting times (0-278 days) between referral and treatment under general anaesthesia. Most children (53%) attended with dento-alveolar abscess, 46% with caries only and 1% for orthodontic extractions. Antibiotics were prescribed to 52% of patients with an abscess and 32% with caries only. Only 16% of patients presented with moderate to severe pain, 5.5% with diffuse swelling and 12% with a raised temperature. Antibiotics were prescribed for patients with diffuse swelling (63%) and raised temperature (50%) but also for patients with pain only (39%) and localised swelling (52%). Amoxicillin was the most frequently prescribed antibiotic (82%), with wide variation in all antibiotic regimens.

CONCLUSION

This study provides evidence of inappropriate prescribing of antibiotics to children referred for treatment under general anaesthesia with wide variations in the regimens employed. There was no conclusive evidence that long waiting times for definitive treatment influenced antibiotic prescribing. In some areas the delay for definitive treatment for this group of vulnerable patients was unacceptably long.

C-reactive protein measurement in general practice may lead to lower antibiotic prescribing for sinusitis

BACKGROUND

Symptoms of bacterial sinusitis overlap with viral sinusitis, and it is difficult to distinguish between the two conditions based only on a clinical examination. Uncertain diagnosis results in the significant overuse of antibiotics, which is considered to be one of the most important reasons for development of bacterial resistance to antibiotics. A raised C-reactive protein (CRP) level is an indicator of bacterial infection and the CRP rapid test has been shown to be useful for the diagnosis of bacterial sinusitis in general practice.

AIMS

To examine whether general practitioners (GPs) who use the CRP rapid test in their practice have a lower antibiotic prescribing rate for sinusitis than GPs who do not use the test.

DESIGN OF STUDY

Observational design.

SETTING

General practice in Denmark.

METHOD

A group of GPs registered all contacts (n = 17 792) with patients who had respiratory tract infections during a 3-week period between 1 November 2001 and 31 January 2002. GPs who used a CRP rapid test were compared with GPs who did not, and the treatment of their patients (n = 1444) with suspected sinusitis was compared.

RESULTS

A CRP rapid test was used by 77% (n = 281) of the GPs. In the group of GPs using a CRP rapid test, the rate of antibiotic prescribing was 59% (95% confidence interval [CI] = 56 to 62) compared with 78% (95% CI = 73 to 82) in the group of GPs who did not use a CRP test. Performing a CRP rapid test was the factor that exerted the greatest influence on whether the patients were prescribed antibiotics, and the level of CRP had a strong influence on the prescribing rate.

CONCLUSION

The CRP rapid test has a substantial influence on the treatment of sinusitis, and implementing the test in general practice may lead to a reduction in antibiotic prescribing to patients with sinusitis.

Optimizing antibiotic prescribing for acute cough in general practice: a cluster-randomized controlled trial

OBJECTIVES

To assess the effect of a tailored professional intervention, including academic detailing, on antibiotic prescribing for acute cough.

METHODS

In a cluster-randomized controlled before and after study 85 Flemish GPs included adult patients with acute cough consulting in the periods February-April 2000 and 2001. The intervention consisted of a clinical practice guideline for acute cough, an educational outreach visit and a postal reminder to support its implementation in January 2001. Antibiotic prescribing rates and patients' symptom resolution were the main outcome measures.

RESULTS

Thirty-six of 42 GPs received the intervention and 35 of 43 GPs served as controls; 1503 patients were eligible for analysis. Only in the intervention group were patients less likely to receive antibiotics after the intervention [OR(adj) (95% CI)=0.56 (0.36-0.87)]. Prescribed antibiotics were also more in line with the guideline in the intervention group [1.90 (0.96-3.75)] and less expensive from the perspective of the National Sickness and Invalidity Insurance Institute [MD(adj) (95% CI)= Euro -6.89 [-11.77-(-2.02)]]. No significant differences were found between the groups for the time to symptom resolution.

CONCLUSIONS

An (inter)actively delivered tailored intervention implementing a guideline for acute cough is successful in optimizing antibiotic prescribing without affecting patients' symptom resolution. Further research efforts should be devoted to cost-effectiveness studies of such interventions.

Measurement of interleukin 8 in combination with C-reactive protein reduced unnecessary antibiotic therapy in newborn infants: a multicenter, randomized, controlled trial

OBJECTIVE

Neonatal bacterial infections carry a high mortality when diagnosed late. Early diagnosis is difficult because initial clinical signs are nonspecific. Consequently, physicians frequently prescribe antibiotic treatment to newborn infants for fear of missing a life-threatening infection. This study was designed to test the hypotheses that a diagnostic algorithm that includes measurements of interleukin 8 (IL-8) and C-reactive protein (CRP) 1) reduces antibiotic therapy and 2) does not result in more initially missed infections compared with standard management that does not include an IL-8 measurement.

METHODS

Term and preterm infants who were <72 hours of age and had clinical signs or obstetric risk factors suggesting neonatal bacterial infection but stable enough to wait for results of diagnostic tests were enrolled into the study. A total of 1291 infants were randomly assigned to receive antibiotic therapy according to the guidelines of each center (standard group) or to receive antibiotic therapy when IL-8 was >70 pg/mL and/or CRP was >10 mg/L (IL-8 group). The primary outcome variables were 1) the number of infants treated with antibiotics and 2) the number of infants with infections missed at the initial evaluation.

RESULTS

In the IL-8 group, fewer infants received antibiotic therapy than in the standard group (36.1% [237 of 656] vs 49.6% [315 of 635]). In the IL-8 group, 24 (14.5%) of 165 infants with infection were not detected at the initial evaluation, compared with 28 (17.3%) of 162 in the standard group.

CONCLUSIONS

The number of newborn infants who received postnatal antibiotic therapy can be reduced with a diagnostic algorithm that includes measurements of IL-8 and CRP. This diagnostic strategy seemed to be safe.

Represcription of penicillin after allergic-like events

OBJECTIVE

We sought to determine the frequency of represcription of penicillin to individuals with penicillin allergy and the risk of a second reaction in those who had a previous reaction.

METHODS

A retrospective cohort study was conducted within the UK General Practice Research Database. All patients who had received a prescription for penicillin were identified. Within that source population, records of patients who had received at least 2 prescriptions for penicillin at least 60 days apart were selected and examined for allergic-like (hypersensitivity) events on the day of or within 30 days after a prescription.

RESULTS

At least one prescription for penicillin was given to 3,375,162 patients. Of 6212 (0.18%) patients who experienced an allergic-like event after the initial prescription, 48.5% were given a second prescription compared with 59.8% of those without an initial allergic-like event (risk ratio, 0.81; 95% CI, 0.79-0.83). Two or more prescriptions for penicillin were given to 2,017,957 patients. Three thousand fourteen (0.15%) patients experienced an allergic-like event after the first prescription, and 57 (1.89%) of those had another event after the second prescription. The unadjusted odds ratio of an allergic-like event after the second prescription for those who experienced an allergic-like event after the first prescription, compared with those who had no initial event was 11.2 (95% CI, 8.6-14.6). Adjusting for confounding had no substantive effect on this result.

CONCLUSION

The risk of an allergic-like event after penicillin is markedly increased in those who have had a prior event, although the absolute difference is small (1.72%). Represcription of penicillin to such patients is more frequent than anticipated.

¿Cuál es la importancia de la erradicación bacteriana en el tratamiento de la infección respiratoria?

During the last few years, increasing antibiotic resistance amongst the major respiratory pathogens in the community has compromised the choice of empirical therapy for some respiratory tract infections. Of special interest has been the progressive increase in the resistance rates of Streptococcus pneumoniae to macrolides and penicillin, and of S. pyogenes to macrolides. Several studies have confirmed the association between community use of certain antibiotics and the development of resistance in S. pneumoniae and S. pyogenes. Nevertheless, not all the antibiotics have the same ability to select resistance and not all microorganisms are affected in the same way. The aim of antimicrobial therapy in respiratory tract infections is bacterial eradication. Pharmacokinetic and pharmacodynamics can be used to predict bacteriological eradication with antimicrobial therapy.

Macrolide resistance in Streptococcus pneumoniae isolated from patients with community-acquired lower respiratory tract infections in Portugal: results of a 3-year (1999-2001) multicenter surveillance study

A nationwide multicenter study (including 31 laboratories) of the antimicrobial susceptibility of 1210 Streptococcus pneumoniae isolates from patients with community-acquired lower respiratory tract infections (LRTI) was carried out over 3 years (1999-2001) in Portugal. Testing of all isolates was undertaken in a central laboratory. Overall macrolide resistance was 13.1%. Decreased susceptibility to penicillin was 24.5% (15.5% low-level and 9.0% high-level resistance). Taken into consideration, the resistance rates reported in a previous surveillance study of 1989-1993, a six-fold increase of erythromycin resistance in the last decade was documented. Resistance to erythromycin, clarithromycin, and azithromycin was higher in pediatric patients than in adults. The overwhelming majority (82.3%) of macrolide-resistant isolates were multidrug resistant, although 44.9% were fully susceptible to penicillin. Most macrolide-resistant isolates (80.4%) showed the MLSB phenotype (76.6% MLSB-constitutive resistance, and 3.8% MLSB-inducible resistance) and were also resistant to clindamycin, tetracycline, and co-trimoxazole. The M phenotype was seen in 19.6% isolates and these had MIC90 values of 8 mg/L for erythromycin and clarithromycin, and of 12 mg/L for azithromycin. The clinical significance of macrolide resistance in the management of LRTI is discussed. Because of the specific situation concerning macrolide resistance described in S. pneumoniae, careful use of macrolide antibiotics in therapy and cautious monitoring of macrolide resistance should be continued in Portugal.

Combating bacterial resistance in otorhinolaryngology

Bacterial resistance appears to be an ever-increasing problem and is threatening to spiral out of control. The scare caused by the rapid spread of methicillin-resistant Staphylococcus aureus among hospitals in the UK is the most recent. Otorhinolaryngology is deeply involved in this problem, as one of the reasons often cited for increasing bacterial resistance is the use of antibiotics in suspected bacterial infections in ear, nose and throat by primary care physicians. This speciality is also involved in the development of guidelines for antimicrobial use by primary and secondary care. This review attempts to discuss the reason for the development of antimicrobial resistance especially in relation to otorhinolaryngology, what can be done to contain this menace and the surveillance system developed to monitor the trend in the development of bacterial resistance.

Antibiotics for coughing in general practice: a questionnaire study to quantify and condense the reasons for prescribing

BACKGROUND

Antibiotics are being overprescribed in ambulant care, especially for respiratory tract infections (RTIs). Gaining insight into the actual reasons for prescribing remains important for the design of effective strategies to optimise antibiotic prescribing. We aimed to determine items of importance for the antibiotic prescribing decision and to make them operational for an intervention trial.

METHODS

A postal questionnaire based upon focus group findings was sent to 316 Flemish general practitioners (GPs). On a verbal rating scale the GPs scored to what extent they consider the questionnaire items in decision making in case of suspected RTI in a coughing patient and how strongly the items support or counter antibiotic treatment. Factor analysis was used to condense the data. The relative importance of the yielded operational factors was assessed using Wilcoxon Matched Pairs test.

RESULTS

59.5% completed the study. Response group characteristics (mean age: 42.8 years; 65.9% men) approximated that of all Flemish GPs. Participants considered all the items included in the questionnaire: always the operational factor 'lung auscultation', often 'whether or not there is something unusual happening' - both medical reasons - and to a lesser extent 'non-medical reasons' (P < 0.001). Non-medical as well as medical reasons support antibiotic treatment, but non-medical reasons to a lesser extent (P < 0.001).

CONCLUSION

This study quantified, condensed and confirmed the findings of previous focus group research. Practice guidelines and interventions to optimise antibiotic prescribing have to take non-medical reasons into account.

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

The aim of this study was to survey current treatment practices for common infections in primary care as a basis for implementation of recently released evidence-based guidelines for community-acquired infections. A point-prevalence survey was conducted in 30 health centres in the Finnish primary care system with a population base of 819,777. All patients consulting the health centres for an infection during a 1-week period were included in the study. The main outcome measures were the prevalence of antibiotic prescription and the selection of drugs by infection diagnosis. Of the 7777 recorded consultations, 85% were with a physician and the rest with a nurse. The most common cause for a visit was respiratory tract infections (74%), followed by skin/wound infections and urinary tract infections (both 6%). The infection panorama varied markedly according to age: in the youngest children (< 5 y) 84% of the infections were respiratory tract infections whereas the corresponding figure for patients > 65 y was 50%; the proportions of visits for urinary tract infections in these age groups were 7% and 26%, respectively. Of the patients with acute bronchitis, 70% were treated with antimicrobial agents, mostly macrolides (39%) and doxycycline (36%). Of the otitis media patients, 53% were treated with amoxicillin, 16% with macrolides and 16% with sulphatrimethoprim. Macrolides were mostly used to treat otitis media (31%), acute bronchitis (26%) and sinusitis (20%). In conclusion, antimicrobial agents are still used excessively in Finland, particularly for the treatment of acute bronchitis. Moreover, the selection of drugs for treating sinusitis and otitis media is non-optimal; macrolides and cephalosporins are frequently chosen unnecessarily. Knowledge of the indication-based prescription practices for antimicrobial agents is essential in order to improve the treatment habits of primary care physicians. The data obtained in this study provide a unique tool for the active and targeted implementation of evidence-based guidelines for primary care physicians.

Chlamydia trachomatis in subfertile women undergoing uterine instrumentation. The clinician's role

Most women attending a fertility clinic will undergo uterine instrumentation either diagnostically and/or therapeutically. This places them at potential risk of chlamydial pelvic inflammatory disease. Clinicians remain unclear about the roles of screening, serology and prophylactic antibiotics. A review of the evidence suggests that women <25 years and those older with risk factors, men with risk factors and gamete donors should have their lower genital tract screened for Chlamydia trachomatis by a sensitive test. More information is required before screening men by age can be recommended. Serology in its present form cannot be advocated as a screening tool. Those women with a past history of chlamydial morbidity or a diagnosis of tubal pathology should, in addition to screening, be covered with prophylactic antibiotics when undergoing uterine instrumentation. The partner should be screened for sexually transmitted infections. Non-selective use of prophylactic antibiotics serves only to increase the problem of antibiotic resistance and maintain the bacterial load of chlamydia in the community.

Azithromycin for acute bronchitis: a randomised, double-blind, controlled trial

BACKGROUND

The value of azithromycin for treatment of acute bronchitis is unknown, even though this drug is commonly prescribed. We have investigated this question in a randomised, double-blind, controlled trial.

METHODS

Adults diagnosed with acute bronchitis, without evidence of underlying lung disease, were randomly assigned azithromycin (n=112) or vitamin C (n=108) for 5 days (total dose for each 1.5 g). All individuals were also given liquid dextromethorphan and albuterol inhaler with a spacer. The primary outcome was improvement in health-related quality of life at 7 days; an important difference was defined as 0.5 or greater. Analysis was by intention to treat.

FINDINGS

The study was stopped by the data-monitoring and safety committee when 220 patients had been recruited. On day 7, the adjusted difference in health-related quality of life was small and not significant (difference 0.03 [95% CI -0.20 to 0.26], p=0.8). 86 (89%) of 97 patients in the azithromycin group and 82 (89%) of 92 in the vitamin C group had returned to their usual activities by day 7 (difference 0.5% [-10% to 9%], p>0.9). There were no differences in the frequency of adverse effects; three patients in the vitamin C group discontinued the study medicine because of perceived adverse effects, compared with none in the azithromycin group. Most patients (81%) reported benefit from the albuterol inhaler.

INTERPRETATION

Azithromycin is no better than low-dose vitamin C for acute bronchitis. Further studies are needed to identify the best treatment for this disorder.

Antimicrobial susceptibilities of 1,684 Streptococcus pneumoniae and 2,039 Streptococcus pyogenes isolates and their ecological relationships: results of a 1-year (1998-1999) multicenter surveillance study in Spain

A nationwide multicenter susceptibility surveillance study which included 1,684 Streptococcus pneumoniae and 2,039 S. pyogenes isolates was carried out over 1 year in order to assess the current resistance patterns for the two most important gram-positive microorganisms responsible for community-acquired infections in Spain. Susceptibility testing was done by a broth microdilution method according to National Committee for Clinical Laboratory Standards M100-S10 interpretative criteria. For S. pneumoniae, the prevalences of highly resistant strains were 5% for amoxicillin and amoxicillin-clavulanic acid; 7% for cefotaxime; 22% for penicillin; 31% for cefuroxime; 35% for erythromycin, clarithromycin, and azithromycin; and 42% for cefaclor. For S. pyogenes, the prevalence of erythromycin resistance was 20%. Efflux was encountered in 90% of S. pyogenes and 5% of S. pneumoniae isolates that exhibited erythromycin resistance. Erythromycin resistance was associated with clarithromycin and azithromycin in both species, regardless of phenotype. Despite the different nature of the mechanisms of resistance, a positive correlation (r = 0.612) between the two species in the prevalence of erythromycin resistance was found in site-by-site comparisons, suggesting some kind of link with antibiotic consumption. Regarding ciprofloxacin, the MIC was >or=4 microg/ml for 7% of S. pneumoniae and 3.5% of S. pyogenes isolates. Ciprofloxacin resistance (MIC, >or=4 microg/ml) was significantly (P < 0.05) associated with macrolide resistance in both S. pyogenes and S. pneumoniae and with penicillin nonsusceptibility in S. pneumoniae.

Antibacterial prescribing and antibacterial resistance in English general practice: cross sectional study

OBJECTIVE

To quantify the relation between community based antibacterial prescribing and antibacterial resistance in community acquired disease.

DESIGN

Cross sectional study of antibacterial prescribing and antibacterial resistance of routine isolates within individual practices and primary care groups.

SETTING

405 general practices (38 groups) in south west and north west England.

MAIN OUTCOME MEASURES

Correlation between antibacterial prescribing and resistance for urinary coliforms and Streptococcus pneumoniae.

RESULTS

Antibacterial resistance in urinary coliform isolates is common but the correlation with prescribing rates was relatively low for individual practices (ampicillin and amoxicillin r(s)=0.20, P=0.001; trimethoprim r(s)=0.24, P=0.0001) and primary care groups (ampicillin and amoxicillin r(s)=0.44, P=0.05; trimethoprim r(s)=0.31, P=0.09). Regression coefficients were also low; a practice prescribing 20% less ampicillin and amoxicillin than average would have about 1% fewer resistant isolates (0.94/100; 95% confidence interval 0.02 to 1.85). Resistance of S pneumoniae to both penicillin and erythromycin remains uncommon, and no clear relation with prescribing was found.

CONCLUSIONS

Routine microbiological isolates should not be used for surveillance of antibacterial resistance in the community or for monitoring the outcome of any change in antibacterial prescribing by general practitioners. Trying to reduce the overall level of antibiotic prescribing in UK general practice may not be the most effective strategy for reducing resistance in the community.

Improving inpatient antibiotic prescribing: insights from participation in a national collaborative

BACKGROUND

Increasing rates of antimicrobial resistance and the role antibiotic overuse plays in contributing to this problem have been widely documented and have prompted appeals to change prescribing practices. How to actually achieve such changes represents a major challenge. As part of the Institute for Healthcare Improvement (IHI) Breakthrough Series project Improving Prescribing Practices (IPP), in 1997-1998, Cook County Hospital (Chicago) worked with other institutions that chose antibiotics as their focus in this national collaborative.

PRACTICAL SUGGESTIONS

Practical suggestions are offered within six categories--adopting a general approach to improving antibiotic prescribing (marshalling credible evidence, addressing physician concerns and skepticism, and removing barriers to make it easier for prescribers to change); rethinking guidelines (providing syndrome-based guidance, revising national guidelines for local use, defining scenarios in which drug(s) can be safely withheld, offering alternatives, prospectively resolving conflicts over drug of choice and empiric regimens, and defining situations in which immediate treatment is and is not critical); getting the message out and changes implemented (using antibiotic order forms, computer order entry, and infectious disease specialist consultation); building viable linkages to leverage change (bridging disciplines); improving measurement; and promoting nondrug strategies and patients' roles in treating and preventing infection.

CONCLUSION

Antimicrobials are unique, being the only class of drug therapy that affects not only the patient to whom it is prescribed but other current and future patients as well. Institutions therefore have a special responsibility to ensure their efficient and judicious use. It is often easier to prescribe antibiotics than to exercise restraint.

Surveillance of antimicrobial resistance--what, how and whither?

OBJECTIVE

To express the views of a working party held to consider antibiotic resistance surveillance systems, their strengths and weaknesses, and their current and future applications.

METHODS

The participants, all of whom were experienced in this field, discussed the development of surveillance systems in relation to the increasing prevalence of resistance to antibacterial agents and the current interest in surveillance systems shown by many official bodies, in both the human and veterinary fields. The problems inherent in surveillance systems were considered together with the applications of different systems.

RESULTS

The properties of good antibiotic resistance surveillance systems were defined. Surveillance systems vary widely from those with a narrow base, focusing on few organisms in one disease area, to those covering many diseases, many organisms (including normal flora) and many compounds. Whatever their design, they should be able to detect significant differences and shifts in susceptibility to various antibacterial agents, and the information derived from them should reach as many interested parties as possible in a timely manner. In using this information to decide strategies, criteria for action need to be determined by pragmatic consensus. Funding remains a major problem, with few large studies being supported by official bodies in spite of their professed enthusiasm for surveillance. In consequence, many current systems are funded by the pharmaceutical industry and are of necessity restricted in their focus.

CONCLUSIONS

Antibiotic resistance surveillance studies should and can be well planned and well executed. Many current systems suffer from well-recognized but uncorrected biases. Consortium funding will be necessary for large schemes to be successful. There is no "ideal" surveillance system.

Trends in primary care antibiotic prescribing in England 1994-1998

PURPOSE

To investigate the changing decisions to prescribe antibiotics as manifest in the patterns of prescriptions dispensed in England, and to investigate antibiotic prescribing in different types of practice.

METHODS

Antibiotic prescribing data and practice characteristics collected for every practice in England for the years 1994/5-1997/8. Morbidity data for common infections was also obtained from published sources.

RESULTS

Antibiotic prescribing was related to practice characteristics, with high prescribing in deprived and single-handed practices in particular. There was a fall in antibiotic prescribing in all types of practice of practice over the period of the study. Morbidity data from other sources shows a fall in diagnosed morbidity from some infectious diseases over the same period. There were no differences in choice of antibiotic in different types of practice.

CONCLUSIONS

The fall in antibiotic prescribing is universal across all kinds of practices and is possibly related to the fall in diagnoses. It is uncertain whether this reflects true morbidity.

A case study of nurse management of upper respiratory tract infections in general practice

BACKGROUND

Nurses increasingly manage acute illness in United Kingdom (UK) general practice. Few data exist about patients routinely consulting with these nurses. There are concerns that providing this additional service will lower thresholds for consulting with an overall increase in workload. Upper respiratory tract infection (URTI) is the commonest reason for consulting. Inappropriate antibiotics promote resistant bacteria. Nurse management of URTI is an ideal opportunity to promote self-care and nonantibiotic management.

AIMS

To describe the effects of a specially trained practice nurse managing URTI in a general practice in Cardiff, UK.

METHODS

Descriptive study.

RESULTS

Data were collected on 132 patients consulting with the nurse. We also collected data on 234 patients consulting general practitioners (GPs) in the same practice. Patients seen by the nurse were younger and less likely to be given antibiotics at the time of their index illness than those who saw GPs (7% vs. 93%; P < 0.001). During the year following the consultation with the nurse, patients consulted slightly less often and received antibiotics for URTI less often compared with the year preceding this consultation (P=0.02). Their consultation rate for all conditions did not change. The consultation rates for URTI of the patients managed by the GPs remained constant and consultations for all conditions increased (P < 0.01).

CONCLUSIONS

Nurse management of URTI did not lower patients' threshold for future consulting, and patients who saw her were prescribed antibiotics less often.

Effect of antimicrobial apomyoglobin 56-131 peptide on liposomes and planar lipid bilayer membrane

The horse apomyoglobin 56-131 peptide is a convenient object for studies on the recently discovered antimicrobial activities of haem-binding protein fragments called haemocidins. The purpose of this study was to determine the effect of this peptide on planar lipid bilayer membranes and on liposomes of different lipid compositions. Micromolar concentrations of the apomyoglobin 56-131 fragment disrupt phosphatidylserine/phosphatidylethanolamine planar lipid bilayers without discrete conductance changes. The observed detergent-like action is dependent on peptide concentration; the lower amount of peptide resulted in longer bilayer lifetime. The cholesterol has an inhibitory effect on peptide-induced liposome lysis as shown by calcein release from liposomes. Additionally, there was considerable lytic activity on liposomes formed from anionic lipids of the sort found in bacterial membranes. Circular dichroism (CD) experiments showed that the peptide had a disordered structure in aqueous solutions and folds gradually to form helices in both membrane-mimetic trifluoroethanol solutions as well as in liposome suspensions. The features of the apomyoglobin 56-131 fragment that are similar to the cationic antimicrobial peptides acting in a 'carpet-like' manner are discussed.

Management of urinary tract infection in general practice: a cost-effectiveness analysis

BACKGROUND

Symptoms associated with urinary tract infection (UTI) are common in women in general practice and represent a significant burden for the National Health Service. There is considerable variation among general practitioners in the management of patients presenting with these symptoms.

AIM

To identify the most appropriate patient management strategy given current information for non-pregnant, adult women presenting in general practice with symptoms of uncomplicated UTI.

METHOD

A decision analytic model incorporating a variety of patient management strategies was constructed using available published information and expert opinion. This model was able to provide guidance on current best practice based upon cost-effectiveness (cost per symptom-free day).

RESULTS

Empiric treatment was found to be the least costly strategy available. It saved two days of symptoms per episode of UTI at a cost of 14 Pounds. The empiric-and-laboratory strategy involves an incremental cost-effectiveness ratio of 215 Pounds per symptom day averted per episode of UTI. The remaining patient management strategies are never optimal.

CONCLUSION

Empiric treatment of patients presenting with symptoms of UTI was found to be cost-effective under a range of assumptions for this patient group. However, recognition of the impact of this strategy upon antibiotic resistance may lead to the dipstick strategy being considered a superior strategy overall.