Association between use of rapid antigen detection tests and adherence to antibiotics in suspected streptococcal pharyngitis

[Introduction of rapid streptococcal antigen test: can its use improve adherence to antibiotic therapy?]

OBJECTIVE

To evaluate the influence of the result of a rapid streptococcal antigen test in paediatric pharyngotonsillitis infections, in terms of improvement of antibiotic therapy adherence.

DESIGN

Randomized community clinical trial with two study groups.

LOCATION

Primary Care Centers in Central Catalonia.

PARTICIPANTS

Patients aged from 3 to 15 years, who were attended at paediatric consultations on suspicion of pharyngotonsillitis caused by an infection between November 2010 and February 2011 (both included), were included in the study on a consecutive basis. 557 patients met the inclusion criteria and 519 were evaluated.

INTERVENTION

The control group received the usual diagnostic-therapeutic algorithm. Rapid streptococcal antigen test was additionally performed to experimental group participants and it was indicated the more convenient treatment.

MAIN MEASUREMENTS

Antibiotic adherence, non-adherence causes and socio-demographic risk factors were evaluated via telephone survey.

RESULTS

Antibiotics were prescribed to 65.6% and paediatricians of the control group were more likely to prescribe antibiotic than the ones in the intervention group (88.5% vs 45.5%, p< 0.0001). 64.8% followed doctor's treatment orders, being failure following medication scheduling the main cause of non-adherence (25.6%). Medication adherence was higher in the experimental group (68%) than in the control group (62.9%) but no significant differences were found.

CONCLUSION

Rapid strep test, complementing the use of Centor Criteria avoids unnecessary antibiotics prescriptions, but had not been proven to be effective in increasing medication adherence.

Point-of-care tests in general practice: hope or hype?

Point-of-care tests are biomedical tests on patients' specimens like blood, saliva, urine or faeces, which can be used near the patient, without interference of a laboratory. The use of these tests, many of which have been recently developed, is increasing in general practice, where they add to the GP's set of diagnostic instruments. The question is, however, whether they always contribute to an effective and high-quality diagnostic process by GPs. We present a set of criteria that can be used by guideline developers, regional primary care organizations and individual GPs to evaluate a new point-of-care test in a practice setting. These criteria do not relate only to their use and quality. A point-of-care test needs to be evaluated in the right population and for the right indications, and GPs then need to use them for the indications for which they were evaluated. Expanding the range of indications can lead to an increase in false-positive and false-negative test results.

Bacterial cultures, rapid strep test, and antibiotic treatment in infected hard-to-heal ulcers in primary care

OBJECTIVE

In-depth studies on antibiotic treatment for patients with hard-to-heal ulcers in primary care are lacking. The present study was undertaken to update the bacteriological spectrum for this patient group and to investigate antibiotic treatment. A further aim was to investigate the potential of a rapid strep test to find group A streptococci (GAS) causing ulcer infection.

DESIGN

A prospective study from August 2009 to August 2010.

SETTING

Blekinge Wound Healing Center.

SUBJECTS

Patients with clinical signs of infected hard-to-heal ulcers of any etiology.

MAIN OUTCOME MEASURES

A bacterial culture and a rapid strep test were taken from every ulcer to capture the bacteriological spectrum. Antibiotic treatment before and during the study period was measured.

RESULTS

Forty-one patients with 49 infected ulcers were recruited. Staphylococcus aureus, found in 68.8% of all cultures, was the most observed species. Group G streptococci (GGS) were found in 12.5%. GAS was found in one case where the rapid strep test was positive. Staphylococcus aureus was found in three patients out of four with clinical signs of erysipelas. Some 59% of the patients were treated with antibiotics before the study period compared with 44% during the study period.

CONCLUSION

Antibiotic treatment was largely reduced because of structured wound management. The current bacteriological spectrum showed high rates of GGS and erysipelas caused by Staphylococcus aureus. The rapid strep test was found useful in identifying GAS but we would not recommend its use in the clinical setting due to the low rate of GAS in this patient group.

MS patients report excellent compliance with oral prednisone for acute relapses

BACKGROUND

Multiple Sclerosis is characterized by relapses separated by periods of relative quiescence. High dose intravenous corticosteroid pulses for three to five days is the current standard for the treatment of acute relapses, but recent evidence supports the use of equivalent doses of oral therapy as an alternative. The highest single dose preparation of oral prednisone is a 50mg tablet, requiring patients to take 25 tablets a day. Questions regarding compliance with this oral regimen have been raised.

OBJECTIVES

To determine whether MS patients are complaint with 1,250 mg of oral prednisone daily for acute relapses.

METHODS

Between November 2008 and December 2009, all patients diagnosed with an acute relapse in the London (Ontario) MS clinic were prospectively identified. If treatment with oral prednisone was initiated, subjects were given a survey to be mailed anonymously to the clinic.

RESULTS

Sixty eight MS relapses were diagnosed and treated with corticosteroids in 66 patients of which 60 (58 subjects) were treated with 1,250 mg prednisone. Fifty-three (91.4%) surveys were returned. The reported compliance rate was high at 94.3% (50/53) with only one patient reporting being unable to take all the required pills due to intolerance. Most subjects (43, 86.0%) encountered at least one side effect, most commonly insomnia, mood changes and increased appetite. Two thirds of subjects (69.8%) indicated a preference for oral medication for future relapses.

CONCLUSION

High dose (1,250 mg) oral prednisone is an acceptable therapy to MS patients for the treatment of acute relapses with a high rate of compliance.

Antibiotics for acute cough: an international observational study of patient adherence in primary care

BACKGROUND

Non-adherence to acute antibiotic prescriptions is poorly described and may impact on clinical outcomes, healthcare costs, and interpretation of research. It also results in leftover antibiotics that could be used inappropriately.

AIM

To describe adherence to antibiotics prescribed for adults presenting with acute cough in primary care, factors associated with non-adherence, and associated recovery.

DESIGN AND SETTING

Prospective observational cohort study in general practices in 14 European primary care networks.

METHOD

GPs recorded patient characteristics and prescribing decisions for adults with acute cough or clinical presentation suggestive of lower respiratory tract infection. Patients recorded antibiotic consumption and daily symptoms over 28 days. Rates of adherence to prescribed antibiotics were assessed, and factors associated with non-adherence were identified using logistic regression. Recovery was compared using a Cox proportional hazards model.

RESULTS

Of 2520 patients prescribed immediate or no antibiotics at the index consultation, 282 (11.2%) took an antibiotic during the follow-up period that was not prescribed for them at the index consultation. Of these, 38.1% had no reconsultations during this period. Prior duration of symptoms, antibiotic treatment duration, antibiotic choice, and primary care network were all associated with adherence. There was no difference in time to recovery between those who were prescribed antibiotics at the index consultation and were fully adherent, partially adherent, and non-adherent.

CONCLUSION

Non-adherence to antibiotics for acute cough or lower respiratory tract infection is common. Duration of treatment, choice of antibiotic, and setting were associated with adherence but adherence to treatment was not associated with differences in recovery.

The feasibility of antibiotic dosing four times per day: a prospective observational study in primary health care

OBJECTIVE

To investigate whether the increase in the number of doses of penicillin V from three times daily to four times daily for common infections, as recommended in the new Norwegian guidelines for antibiotic treatment in primary health care, would lead to reduced patient compliance.

DESIGN

Prospective observational study.

SETTING AND SUBJECTS

Six general practitioners included all patients who were prescribed systemic antibiotic treatment regardless of indication during a 10-month period. A total of 270 patients provided data for the study.

METHODS

Telephone interview focusing on omitted antibiotic doses.

RESULTS

Some 17% of patients had poor compliance, defined as failing to take 5% or more of total antibiotic doses. Neither level of poor compliance nor number of omitted doses differed significantly when the number of daily doses increased from three to four. There were significantly fewer omitted doses in the group given two doses per day when compared with three doses (p = 0.04) and four doses per day (p = 0.01).

CONCLUSION

We found no difference in compliance or omitted doses between antibiotic regimens of three and four doses per day. The new Norwegian guidelines for antibiotic treatment in primary health care appear feasible with regard to patient compliance.

[Prudent use of antibiotics and suggestions for improvement in the primary health care system]

A third of all primary care (PC) visits are due to infectious diseases and more than half of these are due to respiratory tract infections. In most cases, data from the clinical history and physical examinations do not help discern whether the aetiology of the infection is bacterial or not and, when in doubt, the family doctor tends to prescribe antibiotics despite the marginal effect that these drugs have on most respiratory infections. Moreover, PC physicians overestimate the proportion of patients with infections who expect to receive antibiotics and according to the scientific literature this perception is often wrong. In addition, patient expectations are often based on false assumptions or experiences from previous visits. Various strategies have proven useful in promoting more prudent use of antibiotics in PC. Delayed prescription of antibiotics is recommended mainly in non-serious infections of suspected viral aetiology in patients who express a preference for antibiotics. Improving communication skills has also proven useful in reducing prescriptions of antibiotics as has the use of rapid diagnostic tests in the doctor's office, mainly rapid antigen techniques for diagnosis of strep throat and determination of C-reactive protein. The results of the Happy Audit study recently conducted in Spain confirm these findings.