Use of rapid diagnostic tests and choice of antibiotics in respiratory tract infections in primary healthcare--a 6-y follow-up study

Use of point-of-care tests in pharyngotonsillitis - a registry-based study in primary health care

BACKGROUND

Point-of-care (POC) tests, including C-reactive protein (CRP) tests and rapid antigen detection tests (RADT) for group A streptococci (GAS), are widely used in Swedish primary health care (PHC). This study quantifies their use in pharyngotonsillitis and explore their association with antibiotic prescribing.

MATERIAL AND METHODS

Retrospective data from 2012-2016 in Region Kronoberg, Sweden, included all PHC visits with a pharyngotonsillitis diagnosis. Patient characteristics, test usage and antibiotic prescriptions were linked by visit date and personal identification number. Descriptive statistics were used for POC test analysis. Logistic regression assessed the association between CRP levels and antibiotic prescribing.

RESULTS

Of 24,237 visits, 68% included RADT and 36% included a CRP test, with 89% of CRP tests performed alongside RADT. CRP testing was more frequent in patients with negative (56%) than positive RADTs (42%) (p < .001). Overall, 66% of RADTs were positive. Median CRP levels were 23 mg/l for positive RADT and 31 mg/l for negative RADT (p < .001). Antibiotics were prescribed for 95% of positive RADTs and 43% of negative RADTs (p < .001). In patients with negative RADTs, CRP testing was associated with higher antibiotic prescribing (57%) compared to no CRP testing (26%) (p < .001). Among these patients, CRP levels were associated with prescribing (aOR 1.032; 95% CI 1.029-1.035; p < .001), with 50% of prescriptions occuring at CRP levels ≤ 20 mg/l.

CONCLUSION

The use of RADTs and the proportion of positive test were higher than expected, indicating inappropriate use and diagnostic bias. CRP testing, contrary to guidelines, was common and associated with increased antibiotic prescribing.

Assessment of Medical Test Overuse and Its Impact on Pediatric Emergency Department Outcomes in Upper Respiratory Tract Infections in a University Hospital in Lithuania

Medical overuse poses potential risks to patients and contributes to increasing healthcare costs, pediatric emergency departments (PED) in particular. Often, upper respiratory tract infection (URTI) cases are viral-induced and self-limiting, and they do not require specific investigations or treatment. We conducted a retrospective study from 1 December 2021 to 31 January 2022, thereby aiming to identify the common tests and factors influencing specific diagnostic and treatment decisions for URTI in PED. In total, 307 (74.9%) URTI cases underwent complete blood count (CBC) tests, 312 (76.1%) were subjected to C-reactive protein (CRP) tests, and 110 (26.8%) received urinalysis tests. Patients with a longer duration of fever and a physician's suspicion of bacterial infection were more likely to receive CBC, CRP, and/or urinalysis tests (p < 0.05). Moreover, 75.1% of the cases were classified as viral URTIs, 9.8% were bacterial URTIs, and 15.1% were unspecified. Notably, 86 (20.1%) children received antibiotics and antibiotic prescription correlated with age, tonsillitis diagnosis, CRP values higher than 30 mg/L, and a CBC of p < 0.05. Patients triaged in the second or third categories were three times more likely to be observed for 24 h compared to patients with URTI and the fourth triage category (p < 0.05). This study highlights the need for interventions to improve the appropriateness of emergency service utilization, thereby emphasizing the importance of judicious decision making in managing pediatric URTIs.

Antibiotic consumption for sore throat and the potential effect of a vaccine against group A Streptococcus: a systematic review and modelling study

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.

Influence of a guideline or an additional rapid strep test on antibiotic prescriptions for sore throat: the cluster randomized controlled trial of HALS (Hals und Antibiotika Leitlinien Strategien)

BACKGROUND

Pharyngitis due to Group A beta-hemolytic streptococci (GAS) is seen as the main indication for antibiotics for sore throat. In primary care settings prescription rates are much higher than the prevalence of GAS. Recommendations in international guidelines differ considerably. A German guideline suggested to consider antibiotics for patients with Centor or McIsaac scores ≥ 3, first choice being penicillin V for 7 days, and recommended analgesics for all. We investigated, if the implementation of this guideline lowers the antibiotic prescription rate, and if a rapid antigen detection strep-test (RADT) in patients with scores ≥ 3 lowers the rate further.

METHODS

HALS was an open pragmatic parallel group three-arm cluster-randomized controlled trial. Primary care practices in Northern Germany were randomized into three groups: Guideline (GL-group), modified guideline with a RADT for scores ≥ 3 (GL-RADT-group) or usual care (UC-group). All practices were visited and instructed by the study team (outreach visits) and supplied with material according to their group. The practices were asked to recruit 11 consecutive patients ≥ 2 years with an acute sore throat and being at least moderately impaired. A study throat swab for GAS was taken in every patient. The antibiotic prescription rate at the first consultation was the primary outcome.

RESULTS

From October 2010 to March 2012, 68 general practitioners in 61 practices recruited 520 patients, 516 could be analyzed for the primary endpoint. Antibiotic prescription rates did not differ between groups (p = 0.162) and were about three times higher than the GAS rate: GL-group 97/187 patients (52%; GAS = 16%), GL-RADT-group 74/172 (43%; GAS = 16%) and UC-group 68/157 (43%; GAS = 14%). In the GL-RADT-group 55% of patients had scores ≥ 3 compared to 35% in GL-group (p < 0.001). After adjustment, in the GL-RADT-group the OR was 0.23 for getting an antibiotic compared to the GL-group (p = 0.010), even though 35 of 90 patients with a negative Strep-test got an antibiotic in the GL-RADT-group. The prescription rates per practice covered the full range from 0 to 100% in all groups.

CONCLUSION

The scores proposed in the implemented guideline seem inappropriate to lower antibiotic prescriptions for sore throat, but better adherence of practitioners to negative RADTs should lead to fewer prescriptions.

TRIAL REGISTRATION

DRKS00013018, retrospectively registered 28.11.2017.

Availability and use of rapid diagnostic tests for the management of acute childhood infections in Europe: A cross-sectional survey of paediatricians

BACKGROUND

Point-of-care-tests (POCTs) have been advocated to optimise care in patients with infections but their actual use varies. This study aimed to estimate the variability in the adoption of current POCTs by paediatricians across Europe, and to explore the determinants of variability.

METHODS AND FINDINGS

A cross-sectional survey was conducted of hospital and primary care paediatricians, recruited through professional networks. Questions focused on the availability and use of currently available POCTs. Data were analysed descriptively and using Median Odds Ratio (MOR) to measure variation between countries. Multilevel regression modelling using changes in the area under the receiver operating characteristic curve of models were used to assess the contribution of individual or workplace versus country level factors, to the observed variation. The commonest POCT was urine dipsticks (UD) which were available to >80% of primary care and hospital paediatricians in 68% (13/19) and 79% (23/29) countries, respectively. Availability of all POCTs varied between countries. In primary care, the country (MOR) varied from 1.61 (95%CI: 1.04-2.58) for lactate to 7.28 (95%CI: 3.04-24.35) for UD. In hospitals, the country MOR varied from 1.37 (95%CI:1.04-1.80) for lactate to 11.93 (95%CI:3.35-72.23) for UD. Most paediatricians in primary care (69%, 795/1154) and hospital (81%, 962/1188) would use a diagnostic test in the case scenario of an infant with undifferentiated fever. Multilevel regression modelling showed that the country of work was more important in predicting both the availability and use of POCTs than individual or workplace characteristics.

CONCLUSION

There is substantial variability in the adoption of POCTs for the management of acute infections in children across Europe. To inform future implementation of both existing and innovative tests, further research is needed to understand what drives the variation between countries, the needs of frontline clinicians, and the role of diagnostic tests in the management of acute childhood infections.

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

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.

The Role of Point-of-Care C-Reactive Protein Testing in Antibiotic Prescribing for Respiratory Tract Infections: A Survey among Swiss General Practitioners

Understanding the decision-making strategies of general practitioners (GPs) could help reduce suboptimal antibiotic prescribing. Respiratory tract infections (RTIs) are the most common reason for inappropriate antibiotic prescribing in primary care, a key driver of antibiotic resistance (ABR). We conducted a nationwide prospective web-based survey to explore: (1) The role of C-reactive protein (CRP) point-of-care testing (POCT) on antibiotic prescribing decision-making for RTIs using case vignettes; and (2) the knowledge, attitudes and barriers/facilitators of antibiotic prescribing using deductive analysis. Most GPs (92-98%) selected CRP-POCT alone or combined with other diagnostics. GPs would use lower CRP cut-offs to guide prescribing for (more) severe RTIs than for uncomplicated RTIs. Intermediate CRP ranges were significantly wider for uncomplicated than for (more) severe RTIs (p = 0.001). Amoxicillin/clavulanic acid was the most frequently recommended antibiotic across all RTI case scenarios (65-87%). Faced with intermediate CRP results, GPs preferred 3-5-day follow-up to delayed prescribing or other clinical approaches. Patient pressure, diagnostic uncertainty, fear of complications and lack of ABR understanding were the most GP-reported barriers to appropriate antibiotic prescribing. Stewardship interventions considering CRP-POCT and the barriers and facilitators to appropriate prescribing could guide antibiotic prescribing decisions at the point of care.

Does C-reactive protein predict time to recovery and benefit from oseltamivir treatment in primary care patients with influenza-like illness? A randomized controlled trial secondary analysis

OBJECTIVE

Recovery time and treatment effect of oseltamivir in influenza-like illness (ILI) differs between patient groups. A point-of-care test to better predict ILI duration and identify patients who are most likely to benefit from oseltamivir treatment would aid prescribing decisions in primary care. This study aimed to investigate whether a C-reactive protein (CRP) concentration of ≥30 mg/L can predict (1) ILI disease duration, and (2) which patients are most likely to benefit from oseltamivir treatment.

DESIGN

Secondary analysis of randomized controlled trial data.

SETTING

Primary care in Lithuania, Sweden and Norway during three consecutive influenza seasons 2016-2018.

SUBJECTS

A total of 277 ILI patients aged one year or older and symptom duration of ≤72 h.

MAIN OUTCOME MEASURES

Capillary blood CRP concentration at baseline, and ILI recovery time defined as having 'returned to usual daily activity' with residual symptoms minimally interfering.

RESULTS

At baseline, 20% (55/277) had CRP concentrations ≥30mg/L (range 0-210). CRP concentration ≥30 mg/L was not associated with recovery time (adjusted hazards ratio (HR) 0.80: 95% CI 0.50-1.3; p = 0.33). Interaction analysis of CRP concentration ≥30 mg/L and oseltamivir treatment did not identify which patients benefit more from oseltamivir treatment (adjusted HR 0.69: 95% CI 0.37-1.3; p = 0.23).

CONCLUSION

There was no association between CRP concentration of ≥30 mg/L and recovery time from ILI. Furthermore, CRP could not predict which ILI patients benefit more from oseltamivir treatment. Hence, we do not recommend CRP testing for predicting ILI recovery time or identifying patients who will receive particular benefit from oseltamivir treatment.Key PointsPredicting disease course of influenza-like illness (ILI), and identifying which patients benefit from oseltamivir treatment is a challenge for physicians.• There was no association between CRP concentration at baseline and recovery time in patients consulting with ILI in primary care.• There was no association between CRP concentration at baseline and benefit from oseltamivir treatment.• We, therefore, do not recommend CRP testing for predicting recovery time or in decision-making concerning oseltamivir prescribing in ILI patients.

Latvian Primary Care Management of Children with Acute Infections: Antibiotic-Prescribing Habits and Diagnostic Process Prior to Treatment

Background and Objectives: Primary care physicians frequently prescribe antibiotics for acutely ill children, even though they usually have self-limiting diseases of viral etiology. The aim of this research was to evaluate the routine antibiotic-prescribing habits of primary care in Latvia, in response to children presenting with infections. Materials and Methods: This cross-sectional study included acutely ill children who consulted eighty family physicians (FP) in Latvia, between November 2019 and May 2020. The data regarding patient demographics, diagnoses treated with antibiotics, the choice of antibiotics and the use of diagnostic tests were collected. Results: The study population comprised 2383 patients aged between one month and 17 years, presenting an acute infection episode, who had a face-to-face consultation with an FP. Overall, 29.2% of these patients received an antibiotic prescription. The diagnoses most often treated with antibiotics were otitis (45.8% of all antibiotic prescriptions), acute bronchitis (25.0%) and the common cold (14.8%). The most commonly prescribed antibiotics were amoxicillin (55.9% of prescriptions), amoxicillin/clavulanate (18.1%) and clarithromycin (11.8%). Diagnostic tests were carried out for 59.6% of children presenting with acute infections and preceded 66.4% of antibiotic prescriptions. Conclusion: Our data revealed that a high level of antibiotic prescribing for self-limiting viral infections in children continues to occur. The underuse of narrow-spectrum antibiotics and suboptimal use of diagnostic tests before treatment decision-making were also identified. To achieve a more rational use of antibiotics in primary care for children with a fever, professionals and parents need to be better educated on this subject, and diagnostic tests should be used more extensively, including the implementation of daily point-of-care testing.

Determinants of antibiotic over-prescribing for upper respiratory tract infections in an emergency department with good primary care access: a quantitative analysis

BACKGROUND

Upper respiratory tract infections (URTI) account for the highest proportion of non-urgent visits to the emergency department (ED), resulting in unnecessary antibiotic use.

AIM

This study sought to understand the determinants of antibiotic prescribing for URTI among 130 junior physicians in a busy adult ED in Singapore.

METHODS

Forty-four Likert-scale statements were developed with reference to a prior qualitative study, followed by an anonymous cross-sectional survey among ED junior physicians. Data analysis was performed with factor reduction and multivariable logistic regression.

FINDINGS

One-in-six (16.9%) physicians were high antibiotic prescribers (self-reported antibiotic prescribing rate of >30% of URTI patients). After adjusting for place of medical education and years of practice as a physician, perceived over-prescribing of antibiotics in the ED (adjusted odds ratio (OR) 2.37, 95% confidence interval (CI) (1.15, 4.86), P=0.019) and perceived compliance with the antibiotic prescribing practices in the ED (adjusted OR 2.10, 95% CI (1.02, 4.30), P=0.043) were positively associated with high antibiotic prescribing. In contrast, high antibiotic prescribers were 6.67 times (95% CI (1.67, 25.0), P=0.007) less likely to treat and manage patients with URTI symptomatically and 7.12 times (95% CI (1.28, 39.66), P=0.025) more likely to depend on diagnostic tests to prescribe antibiotics than the regular antibiotic prescribers.

CONCLUSION

Organizational-related factors (organizational norms and culture) were strong determinants of antibiotic prescribing practices for uncomplicated URTI in the ED. Other contributing factors include diagnostic uncertainty and knowledge gaps. Role-modelling of institutional best practice norms and clinical decision support tools based on local epidemiology can optimize antibiotic prescribing in the ED.

Maternal sensitivity and mother-infant attachment are associated with antibiotic uptake in infancy

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.

Assessing the appropriateness of the management of otitis media in Australia: A population-based sample survey

AIM

Acute otitis media (AOM) is the most common infectious disease for which antibiotics are prescribed; its management is costly and has the potential to increase the antimicrobial resistance of this infection. This study measured the levels of adherence to the clinical practice guidelines (CPGs) of AOM and otitis media with effusion (OME) management in Australian children.

METHODS

We searched for national and international CPGs relating to AOM and OME in children and created 37 indicators for assessment. We reviewed medical records for adherence to these indicators in 120 locations, across one inpatient and three ambulatory health-care settings. Our review sample was obtained from three Australian states that contain 60% of the nation's children.

RESULTS

We reviewed the records of 1063 children with one or more assessments of CPG adherence for otitis media. Of 22 indicators with sufficient data, estimated adherence ranged from 7.4 to 99.1%. Overuse of treatment, particularly overprescribing of antibiotics, was more common than underuse. A frequent lack of adherence with recommended care was observed for children aged between 1 and 2 years with AOM. Adherence varied by health-care setting, with emergency departments and inpatient settings more adherent to CPGs than general practices.

CONCLUSIONS

Our assessment of a number of indicators in the common settings in which otitis media is treated found that guideline adherence varied widely between individual indicators. Internationally agreed standards for diagnosis and treatment, coupled with clinician education on the existence and content of CPGs and clinical decision support, are needed to improve the management of children presenting with AOM and OME.

Megatrends in Infectious Diseases: The Next 10 to 15 Years

It has been about 100 years since the Spanish influenza pandemic of 1918-19 that killed an estimated 50 million individuals globally. While we have made remarkable progress in reducing infection-related mortality, infections still account for 13 to 15 million deaths annually. This estimate is projected to remain unchanged until 2050. We have identified 4 megatrends in infectious diseases and these are “emerging and re-emerging infections”, “antimicrobial resistance”, “demographic changes” and “technological advances”. Understanding these trends and challenges should lead to opportunities for the medical community to reshape the future. Further inroads will also require broad approaches involving surveillance, public health and translating scientific discoveries into disease control efforts. Key words: Antimicrobial resistance, Demographic changes, Emerging infections, Technological advances

Danish GPs' and practice nurses' management of acute sore throat and adherence to guidelines

BACKGROUND

Sore throat is a frequent presentation of acute respiratory tract infections in general practice. Though these infections are often harmless and self-limiting, antibiotics are frequently prescribed. In Denmark, practice nurses manage an increasing part of patients with acute minor illnesses.

OBJECTIVES

We aimed (i) to investigate Danish practice nurses' and GPs' management of patients presenting with a sore throat and (ii) to explore to what extent management is according to current Danish guidelines.

METHODS

A cross-sectional study was conducted during winter 2017, involving GPs and practice nurses in Danish general practices. Patients with a sore throat were registered according to the Audit Project Odense method.

RESULTS

A total of 44 practices participated with the registration of 1503 patients presenting with a sore throat. Most patients had a strep A test performed, especially when managed by a practice nurse (84.6% versus 61.8%, χ2 = 90.1, P < 0.05). In total, 40.6% of performed strep A tests were not according to guideline recommendations. Antibiotics were prescribed for about one-third of patients, regardless whether managed by a practice nurse or a GP (χ2 = 0.33, P = 0.57). However, 32.4% of these prescriptions were not in line with Danish guidelines.

CONCLUSION

Patients with acute sore throat were managed similarly by GPs and practice nurses, apart from a higher use of strep A tests in patients seen by practice nurses. Importantly, this study demonstrated that there is still room for improvement of the management of these patients in Danish general practice.

Quality assessment in general practice: diagnosis and antibiotic treatment of acute respiratory tract infections

OBJECTIVE

To investigate areas in need of quality improvement within the diagnostic process and antibiotic treatment of acute respiratory tract infections (RTIs) in Danish general practice by using quality indicators (QIs).

DESIGN AND SETTING

During a 4-week period in winter 2017, a prospective registration of patients diagnosed with RTIs was conducted in general practice in two regions of Denmark.

SUBJECTS

Throughout the registration period each patient with symptoms of an RTI was registered. Information about age, symptoms and findings, duration of symptoms, the use and result of clinical tests, allergy towards penicillin, referral to secondary care and the antibiotic given were recorded.

MAIN OUTCOME MEASURES

Values and acceptable ranges for QIs focusing on the diagnostic process, the decision to prescribe antibiotics and the choice of antibiotics for patients with RTIs.

RESULTS

Regarding the diagnostic process nearly all QIs for patients diagnosed with acute pharyngotonsillitis and pneumonia fell within the acceptable range. Contrarily, the diagnostic QIs for patients with acute otitis media and acute rhinosinusitis were outside the acceptable range. All indicators designed to measure overuse of antibiotics were outside the acceptable range and nearly all indicators assessing if patients were sufficiently treated fell within the acceptable range. QIs assessing use of the recommended type of antibiotic were only within the acceptable range for patients diagnosed with acute pharyngotonsillitis.

CONCLUSION

The findings indicate an overuse of antibiotics for RTIs in Danish general practice. Especially management of acute rhinosinusitis and acute bronchitis should be targeted in future quality improvement projects.

KEY POINTS

To improve antibiotic prescribing in general practice it is important to focus on both the diagnostic process and the prescribing patterns. The findings indicate an overuse of antibiotics for acute respiratory tract infections in Danish general practice. Especially the diagnostic process and antibiotic prescribing patterns for acute rhinosinusitis and acute bronchitis could benefit from future quality improvement interventions.

Actual versus 'ideal' antibiotic prescribing for common conditions in English primary care

Objectives

Previous work based on guidelines and expert opinion identified 'ideal' prescribing proportions-the overall proportion of consultations that should result in an antibiotic prescription-for common infectious conditions. Here, actual condition-specific prescribing proportions in primary care in England were compared with ideal prescribing proportions identified by experts.

Methods

All recorded consultations for common infectious conditions (cough, bronchitis, exacerbations of asthma or chronic obstructive pulmonary disease, sore throat, rhinosinusitis, otitis media, lower respiratory tract infection, upper respiratory tract infection, influenza-like illness, urinary tract infection, impetigo, acne, gastroenteritis) for 2013-15 were extracted from The Health Improvement Network (THIN) database. The proportions of consultations resulting in an antibiotic prescription were established, concentrating on acute presentations in patients without relevant comorbidities. These actual prescribing proportions were then compared with previously established 'ideal' proportions by condition.

Results

For most conditions, substantially higher proportions of consultations resulted in an antibiotic prescription than was deemed appropriate according to expert opinion. An antibiotic was prescribed in 41% of all acute cough consultations when experts advocated 10%. For other conditions the proportions were: bronchitis (actual 82% versus ideal 13%); sore throat (actual 59% versus ideal 13%); rhinosinusitis (actual 88% versus ideal 11%); and acute otitis media in 2- to 18-year-olds (actual 92% versus ideal 17%). Substantial variation between practices was found.

Conclusions

This work has identified substantial overprescribing of antibiotics in English primary care, and highlights conditions where this is most pronounced, particularly in respiratory tract conditions.

Factors influencing the development of primary care data collection projects from electronic health records: a systematic review of the literature

BACKGROUND

Primary care data gathered from Electronic Health Records are of the utmost interest considering the essential role of general practitioners (GPs) as coordinators of patient care. These data represent the synthesis of the patient history and also give a comprehensive picture of the population health status. Nevertheless, discrepancies between countries exist concerning routine data collection projects. Therefore, we wanted to identify elements that influence the development and durability of such projects.

METHODS

A systematic review was conducted using the PubMed database to identify worldwide current primary care data collection projects. The gray literature was also searched via official project websites and their contact person was emailed to obtain information on the project managers. Data were retrieved from the included studies using a standardized form, screening four aspects: projects features, technological infrastructure, GPs' roles, data collection network organization.

RESULTS

The literature search allowed identifying 36 routine data collection networks, mostly in English-speaking countries: CPRD and THIN in the United Kingdom, the Veterans Health Administration project in the United States, EMRALD and CPCSSN in Canada. These projects had in common the use of technical facilities that range from extraction tools to comprehensive computing platforms. Moreover, GPs initiated the extraction process and benefited from incentives for their participation. Finally, analysis of the literature data highlighted that governmental services, academic institutions, including departments of general practice, and software companies, are pivotal for the promotion and durability of primary care data collection projects.

CONCLUSION

Solid technical facilities and strong academic and governmental support are required for promoting and supporting long-term and wide-range primary care data collection projects.

Antibiotic prescribing in relation to diagnoses and consultation rates in Belgium, the Netherlands and Sweden: use of European quality indicators

OBJECTIVE

To assess the quality of antibiotic prescribing in primary care in Belgium, the Netherlands and Sweden using European disease-specific antibiotic prescribing quality indicators (APQI) and taking into account the threshold to consult and national guidelines.

DESIGN

A retrospective observational database study.

SETTING

Routine primary health care registration networks in Belgium, the Netherlands and Sweden.

SUBJECTS

All consultations for one of seven acute infections [upper respiratory tract infection (URTI), sinusitis, tonsillitis, otitis media, bronchitis, pneumonia and cystitis] and the antibiotic prescriptions in 2012 corresponding to these diagnoses.

MAIN OUTCOME MEASURES

Consultation incidences for these diagnoses and APQI values (a) the percentages of patients receiving an antibiotic per diagnosis, (b) the percentages prescribed first-choice antibiotics and (c) the percentages prescribed quinolones.

RESULTS

The consultation incidence for respiratory tract infection was much higher in Belgium than in the Netherlands and Sweden. Most of the prescribing percentage indicators (a) were outside the recommended ranges, with Belgium deviating the most for URTI and bronchitis, Sweden for tonsillitis and the Netherlands for cystitis. The Netherlands and Sweden prescribed the recommended antibiotics (b) to a higher degree and the prescribing of quinolones exceeded the proposed range for most diagnoses (c) in Belgium. The interpretation of APQI was found to be dependent on the consultation incidences. High consultation incidences were associated with high antibiotic prescription rates. Taking into account the recommended treatments from national guidelines improved the results of the APQI values for sinusitis in the Netherlands and cystitis in Sweden.

CONCLUSION

Quality assessment using European disease-specific APQI was feasible and their inter-country comparison can identify opportunities for quality improvement. Their interpretation, however, should take consultation incidences and national guidelines into account. Differences in registration quality might limit the comparison of diagnosis-linked data between countries, especially for conditions such as cystitis where patients do not always see a clinician before treatment. Key points The large variation in antibiotic use between European countries points towards quality differences in prescribing in primary care.  • The European disease-specific antibiotic prescribing quality indicators (APQI) provide insight into antibiotic prescribing, but need further development, taking into account consultation incidences and country-specific guidelines.  • The incidence of consultations for respiratory tract infections was almost twice as high in Belgium compared to the Netherlands and Sweden.  • Comparison between countries of diagnosis-linked data were complicated by differences in data collection, especially for urinary tract infections.

Factors predicting antibiotic prescription and referral to hospital for children with respiratory symptoms: secondary analysis of a randomised controlled study at out-of-hours services in primary care

OBJECTIVES

Acute respiratory infections and fever among children are highly prevalent in primary care. It is challenging to distinguish between viral and bacterial infections. Norway has a relatively low prescription rate of antibiotics, but it is still regarded as too high as the antimicrobial resistance is increasing. The aim of the study was to identify predictors for prescribing antibiotics or referral to hospital among children.

DESIGN

Secondary analysis of a randomised controlled study.

SETTING

4 out-of-hours services and 1 paediatric emergency clinic in Norwegian primary care.

PARTICIPANTS

401 children aged 0-6 years with respiratory symptoms and/or fever visiting the out-of-hours services.

OUTCOMES

2 main outcome variables were registered: antibiotic prescription and referral to hospital.

RESULTS

The total prescription rate of antibiotics was 23%, phenoxymethylpenicillin was used in 67% of the cases. Findings on ear examination (OR 4.62; 95% CI 2.35 to 9.10), parents' assessment that the child has a bacterial infection (OR 2.45; 95% CI 1.17 to 5.13) and a C reactive protein (CRP) value >20 mg/L (OR 3.57; 95% CI 1.43 to 8.83) were significantly associated with prescription of antibiotics. Vomiting in the past 24 hours was negatively associated with prescription (OR 0.26; 95% CI 0.13 to 0.53). The main predictors significantly associated with referral to hospital were respiratory rate (OR 1.07; 95% CI 1.03 to 1.12), oxygen saturation <95% (OR 3.39; 95% CI 1.02 to 11.23), signs on auscultation (OR 5.57; 95% CI 1.96 to 15.84) and the parents' assessment before the consultation that the child needs hospitalisation (OR 414; 95% CI 26 to 6624).

CONCLUSIONS

CRP values >20 mg/L, findings on ear examination, use of paracetamol and no vomiting in the past 24 hours were significantly associated with antibiotic prescription. Affected respiration was a predictor for referral to hospital. The parents' assessment was also significantly associated with the outcomes.

TRIAL REGISTRATION NUMBER

NCT02496559; Results.

Estimated saving of antibiotics in pharyngitis and lower respiratory tract infections if general practitioners used rapid tests and followed guidelines

Introduction

General practitioners (GP) in Spain do not have access to rapid tests and adherence to guidelines is usually suboptimal. The aim of the study is to evaluate the estimated number of antibiotics that could have been saved if GPs had appropriately used these tests and had followed the guidelines.

Design

Observational study.

Setting

Primary care centres from eight Autonomous Communities in Spain.

Participants

GPs who had not participated in previous studies on rational use of antibiotics.

Intervention

GPs registered all the cases of pharyngitis and lower respiratory tract infections (LRTI) during 15 working days in 2015, by means of a 47-item audit.

Main measurements

Actual GPs’ antibiotic prescription and estimated number of antibiotics that could have been saved according to recent guidelines.

Results

A total of 126 GPs registered 1012 episodes of pharyngitis and 1928 LRTIs. Antibiotics were given or patients were referred in 497 patients with pharyngitis (49.1%) and 963 patients with LRTI (49.9%). If GPs had appropriately used rapid antigen detection tests and C-reactive protein tests and had strictly followed current guidelines, antibiotics would have been given to 7.6% and 15.1%, respectively, with an estimated saving of 420 antibiotics in patients with sore throat (estimated saving of 84.5%; 95% CI: 81.1–87.4%) and 672 antibiotics in LRTIs (estimated saving of 69.8%,95% CI: 67.1–72.5%).

Conclusions

GP adherence to guidelines and a correct introduction of rapid tests in clinical practice in Spain could result in a considerable saving of unnecessary prescription of antibiotics in pharyngitis and LRTIs.

14-Year Survey in a Swedish County Reveals a Pronounced Increase in Bloodstream Infections (BSI). Comorbidity - An Independent Risk Factor for Both BSI and Mortality

OBJECTIVES

we assessed the incidence, risk factors and outcome of BSI over a 14-year period (2000-2013) in a Swedish county.

METHODS

retrospective cohort study on culture confirmed BSI among patients in the county of Östergötland, Sweden, with approximately 440,000 inhabitants. A BSI was defined as either community-onset BSI (CO-BSI) or hospital-acquired BSI (HA-BSI).

RESULTS

of a total of 11,480 BSIs, 67% were CO-BSI and 33% HA-BSI. The incidence of BSI increased by 64% from 945 to 1,546 per 100,000 hospital admissions per year during the study period. The most prominent increase, 83% was observed within the CO-BSI cohort whilst HA-BSI increased by 32%. Prescriptions of antibiotics in outpatient care decreased with 24% from 422 to 322 prescriptions dispensed/1,000 inhabitants/year, whereas antibiotics prescribed in hospital increased by 67% (from 424 to 709 DDD per 1,000 days of care). The overall 30-day mortality for HA-BSIs was 17.2%, compared to 10.6% for CO-BSIs, with an average yearly increase per 100,000 hospital admissions of 2 and 5% respectively. The proportion of patients with one or more comorbidities, increased from 20.8 to 55.3%. In multivariate analyses, risk factors for mortality within 30 days were: HA-BSI (2.22); two or more comorbidities (1.89); single comorbidity (1.56); CO-BSI (1.21); male (1.05); and high age (1.04).

CONCLUSION

this survey revealed an alarming increase in the incidence of BSI over the 14-year study period. Interventions to decrease BSI in general should be considered together with robust antibiotic stewardship programmes to avoid both over- and underuse of antibiotics.

Interacting factors associated with Low antibiotic prescribing for respiratory tract infections in primary health care - a mixed methods study in Sweden

Background

Prescribing of antibiotics for common infections varies widely, and there is no medical explanation. Systematic reviews have highlighted factors that may influence antibiotic prescribing and that this is a complex process. It is unclear how factors interact and how the primary care organization affects diagnostic procedures and antibiotic prescribing. Therefore, we sought to explore and understand interactions between factors influencing antibiotic prescribing for respiratory tract infections in primary care.

Methods

Our mixed methods design was guided by the Triangulation Design Model according to Creswell. Quantitative and qualitative data were collected in parallel. Quantitative data were collected by prescription statistics, questionnaires to patients, and general practitioners’ audit registrations. Qualitative data were collected through observations and semi-structured interviews.

Results

From the analysis of the data from the different sources an overall theme emerged: A common practice in the primary health care centre is crucial for low antibiotic prescribing in line with guidelines. Several factors contribute to a common practice, such as promoting management and leadership, internalized guidelines including inter-professional discussions, the general practitioner’s diagnostic process, nurse triage, and patient expectation. These factors were closely related and influenced each other. The results showed that knowledge must be internalized and guidelines need to be normative for the group as well as for every individual.

Conclusions

Low prescribing is associated with adapted and transformed guidelines within all staff, not only general practitioners. Nurses’ triage and self-care advice played an important role. Encouragement from the management level stimulated inter-professional discussions about antibiotic prescribing. Informal opinion moulders talking about antibiotic prescribing was supported by the managers. Finally, continuous professional development activities were encouraged for up-to-date knowledge.

Out-of-hours antibiotic prescription after screening with C reactive protein: a randomised controlled study

OBJECTIVE

To evaluate the effect of preconsultation C reactive protein (CRP) screening on antibiotic prescribing and referral to hospital in Norwegian primary care settings with low prevalence of serious infections.

DESIGN

Randomised controlled observational study at out-of-hours services in Norway.

SETTING

Primary care.

PARTICIPANTS

401 children (0-6 years) with fever and/or respiratory symptoms were recruited from 5 different out-of-hours services (including 1 paediatric emergency clinic) in 2013-2015.

INTERVENTION

Data were collected from questionnaires and clinical examination results. Every third child was randomised to a CRP test before the consultation; for the rest, the doctor ordered a CRP test if considered necessary.

OUTCOME MEASURES

Main outcome variables were prescription of antibiotics and referral to hospital.

RESULTS

In the group pretested with CRP, the antibiotic prescription rate was 26%, compared with 22% in the control group. In the group pretested with CRP, 5% were admitted to hospital, compared with 9% in the control group. These differences were not statistically significant. The main predictors for ordering a CRP test were parents' assessment of seriousness of the illness and the child's temperature. Paediatricians ordered CRP tests less frequently than did other doctors (9% vs 56%, p<0.001).

CONCLUSIONS

Preconsultation screening with CRP of children presenting to out-of-hours services with fever and/or respiratory symptoms does not significantly affect the prescription of antibiotics or referral to hospital.

TRIAL REGISTRATION NUMBER

NCT02496559; Results.

What a difference a CRP makes. A prospective observational study on how point-of-care C-reactive protein testing influences antibiotic prescription for respiratory tract infections in Swedish primary health care

OBJECTIVE

To explore how C-reactive protein (CRP) tests serve to support physicians in decisions concerning antibiotic prescription to patients with respiratory tract infections (RTI).

DESIGN

Prospective observational study.

SETTING

Primary health care centres in western Sweden.

SUBJECTS

Physicians in primary health care. Patients with acute RTI.

MAIN OUTCOME MEASURES

Physician willingness to measure CRP, their ability to estimate CRP, and changes in decision-making concerning antibiotic treatment based on error estimate and the physician's opinion of whether CRP measurement was crucial.

RESULTS

Data from 340 consultations were gathered. CRP testing was found to be crucial in 130 cases. In 86% of visits decisions regarding antibiotic prescription were unchanged. Physicians considering CRP crucial and physicians making an error estimate of CRP altered their decisions concerning antibiotic prescription after CRP testing more often than those who considered CRP unnecessary, and those making a more accurate estimate. Physicians changed their decision on antibiotic prescription in 49 cases. In the majority of these 49 cases physicians underestimated CRP levels, and the majority of changes were from "no" to "yes" as to whether to prescribe antibiotics.

CONCLUSION

CRP is an important factor in the decision on whether to prescribe antibiotics for RTIs. Error estimates of CRP and willingness to measure CRP are important factors leading to physicians changing decisions on antibiotic treatment. Key points There is a generally low antibiotic prescription rate and a high frequency of C-reactive protein (CRP) testing for respiratory tract infections (RTIs) in Sweden. CRP testing was considered essential to further management in 38% of cases. In 86% of visits decisions concerning antibiotic prescription were unchanged. The strongest predictors for revised decisions on antibiotic treatment were error estimates of CRP and the physician's opinion that CRP measurement was crucial.

Point-of-care testing with CRP in primary care: a registry-based observational study from Norway

Background

Norwegian primary health care is maintained on the regular general practitioners (RGPs), GP’s contracted to the municipalities in a list patient system, working at daytime and at out-of-hours services (OOH services). Respiratory disease is most prevalent during OOH services, and in more than 50 % of the consultations, a CRP test is performed. Children in particular have a high consultation rate, and the CRP test is frequently conducted, but the contributing factors behind its frequent use are not known. This study compares the RGPs rate of CRP use at daytime and OOH in consultations with children and how this rate is influenced by characteristics of the RGPs.

Methods

A cross-sectional register study was conducted based on all (N = 2 552 600) electronic compensation claims from consultations with children ≤ 5 year during the period 2009–2011 from primary health care. Consultation rates and CRP use were estimated and analysed using descriptive methods. Being among the 20 % of RGPs with the highest rate of CRP use at daytime or OOH was an outcome measure in regression analyses using RGP-, and RGP list characteristics as explanatory variables.

Results

One third of all RGPs work regularly in OOH services, and they use CRP 1.42 times more frequently in consultations with children in OOH services than in daytime services even when the distribution of diagnosis according to ICPC-2 chapters is similar. Not being approved specialist, have a large number at their patient-lists but relatively few children on their list and a large number of consultations with children were significantly associated with frequent use of CRP in daytime services. The predictors for frequent CRP use in OOH services were being a young doctor, having many consultations with children during OOH and a frequent use of CRP in daytime services.

Conclusions

The increase in the frequency of CRP test use from daytime to OOH occurs in general for RGPs and for all most used diagnoses. The RGPs who use the CRP test most frequently in their daytime practice have the highest rate of CRP in OOH services.

Near-patient tests and the clinical gaze in decision-making of Swedish GPs not following current guidelines for sore throat - a qualitative interview study

Background

Excessive antibiotics use increases the risk of resistance. Previous studies have shown that the Centor score combined with Rapid Antigen Detection Test (RADT) for Group A Streptococci can reduce unnecessary antibiotic prescribing in patients with sore throat. According to the former Swedish guidelines RADT was recommended with 2–4 Centor criteria present and antibiotics were recommended if the test was positive. C- reactive protein (CRP) was not recommended for sore throats. Inappropriate use of RADT and CRP has been reported in several studies.

Methods

From a larger project 16 general practitioners (GPs) who stated management of sore throats not according to the guidelines were identified. Half-hour long semi-structured interviews were conducted. The topics were the management of sore throats and the use of near-patient tests. Qualitative content analysis was used.

Results

The use of the near-patient test interplayed with the clinical assessment and the perception that all infections caused by bacteria should be treated with antibiotics. The GPs expressed a belief that the clinical picture was sufficient for diagnosis in typical cases. RADT was not believed to be relevant since it detects only one bacterium, while CRP was considered as a reliable numerical measure of bacterial infection.

Conclusions

Inappropriate use of near-patient test can partly be understood as remnants of outdated knowledge. When new guidelines are introduced the differences between them and the former need to be discussed more explicitly.

Antibiotic prescribing in primary care by international medical graduates and graduates from Swedish medical schools

BACKGROUND

Studies of antibiotic prescribing related to diagnosis comparing prescribers trained abroad with those trained in Sweden are lacking.

OBJECTIVES

To determine whether general practices (GPs) and GP residents trained abroad had different prescribing patterns for antibiotics for common infections than those trained in Sweden using retrospective data from electronic patient records from primary health care in Kalmar County, Sweden.

METHODS

Consultations with an infection diagnosis, both with and without the prescription of antibiotics to 67 GPs and residents trained in Western Europe outside Sweden and other countries, were compared with a matched control group trained in Sweden.

RESULTS

For 1 year, 44101 consultations of patients with an infection diagnosis and 16276 prescriptions of antibiotics were registered. Foreign-trained physicians had 20% more visits compared with physicians trained in Sweden. The prescription of antibiotics per visit and physician in the respective groups, and independent of diagnosis, did not significantly differ between groups, when scaled down from number of consultations to number of prescribing physicians.

CONCLUSIONS

There were minor and non-significant differences in antibiotic prescribing comparing GPs and residents trained abroad and in Sweden, most likely the result of an adaptation to Swedish conditions. Nevertheless, no group prescribed antibiotics in accordance to national guidelines. The results suggest that interventions are needed to reduce irrational antibiotic prescribing patterns, targeting all physicians working in Swedish primary health care.

Appropriate international measures for outpatient antibiotic prescribing and consumption: recommendations from a national data comparison of different measures

OBJECTIVES

Many European countries have engaged in awareness campaigns to decrease outpatient antibiotic use and several measures have been proposed, e.g. the number of defined daily doses (DDDs) or packages per 1000 inhabitants per day, producing conflicting findings. Therefore, we set out to explore what measure is most appropriate.

METHODS

Outpatient data on each dispensed and reimbursed medicinal package in Belgium between 2002 and 2009 were aggregated at the level of the active substance in accordance with the Anatomical Therapeutic Chemical classification and expressed as the numbers of DDDs (WHO, version 2010), packages, treatments and insured individuals per 1000 inhabitants, insured individuals and patient contacts, per day, and in July-June years. Using these measures, time trends of outpatient antibiotic use were compared and explored in detail.

RESULTS

Expressed per 1000 inhabitants per day, outpatient antibiotic use increased between 2002-03 and 2008-09 in DDDs, whereas in packages, treatments and insured individuals it decreased. The same was true for use expressed per 1000 insured individuals or when allowing for the decreasing number of patient contacts. Increasing numbers of DDDs per package (more items per package and higher doses per unit for amoxicillin and co-amoxiclav) explain these discrepancies.

CONCLUSIONS

The number of packages is a more appropriate measure than the number of DDDs when assessing outpatient antibiotic use over time and the impact of awareness campaigns in countries dispensing 'complete packages'. We recommended the use of different complementary measures or caution when interpreting trends based only on DDDs.

In primary health care, never prescribe antibiotics to patients suspected of having an uncomplicated sore throat caused by group A beta-haemolytic streptococci without first confirming the presence of this bacterium

BACKGROUND

There are several consensus-describing decision rules for patients in primary health care with a sore throat. The objective of this study was to estimate the number of unnecessary antibiotic prescriptions in primary health care given to patients with a sore throat, due to these different decision rules. A further aim was to suggest revised rules for decision-making in primary health care, when a sore throat caused by group A beta-haemolytic streptococci (GAS) is suspected.

METHODS

The design was a reanalysis of previously published articles describing the prevalence of GAS and physician behaviour when treating patients with a sore throat. The risk of unnecessary antibiotic prescribing in different situations was estimated and applied to the Swedish population.

RESULTS

Introducing the rule of never prescribing antibiotics without first confirming the presence of GAS would result in an annual reduction in Sweden of 20,360-25,192 unnecessary antibiotic prescriptions in children and 65,311-98,160 in adults.

CONCLUSIONS

The single most important rule in primary health care to minimize the risk of unnecessary antibiotic prescription to patients with an uncomplicated sore throat, and where an infection with GAS is suspected, is to never prescribe antibiotics at the first visit without first confirming the presence of this bacterium. Adding more decision rules may to some extent further reduce the number of unnecessary antibiotic prescriptions.

Use of laboratory tests in out-of-hours services in Norway

OBJECTIVE

To investigate the use of laboratory tests and which factors influence the use in Norwegian out-of-hours (OOH) services.

DESIGN

Cross-sectional observational study.

SETTING

Out-of-hours services in Norway.

SUBJECTS

All electronic reimbursement claims from doctors at OOH services in Norway in 2007.

MAIN OUTCOME MEASURES

Number of contacts and laboratory tests in relation to patients' and doctors' characteristics.

RESULTS

1 323 281 consultations and home visits were reported. Laboratory tests were used in 31% of the contacts. C-reactive protein (CRP) was the most common test (27% of all contacts), especially in respiratory illness (55%) and infants (44%). Electrocardiogram and rapid strep A test were used in 4% of the contacts. Young doctors, female doctors, and doctors in central areas used laboratory tests more often.

CONCLUSION

CRP is extensively used in OOH services, especially by young and inexperienced doctors, and in central areas. Further investigations are required to see if this extensive use of CRP is of importance for correct diagnosis and treatment.

Perceptions and attitudes of French general practitioners towards rapid antigen diagnostic tests in acute pharyngitis using a randomized case vignette study

OBJECTIVES

This study had three objectives: (i) to assess the use of rapid antigen diagnostic tests (RADTs) and their impact on the antibiotic prescribing behaviour of general practitioners (GPs) for acute pharyngitis; (ii) to study the barriers to the use of RADTs; and (iii) to identify GPs' characteristics associated with non-compliance with French guidelines.

METHODS

We conducted a cross-sectional survey of a representative sample of 369 self-employed GPs in south-eastern France using a randomized case vignette study.

RESULTS

The availability of an RADT allowed a 44% relative reduction in the rate of antibiotic prescriptions. Of GPs for whom the test was available, 34% did not use an RADT in our acute pharyngitis vignette and 13% of those who used the test prescribed an antibiotic despite a negative RADT result. Non-compliance with French guidelines (i.e. not using an RADT and/or prescribing an antibiotic despite a negative RADT result) was independently associated with the following factors: less reading of medical journals, less benefits/risks discussion with patients about vaccinations and higher perception that clinical examination was sufficient to prescribe antibiotics. The three main declared barriers to RADT use were: time to perform the test, patient expectations regarding antibiotics and the perception that clinical examination was sufficient to decide to prescribe an antibiotic.

CONCLUSIONS

RADTs are a useful but not sufficient tool to reduce antibiotic prescribing in general practice. The results of this study increase understanding of the factors underlying clinical decision making for acute pharyngitis and may contribute to the development of interventions to improve practice.

Treatment of acute otitis media in general practice: quality variations across countries

BACKGROUND

Recommendations for antibiotic treatment of acute otitis media (AOM) have changed over the years, and today many experts recommend initial observation. However, antibiotic prescribing should be considered in children aged <2 years or if AOM is accompanied by discharging ear.

OBJECTIVES

To investigate the quality of treatment of AOM in general practice and to explore the influence of selected GP and patient characteristics on antibiotic prescribing.

METHODS

During the winter 2008, a prospective registration of patients diagnosed with AOM was conducted in general practice in Lithuania, Kaliningrad, Spain, Argentina, Sweden and Denmark. Some 1175 patients diagnosed with AOM were registered. Information about age and sex of the patient, duration of symptoms (days), temperature >38.5°C, ear discharge and the antibiotic treatment given was recorded.

RESULTS

Danish GPs had the lowest antibiotic prescription rate for AOM [72.7% (95% confidence interval (CI) = 67.0-77.8)] and GPs in Kaliningrad had the highest [97.1% (95% CI = 89.8-99.6)]. Narrow-spectrum penicillin was almost exclusively prescribed in the two Nordic countries, while broad-spectrum penicillins, often in combination with clavulanic acid, were prescribed in the other four countries. Macrolides comprised 5-10% of prescriptions. Antibiotic prescribing was associated with the following characteristics of the patients: symptoms for >3 days, ear discharge and fever.

CONCLUSION

The majority of patients with AOM were treated with antibiotics in all six countries, but considerable variations in both prescribing rate and choice of antibiotics were identified.

Acute mastoiditis in children in Sweden 1993-2007--no increase after new guidelines

OBJECTIVE

To study whether the incidence and characteristics of acute mastoiditis in children changed in Sweden following the introduction of new guidelines for diagnosis and treatment of acute otitis media advocating "watchful waiting" as an option in children 2-16 years of age with uncomplicated acute otitis media.

METHODS

The records for all patients treated for mastoiditis during 1993-2007 at all Ear, Nose and Throat departments in Sweden were reviewed retrospectively according to defined criteria for acute mastoiditis. In this study the data from children aged 0-16 years were analyzed and compared 71/2 years before and 71/2 years after the introduction of the new guidelines in 2000.

RESULTS

A total of 577 cases aged 0-16 years fulfilled the inclusion criteria during the whole study period. Cases involving cholesteatoma were excluded. The number of children affected by acute mastoiditis did not increase after the introduction of new guidelines. Acute mastoiditis was most common in children younger than two years of age. The proportion of acute mastoiditis increased after 2000 in the group aged 2-23 months although they were not affected concerning treatment by the new guidelines. No decrease was found in the frequency of prehospital antibiotic treatment among the children admitted with acute mastoiditis, and no increase was seen in the duration of ear symptoms before hospital admission, duration of hospital stay, or in the frequency of complications or mastoidectomies, after the introduction of the new guidelines in either group of children.

CONCLUSIONS

The incidence of acute mastoiditis in children in Sweden did not increase following the introduction of new guidelines in 2000 for the diagnosis and treatment of acute otitis media. This is despite the fact that a significant decrease in antibiotic prescriptions for otitis media has been reported during the same time period. The characteristics of acute mastoiditis reflecting severity of illness did not change over time. Acute mastoiditis was most common and increased after 2000 only in children younger than two years of age in which antibiotics were still recommended in all cases of acute otitis media.

Impact on antibiotic prescription of rapid antigen detection testing in acute pharyngitis in adults: a randomised clinical trial

BACKGROUND

Acute pharyngitis is one of the most frequent reasons for a GP consultation, and in most cases an antibiotic is prescribed.

AIM

To determine the impact of rapid antigen detection testing (RADT) to identify group A beta haemolytic streptococcus in acute pharyngitis on the utilisation of antibiotics and appropriateness of their use.

DESIGN AND SETTING

Cluster randomised controlled trial in primary care centres in Catalonia, Spain.

METHOD

Patients with acute pharyngitis aged 14 years or older with at least one Centor criterion (fever, tonsillar exudate, tender enlarged anterior cervical lymph nodes, or absence of cough) were recruited. Participant physicians were randomly assigned to one of two study arms: an intervention group (assigned to RADT) and a control group (following usual care, without RADT).

RESULTS

Of the 557 adults enrolled, 543 could be evaluated for analysis (281 [51.7%] in the intervention group and 262 [48.3%] in the control group). GPs without access to RADT were more likely to prescribe antibiotics compared with those who performed rapid tests (64.1% versus 43.8%, P<0.001). The more Centor criteria the patients presented, the greater the number of antibiotics prescribed, regardless of whether RADT was available (P<0.001). Antibiotics were prescribed in 30.7% of the cases with negative RADT results. Inappropriate antibiotic prescription was observed in 226 cases (43%), and was significantly greater in the control than in the intervention group (60% versus 26.9%; P<0.001).

CONCLUSION

Even though more than 30% of negative RADT results resulted in antibiotic prescribing, the study findings support the use of RADT in the consultation. This strategy has an important impact on reducing antibiotic prescription among adults with acute pharyngitis.

Access to a polymerase chain reaction assay method targeting 13 respiratory viruses can reduce antibiotics: a randomised, controlled trial

BACKGROUND

Viral respiratory infections are common worldwide and range from completely benign disease to life-threatening illness. Symptoms can be unspecific, and an etiologic diagnosis is rarely established because of a lack of suitable diagnostic tools. Improper use of antibiotics is common in this setting, which is detrimental in light of the development of bacterial resistance. It has been suggested that the use of diagnostic tests could reduce antibiotic prescription rates. The objective of this study was to evaluate whether access to a multiplex polymerase chain reaction (PCR) assay panel for etiologic diagnosis of acute respiratory tract infections (ARTIs) would have an impact on antibiotic prescription rate in primary care clinical settings.

METHODS

Adult patients with symptoms of ARTI were prospectively included. Nasopharyngeal and throat swabs were analysed by using a multiplex real-time PCR method targeting thirteen viruses and two bacteria. Patients were recruited at 12 outpatient units from October 2006 through April 2009, and samples were collected on the day of inclusion (initial visit) and after 10 days (follow-up visit). Patients were randomised in an open-label treatment protocol to receive a rapid or delayed result (on the following day or after eight to twelve days). The primary outcome measure was the antibiotic prescription rate at the initial visit, and the secondary outcome was the total antibiotic prescription rate during the study period.

RESULTS

A total sample of 447 patients was randomised. Forty-one were excluded, leaving 406 patients for analysis. In the group of patients randomised for a rapid result, 4.5% (9 of 202) of patients received antibiotics at the initial visit, compared to 12.3% (25 of 204) (P = 0.005) of patients in the delayed result group. At follow-up, there was no significant difference between the groups: 13.9% (28 of 202) in the rapid result group and 17.2% (35 of 204) in the delayed result group (P = 0.359), respectively.

CONCLUSIONS

Access to a rapid method for etiologic diagnosis of ARTIs may reduce antibiotic prescription rates at the initial visit in an outpatient setting. To sustain this effect, however, it seems necessary to better define how to follow and manage the patient according to the result of the test, which warrants further investigation.

Effect of two interventions on reducing antibiotic prescription in pharyngitis in primary care

OBJECTIVES

to evaluate the effect of two interventions on reducing antibiotic prescription in pharyngitis.

METHODS

a prospective, non-randomized, before-after controlled study was carried out in primary care centres throughout Spain. General practitioners (GPs) registered all cases of pharyngitis during a 3 week period before and after two types of intervention in 2008 and 2009, respectively. Full intervention consisted of discussion sessions of the results of the first registry, courses for GPs, guidelines, patient information leaflets, workshops on rapid tests and the use of rapid antigen detection tests (RADTs) in their consulting offices. The physicians in the partial intervention group underwent all the above intervention except for the workshop, and RADTs were not provided. A control group was also included in 2009. Multilevel logistic regression was performed considering the prescription of antibiotics as the dependent variable.

RESULTS

a total of 280 GPs registered cases with pharyngitis (70 partial intervention and 210 full intervention). Fifty-nine new physicians were included as a control group. A total of 6849 episodes of pharyngitis were registered. Antibiotic prescription was significantly lower after intervention for the full intervention group, but not for the partial intervention group. According to the multivariate model, in comparison with the control group, the odds ratio of antibiotic prescription after the intervention was 0.52 [95% confidence interval (95% CI) 0.23-1.18] in the partial intervention group and 0.23 (95% CI 0.11-0.47) in the full intervention group.

CONCLUSIONS

intervention was beneficial for reducing the prescription of antibiotics, but was only statistically significant when the GPs were provided with RADTs.

Infectious morbidity in 18-month-old children with and without older siblings

BACKGROUND

Infections are the most commonly reported health problems in children. Younger age and day care outside the home are two factors of importance for infectious morbidity. The influence of siblings on infectious symptoms is not clear.

OBJECTIVES

To compare families with one child and families with more than one child in terms of reported infectious symptoms, physician consultations and antibiotic prescriptions.

METHODS

A prospective population-based survey was performed. During 1 month, all infectious symptoms, physician consultations and antibiotic prescriptions for 18-month-old children were noted by the parents. The 789 families also answered questions about socio-economic factors, numbers of siblings in the family and type of day care.

RESULTS

No difference in number of symptom days was found between children with and without older siblings. Neither could we find any significance in terms of having older siblings in relation to physician consultations and antibiotic prescriptions.

CONCLUSIONS

The results of our study indicate that having older siblings not was important in relation to number of symptoms days, physician consultations or antibiotic prescriptions for 18-month-old children in Sweden today. Changes in social activities and attitudes towards antibiotic prescription may explain our different findings as compared with previous Swedish studies and studies from other countries.