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Graziadio S, Gregg E, Allen AJ, Neveux P, Monz BU, Davenport C, Mealing S, Holmes H, Ferrante di Ruffano L. Is the Comparator in Your Diagnostic Cost-Effectiveness Model "Standard of Care"? Recommendations from Literature Reviews and Expert Interviews on How to Identify and Operationalize It. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2024; 27:585-597. [PMID: 38401794 DOI: 10.1016/j.jval.2024.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 02/08/2024] [Accepted: 02/14/2024] [Indexed: 02/26/2024]
Abstract
OBJECTIVES This research aimed to develop best-practice recommendations for identifying the "standard of care" (SoC) and integrate it when it is the comparator in diagnostic economic models (SoC comparator). METHODS A multi-methods approach comprising 2 pragmatic literature reviews and 9 expert interviews was used. Experts rated their agreement with draft recommendations based on the authors' analysis of the reviews. These were refined iteratively to produce final recommendations. RESULTS Fourteen best-practice recommendations are provided. Care pathway mapping (using quantitative, qualitative, or mixed-methods approaches) should be used for identifying the SoC comparator. Guidelines analysis can be integrated with expert opinion to identify pathway variability and discrepancies from clinical practice. For integrating the SoC comparator into the model, recommendations around structure, input sourcing, data aggregation and reporting, input uncertainty, and model variability are presented. For example, modelers should consider that the reference standard is not synonymous with the SoC, and the SoC may not be the only comparator. The comparator limitations should be discussed with clinical experts, but elicitation of its diagnostic accuracy is not recommended. Probabilistic sensitivity analysis is recommended when evaluating the overall input uncertainty, and deterministic sensitivity analysis is useful when there is high model uncertainty or SoC variability. Consensus could not be reached for some topics (eg, the role of real-world data, model averaging, and alternative model structures), but the reported discussions provide points for consideration. CONCLUSIONS To our knowledge, this is the first guidance to support modelers when identifying and operationalizing the SoC comparator in diagnostic cost-effectiveness models.
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Affiliation(s)
- Sara Graziadio
- York Health Economics Consortium, Enterprise House, University of York, Innovation Way, York, England, UK.
| | - Emily Gregg
- York Health Economics Consortium, Enterprise House, University of York, Innovation Way, York, England, UK
| | - A Joy Allen
- Health Economics, Roche Diagnostics UK and Ireland, Burgess Hill, England, UK
| | - Paul Neveux
- Global Access & Policy, Roche Diagnostics International AG, Rotkreuz, Switzerland
| | - Brigitta U Monz
- Global Access & Policy, Roche Diagnostics International AG, Rotkreuz, Switzerland
| | - Clare Davenport
- Institute of Applied Health Research, University of Birmingham, Birmingham, England, UK
| | - Stuart Mealing
- York Health Economics Consortium, Enterprise House, University of York, Innovation Way, York, England, UK
| | - Hayden Holmes
- York Health Economics Consortium, Enterprise House, University of York, Innovation Way, York, England, UK
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Kanagasabai A, Evans C, Jones HE, Hay AD, Dawson S, Savović J, Elwenspoek MMC. Systematic review and meta-analysis of the accuracy of McIsaac and Centor score in patients presenting to secondary care with pharyngitis. Clin Microbiol Infect 2024; 30:445-452. [PMID: 38182052 DOI: 10.1016/j.cmi.2023.12.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 12/11/2023] [Accepted: 12/24/2023] [Indexed: 01/07/2024]
Abstract
BACKGROUND Centor and McIsaac scores are clinical prediction rules for diagnosing group A streptococcus (GAS) infection in patients with pharyngitis. Their recommended thresholds vary between guidelines. OBJECTIVES To estimate the sensitivity and specificity of the McIsaac and Centor scores to diagnose GAS pharyngitis and evaluate their impact on antibiotic prescribing at each threshold in patients presenting to secondary care. DATA SOURCES MEDLINE, Embase, and Web of Science were searched from inception to September 2022. STUDY ELIGIBILITY CRITERIA Studies of patients presenting with acute pharyngitis to emergency or outpatient clinics that estimated the accuracy of McIsaac or Centor scores against throat cultures and/or rapid antigen detection tests (RADT) as reference standards. TESTS Centor or McIsaac score. REFERENCE STANDARD Throat cultures and/or RADT. ASSESSMENT OF RISK OF BIAS Quality Assessment of Diagnostic Accuracy Studies. METHODS OF DATA SYNTHESIS The sensitivities and specificities of the McIsaac and Centor scores were pooled at each threshold using bivariate random effects meta-analysis. RESULTS Fourteen studies were included (eight McIsaac and six Centor scores). Eight studies had unclear and six had a high risk of bias. The McIsaac score had higher estimated sensitivity and lower specificity relative to Centor scores at equivalent thresholds but with wide and overlapping confidence regions. Using either score as a triage to RADT to decide antibiotic treatment would reduce antibiotic prescription to patients with non-GAS pharyngitis relative to RADT test for everyone, but also reduce antibiotic prescription to patients with GAS. DISCUSSION Centor and McIsaac scores are equally ineffective at triaging patients who need antibiotics presenting with pharyngitis at hospitals. At high thresholds, too many true positive cases are missed, whereas at low thresholds, too many false positives are treated, leading to the over prescription of antibiotics. The former may be compensated by adequate safety netting by clinicians, ensuring that patients can seek help if symptoms worsen.
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Affiliation(s)
| | - Callum Evans
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Hayley E Jones
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Alastair D Hay
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, UK
| | - Sarah Dawson
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK; The National Institute for Health Research Applied Research Collaboration West (NIHR ARC West), University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Jelena Savović
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK; The National Institute for Health Research Applied Research Collaboration West (NIHR ARC West), University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Martha M C Elwenspoek
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK; The National Institute for Health Research Applied Research Collaboration West (NIHR ARC West), University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
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3
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Pellegrino R, Timitilli E, Verga MC, Guarino A, Iacono ID, Scotese I, Tezza G, Dinardo G, Riccio S, Pellizzari S, Iavarone S, Lorenzetti G, Simeone G, Bergamini M, Donà D, Pierantoni L, Garazzino S, Esposito S, Venturini E, Gattinara GC, Lo Vecchio A, Marseglia GL, Di Mauro G, Principi N, Galli L, Chiappini E. Acute pharyngitis in children and adults: descriptive comparison of current recommendations from national and international guidelines and future perspectives. Eur J Pediatr 2023; 182:5259-5273. [PMID: 37819417 PMCID: PMC10746578 DOI: 10.1007/s00431-023-05211-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 09/12/2023] [Accepted: 09/15/2023] [Indexed: 10/13/2023]
Abstract
This study aims to provide a comparison of the current recommendations about the management of acute pharyngitis. A literature search was conducted from January 2009 to 2023. Documents reporting recommendations on the management of acute pharyngitis were included, pertinent data were extracted, and a descriptive comparison of the different recommendations was performed. The quality of guidelines was assessed through the AGREE II instrument. Nineteen guidelines were included, and an overall moderate quality was found. Three groups can be distinguished: one group supports the antibiotic treatment of group A β-hemolytic Streptococcus (GABHS) to prevent acute rheumatic fever (ARF); the second considers acute pharyngitis a self-resolving disease, recommending antibiotics only in selected cases; the third group recognizes a different strategy according to the ARF risk in each patient. An antibiotic course of 10 days is recommended if the prevention of ARF is the primary goal; conversely, some guidelines suggest a course of 5-7 days, assuming the symptomatic cure is the goal of treatment. Penicillin V and amoxicillin are the first-line options. In the case of penicillin allergy, first-generation cephalosporins are a suitable choice. In the case of beta-lactam allergy, clindamycin or macrolides could be considered according to local resistance rates. Conclusion: Several divergencies in the management of acute pharyngitis were raised among guidelines (GLs) from different countries, both in the diagnostic and therapeutic approach, allowing the distinction of 3 different strategies. Since GABHS pharyngitis could affect the global burden of GABHS disease, it is advisable to define a shared strategy worldwide. It could be interesting to investigate the following issues further: cost-effectiveness analysis of diagnostic strategies in different healthcare systems; local genomic epidemiology of GABHS infection and its complications; the impact of antibiotic treatment of GABHS pharyngitis on its complications and invasive GABHS infections; the role of GABHS vaccines as a prophylactic measure. The related results could aid the development of future recommendations. What is Known: • GABHS disease spectrum ranges from superficial to invasive infections and toxin-mediated diseases. • GABHS accounts for about 25% of sore throat in children and its management is a matter of debate. What is New: • Three strategies can be distinguished among current GLs: antibiotic therapy to prevent ARF, antibiotics only in complicated cases, and a tailored strategy according to the individual ARF risk. • The impact of antibiotic treatment of GABHS pharyngitis on its sequelae still is the main point of divergence; further studies are needed to achieve a global shared strategy.
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Affiliation(s)
- Roberta Pellegrino
- Department of Health Sciences, Postgraduate School of Pediatrics, University of Florence, Florence, Italy
| | - Edoardo Timitilli
- Department of Health Sciences, Postgraduate School of Pediatrics, University of Florence, Florence, Italy
| | | | - Alfredo Guarino
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Iride Dello Iacono
- Unit of Allergology, Division of Internal Medicine, Fatebenefratelli Hospital, Benevento, Italy
| | | | - Giovanna Tezza
- Department of Pediatrics, Ospedale San Maurizio, Bolzano, Italy
| | - Giulio Dinardo
- Department of Woman, Child and of General and Specialized Surgery, University of Campania 'Luigi Vanvitelli', Naples, Italy
| | - Simona Riccio
- Department of Woman, Child and of General and Specialized Surgery, University of Campania 'Luigi Vanvitelli', Naples, Italy
| | - Sofia Pellizzari
- Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, Pediatric Clinic, University of Verona, Verona, Italy
| | - Sonia Iavarone
- Department of Maternal, Infantile, and Urological Sciences, "Sapienza" University of Rome, Rome, Italy
| | - Giulia Lorenzetti
- Residency School of Pediatrics, University of Rome Tor Vergata, Rome, Italy
| | | | | | - Daniele Donà
- Division of Paediatric Infectious Diseases, Department of Women's and Children's Health, University of Padua, Padua, Italy
| | - Luca Pierantoni
- Pediatric Emergency Unit, IRCCS Azienda Ospedaliero Universitaria Di Bologna, Bologna, Italy
| | - Silvia Garazzino
- Department of Paediatrics, Infectious Diseases Unit, Regina Margherita Children's Hospital, University of Turin, Turin, Italy
| | - Susanna Esposito
- Paediatric Clinic, University Hospital, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | | | | | - Andrea Lo Vecchio
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Gian Luigi Marseglia
- Department of Pediatrics, Foundation IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Giuseppe Di Mauro
- Pediatric Primary Care, National Pediatric Health Care System, Caserta, Italy
| | - Nicola Principi
- Professor Emeritus of Pediatrics, University of Milan, Milan, Italy
| | - Luisa Galli
- Infectious Diseases Unit, Meyer Children's Hospital IRCCS, Florence, Italy
- Department of Health Sciences, University of Florence, Viale Pieraccini 24, 50139, Firenze, Italy
| | - Elena Chiappini
- Infectious Diseases Unit, Meyer Children's Hospital IRCCS, Florence, Italy.
- Department of Health Sciences, University of Florence, Viale Pieraccini 24, 50139, Firenze, Italy.
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4
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Wilson JA, Fouweather T, Stocken DD, Homer T, Haighton C, Rousseau N, O'Hara J, Vale L, Wilson R, Carnell S, Wilkes S, Morrison J, Ah-See K, Carrie S, Hopkins C, Howe N, Hussain M, Lindley L, MacKenzie K, McSweeney L, Mehanna H, Raine C, Whelan RS, Sullivan F, von Wilamowitz-Moellendorff A, Teare D. Tonsillectomy compared with conservative management in patients over 16 years with recurrent sore throat: the NATTINA RCT and economic evaluation. Health Technol Assess 2023; 27:1-195. [PMID: 38204203 PMCID: PMC11017150 DOI: 10.3310/ykur3660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2024] Open
Abstract
Background The place of tonsillectomy in the management of sore throat in adults remains uncertain. Objectives To establish the clinical effectiveness and cost-effectiveness of tonsillectomy, compared with conservative management, for tonsillitis in adults, and to evaluate the impact of alternative sore throat patient pathways. Design This was a multicentre, randomised controlled trial comparing tonsillectomy with conservative management. The trial included a qualitative process evaluation and an economic evaluation. Setting The study took place at 27 NHS secondary care hospitals in Great Britain. Participants A total of 453 eligible participants with recurrent sore throats were recruited to the main trial. Interventions Patients were randomised on a 1 : 1 basis between tonsil dissection and conservative management (i.e. deferred surgery) using a variable block-stratified design, stratified by (1) centre and (2) severity. Main outcome measures The primary outcome measure was the total number of sore throat days over 24 months following randomisation. The secondary outcome measures were the number of sore throat episodes and five characteristics from Sore Throat Alert Return, describing severity of the sore throat, use of medications, time away from usual activities and the Short Form questionnaire-12 items. Additional secondary outcomes were the Tonsil Outcome Inventory-14 total and subscales and Short Form questionnaire-12 items 6 monthly. Evaluation of the impact of alternative sore throat patient pathways by observation and statistical modelling of outcomes against baseline severity, as assessed by Tonsil Outcome Inventory-14 score at recruitment. The incremental cost per sore throat day avoided, the incremental cost per quality-adjusted life-year gained based on responses to the Short Form questionnaire-12 items and the incremental net benefit based on costs and responses to a contingent valuation exercise. A qualitative process evaluation examined acceptability of trial processes and ramdomised arms. Results There was a median of 27 (interquartile range 12-52) sore throats over the 24-month follow-up. A smaller number of sore throats was reported in the tonsillectomy arm [median 23 (interquartile range 11-46)] than in the conservative management arm [median 30 (interquartile range 14-65)]. On an intention-to-treat basis, there were fewer sore throats in the tonsillectomy arm (incident rate ratio 0.53, 95% confidence interval 0.43 to 0.65). Sensitivity analyses confirmed this, as did the secondary outcomes. There were 52 episodes of post-operative haemorrhage reported in 231 participants undergoing tonsillectomy (22.5%). There were 47 re-admissions following tonsillectomy (20.3%), 35 relating to haemorrhage. On average, tonsillectomy was more costly and more effective in terms of both sore throat days avoided and quality-adjusted life-years gained. Tonsillectomy had a 100% probability of being considered cost-effective if the threshold for an additional quality-adjusted life year was £20,000. Tonsillectomy had a 69% probability of having a higher net benefit than conservative management. Trial processes were deemed to be acceptable. Patients who received surgery were unanimous in reporting to be happy to have received it. Limitations The decliners who provided data tended to have higher Tonsillectomy Outcome Inventory-14 scores than those willing to be randomised implying that patients with a higher burden of tonsillitis symptoms may have declined entry into the trial. Conclusions The tonsillectomy arm had fewer sore throat days over 24 months than the conservative management arm, and had a high probability of being considered cost-effective over the ranges considered. Further work should focus on when tonsillectomy should be offered. National Trial of Tonsillectomy IN Adults has assessed the effectiveness of tonsillectomy when offered for the current UK threshold of disease burden. Further research is required to define the minimum disease burden at which tonsillectomy becomes clinically effective and cost-effective. Trial registration This trial is registered as ISRCTN55284102. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 12/146/06) and is published in full in Health Technology Assessment; Vol. 27, No. 31. See the NIHR Funding and Awards website for further award information.
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Affiliation(s)
- Janet A Wilson
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Tony Fouweather
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Deborah D Stocken
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Tara Homer
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Catherine Haighton
- Department of Social Work, Education and Community Wellbeing, Northumbria University, Newcastle upon Tyne, UK
| | - Nikki Rousseau
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - James O'Hara
- Ear, Nose and Throat Department, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Luke Vale
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Rebecca Wilson
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Sonya Carnell
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Scott Wilkes
- School of Medicine, Faculty of Health Sciences and Wellbeing, University of Sunderland, Sunderland, UK
| | | | - Kim Ah-See
- Department of Otolaryngology Head and Neck Surgery, NHS Grampian, Aberdeen, UK
| | - Sean Carrie
- Ear, Nose and Throat Department, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Claire Hopkins
- Ear, Nose and Throat and Head and Neck Department, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Nicola Howe
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | | | | | - Kenneth MacKenzie
- Department of Ear, Nose and Throat Surgery, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Lorraine McSweeney
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Hisham Mehanna
- Institute of Head and Neck Studies and Education, University of Birmingham, Birmingham, UK
| | - Christopher Raine
- Ear, Nose and Throat Department, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Ruby Smith Whelan
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Frank Sullivan
- Population and Behavioural Science Division, School of Medicine, University of St Andrews, St Andrews, UK
| | | | - Dawn Teare
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
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5
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Hedin K, Thorning S, van Driel ML. Different antibiotic treatments for group A streptococcal pharyngitis. Cochrane Database Syst Rev 2023; 11:CD004406. [PMID: 37965935 PMCID: PMC10646936 DOI: 10.1002/14651858.cd004406.pub6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2023]
Abstract
BACKGROUND Antibiotics provide only modest benefit in treating sore throat, although their effectiveness increases in people with positive throat swabs for group A beta-haemolytic streptococci (GABHS). It is unclear which antibiotic is the best choice if antibiotics are indicated. This is an update of a review first published in 2010, and updated in 2013, 2016, and 2021. OBJECTIVES To assess the comparative efficacy of different antibiotics in: (a) alleviating symptoms (pain, fever); (b) shortening the duration of the illness; (c) preventing clinical relapse (i.e. recurrence of symptoms after initial resolution); and (d) preventing complications (suppurative complications, acute rheumatic fever, post-streptococcal glomerulonephritis). To assess the evidence on the comparative incidence of adverse effects and the risk-benefit of antibiotic treatment for streptococcal pharyngitis. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL 2023, Issue 2), MEDLINE Ovid, Embase Elsevier, and Web of Science (Clarivate) up to 19 March 2023. SELECTION CRITERIA Randomised, double-blind trials comparing different antibiotics, and reporting at least one of the following: clinical cure, clinical relapse, or complications and/or adverse events. DATA COLLECTION AND ANALYSIS Two review authors independently screened trials for inclusion and extracted data using standard methodological procedures recommended by Cochrane. We assessed the risk of bias in the included studies according to the methods outlined in the Cochrane Handbook for Systematic Reviews of Interventions, and used the GRADE approach to assess the overall certainty of the evidence for the outcomes. We reported the intention-to-treat analysis, and also performed an analysis of evaluable participants to explore the robustness of the intention-to-treat results. MAIN RESULTS We included 19 trials reported in 18 publications (5839 randomised participants): six trials compared penicillin with cephalosporins; six compared penicillin with macrolides; three compared penicillin with carbacephem; one compared penicillin with sulphonamides; one compared clindamycin with ampicillin; and one compared azithromycin with amoxicillin in children. All participants had confirmed acute GABHS tonsillopharyngitis, and ages ranged from one month to 80 years. Nine trials included only, or predominantly, children. Most trials were conducted in an outpatient setting. Reporting of randomisation, allocation concealment, and blinding was poor in all trials. We downgraded the certainty of the evidence mainly due to lack of (or poor reporting of) randomisation or blinding, or both, heterogeneity, and wide confidence intervals. Cephalosporins versus penicillin We are uncertain if there is a difference in symptom resolution (at 2 to 15 days) for cephalosporins versus penicillin (odds ratio (OR) for absence of symptom resolution 0.79, 95% confidence interval (CI) 0.55 to 1.12; 5 trials, 2018 participants; low-certainty evidence). Results of the sensitivity analysis of evaluable participants differed (OR 0.51, 95% CI 0.27 to 0.97; 5 trials, 1660 participants; very low-certainty evidence). Based on an analysis of evaluable participants, we are uncertain if clinical relapse may be lower for cephalosporins compared with penicillin (OR 0.55, 95% CI 0.30 to 0.99; number needed to treat for an additional beneficial outcome (NNTB) 50; 4 trials, 1386 participants; low-certainty evidence). Very low-certainty evidence showed no difference in reported adverse events. Macrolides versus penicillin We are uncertain if there is a difference between macrolides and penicillin for resolution of symptoms (OR 1.11, 95% CI 0.92 to 1.35; 6 trials, 1728 participants; low-certainty evidence). Sensitivity analysis of evaluable participants resulted in an OR of 0.79 (95% CI 0.57 to 1.09; 6 trials, 1159 participants). We are uncertain if clinical relapse may be different (OR 1.21, 95% CI 0.48 to 3.03; 6 trials, 802 participants; low-certainty evidence). Children treated with macrolides seemed to experience more adverse events than those treated with penicillin (OR 2.33, 95% CI 1.06 to 5.15; 1 trial, 489 participants; low-certainty evidence). However, the test for subgroup differences between children and adults was not significant. Azithromycin versus amoxicillin Based on one unpublished trial in children, we are uncertain if resolution of symptoms is better with azithromycin in a single dose versus amoxicillin for 10 days (OR 0.76, 95% CI 0.55 to 1.05; 1 trial, 673 participants; very low-certainty evidence). Sensitivity analysis for per-protocol analysis resulted in an OR of 0.29 (95% CI 0.11 to 0.73; 1 trial, 482 participants; very low-certainty evidence). We are also uncertain if there was a difference in relapse between groups (OR 0.88, 95% CI 0.43 to 1.82; 1 trial, 422 participants; very low-certainty evidence). Adverse events were more common with azithromycin compared to amoxicillin (OR 2.67, 95% CI 1.78 to 3.99; 1 trial, 673 participants; very low-certainty evidence). Carbacephem versus penicillin There is low-certainty evidence that compared with penicillin, carbacephem may provide better symptom resolution post-treatment in adults and children (OR 0.70, 95% CI 0.49 to 0.99; NNTB 14.3; 3 trials, 795 participants). Studies did not report on long-term complications, so it was unclear if any class of antibiotics was better at preventing serious but rare complications. AUTHORS' CONCLUSIONS We are uncertain if there are clinically relevant differences in symptom resolution when comparing cephalosporins and macrolides with penicillin in the treatment of GABHS tonsillopharyngitis. Low-certainty evidence in children suggests that carbacephem may be more effective than penicillin for symptom resolution. There is insufficient evidence to draw conclusions regarding the other comparisons in this review. Data on complications were too scarce to draw conclusions. Antibiotics have a limited effect in the treatment of GABHS pharyngitis and the results do not demonstrate that other antibiotics are more effective than penicillin. In the context of antimicrobial stewardship, penicillin can be used if treatment with an antibiotic is indicated. All studies were conducted in high-income countries with a low risk of streptococcal complications, so there is a need for trials in low-income countries and disadvantaged populations, where the risk of complications remains high.
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Affiliation(s)
- Katarina Hedin
- Futurum - the Academy for Health and Care, Region Jönköping County, Jönköping, Sweden
- Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
- Department of Clinical Sciences in Malmö, Family Medicine, Lund University, Malmö, Sweden
| | - Sarah Thorning
- Education and Research Unit, Central Queensland Hospital and Health Service, Rockhampton, Australia
| | - Mieke L van Driel
- General Practice Clinical Unit, Faculty of Medicine, The University of Queensland, Brisbane, Australia
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6
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Cannon JW, Wyber R. Modalities of group A streptococcal prevention and treatment and their economic justification. NPJ Vaccines 2023; 8:59. [PMID: 37087467 PMCID: PMC10122086 DOI: 10.1038/s41541-023-00649-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 03/23/2023] [Indexed: 04/24/2023] Open
Abstract
Infection by group A Streptococcus (Strep A) results in a diverse range of clinical conditions, including pharyngitis, impetigo, cellulitis, necrotising fasciitis, and rheumatic heart disease. In this article, we outline the recommended strategies for Strep A treatment and prevention and review the literature for economic evaluations of competing treatment and prevention strategies. We find that most economic evaluations focus on reducing the duration of illness or risk of rheumatic fever among people presenting with sore throat through diagnostic and/or treatment strategies. Few studies have evaluated strategies to reduce the burden of Strep A infection among the general population, nor have they considered the local capacity to finance and implement strategies. Evaluation of validated costs and consequences for a more diverse range of Strep A interventions are needed to ensure policies maximise patient outcomes under budget constraints. This should include attention to basic public health strategies and emerging strategies such as vaccination.
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Affiliation(s)
- Jeffrey W Cannon
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, Nedlands, WA, Australia.
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
| | - Rosemary Wyber
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, Nedlands, WA, Australia
- National Centre for Aboriginal and Torres Strait Islander Wellbeing Research, National Centre for Epidemiology and Population Health, ANU College of Health & Medicine, The Australian National University, Canberra, Australia
- Adjunct Senior Research Fellow, University of Western Australia, Nedlands, WA, Australia
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7
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Gunnarsson RK, Ebell M, Centor R, Little P, Verheij T, Lindbæk M, Sundvall PD. Best management of patients with an acute sore throat – a critical analysis of current evidence and a consensus of experts from different countries and traditions. Infect Dis (Lond) 2023; 55:384-395. [PMID: 36971650 DOI: 10.1080/23744235.2023.2191714] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/29/2023] Open
Abstract
BACKGROUND There is a very large body of publications discussing the management of patients with an acute sore throat. Advocates for a restrictive antibiotic policy and advocates for a more liberal use of antibiotics emphasise different and valid arguments and to date have not been able to unite in a consensus. Contradicting guidelines based on the same body of knowledge is not logical, may cause confusion and cause unwanted variation in clinical management. METHODS In multiple video meetings and email correspondence from March to November 2022 and finally in a workshop at the annual meeting for the North American Primary Care Group in November 2022, experts from different countries representing different traditions agreed on how the current evidence should be interpreted. RESULTS This critical analysis identifies that the problem can be resolved by introducing a new triage scheme considering both the acute risk for suppurative complications and sepsis as well as the long-term risk of developing rheumatic fever. CONCLUSIONS The new triage scheme may solve the long-standing problem of advocating for a restrictive use of antibiotics while also satisfying concerns that critically ill patients might be missed with severe consequences. We acknowledge that the perspective of this problem is vastly different between high- and low-income countries. Furthermore, we discuss the new trend which allows nurses and pharmacists to independently manage these patients and the increased need for safety netting required for such management.
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Wächtler H, Kaduszkiewicz H, Kuhnert O, Malottki KA, Maaß S, Hedderich J, Wiese B, Donner-Banzhoff N, Hansmann-Wiest J. 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). BMC PRIMARY CARE 2023; 24:75. [PMID: 36941540 PMCID: PMC10029262 DOI: 10.1186/s12875-023-01987-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Accepted: 01/18/2023] [Indexed: 03/22/2023]
Abstract
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.
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Affiliation(s)
- Hannelore Wächtler
- Institute of General Practice, Kiel University, Michaelisstr. 5, 24105, Kiel, Germany
| | - Hanna Kaduszkiewicz
- Institute of General Practice, Kiel University, Michaelisstr. 5, 24105, Kiel, Germany.
| | - Oskar Kuhnert
- Institute of General Practice, Kiel University, Michaelisstr. 5, 24105, Kiel, Germany
| | | | - Sonja Maaß
- Institute of General Practice, Kiel University, Michaelisstr. 5, 24105, Kiel, Germany
| | - Jürgen Hedderich
- Institute of Medical Informatics and Statistics, Kiel University, University Hospital Schleswig-Holstein, Campus Kiel, Arnold-Heller-Straße 3, Haus V40, 24105, Kiel, Germany
| | - Birgitt Wiese
- IT Services Applications, Science & Laboratory, MHH Information Technology, Medizinische Hochschule Hannover (MHH), Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Norbert Donner-Banzhoff
- Department of General Practice / Family Medicine, University of Marburg, Karl-von-Frisch-Str. 4, 35043, Marburg, Germany
| | - Julia Hansmann-Wiest
- Institute of General Practice, Kiel University, Michaelisstr. 5, 24105, Kiel, Germany
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Vicentini C, Vola L, Previti C, Brescia V, Dal Mas F, Zotti CM, Bert F. Antimicrobial Stewardship Strategies Including Point-of-Care Testing (POCT) for Pediatric Patients with Upper-Respiratory-Tract Infections in Primary Care: A Systematic Review of Economic Evaluations. Antibiotics (Basel) 2022; 11:antibiotics11081139. [PMID: 36010008 PMCID: PMC9404955 DOI: 10.3390/antibiotics11081139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 08/12/2022] [Accepted: 08/19/2022] [Indexed: 12/02/2022] Open
Abstract
Upper-respiratory-tract infections (URTIs) are among the main causes of antibiotic prescriptions in pediatric patients. Over one-third of all antibiotic prescriptions for URTIs in children are estimated to be inappropriate, as the majority of URTIs are caused by viral agents. Several strategies, including clinical scoring algorithms and different point-of-care tests (POCTs) have been developed to help discriminate bacterial from viral URTIs in the outpatient clinical setting. A systematic review of the literature was conducted following PRISMA guidelines with the objective of summarizing evidence from health–economic evaluations on the use of POCT for URTIs in pediatric outpatients. A total of 3375 records identified from four databases and other sources were screened, of which 8 met the inclusion criteria. Four studies were classified as being of high reporting quality, and three were of medium quality. Five out of eight studies concluded in favor of strategies that included POCTs, with an additional study finding several POCTs to be cost-effective compared to usual care but over an acceptable WTP threshold. This review found POCT could be a valuable tool for antimicrobial stewardship strategies targeted towards childhood URTIs in primary care.
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Affiliation(s)
- Costanza Vicentini
- Department of Public Health Sciences and Pediatrics, University of Turin, 10126 Turin, Italy
| | - Lorenzo Vola
- Department of Public Health Sciences and Pediatrics, University of Turin, 10126 Turin, Italy
| | - Christian Previti
- Department of Public Health Sciences and Pediatrics, University of Turin, 10126 Turin, Italy
- Correspondence: ; Tel.: +39-011-670-5830; Fax: +39-011-670-5889
| | - Valerio Brescia
- Department of Management, University of Turin, 10126 Turin, Italy
| | - Francesca Dal Mas
- Department of Management, Ca’ Foscari University of Venice, Cannaregio, 873, 30100 Venice, Italy
| | - Carla Maria Zotti
- Department of Public Health Sciences and Pediatrics, University of Turin, 10126 Turin, Italy
| | - Fabrizio Bert
- Department of Public Health Sciences and Pediatrics, University of Turin, 10126 Turin, Italy
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10
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Rodrigues AT, Nunes JCF, Estrela M, Figueiras A, Roque F, Herdeiro MT. Comparing Hospital and Primary Care Physicians' Attitudes and Knowledge Regarding Antibiotic Prescribing: A Survey within the Centre Region of Portugal. Antibiotics (Basel) 2021; 10:antibiotics10060629. [PMID: 34070337 PMCID: PMC8229910 DOI: 10.3390/antibiotics10060629] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 05/14/2021] [Accepted: 05/23/2021] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Antibiotic resistance is a worldwide public health problem, leading to longer hospital stays, raising medical costs and mortality levels. As physicians' attitudes are key factors to antibiotic prescribing, this study sought to explore their differences between primary care and hospital settings. METHODS A survey was conducted between September 2011 and February 2012 in the center region of Portugal in the form of a questionnaire to compare hospital (n = 154) and primary care (n = 421) physicians' attitudes and knowledge regarding antibiotic prescribing. RESULTS More than 70% of the attitudes were statistically different (p < 0.05) between hospital physicians (HPs) and primary care physicians (PCPs). When compared to PCPs, HPs showed higher agreement with antibiotic resistances being a public health problem and ascribed more importance to microbiological tests and to the influence of prescription on the development of resistances. On the other hand, PCPs tended to agree more regarding the negative impact of self-medication with antibiotics dispensed without medical prescription and the need for rapid diagnostic tests. Seven out of nine sources of knowledge's usefulness were statistically different between both settings, with HPs considering most of the knowledge sources to be more useful than PCPs. CONCLUSIONS Besides the efforts made to improve both antibiotic prescribing and use, there are differences in the opinions between physicians working in different settings that might impact the quality of antibiotic prescribing. In the future, these differences must be considered to develop more appropriate interventions.
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Affiliation(s)
- António Teixeira Rodrigues
- Department of Medical Sciences, iBiMED—Institute of Biomedicine, University of Aveiro, 3800 Aveiro, Portugal; (A.T.R.); (M.E.); (M.T.H.)
- Centre for Health Evaluation and Research (CEFAR), National Association of Pharmacies, 1249 Lisbon, Portugal
| | - João C. F. Nunes
- Department of Chemistry, CICECO—Aveiro Institute of Materials, University of Aveiro, 3800 Aveiro, Portugal;
| | - Marta Estrela
- Department of Medical Sciences, iBiMED—Institute of Biomedicine, University of Aveiro, 3800 Aveiro, Portugal; (A.T.R.); (M.E.); (M.T.H.)
| | - Adolfo Figueiras
- Department of Preventive Medicine and Public Health, University of Santiago de Compostela, 15702 Santiago de Compostela, Spain;
- Consortium for Biomedical Research in Epidemiology and Public Health (CIBER Epidemiology and Public Health—CIBERESP), 28001 Madrid, Spain
- Health Research Institute of Santiago de Compostela (IDIS), 15706 Santiago de Compostela, Spain
| | - Fátima Roque
- Research Unit for Inland Development, Polytechnic of Guarda (IPG-UDI), 6300 Guarda, Portugal
- Health Sciences Research Centre, University of Beira Interior (CICS-UBI), 6200 Covilhã, Portugal
- Correspondence:
| | - Maria Teresa Herdeiro
- Department of Medical Sciences, iBiMED—Institute of Biomedicine, University of Aveiro, 3800 Aveiro, Portugal; (A.T.R.); (M.E.); (M.T.H.)
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11
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Robinson JL. Paediatrics: how to manage pharyngitis in an era of increasing antimicrobial resistance. Drugs Context 2021; 10:dic-2020-11-6. [PMID: 33828608 PMCID: PMC8007209 DOI: 10.7573/dic.2020-11-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 02/22/2021] [Indexed: 12/15/2022] Open
Abstract
The goal of this narrative review of pharyngitis is to summarize the practical aspects of the management of sore throat in children in high- and middle-income countries. A traditional review of the literature was performed. Most cases of pharyngitis are viral and self-limited, although rarely viral pharyngitis due to Epstein–Barr leads to airway obstruction. Bacterial pharyngitis is usually due to group A streptococcus (GAS), occurs primarily in children aged 5–15 years, and presents as sore throat in the absence of rhinitis, laryngitis or cough. Again, most cases are self-limited; antibiotics hasten recovery by only 1–2 days. Guidelines vary by country, but antibiotics are commonly recommended for proven GAS pharyngitis as they may prevent rare but severe complications, in particular rheumatic fever (RF). In this era of antimicrobial stewardship, it should be extremely rare that antibiotics are prescribed for presumed GAS pharyngitis until GAS has been detected. Even with proven GAS pharyngitis, it is controversial whether children at low risk for RF should routinely be prescribed antibiotics as the number needed to treat to prevent one case of RF is undoubtedly very large. When treatment is offered, the antibiotics of choice are penicillin or amoxicillin as they are narrow spectrum and resistance resulting in clinical failure is yet to be documented. A 10-day oral course is recommended as shorter courses appear to be less likely to clear carriage of GAS. However, the evidence that one needs to clear carriage to prevent RF is low quality and indirect.
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Affiliation(s)
- Joan L Robinson
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
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12
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Update on Post-Streptococcal Reactive Arthritis: Narrative Review of a Forgotten Disease. Curr Rheumatol Rep 2021; 23:19. [PMID: 33569668 DOI: 10.1007/s11926-021-00982-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/05/2021] [Indexed: 10/22/2022]
Abstract
PURPOSE OF THE REVIEW This topical review attempts to build the concepts of PSRA as an independent entity and discuss prevalent diagnostic criteria. It utilizes a search strategy to collate all clinical features of PSRA reported from across the world and also discusses laboratory and treatment options in brief. RECENT FINDINGS There are several immune-mediated diseases described after acute streptococcal infections. Post-streptococcal reactive arthritis (PSRA) is a sterile, self-limiting arthritis that occur as an immune sequelae to streptococcal infection. Though PSRA resembles the arthritis of acute rheumatic fever superficially, it is a separate entity in its own right. It is different from classical reactive arthritis too. It was being recognized worldwide and more frequently in the recent past, possibly due to heightened awareness amongst clinicians. However, research on this enigmatic immune phenomenon is limited. Most acceptable hypotheses suggest molecular mimicry sensitizing the immune system towards synovial peptides such as keratin, vimentin and laminin, leading to arthritis in a genetically predisposed individual. There is still much to be learnt from this unique disease about the vagaries of the immune system.
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13
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Antibiotic stewardship in direct-to-consumer telemedicine consultations leads to high adherence to best practice guidelines and a low prescription rate. Int J Infect Dis 2021; 105:130-134. [PMID: 33578013 DOI: 10.1016/j.ijid.2021.02.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 02/03/2021] [Accepted: 02/05/2021] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVE To analyze the antibiotic prescription rate in low-risk patients evaluated at a telemedicine program that adopts antibiotic stewardship protocols. METHODS Adult patients who accessed a single direct-to-consumer telemedicine center (Jan/2019-Feb/2020) were retrospectively enrolled. Diseases amenable to antimicrobial treatment were classified under five diagnostic groups: upper respiratory tract infection (URI), acute pharyngotonsillitis (PT), acute sinusitis (AS), urinary tract infection (UTI), and acute diarrhea (AD). Physicians were trained on and advised to strictly follow the current guideline recommendations supported by institutional antibiotic stewardship protocols, readily available online during consultations. We analyzed the antibiotic prescription rate among patients, referral rate, and antibiotic class through descriptive statistics. RESULTS A total of 2328 patients were included in the study. A total of 2085 (89·6%) patients were discharged with usual recommendations, medication (if needed), and instructions about red flags, while 243 (10·4%) were referred to a face-to-face consultation. Among the discharged patients, the antibiotic prescription rates by the diagnostic group were URI - 2·5%, PT - 35·0%, AS - 51·8%, UTI - 91.6%, and AD - 1·6%. In most cases, prescribed antibiotics were in line with institutional stewardship protocols. CONCLUSIONS Low prescription rate of antibiotics can be achieved using antibiotic stewardship protocols at direct-to-consumer telemedicine consultations, showing high adherence to international guidelines. These results reinforce telemedicine as a cost-effective and safe strategy for the initial assessment of acute non-urgent symptoms.
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14
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Meskina ER, Stashko TV. [How to reduce the antibacterial load in the treatment of acute tonsillitis and pharyngitis? Possible tactics and practical approaches]. Vestn Otorinolaringol 2021; 85:90-99. [PMID: 33474925 DOI: 10.17116/otorino20208506190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Acute tonsillopharyngitis is one of the most frequent reasons for visiting a doctor and prescribing inappropriate antibiotic therapy (ABT). There are several reasons for this - from the difficulties of etiological diagnosis and the development of relapses and possible severe complications to the personal attitude of doctors and patients to the choice of treatment. At the same time, the issue of antibiotic resistance and other aspects associated with the prescription of ABT is one of the most important problems of modern healthcare worldwide. The purpose of this review is to demonstrate the best practical approaches to the choice of treatment tactics for acute tonsillitis (AT) in the treatment of children and adults, with an emphasis on reducing the load of ABT. The review examines the indications and disadvantages of clinical and laboratory diagnosis of AT. There are no highly sensitive clinical and laboratory instruments that differentiate viral and bacterial AT. Exudativeis AT in children is not an underlying symptom of streptococcal etiology. Despite the limitations, the modified Centor/McIsaac score ≥3 (taking into account age and the presence of respiratory symptoms) should be used as an indication for ABT in conjunction with a rapid streptotest and subsequent bacteriological culture for S. pyogenes if the screening test is negative. Additional examinations (determination of leukocytosis, CRP and procalcitonin test) are not required for most patients. ABT should not be given to low-risk patients for the treatment and prevention of rheumatic fever and acute glomerulonephritis. Prevention of purulent complications (paratonsillitis and retropharyngeal abscess, acute otitis media, cervical lymphadenitis, mastoiditis, or acute sinusitis) is not a specific indication for ABT in AT and is not required in most patients. The strategy of «delayed antibiotic prescriptions» with monitoring the patient's condition for 2-3 days is appropriate and highly effective in doubtful cases. The drugs of choice for treatment of AT are amoxicillin and oral forms of I and II generation cephalosporins. Macrolides are not indicated as first-line treatment for AT. The course of ABT for streptococcal AT is 10 days, which reduces the risk of recurrent episode. Topical drugs can be the only means of etiopathogenetic treatment with viral AT, or additional for bacterial AT. Their use not only relieves sore throat, but also shortens the duration of the disease, and also improves the patients prognosis. Benzalkonium chloride + tyrothricin + benzocaine (Dorithyrcin) may be a rational drug of choice for topical therapy due to the available clinical evidence. There is a significant reserve for reducing the load of ABT during AT. Further clinical trials are needed to assess the efficacy of short courses of ABT in the treatment of AT in high-income countries and provide a basis for strong recommendations for topical drug use. This can reduce the frequency of ABT prescribing and increase the level of interaction between specialists and patients.
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Affiliation(s)
- E R Meskina
- Moscow Regional Research and Clinical Institute (MONIKI), Moskow, Russia
| | - T V Stashko
- Moscow Regional Research and Clinical Institute (MONIKI), Moskow, Russia
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15
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Rusic D, Bukić J, Seselja Perisin A, Leskur D, Modun D, Petric A, Vilovic M, Bozic J. Are We Making the Most of Community Pharmacies? Implementation of Antimicrobial Stewardship Measures in Community Pharmacies: A Narrative Review. Antibiotics (Basel) 2021; 10:antibiotics10010063. [PMID: 33440609 PMCID: PMC7827930 DOI: 10.3390/antibiotics10010063] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 01/05/2021] [Accepted: 01/07/2021] [Indexed: 12/01/2022] Open
Abstract
Community pharmacists recognize the need to implement antimicrobial stewardship activities in community pharmacies. They are in a unique position to provide triage for common primary care indications and to lower the burden of patients at general practitioners’ offices. However, research shows that, in some areas, dispensing of antimicrobials without valid prescription is still highly prevalent. Regardless of training, every community pharmacist can give his contribution to antimicrobial stewardship. One of the basic elements should be antimicrobial dispensing according to regulations, either prescription only, or according to guidelines where pharmacists have prescribing authority. Patient consultation supported with educational materials, such as leaflets, may reduce patients’ expectations to receive antibiotics for self-limiting infections and reduce pressure on general practitioners to prescribe antibiotics on patients’ demand. Treatment optimization may be achieved in collaboration with the prescribing general practitioners or by providing feedback. At last, pharmacists provided with additional training may be encouraged to provide consultation services to long-term care facilities, to introduce point-of-care testing for infectious diseases in their pharmacies or prescribe antimicrobials for uncomplicated infections. These services are welcomed by patients and communities. Expanding pharmacy services and pharmacists’ prescribing autonomy have shown a positive impact by reducing antibiotics consumption, thus ensuring better compliance with treatment guidelines.
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Affiliation(s)
- Doris Rusic
- Department of Pharmacy, University of Split School of Medicine, Soltanska 2, 21 000 Split, Croatia; (D.R.); (J.B.); (A.S.P.); (D.L.); (D.M.); (A.P.)
| | - Josipa Bukić
- Department of Pharmacy, University of Split School of Medicine, Soltanska 2, 21 000 Split, Croatia; (D.R.); (J.B.); (A.S.P.); (D.L.); (D.M.); (A.P.)
| | - Ana Seselja Perisin
- Department of Pharmacy, University of Split School of Medicine, Soltanska 2, 21 000 Split, Croatia; (D.R.); (J.B.); (A.S.P.); (D.L.); (D.M.); (A.P.)
| | - Dario Leskur
- Department of Pharmacy, University of Split School of Medicine, Soltanska 2, 21 000 Split, Croatia; (D.R.); (J.B.); (A.S.P.); (D.L.); (D.M.); (A.P.)
| | - Darko Modun
- Department of Pharmacy, University of Split School of Medicine, Soltanska 2, 21 000 Split, Croatia; (D.R.); (J.B.); (A.S.P.); (D.L.); (D.M.); (A.P.)
| | - Ana Petric
- Department of Pharmacy, University of Split School of Medicine, Soltanska 2, 21 000 Split, Croatia; (D.R.); (J.B.); (A.S.P.); (D.L.); (D.M.); (A.P.)
- The Split-Dalmatia County Pharmacy, Dugopoljska 3, 21 204 Dugopolje, Croatia
| | - Marino Vilovic
- Department of Pathophysiology, University of Split School of Medicine, Soltanska 2, 21 000 Split, Croatia;
| | - Josko Bozic
- Department of Pathophysiology, University of Split School of Medicine, Soltanska 2, 21 000 Split, Croatia;
- Correspondence:
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