Three Years of the Coronavirus Disease 2019 Pandemic in a European Region: A Population-Based Longitudinal Assessment in Madrid Between 2020 and 2022

Background

Our objective was to assess the health impact of coronavirus disease 2019 (COVID-19) during 2020-2022 in the Madrid region.

Methods

We included all individuals registered in the Madrid Health System Registry as of 31 December 2019, and followed them until 31 December 2022. Using a unique personal identifier, we linked the databases of primary care, hospitals, pharmacies, certified laboratories performing diagnostic tests, vaccines, and mortality.

Results

Of 6 833 423 individuals, 21.4% had a confirmed COVID-19 diagnosis, and 1.5% had a COVID-19 hospitalization (primary diagnosis). Thirty-day mortality was 1.6% for confirmed COVID-19 (from 11.4% in first semester 2020 to 0.4% in first semester 2022). Thirty-day mortality was 10.8% for COVID-19 hospitalizations (from 14.0% in first semester 2020 to 6.0% in second semester 2022). There were 24 073 deaths within 30 days of a confirmed COVID-19 diagnosis. Advanced age, male sex, higher socioeconomic deprivation, and comorbidities were associated with higher mortality.

Conclusions

By linking administrative and clinical databases, we characterized the burden of the COVID-19 pandemic in Madrid over 3 years. Our analysis proposes a high-level framework for comparisons of the burden of COVID-19 across areas worldwide.

Interactions listed in the Paxlovid fact sheet, classified according to risks, pharmacological groups, and consequences

Paxlovid (nirmatrelvir plus ritonavir) is a new oral antiviral therapeutic for the treatment of COVID-19. Nirmatrelvir is an inhibitor of SARS-CoV-2 main protease, while ritonavir is used as a CYP3A inhibitor in low doses to slow the metabolism of nirmatrelvir, thus enhancing their therapeutic effect. The iso-enzyme CYP3A4 is responsible for at least part of the oxidative metabolism of approximately 60% of available medications and ritonavir is therefore a significant source of drug interactions. We describe here the drugs that are contraindicated or should be used with or without precautions when Paxlovid (nirmaltrevir plus ritonavir) should be administered according to each fact sheet in force at the Spanish Agency for Medicines and Health Products.

Decalogue for the selection of oral antibiotics for lower respiratory tract infections

Lower respiratory tract infections, including chronic obstructive pulmonary disease exacerbations (COPD-E) and community acquired pneumonia (CAP), are one of the most frequent reasons for consultation in primary care and hospital emergency departments, and are the cause of a high prescription of antimicrobial agents. The selection of the most appropriate oral antibiotic treatment is based on different aspects and includes to first consider a bacterial aetiology and not a viral infection, to know the bacterial pathogen that most frequently cause these infections and the frequency of their local antimicrobial resistance. Treatment should also be prescribed quickly and antibiotics should be selected among those with a quicker mode of action, achieving the greatest effect in the shortest time and with the fewest adverse effects (toxicity, interactions, resistance and/or ecological impact). Whenever possible, antimicrobials should be rotated and diversified and switched to the oral route as soon as possible. With these premises, the oral treatment guidelines for mild or moderate COPD-E and CAP in Spain include as first options beta-lactam antibiotics (amoxicillin and amoxicillin-clavulanate and cefditoren), in certain situations associated with a macrolide, and relegating fluoroquinolones as an alternative, except in cases where the presence of Pseudomonas aeruginosa is suspected.

Clinical effectiveness and bacteriological eradication of three different Short-COurse antibiotic regimens and single-dose fosfomycin for uncomplicated lower Urinary Tract infections in adult women (SCOUT study): study protocol for a randomised clinical trial

INTRODUCTION

Uncomplicated lower urinary tract infections (uLUTI) are a common problem in primary care. Current local guidelines recommend the use of a single 3 g dose of fosfomycin. However, most general practitioners (GP) prefer short-course therapies to single-dose therapy. No study has compared head-to-head short-course antimicrobial agents for uLUTIs. Therefore, the aim of this randomised clinical trial is to compare three different short-course antibiotic therapies with a single-dose of fosfomycin for these infections.

METHODS AND ANALYSIS

This will be a pragmatic, multicentre, parallel group, open trial. Women aged 18 or older and with symptoms of uLUTI and a positive urine dipstick analysis will be randomised to one of the following four groups: a single dose of 3 g of fosfomycin, 2 days of 3 g of fosfomycin o.d., 3 days of pivmecillinam 400 mg three times per day (t.i.d) or 5 days of nitrofurantoin 100 mg t.i.d. A total sample of 1120 patients was calculated. The primary endpoint is clinical effectiveness at day 7, defined as cure of symptoms reported by the patients in a diary including four symptoms: dysuria, urgency, frequency and suprapubic pain, which will be scored on a 4-point severity scale (not present/mild/moderate/severe). Follow-up visits are scheduled at days 7 (phone call), 14 and 28 for assessing evolution. Urine samples will be collected in the three on-site visits and urine cultures performed. If positive, antibiograms for the three antibiotics studied will be performed. Bacterial eradication will be measured at days 14 and 28.

ETHICS AND DISSEMINATION

The study was approved by the Ethical Board of IDIAP Jordi Gol (reference number: 21/173-AC) and Spanish Agency of Medicines and Medical Devices. The findings of this trial will be disseminated through research conferences and peer-review journals.

TRIAL REGISTRATION NUMBER

NCT04959331; EudraCT Number: 2021-001332-26.

TIME SCHEDULE

January 2022 to April 2023.

Recommendations for use of antigenic tests in the diagnosis of acute SARS-CoV-2 infection in the second pandemic wave: attitude in different clinical settings

The high transmissibility of SARS-CoV-2 before and shortly after the onset of symptoms suggests that only diagnosing and isolating symptomatic patients may not be sufficient to interrupt the spread of infection; therefore, public health measures such as personal distancing are also necessary. Additionally, it will be important to detect the newly infected individuals who remain asymptomatic, which may account for 50% or more of the cases. Molecular techniques are the "gold standard" for the diagnosis of SARS-CoV-2 infection. However, the massive use of these techniques has generated some problems. On the one hand, the scarcity of resources (analyzers, fungibles and reagents), and on the other the delay in the notification of results. These two facts translate into a lag in the application of isolation measures among cases and contacts, which favors the spread of the infection. Antigen detection tests are also direct diagnostic methods, with the advantage of obtaining the result in a few minutes and at the very "pointof-care". Furthermore, the simplicity and low cost of these tests allow them to be repeated on successive days in certain clinical settings. The sensitivity of antigen tests is generally lower than that of nucleic acid tests, although their specificity is comparable. Antigenic tests have been shown to be more valid in the days around the onset of symptoms, when the viral load in the nasopharynx is higher. Having a rapid and real-time viral detection assay such as the antigen test has been shown to be more useful to control the spread of the infection than more sensitive tests, but with greater cost and response time, such as in case of molecular tests. The main health institutions such as the WHO, the CDC and the Ministry of Health of the Government of Spain propose the use of antigenic tests in a wide variety of strategies to respond to the pandemic. This document aims to support physicians involved in the care of patients with suspected SC2 infection, in the context of a growing incidence in Spain since September 2020, which already represents the second pandemic wave of COVID-19.

Long-term effect of a practice-based intervention (HAPPY AUDIT) aimed at reducing antibiotic prescribing in patients with respiratory tract infections

Objectives

Few studies have evaluated the long-term effects of educational interventions on antibiotic prescription and the results are controversial. This study was aimed at assessing the effect of a multifaceted practice-based intervention carried out 6 years earlier on current antibiotic prescription for respiratory tract infections (RTIs).

Methods

The 210 general practitioners (GPs) who completed the first two registrations in 2008 and 2009 were invited to participate in a third registration. The intervention held before the second registration consisted of discussion about the first registration of results, appropriate use of antibiotics for RTIs, patient brochures, a workshop and the provision of rapid tests. As in the previous registrations, GPs were instructed to complete a template for all the patients with RTIs during 15 working days in 2015. A new group of GPs from the same areas was also invited to participate and acted as controls. A multilevel logistic regression analysis was performed considering the prescription of antibiotics as the dependent variable.

Results

A total of 121 GPs included in the 2009 intervention (57.6%) and 117 control GPs registered 22 247 RTIs. On adjustment for covariables, compared with the antibiotic prescription observed just after the intervention, GPs assigned to intervention prescribed slightly more antibiotics 6 years later albeit without statistically significant differences (OR 1.08, 95% CI 0.89-1.31, P = 0.46), while GPs in the control group prescribed significantly more antibiotics (OR 2.74, 95% CI 2.09-3.59, P < 0.001).

Conclusions

This study shows that a single multifaceted intervention continues to reduce antibiotic prescribing 6 years later.

Reducing antibiotic prescribing for lower respiratory tract infections 6 years after a multifaceted intervention

AIMS

Few studies have evaluated the long-term impact of interventions on antibiotic prescription for lower respiratory tract infections (LRTI). This study was aimed at evaluating the use of antibiotics prescribed for LRTIs by general practitioners (GP) who underwent a multifaceted intervention carried out 6 years earlier.

METHODS

General practitioners who had completed two registrations in 2008 and 2009 were again invited to participate in a third audit-based study in 2015. A multifaceted intervention was held 1-3 months before the second registration. A new group of GPs with no previous training on the rational use of antibiotics were also invited to participate and acted as controls. Multilevel logistic regression was performed considering the prescription of antibiotics as the dependent variable.

RESULTS

A total of 121 GPs of the 210 who underwent the intervention (57.6%) and 117 control GPs registered 4333 episodes of LRTIs. On adjustment for covariables, compared with the antibiotic prescription for LRTIs observed just after the intervention, antibiotic prescription slightly increased 6 years later among GPs who had undergone the intervention (OR 1.17, 95% CI 0.95-1.43), while control GPs prescribed significantly more antibiotics (OR 2.31, 95% CI 1.62-3.29). However, withholding antibiotic prescribing with C-reactive protein (CRP) values <10 mg/L was more frequently observed just after the intervention compared 6 years later (12.7% vs 32.2%; P < 0.01).

CONCLUSIONS

Antibiotic prescribing for LRTIs remains low 6 years after an intervention, although GPs are less confident to withhold antibiotic therapy in patients with low CRP levels.

[Utilisation of first-line antibiotics six years after a multifaceted intervention]

OBJECTIVE

No study has evaluated the impact of a multifaceted intervention on the quality of the antibiotics prescribed more than 5 years later.

METHODS

A total of 210 general practitioners (GP) from eight different regions of Spain were asked to participate in two registrations of respiratory tract infections (RTI) in 2008, before, and in 2009, just after a multifaceted intervention including prescriber feedback, clinical guidelines, training sessions focused on appropriate antibiotic prescribing, workshop on rapid tests and provision of these tests in the GP consultation. They were all again invited to participate in a similar registration in 2015. A new group of clinicians from the same areas who had never participated in antimicrobial stewardship courses were also invited to participate and acted as controls.

RESULTS

The 121 GPs who continued the study (57.6%) and the 117 control GPs registered 22,407 RTIs. The antibiotic most commonly prescribed was amoxicillin and clavulanic acid, prescribed in 1,801 cases (8.1% of the total), followed by amoxicillin (1,372 prescriptions, 6.2%), being lower among GPs just after the intervention. The third leading antibiotic among GPs just after the intervention was penicillin V (127 cases, 3.3%) whereas macrolides ranked third in the other three groups of GPs.

CONCLUSIONS

The use of first-line antibiotic for RTIs wanes over time after an intervention, but their utilisation is still significantly greater among intervened clinicians six years later compared to GPs who have never been exposed to any antimicrobial stewardship programmes.

The STOP-AB trial protocol: efficacy and safety of discontinuing patient antibiotic treatment when physicians no longer consider it necessary

INTRODUCTION

Since 2011, the Spanish Society of Family Medicine has recommended general practitioners (GPs) to ask their patients to stop taking antibiotics when they suspect a viral infection. However, this practice is seldom used because uncertainty about diagnosis, and fear of consequences of discontinuing antibiotic therapy, as well as perceived pressure to continue prescribing antibiotics and potential conflict with patients are more of a concern for GPs than antibiotic resistance. The main objective of this study is to determine whether discontinuation of antibiotic therapy when a GP no longer considers it necessary has any impact on the number of days with severe symptoms.

METHODS AND ANALYSIS

This is a multicentre, open-label, randomised controlled clinical trial. The study was conducted in 10 primary care centres in Spain. We included patients from 18 to 75 years of age with uncomplicated acute respiratory tract infections-acute rhinosinusitis, acute sore throat, influenza or acute bronchitis-who had previously taken any dose of antibiotic for <3 days, which physicians no longer considered necessary. The patients were randomly assigned to the usual strategy of continuing antibiotic treatment or to discontinuing antibiotic therapy. A sample size of 240 patients per group was calculated on the basis of a reduction of 1 day in the duration of severe symptoms being a clinically relevant outcome. The primary outcome was the duration of severe symptoms, that is, symptoms scored 5 or 6 by means of validated symptom diaries. Secondary outcomes included antibiotics taken, adverse events, patient satisfaction and complications within the first 3 months.

ETHICS AND DISSEMINATION

The study was approved by the Ethical Board of Fundació Jordi Gol i Gurina (reference number: 16/093). The findings of this trial will bedisseminated through research conferences and peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT02900820; pre-results.

[Clinical management of patient with benign prostatic hyperplasia in Spain]

OBJECTIVES

To identify clinical management of benign prostatic hyperplasia (BPH) in Spain and its associated health care resources.

MATERIAL AND METHODS

A qualitative cross-sectional study was conducted through telephone interviews to general practitioners (GP) and urologists. Information about diagnosis, pharmacologic treatment and follow-up was collected. Results were clustered according to the key variables considered as drivers of clinical practice patterns: BPH diagnosis, severity classification, treatment initiation and follow up of patients.

RESULTS

153 GP and 154 urologists participated in the study. 7 different clinical patterns were identified in primary care (PC). Resource use during diagnosis is relatively homogeneous, reporting a range of 2.0 to 2.6 visits employed and being the most frequent test performed PSA and urine test. Follow-up is heterogeneous; frequency of follow-up visits oscillates from 3.2 to 7.0 visits/patient/year and type of tests performed is different among patterns and within the same pattern. In Urology, 3 clinical patterns were identified. Resource use is homogeneous in the diagnosis and in the follow-up; urologists employed 2 visits in diagnosis and a range of 2.1 to 3.2 visits/patient/year in the follow-up. The most frequent tests both in diagnosis and follow-up are PSA and digital test.

CONCLUSIONS

BPH management shows variability in PC, identifying 7 different clinical practice patterns with different resource use during the follow-up among patterns and within the same pattern. The implementation of clinical guidelines could be justified to reduce heterogeneity.

[Cost-effectiveness of the combination therapy of dutasteride and tamsulosin in the treatment of benign prostatic hyperlasia in Spain]

OBJECTIVES

to evaluate the incremental cost-effectiveness ratio (ICER) of the combination therapy with dutasteride and tamsulosin (DUT+TAM) as initiation treatment versus the most used drug in Spain, tamsulosin (TAM), in the treatment of moderate to severe benign prostatic hyperplasia (BPH) with risk of progression.

METHODS

a semi-Markov model was developed using 4-year and 35-year time horizons and from the Spanish National Healthcare Service perspective. Data were obtained from the CombAT trial. Effectiveness was measured in terms of quality adjusted life years (QALYs). Health care resources were defined by an experts' panel, and unitary costs were obtained from published Spanish sources. Pharmacologic cost is expressed in PTP(WAT); in the case of TAM, the generic price is used, in the case of DUT+TAM the price of a fixed dose combination is used. Costs are expressed in 2010 Euros.

RESULTS

combination therapy with DUT+TAM produces an incremental effectiveness of 0.06QALY at year 4 and 0.4QALY at year 35. DUT+TAM represents an incremental cost of € 810.53 at 4 years and € 3,443.62 at 35 years. Therefore, the ICER for DUT+TAM versus TAM is € 14,023.32/QALY at year 4 and € 8,750.15/QALY at year 35.

CONCLUSIONS

initiation treatment with DUT+TAM represents a cost-effective treatment versus TAM, the most used treatment in Spain, due to the fact the ICER is below the threshold that usually allows a technology to be considered as cost-effective.