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

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.

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.

Rapid antigen detection and molecular tests for group A streptococcal infections for acute sore throat: systematic reviews and economic evaluation

BACKGROUND

Sore throat is a common condition caused by an infection of the airway. Most cases are of a viral nature; however, a number of these infections may be caused by the group A Streptococcus bacterium. Most viral and bacterial sore throat infections resolve spontaneously within a few weeks. Point-of-care testing in primary care has been recognised as an emerging technology for aiding targeted antibiotic prescribing for sore throat in cases that do not spontaneously resolve.

OBJECTIVE

Systematically review the evidence for 21 point-of-care tests for detecting group A Streptococcus bacteria and develop a de novo economic model to compare the cost-effectiveness of point-of-care tests alongside clinical scoring tools with the cost-effectiveness of clinical scoring tools alone for patients managed in primary care and hospital settings.

DATA SOURCES

Multiple electronic databases were searched from inception to March 2019. The following databases were searched in November and December 2018 and searches were updated in March 2019: MEDLINE [via OvidSP (Health First, Rockledge, FL, USA)], MEDLINE In-Process & Other Non-Indexed Citations (via OvidSP), MEDLINE Epub Ahead of Print (via OvidSP), MEDLINE Daily Update (via OvidSP), EMBASE (via OvidSP), Cochrane Database of Systematic Reviews [via Wiley Online Library (John Wiley & Sons, Inc., Hoboken, NJ, USA)], Cochrane Central Register of Controlled Trials (CENTRAL) (via Wiley Online Library), Database of Abstracts of Reviews of Effects (DARE) (via Centre for Reviews and Dissemination), Health Technology Assessment database (via the Centre for Reviews and Dissemination), Science Citation Index and Conference Proceedings [via the Web of Science™ (Clarivate Analytics, Philadelphia, PA, USA)] and the PROSPERO International Prospective Register of Systematic Reviews (via the Centre for Reviews and Dissemination).

REVIEW METHODS

Eligible studies included those of people aged ≥ 5 years presenting with sore throat symptoms, studies comparing point-of-care testing with antibiotic-prescribing decisions, studies of test accuracy and studies of cost-effectiveness. Quality assessment of eligible studies was undertaken. Meta-analysis of sensitivity and specificity was carried out for tests with sufficient data. A decision tree model estimated costs and quality-adjusted life-years from an NHS and Personal Social Services perspective.

RESULTS

The searches identified 38 studies of clinical effectiveness and three studies of cost-effectiveness. Twenty-six full-text articles and abstracts reported on the test accuracy of point-of-care tests and/or clinical scores with biological culture as a reference standard. In the population of interest (patients with Centor/McIsaac scores of ≥ 3 points or FeverPAIN scores of ≥ 4 points), point estimates were 0.829 to 0.946 for sensitivity and 0.849 to 0.991 for specificity. There was considerable heterogeneity, even for studies using the same point-of-care test, suggesting that is unlikely that any single study will have accurately captured a test's true performance. There is some randomised controlled trial evidence to suggest that the use of rapid antigen detection tests may help to reduce antibiotic-prescribing rates. Sensitivity and specificity estimates for each test in each age group and care setting combination were obtained using meta-analyses where appropriate. Any apparent differences in test accuracy may not be attributable to the tests, and may have been caused by known differences in the studies, latent characteristics or chance. Fourteen of the 21 tests reviewed were included in the economic modelling, and these tests were not cost-effective within the current National Institute for Health and Care Excellence's cost-effectiveness thresholds. Uncertainties in the cost-effectiveness estimates included model parameter inputs and assumptions that increase the cost of testing, and the penalty for antibiotic overprescriptions.

LIMITATIONS

No information was identified for the elderly population or pharmacy setting. It was not possible to identify which test is the most accurate owing to the paucity of evidence.

CONCLUSIONS

The systematic review and the cost-effectiveness models identified uncertainties around the adoption of point-of-care tests in primary and secondary care settings. Although sensitivity and specificity estimates are promising, we have little information to establish the most accurate point-of-care test. Further research is needed to understand the test accuracy of point-of-care tests in the proposed NHS pathway and in comparable settings and patient groups.

STUDY REGISTRATION

The protocol of the review is registered as PROSPERO CRD42018118653.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 31. See the NIHR Journals Library website for further project information.

Impact of a Social Marketing Intervention on General Practitioners' Antibiotic Prescribing Practices for Acute Respiratory Tract Complaints in Malta

Introduction: Antibiotics are commonly prescribed in primary care for acute respiratory tract complaints (aRTCs), often inappropriately. Social marketing interventions could improve prescribing in such settings. We evaluate the impact of a social marketing intervention on general practitioners' (GPs') antibiotic prescribing for aRTCs in Malta. Methods: Changes in GPs' antibiotic prescribing were monitored over two surveillance periods between 2015 and 2018. Primary outcome: change in antibiotic prescription for aRTCs. Secondary outcomes: change in antibiotic prescription: (i) for immediate use, (ii) for delayed antibiotic prescription, (iii) by diagnosis, and (iv) by antibiotic class. Data were analysed using clustered analysis and interrupted time series analysis (ITSA). Results: Of 33 participating GPs, 18 successfully completed the study. Although clustered analyses showed a significant 3% decrease in overall antibiotic prescription (p = 0.024), ITSA showed no significant change overall (p = 0.264). Antibiotic prescription decreased significantly for the common cold (p < 0.001), otitis media (p = 0.044), and sinusitis (p = 0.004), but increased for pharyngitis (p = 0.015). Conclusions: The intervention resulted in modest improvements in GPs' antibiotic prescribing. A more top-down approach will likely be required for future initiatives to be successful in this setting, focusing on diagnostic and prescribing support like rapid diagnostic testing, prescribing guidelines, and standardised delayed antibiotic prescriptions.

Rapid Antigen Detection Test Using Rates of Family Physicians, Test Results and Its Impact on Their Prescription Behaviours

Aim: The aim of this study is to determine the rates of rapid antigen detection test use, test results and its relationship with Modified Centor Score and investigate the effect of rapid antigen detection test use on prescribing behaviour. Methods: This research was conducted by scanning the family physicians’ information system retrospectively. From the Family Medicine Information System, where polyclinics and prescription records of the family health centers where 12 family physicians work in Kayseri are located, the number and results of rapid antigen detection tests performed between February 2017 and April 2019, the Modified Centor Score automatically calculated by the system, the number of prescribed antibiotics and symptomatic treatment information was recorded. Results: The positivity of rapid antigen detection test was considered, cut-off value of Modified Centor Score was >2 (ROC EAA:63.9, Cl:0.95,0.61-0.66). Sensitivity rate of the test for diagnostic score was 86% and selectivity rate was 48.8%. Conclusion: Family physicians should be encouraged to use rapid antigen detection test. The fact that antibiotics are prescribed in rapid antigen detection testnegative patients may indicate that confidence level of the test is less than physical examination and clinical findings. Keywords: sore throat, primary care, score

Diagnostic Methods, Clinical Guidelines, and Antibiotic Treatment for Group A Streptococcal Pharyngitis: A Narrative Review

The most common bacterial cause of pharyngitis is infection by Group A β-hemolytic streptococcus (GABHS), commonly known as strep throat. 5-15% of adults and 15-35% of children in the United States with pharyngitis have a GABHS infection. The symptoms of GABHS overlap with non-GABHS and viral causes of acute pharyngitis, complicating the problem of diagnosis. A careful physical examination and patient history is the starting point for diagnosing GABHS. After a physical examination and patient history is completed, five types of diagnostic methods can be used to ascertain the presence of a GABHS infection: clinical scoring systems, rapid antigen detection tests, throat culture, nucleic acid amplification tests, and machine learning and artificial intelligence. Clinical guidelines developed by professional associations can help medical professionals choose among available techniques to diagnose strep throat. However, guidelines for diagnosing GABHS created by the American and European professional associations vary significantly, and there is substantial evidence that most physicians do not follow any published guidelines. Treatment for GABHS using analgesics, antipyretics, and antibiotics seeks to provide symptom relief, shorten the duration of illness, prevent nonsuppurative and suppurative complications, and decrease the risk of contagion, while minimizing the unnecessary use of antibiotics. There is broad agreement that antibiotics with narrow spectrums of activity are appropriate for treating strep throat. But whether and when patients should be treated with antibiotics for GABHS remains a controversial question. There is no clearly superior management strategy for strep throat, as significant controversy exists regarding the best methods to diagnose GABHS and under what conditions antibiotics should be prescribed.

Broad-spectrum antibiotic use in Europe: more evidence of cultural influences on prescribing behaviour

OBJECTIVES

Sociocultural factors have been hypothesized as important drivers of inappropriate antibiotic prescribing in European ambulatory care. This study sought to assess whether they can also explain the reported variation in broad-spectrum antibiotic (Br-Ab) use among EU/European Economic Area (EEA) countries.

METHODS

Correlation and regression analysis were performed, using the bootstrap method, between Br-Ab ratios reported from 28 EU countries by the ECDC, and national Hofstede cultural dimensions and control of corruption (CoC) scores.

RESULTS

Significant bootstrapping correlation coefficients were identified between Br-Ab ratios and the dimension of uncertainty avoidance (UAI) as well as CoC. However, following both bootstrapping multiple regression and generalized linear modelling, only UAI was retained as the sole predictor. A logarithmic model explained 58.6% of the variation in European Br-Ab variability solely using national UAI scores (P < 0.001).

CONCLUSIONS

Br-Ab prescribing appears to be driven by the level of UAI within the country. Any interventions aimed at reducing Br-Ab in high-consuming EU/EEA countries need to address this cultural perception to maximize their chances of success.

Antibiotic prescribing for respiratory tract complaints in Malta: a 1 year repeated cross-sectional surveillance study

OBJECTIVES

To determine the 1 year antibiotic prescribing patterns by GPs for acute respiratory tract complaints (aRTCs) in Malta.

METHODS

In this repeated cross-sectional surveillance study, GPs collected data for patients seen for aRTCs during a designated 1 week period each month, between May 2015 and April 2016. GPs received three text reminders during surveillance weeks and were contacted by phone at most four times during the year. GPs also received 3 monthly individual- and aggregate-level feedback reports on their antibiotic prescribing patterns. Descriptive statistics were used to examine patient, consultation and clinical characteristics, and to describe GPs' prescribing patterns.

RESULTS

Participating GPs (n = 33) registered 4641 patients with an aRTC, of whom 2122 (45.7%) received an antibiotic prescription. The majority (99.6%) of antibiotics prescribed were broad-spectrum and the most commonly prescribed antibiotics were macrolides (35.5%), followed by penicillins with a β-lactamase inhibitor (33.2%) and second-generation cephalosporins (14.2%). Specifically, co-amoxiclav (33.2%), clarithromycin (19.6%), azithromycin (15.1%) and cefuroxime axetil (10.9%) represented 78.8% of all antibiotics prescribed. Patients with tonsillar exudate (99.1%), purulent sputum (84%), otorrhoea (78%), tender cervical nodes (74.4%) and fever (73.1%) received most antibiotics. The diagnoses that received the highest proportion of antibiotic treatment were tonsillitis (96.3%), otitis media (92.5%) and bronchitis (87.5%). Wide variation in the choice of antibiotic class by diagnosis was observed.

CONCLUSIONS

GP antibiotic prescribing in Malta is high. The abundant use of broad-spectrum antibiotics, particularly macrolides, is of particular concern and indicates that antibiotics are being used inappropriately. Efforts must be made to improve GP awareness of appropriate antibiotic prescribing.

The antibiotic prescribing behaviors of physicians are changed via rapid antigen test practice in the context of rational drug use

Background/aim

Rapid antigen test (RAT) is a practical test to detect the presence of Group A beta hemolytic streptococcus antigens in throat swab samples. The aim of this study is to investigate the changes in the empiric antibiotic prescribing behavior of 10 family physicians in Kırıkkale Province after using RAT in 2017.

Materials and methods

RAT test practice started in Family Medicine in February 2017. Family Medicine Information System (FMIS) includes clinical and prescription records of 10 family physicians, providing health service to approximately 35,000 residents in Kırıkkale. The numbers of antibiotics prescribed by the physicians according to the ICD-10 codes (including upper respiratory tract infections) in February, March, and April of 2015, 2016, 2017 were determined. The number and group of antibiotics prescribed by the family physicians with the determined diagnosis and time periods were specified in the FMIS and recorded.

Results

Antibiotic prescription behaviors of family physicians do not show a significant difference between 2015 and 2016. There was a dramatic and significant decrease in the number of prescribed antibiotics in 2017 compared to 2015 and 2016 (P < 0.05).

Conclusion

This study shows that there has been a significant decrease in antibiotic prescription in 10 Family Medicine departments in 2017 in comparison to February, March, and April 2015 and 2016. The use of RAT resulted in a decrease in antibiotic prescription rates in 2017.

Efficacy and safety of rapid tests to guide antibiotic prescriptions for sore throat

BACKGROUND

Sore throat is a common condition caused by viruses or bacteria, and is a leading cause of antibiotic prescription in primary care. The most common bacterial species is group A streptococcus ('strep throat'). Between 50% to 70% of pharyngitis cases are treated with antibiotics, despite the majority of cases being viral in origin. One strategy to reduce antibiotics is to use rapid tests for group A streptococcus to guide antibiotic prescriptions. Rapid tests can be used alone or in combination with a clinical scoring system.

OBJECTIVES

To assess the efficacy and safety of strategies based on rapid tests to guide antibiotic prescriptions for sore throat in primary care settings.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL, Web of Science, and LILACS, as well as the trial registries ClinicalTrials.gov and the WHO ICTRP on 5 June 2019.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing rapid tests with management based on clinical grounds to guide the prescription of antibiotics for people with a sore throat in ambulatory care settings. We included trials that randomised individuals, as well as cluster-RCTs in which individual practitioners (or practices) or emergency departments were randomised.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data on the primary outcomes (number of participants provided with an antibiotic prescription; number of participants with an antibiotic dispensed) and secondary outcomes (duration of sore throat symptoms; duration of other symptoms; quality of life measures; number of participants with a complication attributed to the index infection; number of participants in need of re-consultation by the end of follow-up; number of participants in need of hospital admission by the end of follow-up; number of satisfied participants; number of participants with an adverse event attributed to the rapid test). We assessed the risk of bias of all included trials and used GRADE to assess the certainty of the evidence. We performed meta-analyses and sensitivity analyses when feasible.

MAIN RESULTS

We included five trials (2891 children and adult participants in total; 2545 participants after adjusting for clustering). Management in the intervention group was as follows: in three trials rapid tests were used in combination with a clinical scoring system; in one trial, some physicians were asked to use rapid tests alone, while others were asked to use rapid tests in combination with a clinical scoring system; in one trial, rapid tests were used alone. Based on data from five trials (2545 participants), a large reduction in prescribed antibiotics was found in the rapid test group (481/1197) versus management based on clinical grounds (865/1348), for a summary risk difference (RD) of -25%, 95% confidence interval (CI) -31% to -18%; I2 = 62%; moderate-certainty evidence. Estimates of effect on antibiotic prescription rates were stable in various sensitivity analyses. Based on data from two trials (900 people) originating from the same overarching study, the evidence suggests that rapid tests may not reduce dispensed antibiotic treatments: rapid test group (156/445) versus management based on clinical grounds (197/455); summary RD -7%, 95% CI -17% to 2%; I2 = 53%; low-certainty evidence. Four trials (2075 participants) reported data on the number of participants with a complication attributed to the index infection; the summary odds ratio (OR) was 0.85, 95% CI 0.03 to 26.65; P = 0.93; I2 = 62%; very low-certainty evidence, which means that people in the rapid testing group were less likely to develop complications of the index infection, but the evidence is very uncertain. Two trials (1161 participants) reported on the number of participants in need of re-consultation by the end of follow-up; the summary OR was 1.12, 95% CI 0.57 to 2.21; P = 0.74; I2 = 59%; low-certainty evidence, which means that participants in the rapid testing group were more likely to be in need of re-consultation by the end of the study follow-up, but the evidence is uncertain. Lack of data impeded assessment of other secondary outcomes (including safety outcomes) and of sources of heterogeneity.  AUTHORS' CONCLUSIONS: Rapid testing to guide antibiotic treatment for sore throat in primary care probably reduces antibiotic prescription rates by 25% (absolute risk difference), but may have little or no impact on antibiotic dispensing. More studies are needed to assess the efficacy and safety of rapid test-guided antibiotic prescribing, notably to evaluate patient-centred outcomes and variability across subgroups (e.g. adults versus children).

A highly-sensitive rapid test for the diagnosis of streptococcal pharyngitis: BD veritor ™ system

INTRODUCTION

The diagnosis of streptococcal pharyngitis is very important to prevent complications such as acute rheumatic fever. Throat culture is the gold standard method for the diagnosis of streptococcal pharyngitis, however, rapid antigen tests (RAT) have been developed for faster diagnosis. The purpose of this study is to evaluate the efficacy of the BD Veritor ™ System (USA) rapid antigen assay in detecting Group A Streptococcus (GAS) in throat swab samples.

METHODS AND MATERIALS

A total of 12,391 throat swabs, taken with a double swab, were evaluated. The BD Veritor ™ System was used for the detection of GAS antigen. Simultaneous throat cultures were performed.

RESULTS

Throat culture yielded positive for 18.5% (2291) while 19.1% (2369) were positive with RAT. The sensitivity of BD Veritor ™ System was determined as 94.1% and specificity as 97.9%, while positive predictive value, negative predictive value and accuracy were determined as 91.0%, 98.7%, 97%, respectively. When all age groups were included, the rate of GAS positivity was 18.5% and this ratio increased to 27.3% in the five-15 age group.

CONCLUSION

Our study, conducted with quite a large number of patients, yielded high sensitivity for the BD Veritor System. When the RAT is negative, the necessity of culture for pediatric patients should not be forgotten.

General practitioners' perceptions of delayed antibiotic prescription for respiratory tract infections: A phenomenographic study

BACKGROUND

Antibiotic use is a major driver of antibiotic resistance. Although delayed antibiotic prescription is a recommended strategy to reduce antibiotic use, practices vary; it appears less commonly used in southern European countries where antibiotic consumption is highest. Despite these variations, few qualitative studies have explored general practitioners' perceptions of delayed antibiotic prescription. We therefore aimed to explore and describe the perceptions of delayed antibiotic prescription for respiratory tract infections among general practitioners in Malta.

METHODS

This qualitative phenomenographic study was conducted in Malta. A semi-structured interview guide was developed in English, pilot tested and revised accordingly. Interview topics included views on antibiotic resistance, antibiotic use and delayed antibiotic prescription for respiratory tract infections, and barriers and facilitators to antibiotic prescription. Individual, face-to-face interviews were held in 2014 with a quota sample of 20 general practitioners and transcribed verbatim. Data were subsequently analysed using a phenomenographic approach.

FINDINGS

General practitioners perceived delayed antibiotic prescription in five qualitatively different ways: (A) "The Service Provider"-maintaining a good general practitioner-patient relationship to retain patients and avoid doctor-shopping, (B) "The Uncertainty Avoider"-reaching a compromise and providing treatment just in case, (C) "The Comforter"-providing the patient comfort and reassurance, (D) "The Conscientious Practitioner"-empowering and educating patients, and limiting antibiotic use, and (E) "The Holder of Professional Power"-retaining general practitioner responsibility by employing a wait-and-see approach. Although general practitioners were largely positive towards delayed antibiotic prescription, not all supported the strategy; some preferred a wait-and-see approach with follow-up. Many delayed antibiotic prescription users selectively practiced delayed prescription with patients they trusted or who they believed had a certain level of knowledge and understanding. They also preferred a patient-led approach with a one to three day delay; post-dating delayed antibiotic prescriptions was uncommon.

CONCLUSIONS

In this study we have shown that general practitioners hold varying perceptions about delayed antibiotic prescription and that there is variation in the way delayed antibiotic prescription is employed in Malta. Whilst delayed antibiotic prescription is utilised in Malta, not all general practitioners support the strategy, and motivations and practices differ. In high consumption settings, formal and standardised implementation of delayed antibiotic prescription could help curb antibiotic overuse. Diagnosis-specific delayed antibiotic prescription recommendations should also be incorporated into guidelines. Finally, further investigation into patients' and pharmacists' views on delayed antibiotic prescription is required.

TRIAL REGISTRATION NUMBER

NCT03218930.

Potential for Molecular Testing for Group A Streptococcus to Improve Diagnosis and Management in a High-Risk Population: A Prospective Study

Background

In high-burden settings, guidelines recommend antibiotic treatment for all suspected group A Streptococcus (GAS) infections to prevent rheumatic fever and poststreptococcal glomerulonephritis. Highly sensitive rapid GAS tests could reduce unnecessary antibiotic use in these settings.

Methods

This was a prospective study of the Xpert Xpress Strep A (Cepheid) molecular test compared with culture of throat swab samples collected at a referral hospital in northern Australia. Demographic and clinical data and results of streptococcal serology and culture were collected.

Results

Of 164 throat swab samples, 145 (88%) were eligible for inclusion; 49 (34%) were molecular test positive and 24 (17%) were culture positive for GAS. The sensitivity, specificity, and positive and negative predictive values for the molecular test versus culture were 100.0%, 79.3%, 48.8%, and 100.0%, respectively. Among 25 samples testing positive with the molecular test and negative with culture, group C or G streptococci were cultured in 2, and a plausible clinical explanation, such as pharyngotonsillitis, or rheumatic fever with positive results of streptococcal serology, was apparent in 19 instances. In 25 patients with rheumatic fever or poststreptococcal glomerulonephritis diagnoses, molecular testing nearly trebled the detection of GAS in throat swab samples, from 3 (12%) detected with culture to 8 (32%) detected with molecular testing. Reasons for “false-positive” molecular test results could include the presence of GAS below the threshold of culture detection or persistence of nonviable organisms after infection.

Conclusion

Implementation of molecular testing could improve antibiotic use in this high-burden setting. The incremental yield in poststreptococcal syndromes, by which time cultures are negative, has high potential in the diagnostic workup of autoimmune poststreptococcal syndromes and warrants further investigation.

Association between rapid antigen detection tests and antibiotics for acute pharyngitis in Japan: A retrospective observational study

The application and clinical impact of rapid antigen detection test (RADT) in the treatment of acute pharyngitis is unknown in Japan. We aimed to examine the proportions of RADT usage to identify Group A β-hemolytic Streptococcus (GAS) in outpatients with acute pharyngitis and evaluate the association between RADT and antibiotic treatment. We analyzed health insurance claims data from 2013 to 2015. Logistic regression models were used to analyze associated factors with RADT, overall antibiotic prescription, or penicillin use. We analyzed 1.27 million outpatient visits with acute pharyngitis, in which antibiotics were prescribed in 59.3% of visits. Of the total visits, 5.6% of patients received RADT, and 10.8% of the antibiotics were penicillin. Penicillin selection rates were higher in cases with RADT (25.4%) than those without RADT (9.7%). Compared to large-scale facilities, antibiotic prescription rates were higher in physicians' offices. For factor analysis, age (3-15 years), diagnosis code (streptococcal pharyngitis), size of the medical facility (large-scale hospitals), and physician's specialty (pediatrics) were associated with RADT use. Penicillin selection rate increased with RADT implementation (25.4% vs. 9.7%: adjusted odds ratio 1.55; 95% CI, 1.50-1.60). At 63% of the facilities, the RADT implementation rate was <5% of acute pharyngitis visits prescribed antibiotics. In conclusion, the proportion of RADT usage for outpatients with acute pharyngitis was low in Japan. With appropriate indication and evaluation, we expect that more utilization of RADT can help promote antimicrobial stewardship for outpatients with acute pharyngitis by prompting penicillin therapy. Further investigation with detailed clinical data are warranted.

Association Between Rapid Antigen Testing and Antibiotic Use and Accuracy of Peripheral Blood Parameters in Detecting Group A Streptococcus in Children With Tonsillopharyngitis

Objectives: To investigate the effect of rapid antigen testing (RAT) on the practice of antibiotic prescription as well as the accuracy of peripheral blood neutrophil-to-lymphocyte ratio (NLR) and C-reactive protein (CRP) values in detecting group A beta-hemolytic Streptococcus (GABHS) in children with tonsillopharyngitis. Methods: In a multicenter study performed in Turkey, we retrospectively analyzed data from 668 consecutive pediatric patients under 17 years of age, who presented with signs and symptoms of tonsillopharyngitis and underwent RAT. The rates of positive and negative RAT results were determined and patients' antibiotic prescriptions were examined in relation to RAT results. In addition, the accuracy of peripheral blood NLR and CRP values was examined for 212 patients whose laboratory data were available, with RAT as the reference standard. Results: Positive RAT results were observed in 190 of 668 (28.4%) patients. Antibiotics were prescribed to all 190 patients with positive RAT results and to 8 of 478 patients with negative RAT results. Overall, the rate of antibiotic prescription was 29.6%. Patients with positive and negative RAT results did not differ significantly with regard to NLR and CRP values. In ROC analysis, the area under the ROC curve (AUC) of NLR and CRP were 0.54 (95% confidence interval [CI] 0.45-0.64), and 0.55 (95% CI 0.45-0.65), respectively. Conclusion: RAT results proved highly associated with antibiotic prescribing, suggesting that RATs could be of great value in preventing unnecessary antibiotic use. Our findings also suggest that NLR and CRP are poorly accurate to identify GABHS in children with tonsillopharyngitis.

[Twenty-five myths in infectious diseases in primary care associated with overdiagnosis and overtreatment]

Overdiagnosis and overprescribing is common in current clinical practice of infectious diseases in primary care. On the basis of studies published in the medical literature we identify my means of a non-systematic review a total of 25 myths associated with the diagnosis and treatment and present the literature pertaining to each myth. These myths result in extraneous testing (overdiagnosis) and excessive antimicrobial treatment (overtreatment). Most of these myths are ingrained among general practitioners in our country. Not only should these myths be debunked from our clinical practice, but they should also be reversed, and we encourage our readers to critically appraise their practice when it comes down to the misconceptions treated in this manuscript. We attempt to give guidance to clinicians facing these frequent clinical scenarios.

Rapid antigen test use for the management of group A streptococcal pharyngitis in community pharmacies

Despite group A streptococci being an infrequent cause of pharyngitis in adult outpatients, sore throat remains a common indication for antibiotic prescription. This prospective multicentre non-randomised study describes a community pharmacy-based antimicrobial stewardship intervention consisting in the implementation of rapid antigen testing (RAT) for the management of adults with sore throat. Trained pharmacists triaged patients presenting with symptoms of pharyngitis using the modified Centor score. Those at risk for streptococcal infection were tested with RAT. Patients with a positive RAT were invited to consult a physician, whereas others were offered a symptomatic treatment. All patients received educational leaflets and were asked to fill in a follow-up form 7 days later. Ninety-eight pharmacies in one French region participated, and 559 patients were included over 6 months. RAT was proposed in 367 (65.7%) cases, and it was positive in 28 (8.3%). The follow-up form was returned by 140 (38.5%) participants. Of these, 10/10 patients with positive RAT further consulted a physician and were prescribed an antibiotic treatment, whereas 96.5% (110/114) of patients with negative results and not having any other reason to seek for doctor's advice did not consult. All participants found the intervention useful. Pharmacists spent 6-15 min to perform the intervention, and 98.6% (73/74) of pharmacists giving a feedback declared to be ready to implement this intervention in daily practice, if endorsed and reimbursed. Our results suggest that a pharmacy-based programme for the management of sore throat is feasible and could increase adherence to guidelines.

Clinical Impact of a Rapid Streptococcal Antigen Test on Antibiotic Use in Adult Patients

INTRODUCTION

Adult pharyngitis is rarely attributable to group A streptococci. Utilization of a rapid streptococcal antigen test (RADT) may improve appropriate prescribing for bacterial pharyngitis.

METHODS

Clinic 1 performed RADTs with subsequent Group A DNA probe test (GADNA) from November 2014-March 2015 and November 2015-March 2016 while Clinic 2 was the control clinic, then implemented the RADT with a GADNA from November 2015-March 2016. All GADNA results were obtained for each clinic from October 2013-March 2016.

RESULTS

At Clinic 1, 22.2% versus 8.5% of patients received inappropriately prescribed antibiotics for a GADNA or RADT result, respectively (p=0.048). For Clinic 2, 51.1% compared to 21.4% of patients were inappropriately prescribed antibiotic for a GADNA or RADT result, respectively (p=0.038). Overall, the total GADNA without RADT testing or RADTs with subsequent GADNA testing, 41.6% versus 11% of patients were inappropriately prescribed antibiotics, respectively (p=<0.0001).

CONCLUSION

Utilizing the RADT prevented unnecessary prescribing of antibiotics in adults.

Reduction of antibiotic prescriptions for acute respiratory tract infections in primary care: a systematic review

BACKGROUND

Although most respiratory tract infections (RTIs) are due to viral infections, they cause the majority of antibiotic (Abx) prescriptions in primary care. This systematic review summarises the evidence on the effectiveness of interventions in primary care aiming to reduce Abx prescriptions in patients ≥ 13 years for acute RTI.

METHODS

We searched the databases "MEDLINE/PubMed" and "Cochrane Library" for the period from January 1, 2005, to August 31, 2016, for randomised controlled trials (RCTs) in primary care aiming at the reduction of Abx prescriptions for patients suffering from RTI. Out of 690 search results, 67 publications were retrieved and 17 RCTs were included. We assumed an absolute change of 10% as minimal important change.

RESULTS

Twelve out of 17 included RCTs showed statistically significant lower Abx prescription rates in the intervention groups, but only six of them reported a clinically relevant reduction according to our definition. Communication skills training (CST) and point-of-care testing (POCT) were the most effective interventions. Pre-intervention Abx prescription rates varied between 13.5% and 80% and observed reductions ranged from 1.5 to 23.3%. Studies with post-intervention rates lower than 20% had no significant effects. Post-intervention observation periods ranged from 2 weeks up to 3.5 years. The design of the trials was heterogeneous precluding calculation of pooled effect size. The reporting of many RCTs was poor.

CONCLUSIONS

CST and POCT alone or as adjunct can reduce antibiotic prescriptions for RTI. Eleven out of 17 trials were not successfully reducing Abx prescription rates according to our definition of minimal important change. However, five of them reported a statistically significant reduction. Trials with initially lower prescription rates were less likely to be successful. Future trials should investigate sustainability of intervention effects for a longer time period. The generalisability of findings was limited due to heterogeneous designs and outcome measures. Therefore, a consensus of designing and reporting of studies aiming at reducing antibiotic prescriptions is urgently needed to generate meaningful evidence.

A feasibility service evaluation of screening and treatment of group A streptococcal pharyngitis in community pharmacies

OBJECTIVES

The UK 5 year antimicrobial resistance strategy recognizes the role of point-of-care diagnostics to identify where antimicrobials are required, as well as to assess the appropriateness of the diagnosis and treatment. A sore throat test-and-treat service was introduced in 35 community pharmacies across two localities in England during 2014-15.

METHODS

Trained pharmacy staff assessed patients presenting with a sore throat using the Centor scoring system and patients meeting three or all four of the criteria were offered a throat swab test for Streptococcus pyogenes, Lancefield group A streptococci. Patients with a positive throat swab test were offered antibiotic treatment.

RESULTS

Following screening by pharmacy staff, 149/367 (40.6%) patients were eligible for throat swab testing. Of these, only 36/149 (24.2%) were positive for group A streptococci. Antibiotics were supplied to 9.8% (n = 36/367) of all patients accessing the service. Just under half of patients that were not showing signs of a bacterial infection (60/123, 48.8%) would have gone to their general practitioner if the service had not been available.

CONCLUSIONS

This study has shown that it is feasible to deliver a community-pharmacy-based screening and treatment service using point-of-care testing. This type of service has the potential to support the antimicrobial resistance agenda by reducing unnecessary antibiotic use and inappropriate antibiotic consumption.

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.

Rapid antigen detection test for group A streptococcus in children with pharyngitis

BACKGROUND

Group A streptococcus (GAS) accounts for 20% to 40% of cases of pharyngitis in children; the remaining cases are caused by viruses. Compared with throat culture, rapid antigen detection tests (RADTs) offer diagnosis at the point of care (within five to 10 minutes).

OBJECTIVES

To determine the diagnostic accuracy of RADTs for diagnosing GAS in children with pharyngitis. To assess the relative diagnostic accuracy of the two major types of RADTs (enzyme immunoassays (EIA) and optical immunoassays (OIA)) by indirect and direct comparison.

SEARCH METHODS

We searched CENTRAL, MEDLINE, EMBASE, Web of Science, CDSR, DARE, MEDION and TRIP (January 1980 to July 2015). We also conducted related citations tracking via PubMed, handsearched reference lists of included studies and relevant review articles, and screened all articles citing included studies via Google Scholar.

SELECTION CRITERIA

We included studies that compared RADT for GAS pharyngitis with throat culture on a blood agar plate in a microbiology laboratory in children seen in ambulatory care.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles and abstracts for relevance, assessed full texts for inclusion, and carried out data extraction and quality assessment using the QUADAS-2 tool. We used bivariate meta-analysis to estimate summary sensitivity and specificity, and to investigate heterogeneity across studies. We compared the accuracy of EIA and OIA tests using indirect and direct evidence.

MAIN RESULTS

We included 98 unique studies in the review (116 test evaluations; 101,121 participants). The overall methodological quality of included studies was poor, mainly because many studies were at high risk of bias regarding patient selection and the reference standard used (in 73% and 43% of test evaluations, respectively). In studies in which all participants underwent both RADT and throat culture (105 test evaluations; 58,244 participants; median prevalence of participants with GAS was 29.5%), RADT had a summary sensitivity of 85.6%; 95% confidence interval (CI) 83.3 to 87.6 and a summary specificity of 95.4%; 95% CI 94.5 to 96.2. There was substantial heterogeneity in sensitivity across studies; specificity was more stable. There was no evidence of a trade-off between sensitivity and specificity. Heterogeneity in accuracy was not explained by study-level characteristics such as whether an enrichment broth was used before plating, mean age and clinical severity of participants, and GAS prevalence. The sensitivity of EIA and OIA tests was comparable (summary sensitivity 85.4% versus 86.2%). Sensitivity analyses showed that summary estimates of sensitivity and specificity were stable in low risk of bias studies.

AUTHORS' CONCLUSIONS

In a population of 1000 children with a GAS prevalence of 30%, 43 patients with GAS will be missed. Whether or not RADT can be used as a stand-alone test to rule out GAS will depend mainly on the epidemiological context. The sensitivity of EIA and OIA tests seems comparable. RADT specificity is sufficiently high to ensure against unnecessary use of antibiotics. Based on these results, we would expect that amongst 100 children with strep throat, 86 would be correctly detected with the rapid test while 14 would be missed and not receive antibiotic treatment.

Antibiotics for tonsillitis: should the emergency department emulate general practice?

Objectives

To determine whether antibiotics are prescribed appropriately for acute tonsillitis in an emergency department (ED).

Methods

Cross-sectional observational study in large district general hospital in London. Patients diagnosed and coded with ‘acute tonsillitis’ in the ED over a 3-month period in 2015. Medical records were reviewed for Centor criteria, which is a clinical scoring system to guide antibiotic prescribing in UK general practice. Drug charts were reviewed for the specific antibiotic(s) prescribed, and throat swab (TS) cultures were recorded.

Results

273/389 patients with tonsillitis were analysed—186 children, 87 adults. Exclusions were missing patient records (86), patients had/awaiting tonsillectomy (22), receiving antibiotics (6) and immunocompromised (2). Centor score (CS) was not recorded for any patient. Based on derived CS from documented signs/symptoms, antibiotics were prescribed inappropriately to 196/273 patients (80%; 95% CI 74% to 85%) including broad-spectrum antibiotics to 25%. These included co-amoxiclav (18%), amoxicillin (6%), azithromycin (0.5%) and ceftriaxone (0.5%). TSs were taken in 66/273(24%) patients; 10/66 were positive for group A streptococcus (GAS). However, 48/56 GAS negative patients were prescribed antibiotics.

Conclusions

CS was not being used in the ED to guide antibiotic prescribing for acute tonsillitis. Antibiotic prescribing was based on clinical judgement. Based on derived CS (<3), 80% of patients were inappropriately prescribed antibiotics, particularly broad-spectrum antibiotics. Further studies need to assess use of CS to guide antibiotic prescription in ED. TSs were commonly performed in the ED but did not either improve diagnosis or guide antibiotic prescription.

More Than Just Accuracy: A Novel Method to Incorporate Multiple Test Attributes in Evaluating Diagnostic Tests Including Point of Care Tests

Current frameworks for evaluating diagnostic tests are constrained by a focus on diagnostic accuracy, and assume that all aspects of the testing process and test attributes are discrete and equally important. Determining the balance between the benefits and harms associated with new or existing tests has been overlooked. Yet, this is critically important information for stakeholders involved in developing, testing, and implementing tests. This is particularly important for point of care tests (POCTs) where tradeoffs exist between numerous aspects of the testing process and test attributes. We developed a new model that multiple stakeholders (e.g., clinicians, patients, researchers, test developers, industry, regulators, and health care funders) can use to visualize the multiple attributes of tests, the interactions that occur between these attributes, and their impacts on health outcomes. We use multiple examples to illustrate interactions between test attributes (test availability, test experience, and test results) and outcomes, including several POCTs. The model could be used to prioritize research and development efforts, and inform regulatory submissions for new diagnostics. It could potentially provide a way to incorporate the relative weights that various subgroups or clinical settings might place on different test attributes. Our model provides a novel way that multiple stakeholders can use to visualize test attributes, their interactions, and impacts on individual and population outcomes. We anticipate that this will facilitate more informed decision making around diagnostic tests.

Reassessment of the Role of Rapid Antigen Detection Tests in Diagnosis of Invasive Group A Streptococcal Infections

Rapid antigen detection tests (RADTs) for group A streptococci (GAS) are widely used for diagnosing acute pharyngitis, which has led to a considerable reduction in antibiotic prescriptions over the past decade. Beyond this intended use, their reassessment on invasive samples may be relevant in the management of life-threatening GAS infections. To this end, we evaluated the performances of three RADTs, culture, GAS PCR, and 16S rRNA gene PCR assays, and compared them with a composite gold standard (GAS-PCR assay and/or culture) for the diagnosis of severe GAS infection. A total of 192 specimens from deep-tissue (mostly normally sterile) sites enriched for 75 GAS-positive samples were enrolled in the study. The three evaluated RADTs showed sensitivities ranging from 88.0% to 94.7% versus 98.7% for GAS PCR, 84% for 16S rRNA gene PCR, and 77.3% for culture. The sensitivities of the ImmunoCardSTAT! Strep A test (Meridian Bioscience) and the NADAL Strep A strip (Nal Von Minden) were similar to that of GAS PCR (P= 0.25 and 0.03, respectively) and higher than that of culture (P= 0.001 and 0.006, respectively), whereas the SD Bioline Strep A test strip (Standard Diagnostics) showed a performance similar to that of culture (P= 0.02). The three RADTs detected 10 distinctemmtypes, including a predominance ofemm1 (33.3%),emm89 (10.6%), andemm12 (7.6%). No false-positive results were observed, leading to a specificity of 100% for all the evaluated RADTs. The GAS RADTs turned out to be sensitive, specific, and easy-to-use tools that may aid in the management of invasive GAS infections in 24/7 point-of-care laboratories by enabling early diagnosis and focused therapy.

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.

In vitro evaluation and comparison of 5 rapid antigen detection tests for the diagnosis of beta-hemolytic group A streptococcal pharyngitis

Streptococcus pyogenes (group A Streptococcus [GAS]) is the leading cause of bacterial pharyngitis. To perform a rapid diagnosis of GAS pharyngitis, rapid antigen detection tests (RADTs) have been developed. In this study, we evaluated and compared the sensitivity and specificity of 5 RADTs (bioNexia Strep A plus™, bioNexia Strep A dipstick™, Clearview Strep A™, QuickVue Strep A plus™, and Streptatest™), using analytical approaches combining dilutions in NaCl 0.9% or in pharyngeal flora. The practicability of each RADT was also determined. Among the 630 RADTs performed in this work, all were specific, as no false positive was found resulting in a specificity of 100%. The 5 RADTs detected GAS at 10(6)CFU/mL in NaCl 0.9% or pooled pharyngeal flora. Regarding the practicability analysis, bioNexia Strep A plus, bioNexia Strep A dipstick and Streptatest RADTs obtained the highest scores for secondary items including kit content and instructions for use information. We concluded that these 5 easy-to-use RADTs are suitable for diagnosis of GAS pharyngitis, as they all detect GAS at a concentration commonly found during pharyngitis.

[Recommendations for management of acute pharyngitis in adults]

La faringoamigdalitis aguda (FAA) en el adulto es una de las enfermedades infecciosas más comunes en la consulta del médico de familia. La etiología más frecuente es viral. Dentro de la etiología bacteriana, el principal agente responsable es Streptococcus pyogenes o estreptococo β-hemolítico del grupo A (EBHGA), causante del 5-30% de los casos. En el manejo diagnóstico, las escalas de valoración clínica para predecir la posible etiología bacteriana, son una buena ayuda para seleccionar a qué pacientes se deben practicar las técnicas de detección rápida de antígeno estreptocócico. Es conocido que, en general, sin estas técnicas se tiende al sobrediagnóstico de FAA estreptocócica, con la consiguiente prescripción innecesaria de antibióticos, muchas veces de amplio espectro. Así, con el manejo de las escalas y la técnica de diagnóstico rápido, elaboramos los algoritmos de manejo de la FAA. Los objetivos del tratamiento son acelerar la resolución de los síntomas, reducir el tiempo de contagio y prevenir las complicaciones supurativas locales y no supurativas. Los antibióticos de elección para el tratamiento de la FAA estreptocócica son penicilina y amoxicilina. La asociación de amoxicilina y clavulánico no está indicada en el tratamiento inicial en la infección aguda. Los macrólidos tampoco son un tratamiento de primera elección; su uso debe reservarse para pacientes con alergia a la penicilina. Es importante en nuestro país adecuar tanto el diagnóstico de la FAA bacteriana y la prescripción de antibióticos a la evidencia científica disponible. La implantación de protocolos de actuación en las farmacias comunitarias puede ser de utilidad para identificar y cribar los casos que no requieran tratamiento antibiótico.

[Recommendations for management of acute pharyngitis in adults]

Acute pharyngitis in adults is one of the most common infectious diseases seen in general practitioners' consultations. Viral aetiology is the most common. Among bacterial causes, the main agent is Streptococcus pyogenes or group A β-haemolytic streptococcus (GABHS), which causes 5%-30% of the episodes. In the diagnostic process, clinical assessment scales can help clinicians to better predict suspected bacterial aetiology by selecting patients who should undergo a rapid antigen detection test. If these techniques are not performed, an overdiagnosis of streptococcal pharyngitis often occurs, resulting in unnecessary prescriptions of antibiotics, most of which are broad spectrum. Consequently, management algorithms that include the use of predictive clinical rules and rapid tests have been set up. The aim of the treatment is speeding up symptom resolution, reducing the contagious time span and preventing local suppurative and non-suppurative complications. Penicillin and amoxicillin are the antibiotics of choice for the treatment of pharyngitis. The association of amoxicillin and clavulanate is not indicated as the initial treatment of acute infection. Neither are macrolides indicated as first-line therapy; they should be reserved for patients allergic to penicillin. The appropriate diagnosis of bacterial pharyngitis and proper use of antibiotics based on the scientific evidence available are crucial. Using management algorithms can be helpful in identifying and screening the cases that do not require antibiotic therapy.

[Recommendations for management of acute pharyngitis in adults]

La faringoamigdalitis aguda (FAA) en el adulto es una de las enfermedades infecciosas más comunes en la consulta del médico de familia. La etiología más frecuente es viral. Dentro de la etiología bacteriana, el principal agente responsable es Streptococcus pyogenes o estreptococo β-hemolítico del grupo A (EBHGA), causante del 5-30% de los casos. En el manejo diagnóstico, las escalas de valoración clínica para predecir la posible etiología bacteriana, son una buena ayuda para seleccionar a qué pacientes se deben practicar las técnicas de detección rápida de antígeno estreptocócico. Es conocido que, en general, sin estas técnicas se tiende al sobrediagnóstico de FAA estreptocócica, con la consiguiente prescripción innecesaria de antibióticos, muchas veces de amplio espectro. Así, con el manejo de las escalas y la técnica de diagnóstico rápido, elaboramos los algoritmos de manejo de la FAA. Los objetivos del tratamiento son acelerar la resolución de los síntomas, reducir el tiempo de contagio y prevenir las complicaciones supurativas locales y no supurativas. Los antibióticos de elección para el tratamiento de la FAA estreptocócica son penicilina y amoxicilina. La asociación de amoxicilina y clavulánico no está indicada en el tratamiento inicial en la infección aguda. Los macrólidos tampoco son un tratamiento de primera elección; su uso debe reservarse para pacientes con alergia a la penicilina. Es importante en nuestro país adecuar tanto el diagnóstico de la FAA bacteriana y la prescripción de antibióticos a la evidencia científica disponible. La implantación de protocolos de actuación en las farmacias comunitarias puede ser de utilidad para identificar y cribar los casos que no requieran tratamiento antibiótico.

Recommendations for management of acute pharyngitis in adults

Acute pharyngitis in adults is one of the most common infectious diseases seen in general practitioners' consultations. Viral aetiology is the most common. Among bacterial causes, the main agent is Streptococcus pyogenes or group A β-haemolytic streptococcus (GABHS), which causes 5%-30% of the episodes. In the diagnostic process, clinical assessment scales can help clinicians to better predict suspected bacterial aetiology by selecting patients who should undergo a rapid antigen detection test. If these techniques are not performed, an overdiagnosis of streptococcal pharyngitis often occurs, resulting in unnecessary prescriptions of antibiotics, most of which are broad spectrum. Consequently, management algorithms that include the use of predictive clinical rules and rapid tests have been set up. The aim of the treatment is speeding up symptom resolution, reducing the contagious time span and preventing local suppurative and non-suppurative complications. Penicillin and amoxicillin are the antibiotics of choice for the treatment of pharyngitis. The association of amoxicillin and clavulanate is not indicated as the initial treatment of acute infection. Neither are macrolides indicated as first-line therapy; they should be reserved for patients allergic to penicillin. The appropriate diagnosis of bacterial pharyngitis and proper use of antibiotics based on the scientific evidence available are crucial. Using management algorithms can be helpful in identifying and screening the cases that do not require antibiotic therapy.

Antibiotic Resistance: What are the Opportunities for Primary Care in Alleviating the Crisis?

Numerous opportunities are available in primary care for alleviating the crisis of increasing antibiotic resistance. Preventing patients from developing an acute respiratory infection (ARI) will obviate any need for antibiotic use downstream. Hygiene measures such as physical barriers and hand hygiene, and possibly vaccination and exercise, may be effective. Also, a large range of complementary and alternative medicines (e.g. zinc, vitamin C and probiotics) are proposed for preventing and treating ARIs, but evidence for efficacy is scarce. General practitioners' (GPs) attitudes towards antibiotic prescribing are a major factor in the prescribing for ARIs. Professional interventions with educational components are effective, although they have modest effects, and are expensive. GPs' perceptions - that mistakenly assume as a default that patients want antibiotics for their ARIs - are often wrong. Shared decision making might be a solution, as it enables clinician and patient to participate jointly in making a health decision, having discussed the options together with the evidence for their harms as well as benefits. Furthermore, GPs' diagnostic uncertainty - often leading to an antibiotic prescription "just in case" - might be addressed by exploiting strategies such as safety-netting, e.g., establishing with the patient a priori clearly defined actions to take if the course of the illness deviates from the expected. None of these strategies or interventions on their own will greatly improve the use of antibiotics for ARIs. However, used in concert, combinations are likely to enable clinicians and health care systems to implement the strategies that will reduce antimicrobial resistance in the future.

Educational interventions to improve prescription and dispensing of antibiotics: a systematic review

Background

Excessive and inappropriate antibiotic use contributes to growing antibiotic resistance, an important public-health problem. Strategies must be developed to improve antibiotic-prescribing. Our purpose is to review of educational programs aimed at improving antibiotic-prescribing by physicians and/or antibiotic-dispensing by pharmacists, in both primary-care and hospital settings.

Methods

We conducted a critical systematic search and review of the relevant literature on educational programs aimed at improving antibiotic prescribing and dispensing practice in primary-care and hospital settings, published in January 2001 through December 2011.

Results

We identified 78 studies for analysis, 47 in primary-care and 31 in hospital settings. The studies differed widely in design but mostly reported positive results. Outcomes measured in the reviewed studies were adherence to guidelines, total of antibiotics prescribed, or both, attitudes and behavior related to antibiotic prescribing and quality of pharmacy practice related to antibiotics. Twenty-nine studies (62%) in primary care and twenty-four (78%) in hospital setting reported positive results for all measured outcomes; fourteen studies (30%) in primary care and six (20%) in hospital setting reported positive results for some outcomes and results that were not statistically influenced by the intervention for others; only four studies in primary care and one study in hospital setting failed to report significant post-intervention improvements for all outcomes. Improvement in adherence to guidelines and decrease of total of antibiotics prescribed, after educational interventions, were observed, respectively, in 46% and 41% of all the reviewed studies. Changes in behaviour related to antibiotic-prescribing and improvement in quality of pharmacy practice was observed, respectively, in four studies and one study respectively.

Conclusion

The results show that antibiotic use could be improved by educational interventions, being mostly used multifaceted interventions.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2458-14-1276) contains supplementary material, which is available to authorized users.

Rapid antigen group A streptococcus test to diagnose pharyngitis: a systematic review and meta-analysis

Background

Pharyngitis management guidelines include estimates of the test characteristics of rapid antigen streptococcus tests (RAST) using a non-systematic approach.

Objective

To examine the sensitivity and specificity, and sources of variability, of RAST for diagnosing group A streptococcal (GAS) pharyngitis.

Data Sources

MEDLINE, Cochrane Reviews, Centre for Reviews and Dissemination, Scopus, SciELO, CINAHL, guidelines, 2000–2012.

Study Selection

Culture as reference standard, all languages.

Data Extraction and Synthesis

Study characteristics, quality.

Main Outcome(s) and Measure(s)

Sensitivity, specificity.

Results

We included 59 studies encompassing 55,766 patients. Forty three studies (18,464 patients) fulfilled the higher quality definition (at least 50 patients, prospective data collection, and no significant biases) and 16 (35,634 patients) did not. For the higher quality immunochromatographic methods in children (10,325 patients), heterogeneity was high for sensitivity (inconsistency [I²] 88%) and specificity (I² 86%). For enzyme immunoassay in children (342 patients), the pooled sensitivity was 86% (95% CI, 79–92%) and the pooled specificity was 92% (95% CI, 88–95%). For the higher quality immunochromatographic methods in the adult population (1,216 patients), the pooled sensitivity was 91% (95% CI, 87 to 94%) and the pooled specificity was 93% (95% CI, 92 to 95%); however, heterogeneity was modest for sensitivity (I² 61%) and specificity (I² 72%). For enzyme immunoassay in the adult population (333 patients), the pooled sensitivity was 86% (95% CI, 81–91%) and the pooled specificity was 97% (95% CI, 96 to 99%); however, heterogeneity was high for sensitivity and specificity (both, I² 88%).

Conclusions

RAST immunochromatographic methods appear to be very sensitive and highly specific to diagnose group A streptococcal pharyngitis among adults but not in children. We could not identify sources of variability among higher quality studies. The present systematic review provides the best evidence for the wide range of sensitivity included in current guidelines.

PRImary care Streptococcal Management (PRISM) study: in vitro study, diagnostic cohorts and a pragmatic adaptive randomised controlled trial with nested qualitative study and cost-effectiveness study

BACKGROUND

Antibiotics are still prescribed to most patients attending primary care with acute sore throat, despite evidence that there is modest benefit overall from antibiotics. Targeting antibiotics using either clinical scoring methods or rapid antigen detection tests (RADTs) could help. However, there is debate about which groups of streptococci are important (particularly Lancefield groups C and G), and uncertainty about the variables that most clearly predict the presence of streptococci.

OBJECTIVE

This study aimed to compare clinical scores or RADTs with delayed antibiotic prescribing.

DESIGN

The study comprised a RADT in vitro study; two diagnostic cohorts to develop streptococcal scores (score 1; score 2); and, finally, an open pragmatic randomised controlled trial with nested qualitative and cost-effectiveness studies.

SETTING

The setting was UK primary care general practices.

PARTICIPANTS

Participants were patients aged ≥ 3 years with acute sore throat.

INTERVENTIONS

An internet program randomised patients to targeted antibiotic use according to (1) delayed antibiotics (control group), (2) clinical score or (3) RADT used according to clinical score.

MAIN OUTCOME MEASURES

The main outcome measures were self-reported antibiotic use and symptom duration and severity on seven-point Likert scales (primary outcome: mean sore throat/difficulty swallowing score in the first 2-4 days).

RESULTS

The IMI TestPack Plus Strep A (Inverness Medical, Bedford, UK) was sensitive, specific and easy to use. Lancefield group A/C/G streptococci were found in 40% of cohort 2 and 34% of cohort 1. A five-point score predicting the presence of A/C/G streptococci [FeverPAIN: Fever; Purulence; Attend rapidly (≤ 3 days); severe Inflammation; and No cough or coryza] had moderate predictive value (bootstrapped estimates of area under receiver operating characteristic curve: 0.73 cohort 1, 0.71 cohort 2) and identified a substantial number of participants at low risk of streptococcal infection. In total, 38% of cohort 1 and 36% of cohort 2 scored ≤ 1 for FeverPAIN, associated with streptococcal percentages of 13% and 18%, respectively. In an adaptive trial design, the preliminary score (score 1; n = 1129) was replaced by FeverPAIN (n = 631). For score 1, there were no significant differences between groups. For FeverPAIN, symptom severity was documented in 80% of patients, and was lower in the clinical score group than in the delayed prescribing group (-0.33; 95% confidence interval -0.64 to -0.02; p = 0.039; equivalent to one in three rating sore throat a slight rather than moderately bad problem), and a similar reduction was observed for the RADT group (-0.30; -0.61 to 0.00; p = 0.053). Moderately bad or worse symptoms resolved significantly faster (30%) in the clinical score group (hazard ratio 1.30; 1.03 to 1.63) but not the RADT group (1.11; 0.88 to 1.40). In the delayed group, 75/164 (46%) used antibiotics, and 29% fewer used antibiotics in the clinical score group (risk ratio 0.71; 0.50 to 0.95; p = 0.018) and 27% fewer in the RADT group (0.73; 0.52 to 0.98; p = 0.033). No significant differences in complications or reconsultations were found. The clinical score group dominated both other groups for both the cost/quality-adjusted life-years and cost/change in symptom severity analyses, being both less costly and more effective, and cost-effectiveness acceptability curves indicated the clinical score to be the most likely to be cost-effective from an NHS perspective. Patients were positive about RADTs. Health professionals' concerns about test validity, the time the test took and medicalising self-limiting illness lessened after using the tests. For both RADTs and clinical scores, there were tensions with established clinical experience.

CONCLUSIONS

Targeting antibiotics using a clinical score (FeverPAIN) efficiently improves symptoms and reduces antibiotic use. RADTs used in combination with FeverPAIN provide no clear advantages over FeverPAIN alone, and RADTs are unlikely to be incorporated into practice until health professionals' concerns are met and they have experience of using them. Clinical scores also face barriers related to clinicians' perceptions of their utility in the face of experience. This study has demonstrated the limitation of using one data set to develop a clinical score. FeverPAIN, derived from two data sets, appears to be valid and its use improves outcomes, but diagnostic studies to confirm the validity of FeverPAIN in other data sets and settings are needed. Experienced clinicians need to identify barriers to the use of clinical scoring methods. Implementation studies that address perceived barriers in the use of FeverPAIN are needed.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN32027234.

SOURCE OF FUNDING

This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 18, No. 6. See the NIHR Journals Library website for further project information.

Compliance with recommendations on outpatient antibiotic prescribing for respiratory tract infections: the case of Spain

Inappropriate antibiotic use in primary care, such as in respiratory tract infections (RTIs), is an important cause of bacterial resistance. This study aimed at describing the current pattern of outpatient antibiotic use in acute RTIs in Spain and evaluating adherence to national recommendations. A retrospective observational study was performed including all the episodes of RTIs registered during a 1-year period in a north-eastern Spanish region. Data related to patient demography, diagnoses and antibiotic prescriptions were collected from the electronic medical history database in the region, and adherence to recommendations for antibiotic prescribing was assessed. One third of patients with a RTI were prescribed an antibiotic, with young adults (aged 15-64 years) being the most treated. High prescribing rates were observed in patients with acute otitis, sinusitis and acute tonsillitis (about 70%), whereas low rates were found in acute bronchitis (50%) and non-specific upper RTIs (24%) episodes. A high prescription of broad-spectrum agents and antibiotics not recommended as first choice was observed. In accordance with Spanish guidelines, there exists a potential over-prescribing of antibiotics for all the diagnoses studied, especially in the adult population. Moreover, the choice of antibiotics is frequently based on agents with a high risk of increasing antimicrobial resistance. Multifaceted strategies should be implemented to improve the quality of antibiotic prescribing in primary care.

Incidence and clinical variables associated with streptococcal throat infections: a prospective diagnostic cohort study

BACKGROUND

Management of pharyngitis is commonly based on features which are thought to be associated with Lancefield group A beta-haemolytic streptococci (GABHS) but it is debatable which features best predict GABHS. Non-group A strains share major virulence factors with group A, but it is unclear how commonly they present and whether their presentation differs.

AIM

To assess the incidence and clinical variables associated with streptococcal infections.

DESIGN AND SETTING

Prospective diagnostic cohort study in UK primary care.

METHOD

The presence of pathogenic streptococci from throat swabs was assessed among patients aged ≥5 years presenting with acute sore throat.

RESULTS

Pathogenic streptococci were found in 204/597 patients (34%, 95% CI = 31 to 38%): 33% (68/204) were non-group A streptococci, mostly C (n = 29), G (n = 18) and B (n = 17); rarely D (n = 3) and Streptococcus pneumoniae (n = 1). Patients presented with similar features whether the streptococci were group A or non-group A. The features best predicting A, C or G beta-haemolytic streptococci were patient's assessment of severity (odds ratio [OR] for a bad sore throat 3.31, 95% CI = 1.24 to 8.83); doctors' assessment of severity (severely inflamed tonsils OR 2.28, 95% CI = 1.39 to 3.74); absence of a bad cough (OR 2.73, 95% CI = 1.56 to 4.76), absence of a coryza (OR 1.54, 95% CI = 0.99 to 2.41); and moderately bad or worse muscle aches (OR 2.20, 95% CI = 1.41 to 3.42).

CONCLUSION

Non-group A strains commonly cause streptococcal sore throats, and present with similar symptomatic clinical features to group A streptococci. The best features to predict streptococcal sore throat presenting in primary care deserve revisiting.

Enabling factors for antibiotic prescribing for upper respiratory tract infections: perspectives of Lithuanian and Russian general practitioners

INTRODUCTION

General practitioners (GPs) write about 80% of all antibiotic prescriptions, the greatest number of them for patients with respiratory tract infections. However, there is a lack of research targeting the influence of external factors on antibiotic prescribing by physicians. This study aimed to explore experiences of GPs in Lithuania and the Russian Federation with regard to antibiotic prescription for upper respiratory tract infections. By such means it might be possible to reveal external enabling factors that influence antibiotic prescribing in these countries.

METHOD

Five focus groups were performed with 22 GPs from Lithuania and 29 GPs from the Kaliningrad Region of the Russian Federation; then, thematic analysis of data was performed.

RESULTS

Six thematic categories were identified that are related to external forces enabling antibiotic prescription: the necessity for political leadership to encourage clinically grounded antibiotic use; over-the-counter sale of antibiotics; designation of antibiotics as reimbursable medications; supervision by external oversight institutions; lack of guidelines for the treatment of upper respiratory tract infections; and pharmaceutical company activities.

CONCLUSIONS

Comprehensive efforts to reduce the burden of non-clinically grounded antibiotic prescription should go beyond addressing factors at the physician-patient level and take into account important factors in the enabling environment as well.

Evaluation of the implementation of a rapid streptococcal antigen test in a routine primary health care setting: from recommendations to practice

BACKGROUND AND AIM

Pharyngitis is a common reason for consultation in General Practice. Despite the development of diagnostic criteria it remains difficult to clinically diagnose the bacterial type. Therefore, current guidelines recommend the additional use of objective tests. In Austria, the Burgenländische Gebietskrankenkasse introduced a test as service for patients and regular payment position for GPs. It was the aim of this study to analyze this implementation process in General Practice and a possible change in antibiotic prescriptions.

METHODS

The retrospective evaluation lasted from April 2006 to September 2009; in April 2007, rapid-streptococcal-antigen-tests (RSATs) were introduced. GPs were grouped into three clusters according to their use of RSATs. In addition, all antibiotic prescriptions within the evaluation period were analyzed and correlated to the three clusters before and after the implementation.

RESULTS

The overall number of RSATs performed was 6,401. Half of the GPs utilized it regularly. After its introduction, the relative antibiotic prescription frequency was significantly reduced (17.1 vs. 16.4 %, p = 0.0001). The results for the subgroup analyses yielded a significant reduction for the regular user group only (16.0 vs. 15.0 %, p = 0.0001).

CONCLUSION

GPs using the RSAT regularly seem to apply the test appropriately. The decrease of the relative antibiotic prescriptions of all GPs seems to be due to the regular user group of GPs. This could be interpreted as a consequence of the RSAT use. The results show a positive trend for an improvement in diagnostic quality and for an appropriate use of antibiotic prescriptions.

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.