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Bjørk E, Aabenhus R, Larsen SP, Ryg J, Henriksen DP, Lundby C, Pottegård A. Use of antibiotics for urinary tract infections up to and after care home admission in Denmark: a nationwide study. Eur Geriatr Med 2024:10.1007/s41999-024-00976-1. [PMID: 38698277 DOI: 10.1007/s41999-024-00976-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 04/01/2024] [Indexed: 05/05/2024]
Abstract
PURPOSE Older people have the highest use of antibiotics for acute and chronic urinary tract infection (UTI), despite diagnostic uncertainty and the growing problem of antibiotic resistance. We aim to describe use-patterns of UTI antibiotics two years prior to and following care home admission in Denmark. METHODS This was a register-based nationwide drug-utilization study. In a cohort comprising all Danish residents admitted into a care home from 2015 to 2021, we described the use of UTI antibiotics, and examined differences between regions and individual care homes in rates of UTI antibiotic use. Further, we described trends in UTI-related contacts with hospitals in the two years prior to and following care home admission. RESULTS The cohort comprised 101,297 residents (61% female; median age 84 years). UTI antibiotic use doubled from 7 to 14 treatments/100 residents/month two months prior to care home admission and remained at 10 treatments/100 residents/month the following two years. Prescription of pivmecillinam (55%) was most common. Primary care practitioners prescribed the majority (92%) of UTI antibiotics. UTI-related hospital contacts peaked at two months prior to care home admission, with 6 admissions/100 residents/month, subsequently dropping to 2 admission/100 residents/month. We found considerable variation in UTI antibiotic use, with 10% of care homes responsible for 20% of treatments in 2021. CONCLUSION Use of UTI antibiotics increased prior to and remained at a stable high level following care home admission in Denmark. Despite variation in use across regions and individual care homes, an overall decrease was seen throughout the years 2016-2021.
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Affiliation(s)
- Emma Bjørk
- Hospital Pharmacy Funen, Odense University Hospital, Odense C, Denmark.
- Department of Public Health, Clinical Pharmacology, Pharmacy and Environmental Medicine, University of Southern Denmark, JB Winsløwsvej 19, 2, 5000, Odense C, Denmark.
- Odense Deprescribing Initiative (ODIN), Odense University Hospital, University of Southern Denmark, Odense C, Denmark.
| | - Rune Aabenhus
- Section of General Practice and Research Unit for General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | | | - Jesper Ryg
- Odense Deprescribing Initiative (ODIN), Odense University Hospital, University of Southern Denmark, Odense C, Denmark
- Department of Geriatric Medicine, Odense University Hospital, Odense C, Denmark
- Geriatric Research Unit, Department of Clinical Research, University of Southern Denmark, Odense C, Denmark
| | - Daniel P Henriksen
- Department of Clinical Pharmacology, Odense University Hospital, Odense C, Denmark
| | - Carina Lundby
- Hospital Pharmacy Funen, Odense University Hospital, Odense C, Denmark
- Department of Public Health, Clinical Pharmacology, Pharmacy and Environmental Medicine, University of Southern Denmark, JB Winsløwsvej 19, 2, 5000, Odense C, Denmark
- Odense Deprescribing Initiative (ODIN), Odense University Hospital, University of Southern Denmark, Odense C, Denmark
- Department of Public Health, Research Unit of General Practice, University of Southern, Odense C, Denmark
| | - Anton Pottegård
- Hospital Pharmacy Funen, Odense University Hospital, Odense C, Denmark
- Department of Public Health, Clinical Pharmacology, Pharmacy and Environmental Medicine, University of Southern Denmark, JB Winsløwsvej 19, 2, 5000, Odense C, Denmark
- Odense Deprescribing Initiative (ODIN), Odense University Hospital, University of Southern Denmark, Odense C, Denmark
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Vellinga A, Luke-Currier A, Garzón-Orjuela N, Aabenhus R, Anastasaki M, Balan A, Böhmer F, Lang VB, Chlabicz S, Coenen S, García-Sangenís A, Kowalczyk A, Malania L, Tomacinschii A, van der Linde SR, Bongard E, Butler CC, Goossens H, van der Velden AW. Disease-Specific Quality Indicators for Outpatient Antibiotic Prescribing for Respiratory Infections (ESAC Quality Indicators) Applied to Point Prevalence Audit Surveys in General Practices in 13 European Countries. Antibiotics (Basel) 2023; 12:antibiotics12030572. [PMID: 36978439 PMCID: PMC10044809 DOI: 10.3390/antibiotics12030572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 02/23/2023] [Accepted: 03/10/2023] [Indexed: 03/17/2023] Open
Abstract
Up to 80% of antibiotics are prescribed in the community. An assessment of prescribing by indication will help to identify areas where improvement can be made. A point prevalence audit study (PPAS) of consecutive respiratory tract infection (RTI) consultations in general practices in 13 European countries was conducted in January–February 2020 (PPAS-1) and again in 2022 (PPAS-4). The European Surveillance of Antibiotic Consumption quality indicators (ESAC-QI) were calculated to identify where improvements can be made. A total of 3618 consultations were recorded for PPAS-1 and 2655 in PPAS-4. Bacterial aetiology was suspected in 26% (PPAS-1) and 12% (PPAS-4), and an antibiotic was prescribed in 30% (PPAS-1) and 16% (PPAS-4) of consultations. The percentage of adult patients with bronchitis who receive an antibiotic should, according to the ESAC-QI, not exceed 30%, which was not met by participating practices in any country except Denmark and Spain. For patients (≥1) with acute upper RTI, less than 20% should be prescribed an antibiotic, which was achieved by general practices in most countries, except Ireland (both PPAS), Croatia (PPAS-1), and Greece (PPAS-4) where prescribing for acute or chronic sinusitis (0–20%) was also exceeded. For pneumonia in adults, prescribing is acceptable for 90–100%, and this is lower in most countries. Prescribing for tonsillitis (≥1) exceeded the ESAC-QI (0–20%) in all countries and was 69% (PPAS-1) and 75% (PPAS-4). In conclusion, ESAC-QI applied to PPAS outcomes allows us to evaluate appropriate antibiotic prescribing by indication and benchmark general practices and countries.
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Affiliation(s)
- Akke Vellinga
- School of Public Health, Physiotherapy and Sports Science, University College Dublin, D04 V1W8 Dublin, Ireland
- Correspondence:
| | - Addiena Luke-Currier
- School of Public Health, Physiotherapy and Sports Science, University College Dublin, D04 V1W8 Dublin, Ireland
| | - Nathaly Garzón-Orjuela
- School of Public Health, Physiotherapy and Sports Science, University College Dublin, D04 V1W8 Dublin, Ireland
| | - Rune Aabenhus
- Research Unit for General Practice, Department of Public Health, University of Copenhagen, DK-2200 Copenhagen, Denmark
| | - Marilena Anastasaki
- Department of Social Medicine, School of Medicine, University of Crete, 71003 Heraklion, Greece
| | - Anca Balan
- Balan Medfam Srl, 400064 Cluj Napoca, Romania
| | - Femke Böhmer
- Institute of General Practice, Rostock University Medical Center, 18057 Rostock, Germany
| | - Valerija Bralić Lang
- Department of Family Medicine, “Andrija Stampar” School of Public Health, School of Medicine, University of Zagreb, 10020 Zagreb, Croatia
| | - Slawomir Chlabicz
- Department of Family Medicine, Medical University of Bialystok, 15-089 Bialystok, Poland
| | - Samuel Coenen
- Department of Family Medicine & Population Health, University of Antwerp, 2610 Antwerp, Belgium
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute, University of Antwerp, 2610 Antwerp, Belgium
| | - Ana García-Sangenís
- Institut Universitari d’Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), 08007 Barcelona, Spain
- Centro de investigación Biomédica en Red Enfermedades Infecciosas (CIBERINFEC), 28029 Madrid, Spain
| | - Anna Kowalczyk
- Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Lodz, 92-213 Lodz, Poland
| | - Lile Malania
- National Center for Disease Control and Public Health, Tbilisi and Arner Science Management LLC, 0190 Tbilisi, Georgia
| | - Angela Tomacinschii
- University Clinic of Primary Medical Assistance, State University of Medicine and Pharmacy “Nicolae Testemițanu”, MD-2004 Chişinǎu, Moldova
| | - Sanne R. van der Linde
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Universiteitsweg 100, 3584 CG Utrecht, The Netherlands
| | - Emily Bongard
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX1 4BH, UK
| | - Christopher C. Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX1 4BH, UK
| | - Herman Goossens
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute, University of Antwerp, 2610 Antwerp, Belgium
| | - Alike W. van der Velden
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Universiteitsweg 100, 3584 CG Utrecht, The Netherlands
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Smedemark SA, Aabenhus R, Llor C, Fournaise A, Olsen O, Jørgensen KJ. Biomarkers as point-of-care tests to guide prescription of antibiotics in people with acute respiratory infections in primary care. Cochrane Database Syst Rev 2022; 10:CD010130. [PMID: 36250577 PMCID: PMC9575154 DOI: 10.1002/14651858.cd010130.pub3] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Acute respiratory infections (ARIs) are by far the most common reason for prescribing an antibiotic in primary care, even though the majority of ARIs are of viral or non-severe bacterial aetiology. It follows that in many cases antibiotic use will not be beneficial to a patient's recovery but may expose them to potential side effects. Furthermore, limiting unnecessary antibiotic use is a key factor in controlling antibiotic resistance. One strategy to reduce antibiotic use in primary care is point-of-care biomarkers. A point-of-care biomarker (test) of inflammation identifies part of the acute phase response to tissue injury regardless of the aetiology (infection, trauma, or inflammation) and may be used as a surrogate marker of infection, potentially assisting the physician in the clinical decision whether to use an antibiotic to treat ARIs. Biomarkers may guide antibiotic prescription by ruling out a serious bacterial infection and help identify patients in whom no benefit from antibiotic treatment can be anticipated. This is an update of a Cochrane Review first published in 2014. OBJECTIVES To assess the benefits and harms of point-of-care biomarker tests of inflammation to guide antibiotic treatment in people presenting with symptoms of acute respiratory infections in primary care settings regardless of patient age. SEARCH METHODS We searched CENTRAL (2022, Issue 6), MEDLINE (1946 to 14 June 2022), Embase (1974 to 14 June 2022), CINAHL (1981 to 14 June 2022), Web of Science (1955 to 14 June 2022), and LILACS (1982 to 14 June 2022). We also searched three trial registries (10 December 2021) for completed and ongoing trials. SELECTION CRITERIA We included randomised controlled trials (RCTs) in primary care patients with ARIs that compared the use of point-of-care biomarkers with standard care. We included trials that randomised individual participants, as well as trials that randomised clusters of patients (cluster-RCTs). DATA COLLECTION AND ANALYSIS Two review authors independently extracted data on the following primary outcomes: number of participants given an antibiotic prescription at index consultation and within 28 days follow-up; participant recovery within seven days follow-up; and total mortality within 28 days follow-up. We assessed risk of bias using the Cochrane risk of bias tool and the certainty of the evidence using GRADE. We used random-effects meta-analyses when feasible. We further analysed results with considerable heterogeneity in prespecified subgroups of individual and cluster-RCTs. MAIN RESULTS We included seven new trials in this update, for a total of 13 included trials. Twelve trials (10,218 participants in total, 2335 of which were children) evaluated a C-reactive protein point-of-care test, and one trial (317 adult participants) evaluated a procalcitonin point-of-care test. The studies were conducted in Europe, Russia, and Asia. Overall, the included trials had a low or unclear risk of bias. However all studies were open-labelled, thereby introducing high risk of bias due to lack of blinding. The use of C-reactive protein point-of-care tests to guide antibiotic prescription likely reduces the number of participants given an antibiotic prescription, from 516 prescriptions of antibiotics per 1000 participants in the control group to 397 prescriptions of antibiotics per 1000 participants in the intervention group (risk ratio (RR) 0.77, 95% confidence interval (CI) 0.69 to 0.86; 12 trials, 10,218 participants; I² = 79%; moderate-certainty evidence). Overall, use of C-reactive protein tests also reduce the number of participants given an antibiotic prescription within 28 days follow-up (664 prescriptions of antibiotics per 1000 participants in the control group versus 538 prescriptions of antibiotics per 1000 participants in the intervention group) (RR 0.81, 95% CI 0.76 to 0.86; 7 trials, 5091 participants; I² = 29; high-certainty evidence). The prescription of antibiotics as guided by C-reactive protein tests likely does not reduce the number of participants recovered, within seven or 28 days follow-up (567 participants recovered within seven days follow-up per 1000 participants in the control group versus 584 participants recovered within seven days follow-up per 1000 participants in the intervention group) (recovery within seven days follow-up: RR 1.03, 95% CI 0.96 to 1.12; I² = 0%; moderate-certainty evidence) (recovery within 28 days follow-up: RR 1.02, 95% CI 0.79 to 1.32; I² = 0%; moderate-certainty evidence). The use of C-reactive protein tests may not increase total mortality within 28 days follow-up, from 1 death per 1000 participants in the control group to 0 deaths per 1000 participants in the intervention group (RR 0.53, 95% CI 0.10 to 2.92; I² = 0%; low-certainty evidence). We are uncertain as to whether procalcitonin affects any of the primary or secondary outcomes because there were few participants, thereby limiting the certainty of evidence. We assessed the certainty of the evidence as moderate to high according to GRADE for the primary outcomes for C-reactive protein test, except for mortality, as there were very few deaths, thereby limiting the certainty of the evidence. AUTHORS' CONCLUSIONS The use of C-reactive protein point-of-care tests as an adjunct to standard care likely reduces the number of participants given an antibiotic prescription in primary care patients who present with symptoms of acute respiratory infection. The use of C-reactive protein point-of-care tests likely does not affect recovery rates. It is unlikely that further research will substantially change our conclusion regarding the reduction in number of participants given an antibiotic prescription, although the size of the estimated effect may change. The use of C-reactive protein point-of-care tests may not increase mortality within 28 days follow-up, but there were very few events. Studies that recorded deaths and hospital admissions were performed in children from low- and middle-income countries and older adults with comorbidities. Future studies should focus on children, immunocompromised individuals, and people aged 80 years and above with comorbidities. More studies evaluating procalcitonin and potential new biomarkers as point-of-care tests used in primary care to guide antibiotic prescription are needed. Furthermore, studies are needed to validate C-reactive protein decision algorithms, with a specific focus on potential age group differences.
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Affiliation(s)
- Siri Aas Smedemark
- Department of Geriatric Medicine, Odense University Hospital, Odense, Denmark
- Geriatric Research Unit, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Rune Aabenhus
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Carl Llor
- University Institute in Primary Care Research Jordi Gol, Via Roma Health Centre, Barcelona, Spain
- Research Unit of General Practice, Department of Public Health, General Practice, University of Southern Denmark, Odense, Denmark
| | - Anders Fournaise
- Department of Geriatric Medicine, Odense University Hospital, Odense, Denmark
- Geriatric Research Unit, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Cross-sectoral Collaboration, Region of Southern Denmark, Vejle, Denmark
- Epidemiology, Biostatistics and Biodemography, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Ole Olsen
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
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Li X, Bilcke J, van der Velden AW, Bruyndonckx R, Coenen S, Bongard E, de Paor M, Chlabicz S, Godycki-Cwirko M, Francis N, Aabenhus R, Bucher HC, Colliers A, De Sutter A, Garcia-Sangenis A, Glinz D, Harbin NJ, Kosiek K, Lindbæk M, Lionis C, Llor C, Mikó-Pauer R, Radzeviciene Jurgute R, Seifert B, Sundvall PD, Touboul Lundgren P, Tsakountakis N, Verheij TJ, Goossens H, Butler CC, Beutels P. Cost-effectiveness of adding oseltamivir to primary care for influenza-like-illness: economic evaluation alongside the randomised controlled ALIC 4E trial in 15 European countries. Eur J Health Econ 2022:10.1007/s10198-022-01521-2. [PMID: 36131214 DOI: 10.1007/s10198-022-01521-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 08/23/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Oseltamivir is usually not often prescribed (or reimbursed) for non-high-risk patients consulting for influenza-like-illness (ILI) in primary care in Europe. We aimed to evaluate the cost-effectiveness of adding oseltamivir to usual primary care in adults/adolescents (13 years +) and children with ILI during seasonal influenza epidemics, using data collected in an open-label, multi-season, randomised controlled trial of oseltamivir in 15 European countries. METHODS Direct and indirect cost estimates were based on patient reported resource use and official country-specific unit costs. Health-Related Quality of Life was assessed by EQ-5D questionnaires. Costs and quality adjusted life-years (QALY) were bootstrapped (N = 10,000) to estimate incremental cost-effectiveness ratios (ICER), from both the healthcare payers' and the societal perspectives, with uncertainty expressed through probabilistic sensitivity analysis and expected value for perfect information (EVPI) analysis. Additionally, scenario (self-reported spending), comorbidities subgroup and country-specific analyses were performed. RESULTS The healthcare payers' expected ICERs of oseltamivir were €22,459 per QALY gained in adults/adolescents and €13,001 in children. From the societal perspective, oseltamivir was cost-saving in adults/adolescents, but the ICER is €8,344 in children. Large uncertainties were observed in subgroups with comorbidities, especially for children. The expected ICERs and extent of decision uncertainty varied between countries (EVPI ranged €1-€35 per patient). CONCLUSION Adding oseltamivir to primary usual care in Europe is likely to be cost-effective for treating adults/adolescents and children with ILI from the healthcare payers' perspective (if willingness-to-pay per QALY gained > €22,459) and cost-saving in adults/adolescents from a societal perspective.
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Affiliation(s)
- Xiao Li
- Centre for Health Economics Research and Modelling Infectious Diseases (CHERMID), Vaccine and Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Campus Drie Eiken, room D.S.221, Universiteitsplein 1, 2610, Antwerp, Belgium.
| | - Joke Bilcke
- Centre for Health Economics Research and Modelling Infectious Diseases (CHERMID), Vaccine and Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Campus Drie Eiken, room D.S.221, Universiteitsplein 1, 2610, Antwerp, Belgium
| | - Alike W van der Velden
- Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht, The Netherlands
| | - Robin Bruyndonckx
- Interuniversity Institute for Biostatistics and Statistical Bioinformatics (I-BIOSTAT), Data Science Institute (DSI), Hasselt University, Hasselt, Belgium
- Laboratory of Medical Microbiology, Vaccine and Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium
| | - Samuel Coenen
- Laboratory of Medical Microbiology, Vaccine and Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium
- Department of Family Medicine and Population Health (FAMPOP), University of Antwerp, Antwerp, Belgium
| | - Emily Bongard
- The Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Muirrean de Paor
- RCSI Department of General Practice, 123 St Stephens Green, Dublin 2, Ireland
| | - Slawomir Chlabicz
- Department of Family Medicine, Medical University of Bialystok, Białystok, Poland
| | | | - Nick Francis
- School of Primary Care, Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Rune Aabenhus
- Section and Research Unit of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Heiner C Bucher
- Division of Infectious Diseases and Hospital Hygiene, Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Basel, Switzerland
| | - Annelies Colliers
- Department of Family Medicine and Population Health (FAMPOP), University of Antwerp, Antwerp, Belgium
| | - An De Sutter
- Department of Public Health and Primary Care (Centre for Family Medicine), Gent University, Gent, Belgium
| | - Ana Garcia-Sangenis
- University Institute in Primary Care Research Jordi Gol, Via Roma Health Centre, Barcelona, Spain
| | - Dominik Glinz
- Department of Clinical Research, Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Basel, Switzerland
| | - Nicolay J Harbin
- Department of General Practice, Antibiotic Center for Primary Care, Institute of Health and Society, University of Oslo, Oslo, Norway
| | | | - Morten Lindbæk
- Research Leader Antibiotic Centre for Primary Care, Department of General Practice, University of Oslo, Oslo, Norway
| | - Christos Lionis
- General Practice and Primary Health Care at the School of Medicine, University of Crete, Crete, Greece
| | - Carl Llor
- University Institute in Primary Care Research Jordi Gol, Via Roma Health Centre, Barcelona, Spain
- Research Unit for General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | | | | | - Bohumil Seifert
- Institute of General Practice, First Faculty of Medicine, Charles University in Prague, Prague, Czech Republic
| | - Pär-Daniel Sundvall
- General Practice/Family Medicine, School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Research, Education, Development and Innovation, Primary Health Care, Region Västra Götaland, Sandared, Sweden
| | | | | | - Theo J Verheij
- Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht, The Netherlands
| | - Herman Goossens
- Department of Family Medicine and Population Health (FAMPOP), University of Antwerp, Antwerp, Belgium
| | - Christopher C Butler
- The Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Philippe Beutels
- Centre for Health Economics Research and Modelling Infectious Diseases (CHERMID), Vaccine and Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Campus Drie Eiken, room D.S.221, Universiteitsplein 1, 2610, Antwerp, Belgium
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Ouchi D, García-Sangenís A, Moragas A, van der Velden AW, Verheij TJ, Butler CC, Bongard E, Coenen S, Cook J, Francis NA, Godycki-Cwirko M, Lundgren PT, Lionis C, Radzeviciene Jurgute R, Chlabicz S, De Sutter A, Bucher HC, Seifert B, Kovács B, de Paor M, Sundvall PD, Aabenhus R, Harbin NJ, Ieven G, Goossens H, Lindbæk M, Bjerrum L, Llor C. Clinical prediction of laboratory-confirmed influenza in adults with influenza-like illness in primary care. A randomized controlled trial secondary analysis in 15 European countries. Fam Pract 2022; 39:398-405. [PMID: 34611715 DOI: 10.1093/fampra/cmab122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Clinical findings do not accurately predict laboratory diagnosis of influenza. Early identification of influenza is considered useful for proper management decisions in primary care. OBJECTIVE We evaluated the diagnostic value of the presence and the severity of symptoms for the diagnosis of laboratory-confirmed influenza infection among adults presenting with influenza-like illness (ILI) in primary care. METHODS Secondary analysis of patients with ILI who participated in a clinical trial from 2015 to 2018 in 15 European countries. Patients rated signs and symptoms as absent, minor, moderate, or major problem. A nasopharyngeal swab was taken for microbiological identification of influenza and other microorganisms. Models were generated considering (i) the presence of individual symptoms and (ii) the severity rating of symptoms. RESULTS A total of 2,639 patients aged 18 or older were included in the analysis. The mean age was 41.8 ± 14.7 years, and 1,099 were men (42.1%). Influenza was microbiologically confirmed in 1,337 patients (51.1%). The area under the curve (AUC) of the model for the presence of any of seven symptoms for detecting influenza was 0.66 (95% confidence interval [CI]: 0.65-0.68), whereas the AUC of the symptom severity model, which included eight variables-cough, fever, muscle aches, sweating and/or chills, moderate to severe overall disease, age, abdominal pain, and sore throat-was 0.70 (95% CI: 0.69-0.72). CONCLUSION Clinical prediction of microbiologically confirmed influenza in adults with ILI is slightly more accurate when based on patient reported symptom severity than when based on the presence or absence of symptoms.
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Affiliation(s)
- Dan Ouchi
- University Institute in Primary Care Research Jordi Gol i Gurina, Barcelona, Spain.,Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Spain
| | - Ana García-Sangenís
- University Institute in Primary Care Research Jordi Gol i Gurina, Barcelona, Spain
| | - Ana Moragas
- University Institute in Primary Care Research Jordi Gol i Gurina, Barcelona, Spain
| | - Alike W van der Velden
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands
| | - Theo J Verheij
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands
| | - Christopher C Butler
- Nuffield Department of Primary Health Care Sciences, University of Oxford, Oxford, United Kingdom
| | - Emily Bongard
- Nuffield Department of Primary Health Care Sciences, University of Oxford, Oxford, United Kingdom
| | - Samuel Coenen
- Centre for General Practice, Department of Family Medicine & Population Health, University of Antwerp, Antwerp, Belgium
| | - Johanna Cook
- Nuffield Department of Primary Health Care Sciences, University of Oxford, Oxford, United Kingdom
| | - Nick A Francis
- Primary Care Research Centre, University of Southampton, Southampton,United Kingdom
| | - Maciek Godycki-Cwirko
- Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Lodz, Lodz, Poland
| | - Pia Touboul Lundgren
- Département de Santé Publique, Université Côte d'Azur, Centre Hospitalier Universitaire de Nice, Nice, France
| | - Christos Lionis
- Clinic of Social and Family Medicine, Faculty of Medicine, University of Crete, Crete, Greece
| | | | - Sławomir Chlabicz
- Department of Family Medicine, Medical University of Bialystok, Bialystok, Poland
| | - An De Sutter
- Centre for Family Medicine UGent, Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Heiner C Bucher
- Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Bohumil Seifert
- Department of General Practice, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | | | - Muireann de Paor
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland (RCSI), Health Research Board Primary Care Clinical Trial Network Ireland, National University of Ireland Galway, Galway, Ireland
| | - Pär-Daniel Sundvall
- Research, Education, Development & Innovation Primary Health Care, Region Västra Götaland and Institute of Medicine, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
| | - Rune Aabenhus
- Section and Research Unit of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Nicolay Jonassen Harbin
- Antibiotic Centre for Primary Care, Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Greet Ieven
- Laboratory of Clinical Microbiology, Antwerp, University Hospital, Edegem, Belgium
| | - Herman Goossens
- Laboratory of Clinical Microbiology, Antwerp, University Hospital, Edegem, Belgium
| | - Morten Lindbæk
- Antibiotic Centre for Primary Care, Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Lars Bjerrum
- Section and Research Unit of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Carl Llor
- University Institute in Primary Care Research Jordi Gol i Gurina, Barcelona, Spain.,Department of Public Health, General Practice, University of Southern Denmark, Odense, Denmark
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Holm A, Møller A, Aabenhus R. Management of symptomatic patients with suspected mild-moderate COVID-19 in general practice. What was published within the first year of the pandemic? A scoping review. Eur J Gen Pract 2021; 27:339-345. [PMID: 34789061 PMCID: PMC8604528 DOI: 10.1080/13814788.2021.2002295] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Most COVID-19 patients experience a mild course of the disease and can be managed in general practice. However, in the early pandemic, most research was conducted in secondary care. OBJECTIVES This scoping review aimed to identify original research published within the first year of the pandemic relevant to general practice regarding symptomatic, non-hospitalised patients with mild to moderate COVID-19 disease to provide an overview of published research. METHODS PubMed was searched for studies written in English, Swedish, Danish, or Norwegian published before 1 April 2021. Two authors screened all titles and abstracts and identified full texts. RESULTS We screened 1303 titles and abstracts and retrieved 128 full texts. An additional 44 full-texts were obtained from references. After full-text reading, 79 articles were included, six of which were conducted in general practice, 20 in the community, 42 in hospitals, and 11 in other settings. Therapy and harm were investigated in randomised controlled trials in 11 out of 17 studies; the diagnosis was investigated using a diagnostic accuracy design in four out of 26 studies and prognosis in prospective studies in 10 out of 21 studies. The remaining 15 studies had other research questions. CONCLUSION Although general practitioners in most countries must have been involved in managing patients with COVID-19, little research has been published from general practice during the first year of the pandemic. General practice research environments must be able to respond quickly in case of future pandemics.
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Affiliation(s)
- Anne Holm
- Research Unit for General Practice, Department of General Practice, University of Copenhagen, Copenhagen, Denmark
| | - Anne Møller
- Research Unit for General Practice, Department of General Practice, University of Copenhagen, Copenhagen, Denmark
| | - Rune Aabenhus
- Research Unit for General Practice, Department of General Practice, University of Copenhagen, Copenhagen, Denmark
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Butler CC, van der Velden AW, Bongard E, Saville BR, Holmes J, Coenen S, Cook J, Francis NA, Lewis RJ, Godycki-Cwirko M, Llor C, Chlabicz S, Lionis C, Seifert B, Sundvall PD, Colliers A, Aabenhus R, Bjerrum L, Jonassen Harbin N, Lindbæk M, Glinz D, Bucher HC, Kovács B, Radzeviciene Jurgute R, Touboul Lundgren P, Little P, Murphy AW, De Sutter A, Openshaw P, de Jong MD, Connor JT, Matheeussen V, Ieven M, Goossens H, Verheij TJ. Oseltamivir plus usual care versus usual care for influenza-like illness in primary care: an open-label, pragmatic, randomised controlled trial. Lancet 2020; 395:42-52. [PMID: 31839279 DOI: 10.1016/s0140-6736(19)32982-4] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Revised: 11/06/2019] [Accepted: 11/08/2019] [Indexed: 12/25/2022]
Abstract
BACKGROUND Antivirals are infrequently prescribed in European primary care for influenza-like illness, mostly because of perceived ineffectiveness in real world primary care and because individuals who will especially benefit have not been identified in independent trials. We aimed to determine whether adding antiviral treatment to usual primary care for patients with influenza-like illness reduces time to recovery overall and in key subgroups. METHODS We did an open-label, pragmatic, adaptive, randomised controlled trial of adding oseltamivir to usual care in patients aged 1 year and older presenting with influenza-like illness in primary care. The primary endpoint was time to recovery, defined as return to usual activities, with fever, headache, and muscle ache minor or absent. The trial was designed and powered to assess oseltamivir benefit overall and in 36 prespecified subgroups defined by age, comorbidity, previous symptom duration, and symptom severity, using a Bayesian piece-wise exponential primary analysis model. The trial is registered with the ISRCTN Registry, number ISRCTN 27908921. FINDINGS Between Jan 15, 2016, and April 12, 2018, we recruited 3266 participants in 15 European countries during three seasonal influenza seasons, allocated 1629 to usual care plus oseltamivir and 1637 to usual care, and ascertained the primary outcome in 1533 (94%) and 1526 (93%). 1590 (52%) of 3059 participants had PCR-confirmed influenza infection. Time to recovery was shorter in participants randomly assigned to oseltamivir (hazard ratio 1·29, 95% Bayesian credible interval [BCrI] 1·20-1·39) overall and in 30 of the 36 prespecified subgroups, with estimated hazard ratios ranging from 1·13 to 1·72. The estimated absolute mean benefit from oseltamivir was 1·02 days (95% [BCrI] 0·74-1·31) overall, and in the prespecified subgroups, ranged from 0·70 (95% BCrI 0·30-1·20) in patients younger than 12 years, with less severe symptoms, no comorbidities, and shorter previous illness duration to 3·20 (95% BCrI 1·00-5·50) in patients aged 65 years or older who had more severe illness, comorbidities, and longer previous illness duration. Regarding harms, an increased burden of vomiting or nausea was observed in the oseltamivir group. INTERPRETATION Primary care patients with influenza-like illness treated with oseltamivir recovered one day sooner on average than those managed by usual care alone. Older, sicker patients with comorbidities and longer previous symptom duration recovered 2-3 days sooner. FUNDING European Commission's Seventh Framework Programme.
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Affiliation(s)
| | - Alike W van der Velden
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands
| | - Emily Bongard
- Department of Primary Care Health Services, University of Oxford, Oxford, UK
| | - Benjamin R Saville
- Berry Consultants, Austin, Texas; Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Jane Holmes
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Samuel Coenen
- Centre for General Practice, Department of Primary and Interdisciplinary Care, University of Antwerp, Antwerp, Belgium
| | - Johanna Cook
- Department of Primary Care Health Services, University of Oxford, Oxford, UK
| | - Nick A Francis
- Primary Care and Population Sciences, University of Southampton, Southampton, UK
| | - Roger J Lewis
- Harbor-UCLA Medical Center, Torrance, CA, USA; David Geffen School of Medicine at UCLA, Los Angeles, CA, USA; Berry Consultants, Austin, TX, USA
| | - Maciek Godycki-Cwirko
- Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Lodz, Lodz, Poland
| | - Carl Llor
- University Institute in Primary Care Research Jordi Gol, Via Roma Health Centre, Barcelona, Spain
| | - Sławomir Chlabicz
- Department of Family Medicine, Medical University of Bialystok, Bialystok, Poland
| | - Christos Lionis
- Clinic of Social and Family Medicine, Faculty of Medicine, University of Crete, Crete, Greece
| | - Bohumil Seifert
- Department of General Practice, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Pär-Daniel Sundvall
- Research and Development Primary Health Care-Region Västra Götaland, Institute of Medicine, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
| | - Annelies Colliers
- Centre for General Practice, Department of Primary and Interdisciplinary Care, University of Antwerp, Antwerp, Belgium
| | - Rune Aabenhus
- Section and Research Unit of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Lars Bjerrum
- Section and Research Unit of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Nicolay Jonassen Harbin
- Antibiotic Center for Primary Care, Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Morten Lindbæk
- Antibiotic Center for Primary Care, Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Dominik Glinz
- Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Heiner C Bucher
- Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University Hospital Basel and University of Basel, Basel, Switzerland
| | | | | | - Pia Touboul Lundgren
- Département de Santé Publique, Université Côte d'Azur, Centre Hospitalier Universitaire de Nice, Nice, France
| | - Paul Little
- Primary Care and Population Sciences, University of Southampton, Southampton, UK
| | - Andrew W Murphy
- Health Research Board Primary Care Clinical Trial Network Ireland, National University of Ireland Galway, Galway, Ireland
| | - An De Sutter
- Center for Family Medicine UGent, Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Peter Openshaw
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Menno D de Jong
- Department of Medical Microbiology, Amsterdam UMC, University of Amsterdam, Netherlands
| | - Jason T Connor
- ConfluenceStat, Orlando, FL, USA; College of Medicine, University of Central Florida, Orlando, FL, USA
| | - Veerle Matheeussen
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute, University of Antwerp, Antwerp, Belgium; Laboratory of Clinical Microbiology, Antwerp University Hospital, Edegem, Belgium
| | - Margareta Ieven
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute, University of Antwerp, Antwerp, Belgium; Laboratory of Clinical Microbiology, Antwerp University Hospital, Edegem, Belgium
| | - Herman Goossens
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute, University of Antwerp, Antwerp, Belgium; Laboratory of Clinical Microbiology, Antwerp University Hospital, Edegem, Belgium
| | - Theo J Verheij
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands
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Rozing MP, Møller A, Aabenhus R, Siersma V, Rasmussen K, Køster-Rasmussen R. Changes in HbA1c during the first six years after the diagnosis of Type 2 diabetes mellitus predict long-term microvascular outcomes. PLoS One 2019; 14:e0225230. [PMID: 31774849 PMCID: PMC6881005 DOI: 10.1371/journal.pone.0225230] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 10/30/2019] [Indexed: 12/25/2022] Open
Abstract
To analyze the association between change in HbA1c during the first 6 years after diagnosis of Type 2 diabetes mellitus (Type 2 DM) and incident micro- and macrovascular morbidity and mortality during 13 years thereafter. This is an observational study of the participants in the intervention arm of the randomized controlled trial Diabetes Care in General Practice (DCGP) in Denmark. 494 newly diagnosed persons with Type 2 DM aged 40 years and over with three or more measurements of HbA1c during six years of intervention were included in the analyses. Based on a regression line, fitted through the HbA1c-measurements from 1 to 6 years after diabetes diagnosis, glycaemic control was characterized by the one-year level of HbA1c after diagnosis, and the slope of the regression line. Outcomes were incident diabetes-related morbidity and mortality from 6 to 19 years after diabetes diagnosis. The association between change in HbA1c (the slope of the regression line) and clinical outcomes were assessed in adjusted Cox regression models. The median HbA1c level at year one was 60 (IQR: 52–71) mmol/mol or (7.65 (IQR: 6.91–8.62) %). Higher HbA1c levels one year after diagnosis were associated with a higher risk of later diabetes-related morbidity and mortality. An increase in HbA1c during the first 6 years after diabetes diagnosis was associated with later microvascular complications (HR per 1.1 mmol/mol or 0.1% point increase in HbA1c per year; 95% CI) = 1.14; 1.05–1.24). Change in HbA1c did not predict the aggregate outcome ‘any diabetes-related endpoint, all-cause mortality, diabetes-related mortality, myocardial infarction, stroke, or peripheral vascular diseases. We conclude that suboptimal development of glycaemic control during the first 6 years after diabetes diagnosis was an independent risk factor for microvascular complications during the succeeding 13-year follow-up, but not for mortality or macrovascular complications.
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Affiliation(s)
- Maarten P. Rozing
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
- * E-mail:
| | - Anne Møller
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Rune Aabenhus
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Volkert Siersma
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Katja Rasmussen
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Rasmus Køster-Rasmussen
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
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Aabenhus R, Vøhtz C, Køster-Rasmussen R. [Genomic medicine in primary care]. Ugeskr Laeger 2019; 181:V11180754. [PMID: 30950378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Genomic medicine holds promise as a potential important novel tool in primary care. However, the current evidence basis regarding pharmogenetics and genetic risk estimates and the trade-off between benefits and harm of introducing genomic medicine in present day primary care is low. More research into this new area is warranted. Also training of general practitioners in correct use and interpretation of genetic testing is needed to ensure successful implementation.
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Abstract
OBJECTIVE The aim of this study was to describe and characterize the prescription of antibiotics for urinary tract infection (UTI) in general practice in Denmark and to evaluate compliance with current recommendations. DESIGN National registry-based study Setting: Danish general practice Patients: 267.539 patients who redeemed a prescription for antibiotics with the clinical indication UTI at community pharmacies between July 1st 2012 and June 31st 2013. MAIN OUTCOME MEASURES Antibiotics prescribed for 1) acute lower UTI, 2) acute upper UTI and 3) recurrent UTI presented as amount of prescriptions, number of treatments per 1000 inhabitants per day (TID) and defined daily doses per 1000 inhabitants per day (DID). RESULTS A total of 507.532 prescriptions were issued to 267.539 patients during the one year study period, representing 2.35 DID. Acute lower UTI was the most common reason for prescription of antibiotics (89.5%) followed by recurrent UTI (8.4%). The majority of the prescriptions were issued to people above 60 year old (57.6%). Pivmecillinam was the most commonly prescribed antibiotic in acute lower (45.8%) and acute upper (63.3%) UTI. Trimethroprim was the most commonly prescribed antibiotic in recurrent UTI (45.9%). Prescription of quinolones increased with increasing patient-age (p = <.0001). CONCLUSION Compliance with current Danish recommendations was moderately high. Pivmecillinam is the first line antibiotic for the management of acute lower and upper UTI, and trimethroprim is the first line option of recurrent UTI. A high proportion of the antibiotic prescriptions were issued in the elderly population including a relatively high prescription rate of quinolones. Key points Urinary tract infection (UTI) is a common cause for prescription of antibiotics in general practice Poor compliance in general practice with recommendations for first-line treatment of UTI may increase antibiotic resistance Danish general practitioners are generally compliant with national and regional guidelines for antibiotic treatment of UTI There is high use of antibiotics in the elderly population including a worrisome high use of broad-spectrum antibiotics, such as Quinolones.
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Affiliation(s)
- Anne Holm
- Research Unit for General practice and Department of General Practice, University of Copenhagen, Copenhagen, Denmark
- CONTACT Anne Holm Department of General Practice, University of Copenhagen, Øster Farimagsgade 5, PO box 2099, 1014Copenhagen, Denmark
| | - Gloria Cordoba
- Research Unit for General practice and Department of General Practice, University of Copenhagen, Copenhagen, Denmark
| | - Rune Aabenhus
- Research Unit for General practice and Department of General Practice, University of Copenhagen, Copenhagen, Denmark
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Bordado Sköld M, Aabenhus R, Guassora AD, Mäkelä M. Antibiotic treatment failure when consulting patients with respiratory tract infections in general practice. A qualitative study to explore Danish general practitioners' perspectives. Eur J Gen Pract 2018; 23:120-127. [PMID: 28394180 PMCID: PMC5774263 DOI: 10.1080/13814788.2017.1305105] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Prescribing antibiotics for acute respiratory tract infections (RTIs) is common in primary healthcare although most of these infections are of viral origin and antibiotics may not be helpful. Some of these prescriptions will not be associated with a quick recovery, and might be regarded as cases of antibiotic treatment failure (ATF). OBJECTIVES We studied antibiotic treatment failure in patients with acute RTIs from a general practitioner (GP) perspective, aiming to explore (i) GPs' views of ATF in primary care; (ii) how ATF influences the doctor-patient relationship; and (iii) GPs' understanding of patients' views of ATF. METHODS Qualitative study based on semi-structured, recorded interviews of 18 GPs between August and October 2012. The interviews started with discussion of a unique case of acute RTI involving ATF, followed by a more general reflection of the topic. Interviews were analysed using qualitative content analysis. RESULTS In patients with acute RTIs, GPs proposed and agreed to a medical definition of antibiotic treatment failure but believed patients' views to differ significantly from this medical definition. GPs thought ATF affected their daily work only marginally. GPs used many communicative tools to maintain trust with patients in cases of ATF, but they did not consider such incidents to affect the doctor-patient relationship adversely. CONCLUSION These findings suggest a possible communication gap between doctors and patients, partly due to a narrow medical definition of ATF. Studies describing patients' views are still missing. General practitioners' experiences and views on antibiotic treatment failure in acute respiratory infections or its effects on the doctor-patient relationship have not been studied previously.
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Affiliation(s)
- Margrethe Bordado Sköld
- a Center for Education and Research in General Practice, Department of Public Health, Faculty of Health Sciences , University of Copenhagen , Copenhagen , Denmark
| | - Rune Aabenhus
- a Center for Education and Research in General Practice, Department of Public Health, Faculty of Health Sciences , University of Copenhagen , Copenhagen , Denmark
| | - Ann Dorrit Guassora
- a Center for Education and Research in General Practice, Department of Public Health, Faculty of Health Sciences , University of Copenhagen , Copenhagen , Denmark
| | - Marjukka Mäkelä
- a Center for Education and Research in General Practice, Department of Public Health, Faculty of Health Sciences , University of Copenhagen , Copenhagen , Denmark.,b Finnish Office for Health Technology Assessment (FINOHTA) , THL (National Institute for Health and Welfare) , Helsinki , Finland
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12
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Aabenhus R, Siersma V, Sandholdt H, Køster-Rasmussen R, Hansen MP, Bjerrum L. Identifying practice-related factors for high-volume prescribers of antibiotics in Danish general practice. J Antimicrob Chemother 2018; 72:2385-2391. [PMID: 28430992 DOI: 10.1093/jac/dkx115] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Accepted: 03/17/2017] [Indexed: 11/12/2022] Open
Abstract
Objectives In Denmark, general practice is responsible for 75% of antibiotic prescribing in the primary care sector. We aimed to identify practice-related factors associated with high prescribers, including prescribers of critically important antibiotics as defined by WHO, after accounting for case mix by practice. Methods We performed a nationwide register-based survey of antibiotic prescribing in Danish general practice from 2012 to 2013. The unit of analysis was the individual practice. We used multivariable regression analyses and an assessment of relative importance to identify practice-related factors driving high antibiotic prescribing rates. Results We included 98% of general practices in Denmark ( n = 1962) and identified a 10% group of high prescribers who accounted for 15% of total antibiotic prescriptions and 18% of critically important antibiotic prescriptions. Once case mix had been accounted for, the following practice-related factors were associated with being a high prescriber: lack of access to diagnostic tests in practice (C-reactive protein and urine culture); high use of diagnostic tests (urine culture and strep A throat test); a low percentage of antibiotic prescriptions issued over the phone compared with all antibiotic prescriptions; and a high number of consultations per 1000 patients. We also found that a low number of consultations per 1000 patients was associated with a reduced likelihood of being a high prescriber of antibiotics. Conclusions An apparent underuse or overuse of diagnostic tests in general practice as well as organizational factors were associated with high-prescribing practices. Furthermore, the choice of antibiotic type seemed less rational among high prescribers.
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Affiliation(s)
- Rune Aabenhus
- Research Unit of General Practice and Section of General Practice, Institute of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Volkert Siersma
- Research Unit of General Practice and Section of General Practice, Institute of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Håkon Sandholdt
- Research Unit of General Practice and Section of General Practice, Institute of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Rasmus Køster-Rasmussen
- Research Unit of General Practice and Section of General Practice, Institute of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Malene Plejdrup Hansen
- Research Unit of General Practice and Section of General Practice, Institute of Public Health, University of Copenhagen, Copenhagen, Denmark.,Research Unit of General Practice in Aalborg, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Lars Bjerrum
- Research Unit of General Practice and Section of General Practice, Institute of Public Health, University of Copenhagen, Copenhagen, Denmark
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Aabenhus R, Hansen MP, Siersma V, Bjerrum L. Clinical indications for antibiotic use in Danish general practice: results from a nationwide electronic prescription database. Scand J Prim Health Care 2017; 35:162-169. [PMID: 28585886 PMCID: PMC5499316 DOI: 10.1080/02813432.2017.1333321] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/30/2022] Open
Abstract
OBJECTIVE To assess the availability and applicability of clinical indications from electronic prescriptions on antibiotic use in Danish general practice. DESIGN Retrospective cohort register-based study including the Danish National Prescription Register. SETTING Population-based study of routine electronic antibiotic prescriptions from Danish general practice. SUBJECTS All 975,626 patients who redeemed an antibiotic prescription at outpatient pharmacies during the 1-year study period (July 2012 to June 2013). MAIN OUTCOME MEASURES Number of prescriptions per clinical indication. Number of antibiotic prescriptions per 1000 inhabitants by age and gender. Logistic regression analysis estimated the association between patient and provider factors and missing clinical indications on antibiotic prescriptions. RESULTS A total of 2.381.083 systemic antibiotic prescriptions were issued by Danish general practitioners in the study period. We identified three main clinical entities: urinary tract infections (n = 506.634), respiratory tract infections (n = 456.354) and unspecified infections (n = 416.354). Women were more exposed to antibiotics than men. Antibiotic use was high in children under 5 years and even higher in elderly people. In 32% of the issued prescriptions, the clinical indication was missing. This was mainly associated with antibiotic types. We found that a prescription for a urinary tract agent without a specific clinical indication was uncommon. CONCLUSION Clinical indications from electronic prescriptions are accessible and available to provide an overview of drug use, in casu antibiotic prescriptions, in Danish general practice. These clinical indications may be further explored in detail to assess rational drug use and congruence with guidelines, but validation and optimisation of the system is preferable.
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Affiliation(s)
- Rune Aabenhus
- The Research Unit for General Practice and Section of General Practice, University of Copenhagen, Copenhagen, Denmark
- CONTACT Rune Aabenhus Specialist in General Practice, The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, 1014 Copenhagen K, Denmark
| | - Malene Plejdrup Hansen
- The Research Unit for General Practice and Section of General Practice, University of Copenhagen, Copenhagen, Denmark
- Research Unit for General Practice and Department of Clinical Medicine, Aalborg University, Denmark
| | - Volkert Siersma
- The Research Unit for General Practice and Section of General Practice, University of Copenhagen, Copenhagen, Denmark
| | - Lars Bjerrum
- The Research Unit for General Practice and Section of General Practice, University of Copenhagen, Copenhagen, Denmark
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Holm A, Aabenhus R. Urine sampling techniques in symptomatic primary-care patients: a diagnostic accuracy review. BMC Fam Pract 2016; 17:72. [PMID: 27278078 PMCID: PMC4898352 DOI: 10.1186/s12875-016-0465-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/19/2015] [Accepted: 05/23/2016] [Indexed: 12/04/2022]
Abstract
Background Choice of urine sampling technique in urinary tract infection may impact diagnostic accuracy and thus lead to possible over- or undertreatment. Currently no evidencebased consensus exists regarding correct sampling technique of urine from women with symptoms of urinary tract infection in primary care. The aim of this study was to determine the accuracy of urine culture from different sampling-techniques in symptomatic non-pregnant women in primary care. Methods A systematic review was conducted by searching Medline and Embase for clinical studies conducted in primary care using a randomized or paired design to compare the result of urine culture obtained with two or more collection techniques in adult, female, non-pregnant patients with symptoms of urinary tract infection. We evaluated quality of the studies and compared accuracy based on dichotomized outcomes. Results We included seven studies investigating urine sampling technique in 1062 symptomatic patients in primary care. Mid-stream-clean-catch had a positive predictive value of 0.79 to 0.95 and a negative predictive value close to 1 compared to sterile techniques. Two randomized controlled trials found no difference in infection rate between mid-stream-clean-catch, mid-stream-urine and random samples. Conclusions At present, no evidence suggests that sampling technique affects the accuracy of the microbiological diagnosis in non-pregnant women with symptoms of urinary tract infection in primary care. However, the evidence presented is in-direct and the difference between mid-stream-clean-catch, mid-stream-urine and random samples remains to be investigated in a paired design to verify the present findings. Electronic supplementary material The online version of this article (doi:10.1186/s12875-016-0465-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Anne Holm
- Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, PO box 2099, 1014, Copenhagen, Denmark.
| | - Rune Aabenhus
- Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, PO box 2099, 1014, Copenhagen, Denmark
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Aabenhus R, Siersma V, Hansen MP, Bjerrum L. Antibiotic prescribing in Danish general practice 2004-13. J Antimicrob Chemother 2016; 71:2286-94. [PMID: 27107098 DOI: 10.1093/jac/dkw117] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Accepted: 03/09/2016] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Antibiotic consumption in the primary care sector is often perceived as synonymous with consumption in general practice despite the fact that few countries stratify the primary care sector by providers' medical specialty. We aimed to characterize and quantify antibiotic use in Danish general practice relative to the entire primary care sector. METHODS This was a registry-based study including all patients who redeemed an antibiotic prescription between July 2004 and June 2013 at a Danish community pharmacy. Antibiotic use was expressed as DDDs and treatments/1000 inhabitants/day (DIDs and TIDs, respectively) and assessed according to antibiotic spectrum (narrow versus broad) and their anatomical therapeutic classification codes in total as well as in six age groups. RESULTS The contribution of general practice to the entire antibiotic use in the primary care sector declined during the study period (TIDs, 79%-75%; DIDs, 77%-73%). Antibiotic use in general practice increased 8% when expressed as DIDs, while a 9% decrease was observed when expressed as TIDs. The use of broad-spectrum agents increased while narrow-spectrum agents decreased. The decline in antibiotic use was most prominent in children aged <5 years, while elderly patients were increasingly prescribed antibiotics. CONCLUSIONS Using the entire primary care sector as a proxy for general practice prescribing is imprecise. Antibiotic use in general practice is at a stable high level, but DID and TID analyses show different trends and both should be applied when detailing changes in antibiotic consumption. While children are prescribed fewer narrow-spectrum agents, the observed increase in the use of broad-spectrum agents is worrisome and should be addressed in future interventions.
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Affiliation(s)
- Rune Aabenhus
- Research Unit of General Practice and Section of General Practice, Institute of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Volkert Siersma
- Research Unit of General Practice and Section of General Practice, Institute of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Malene Plejdrup Hansen
- Research Unit of General Practice, University of Southern Denmark, Odense, Denmark Centre for Research in Evidence-Based Practice, Bond University, Gold Coast, Australia
| | - Lars Bjerrum
- Research Unit of General Practice and Section of General Practice, Institute of Public Health, University of Copenhagen, Copenhagen, Denmark
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Cordoba G, Siersma V, Lopez-Valcarcel B, Bjerrum L, Llor C, Aabenhus R, Makela M. Prescribing style and variation in antibiotic prescriptions for sore throat: cross-sectional study across six countries. BMC Fam Pract 2015; 16:7. [PMID: 25630870 PMCID: PMC4316394 DOI: 10.1186/s12875-015-0224-y] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Accepted: 01/12/2015] [Indexed: 11/18/2022]
Abstract
Background Variation in prescription of antibiotics in primary care can indicate poor clinical practice that contributes to the increase of resistant strains. General Practitioners (GPs), as a professional group, are expected to have a fairly homogeneous prescribing style. In this paper, we describe variation in prescribing style within and across groups of GPs from six countries. Methods Cross-sectional study with the inclusion of 457 GPs and 6394 sore throat patients. We describe variation in prescribing antibiotics for sore throat patients across six countries and assess whether variation in “prescribing style” – understood as a subjective tendency to prescribe – has an important effect on variation in prescription of antibiotics by using the concept of prescribing style as a latent variable in a multivariable model. We report variation as a Median Odds Ratio (MOR) which is the transformation of the random effect variance onto an odds ratio; Thus, MOR = 1 means similar odds or strict homogeneity between GPs’ prescribing style, while a MOR higher than 1 denotes heterogeneity in prescribing style. Results In all countries some GPs always prescribed antibiotics to all their patients, while other GPs never did. After adjusting for patient and GP characteristics, prescribing style in the group of GPs from Russia was about three times more heterogeneous than the prescribing style in the group of GPs from Denmark – Median Odds Ratio (6.8, 95% CI 3.1;8.8) and (2.6, 95% CI 2.2;4.4) respectively. Conclusion Prescribing style is an important source of variation in prescription of antibiotics within and across countries, even after adjusting for patient and GP characteristics. Interventions aimed at influencing the prescribing style of GPs must encompass context-specific actions at the policy-making level alongside GP-targeted interventions to enable GPs to react more objectively to the external demands that are in place when making the decision of prescribing antibiotics or not.
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Affiliation(s)
- Gloria Cordoba
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, ØsterFarimagsgade 5, P. O. Box 2099, DK-1440, Copenhagen, Denmark.
| | - Volkert Siersma
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, ØsterFarimagsgade 5, P. O. Box 2099, DK-1440, Copenhagen, Denmark.
| | - Beatriz Lopez-Valcarcel
- Universityof Las Palmas de Gran Canaria, Campus Universitario de Tafira, Las Palmas de GC, CanaryIslands, Spain.
| | - Lars Bjerrum
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, ØsterFarimagsgade 5, P. O. Box 2099, DK-1440, Copenhagen, Denmark.
| | - Carl Llor
- University Rovira i Virgili, Spanish Society of Family Medicine, Primary Healthcare Centre Jaume I, Tarragona, Spain.
| | - Rune Aabenhus
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, ØsterFarimagsgade 5, P. O. Box 2099, DK-1440, Copenhagen, Denmark.
| | - Marjukka Makela
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, ØsterFarimagsgade 5, P. O. Box 2099, DK-1440, Copenhagen, Denmark. .,Finnish Office for Health Technology Assessment, National Institute for Health and Welfare, Helsinki, Finland.
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Aabenhus R, Jensen JUS, Jørgensen KJ, Hróbjartsson A, Bjerrum L. Biomarkers as point-of-care tests to guide prescription of antibiotics in patients with acute respiratory infections in primary care. Cochrane Database Syst Rev 2014:CD010130. [PMID: 25374293 DOI: 10.1002/14651858.cd010130.pub2] [Citation(s) in RCA: 111] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Background Acute respiratory infections (ARIs) are by far the most common reason for prescribing an antibiotic in primary care, even though the majority of ARIs are of viral or non-severe bacterial aetiology. Unnecessary antibiotic use will, in many cases, not be beneficial to the patients' recovery and expose them to potential side effects. Furthermore, as a causal link exists between antibiotic use and antibiotic resistance, reducing unnecessary antibiotic use is a key factor in controlling this important problem. Antibiotic resistance puts increasing burdens on healthcare services and renders patients at risk of future ineffective treatments, in turn increasing morbidity and mortality from infectious diseases. One strategy aiming to reduce antibiotic use in primary care is the guidance of antibiotic treatment by use of a point-of-care biomarker. A point-of-care biomarker of infection forms part of the acute phase response to acute tissue injury regardless of the aetiology (infection, trauma and inflammation) and may in the correct clinical context be used as a surrogate marker of infection,possibly assisting the doctor in the clinical management of ARIs.Objectives To assess the benefits and harms of point-of-care biomarker tests of infection to guide antibiotic treatment in patients presenting with symptoms of acute respiratory infections in primary care settings regardless of age.Search methods We searched CENTRAL (2013, Issue 12), MEDLINE (1946 to January 2014), EMBASE (2010 to January 2014), CINAHL (1981 to January 2014), Web of Science (1955 to January 2014) and LILACS (1982 to January 2014).Selection criteria We included randomised controlled trials (RCTs) in primary care patients with ARIs that compared use of point-of-care biomarkers with standard of care. We included trials that randomised individual patients as well as trials that randomised clusters of patients(cluster-RCTs).Two review authors independently extracted data on the following outcomes: i) impact on antibiotic use; ii) duration of and recovery from infection; iii) complications including the number of re-consultations, hospitalisations and mortality; iv) patient satisfaction. We assessed the risk of bias of all included trials and applied GRADE. We used random-effects meta-analyses when feasible. We further analysed results with a high level of heterogeneity in pre-specified subgroups of individually and cluster-RCTs.Main results The only point-of-care biomarker of infection currently available to primary care identified in this review was C-reactive protein. We included six trials (3284 participants; 139 children) that evaluated a C-reactive protein point-of-care test. The available information was from trials with a low to moderate risk of bias that address the main objectives of this review.Overall a reduction in the use of antibiotic treatments was found in the C-reactive protein group (631/1685) versus standard of care(785/1599). However, the high level of heterogeneity and the statistically significant test for subgroup differences between the three RCTs and three cluster-RCTs suggest that the results of the meta-analysis on antibiotic use should be interpreted with caution and the pooled effect estimate (risk ratio (RR) 0.78, 95% confidence interval (CI) 0.66 to 0.92; I2 statistic = 68%) may not be meaningful.The observed heterogeneity disappeared in our pre planned subgroup analysis based on study design: RR 0.90, 95% CI 0.80 to 1.02; I2 statistic = 5% for RCTs and RR 0.68, 95% CI 0.61 to 0.75; I2 statistic = 0% for cluster-RCTs, suggesting that this was the cause of the observed heterogeneity.There was no difference between using a C-reactive protein point-of-care test and standard care in clinical recovery (defined as at least substantial improvement at day 7 and 28 or need for re-consultations day 28). However, we noted an increase in hospitalisations in the C-reactive protein group in one study, but this was based on few events and may be a chance finding. No deaths were reported in any of the included studies.We classified the quality of the evidence as moderate according to GRADE due to imprecision of the main effect estimate.Authors' conclusions A point-of-care biomarker (e.g. C-reactive protein) to guide antibiotic treatment of ARIs in primary care can reduce antibiotic use,although the degree of reduction remains uncertain. Used as an adjunct to a doctor's clinical examination this reduction in antibiotic use did not affect patient-reported outcomes, including recovery from and duration of illness.However, a possible increase in hospitalisations is of concern. A more precise effect estimate is needed to assess the costs of the intervention and compare the use of a point-of-care biomarker to other antibiotic-saving strategies.
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Affiliation(s)
- Rune Aabenhus
- Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, Copenhagen, 1014, Denmark. . ;
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Aabenhus R, Thorsen H, Siersma V, Brodersen J. The development and validation of a multidimensional sum-scaling questionnaire to measure patient-reported outcomes in acute respiratory tract infections in primary care: the acute respiratory tract infection questionnaire. Value Health 2013; 16:987-992. [PMID: 24041348 DOI: 10.1016/j.jval.2013.06.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/02/2012] [Revised: 04/16/2013] [Accepted: 06/07/2013] [Indexed: 06/02/2023]
Abstract
OBJECTIVE Patient-reported outcomes are seldom validated measures in clinical trials of acute respiratory tract infections (ARTIs) in primary care. We developed and validated a patient-reported outcome sum-scaling measure to assess the severity and functional impacts of ARTIs. METHODS Qualitative interviews and field testing among adults with an ARTI were conducted to ascertain a high degree of face and content validity of the questionnaire. Subsequently, a draft version of the Acute Respiratory Tract Infection Questionnaire (ARTIQ) was statistically validated by using the partial credit Rasch model to test dimensionality, objectivity, and reliability of items. Test of known groups' validity was conducted by comparing participants with and without an ARTI. RESULTS The final version of the ARTIQ consisted of 38 items covering five dimensions (Physical-upper, Physical-lower, Psychological, Sleep, and Medicine) and five single items. All final dimensions were confirmed to fit the Rasch model, thus enabling sum-scaling of responses. The ARTIQ scores in participants with an ARTI were significantly higher than in those without ARTI (known groups' validity). CONCLUSION A self-administered, multidimensional, sum-scaling questionnaire with high face and content validity and adequate psychometric properties for assessing severity and functional impacts from ARTIs in adults is available to clinical trials and audits in primary care.
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Affiliation(s)
- Rune Aabenhus
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark.
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Østergaard MS, Nantanda R, Tumwine JK, Aabenhus R. Childhood asthma in low income countries: an invisible killer? Prim Care Respir J 2012; 21:214-9. [PMID: 22623048 DOI: 10.4104/pcrj.2012.00038] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Bacterial pneumonia has hitherto been considered the key cause of the high respiratory morbidity and mortality in children under five years of age (under-5s) in low-income countries, while asthma has not been stated as a significant reason. This paper explores the definitions and concepts of pneumonia and asthma/wheezing/bronchiolitis and examines whether asthma in under-5s may be confused with pneumonia. Over-diagnosing of bacterial pneumonia can be suspected from the limited association between clinical pneumonia and confirmatory test results such as chest x-ray and microbiological findings and poor treatment results using antibiotics. Moreover, children diagnosed with recurrent pneumonia in infancy were often later diagnosed with asthma. Recent studies showed a 10-15% prevalence of preschool asthma in low-income countries, although under-5s with long-term cough and difficulty breathing remain undiagnosed. New studies demonstrate that approximately 50% of acutely admitted under-5s diagnosed with pneumonia according to Integrated Management of Childhood Illnesses could be re-diagnosed with asthma or wheezing when using re-defined diagnostic criteria and treatment. It is hypothesised that untreated asthma may contribute to respiratory mortality since respiratory syncytial virus (RSV) is an important cause of respiratory death in childhood, and asthma in under-5s is often exacerbated by viral infections, including RSV. Furthermore, acute respiratory treatment failures were predominantly seen in under-5s without fever, which suggests the diagnosis of asthma/wheezing rather than bacterial pneumonia. Ultimately, underlying asthma may have contributed to malnutrition and fatal bacterial pneumonia. In conclusion, preschool asthma in low-income countries may be significantly under-diagnosed and misdiagnosed as pneumonia, and may be the cause of much morbidity and mortality.
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Affiliation(s)
- Marianne Stubbe Østergaard
- Department of General Practice and Research Unit of General Practice, University of Copenhagen, Copenhagen, Denmark.
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Aabenhus R, Hallas P. [The Danish Health Act and health-care services to undocumented migrants]. Ugeskr Laeger 2012; 174:2216-2219. [PMID: 22992477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Health-care workers may experience uncertainty regarding legal matters when attending to medical needs of undocumented migrants. This paper applies a pragmatic focus when addressing the legal aspects involved in providing health-care services to undocumented migrants with examples from the Danish Health Act and international conventions. The delivery of medical care to vulnerable groups such as pregnant women and children is described.
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Affiliation(s)
- Rune Aabenhus
- Forskningsenheden for Almen Praksis, Center for Sundhed og Samfund, Øster Farimagsgade 5, 1014 København K, Denmark.
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Aabenhus R, Jensen JUS. Procalcitonin-guided antibiotic treatment of respiratory tract infections in a primary care setting: are we there yet? Prim Care Respir J 2012; 20:360-7. [PMID: 21808938 DOI: 10.4104/pcrj.2011.00064] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Clinical signs of infection do not allow for correct identification of bacterial and viral aetiology in acute respiratory infections. A valid tool to assist the clinician in identifying patients who will benefit from antibiotic therapy, as well as patients with a potentially serious infection, could greatly improve patient care and limit excessive antibiotic prescriptions. Procalcitonin is a new marker of suspected bacterial infection that has shown promise in guiding antibiotic therapy in acute respiratory tract infections in hospitals without compromising patient safety. Procalcitonin concentrations in primary care are low and can be used primarily to rule out serious infection. However, procalcitonin measurement should not be used as the sole basis for clinical decisions; clinical skills are prerequisites for the correct use of this new tool in practice. At present there is no point-of-care test for procalcitonin with acceptable precision, severely hampering its application in primary care. This article reviews the physiology of procalcitonin, describes the assays available for its measurement, evaluates the present evidence from primary care on its use to identify correctly patients who are likely to benefit from antibiotic treatment and to rule out serious infections, and comments on further research to determine a future role for procalcitonin in primary care.
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Affiliation(s)
- Rune Aabenhus
- Research Unit for General Practice, University of Copenhagen, Denmark.
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Suppli M, Aabenhus R, Harboe Z, Andersen L, Tvede M, Jensen JUS. Mortality in enterococcal bloodstream infections increases with inappropriate antimicrobial therapy. Clin Microbiol Infect 2011; 17:1078-83. [DOI: 10.1111/j.1469-0691.2010.03394.x] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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Abstract
AIM: To infect mice with atypical Campylobacter concisus (C. concisus) for the first time.
METHODS: Three separate experiments were conducted in order to screen the ability of five clinical C. concisus isolates of intestinal origin and the ATCC 33237 type strain of oral origin to colonize and produce infection in immunocompetent BALB/cA mice. The majority of the BALB/cA mice were treated with cyclophosphamide prior to C. concisus inoculation to suppress immune functions. Inoculation of C. concisus was performed by the gastric route.
RESULTS: C. concisus was isolated from the liver, ileum and jejunum of cyclophosphamide-treated mice in the first experiment. No C. concisus strains were isolated in the two subsequent experiments. Mice infected with C. concisus showed a significant loss of body weight from day two through to day five of infection but this decreased at the end of the first week. Histopathological examination did not consistently find signs of inflammation in the gut, but occasionally microabscesses were found in the liver of infected animals.
CONCLUSION: Transient colonization with C. concisus was observed in mice with loss of body weight. Future studies should concentrate on the first few days after inoculation and in other strains of mice.
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Suppli M, Aabenhus R, Harboe Z, Andersen L, Tvede M, Kirkby N, Jensen J. R2268 Enterococcus bacteraemia: striking high mortality. Int J Antimicrob Agents 2007. [DOI: 10.1016/s0924-8579(07)72107-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Aabenhus R, On SLW, Siemer BL, Permin H, Andersen LP. Delineation of Campylobacter concisus genomospecies by amplified fragment length polymorphism analysis and correlation of results with clinical data. J Clin Microbiol 2005; 43:5091-6. [PMID: 16207968 PMCID: PMC1248439 DOI: 10.1128/jcm.43.10.5091-5096.2005] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Campylobacter concisus has been as frequently isolated from human diarrhea as the important enteropathogen Campylobacter jejuni, but it also occurs in the feces of healthy individuals. The role of C. concisus in human disease has been difficult to determine, since the species comprises at least two phenotypically indistinguishable but genetically distinct taxa (i.e., genomospecies) that may vary in pathogenicity. We examined 62 C. concisus strains by amplified fragment length polymorphism (AFLP) profiling and correlated the results with clinical data. All C. concisus strains gave unique AFLP profiles, and numerical analysis of these data distributed the strains among four clusters. The clustering was of taxonomic significance: two clusters contained, respectively, the type strain (of oral origin) and a reference strain (from diarrhea) of each of the known genomospecies. Genomospecies 2 strains were more frequently isolated from immunocompetent patients and/or patients without concomitant infections that presented with fever, chronic diarrhea, and gut inflammation than was genomospecies 1, clustering with the type strain of oral origin. Bloody diarrhea was recorded only with C. concisus genomospecies 2 infections. We identified two additional C. concisus genomospecies: genomospecies 3 comprised a single strain from an immunocompetent patient, and genomospecies 4 contained five isolates from severely immunodeficient patients, i.e., organ transplantation recipients or those with hematological malignancies. All genomospecies 4 strains were of the same protein profile group and failed to react with a C. concisus species-specific PCR assay based on 23S rRNA gene sequences: the taxonomic position of this group requires closer investigation. Campylobacter concisus is genetically and taxonomically diverse and contains at least four distinct genomospecies that may exhibit differences in their spectra of virulence potential.
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Affiliation(s)
- Rune Aabenhus
- Department of Clinical Microbiology, Rigshospitalet, Copenhagen, Denmark
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Aabenhus R, Permin H, Andersen LP. Characterization and subgrouping of Campylobacter concisus strains using protein profiles, conventional biochemical testing and antibiotic susceptibility. Eur J Gastroenterol Hepatol 2005; 17:1019-24. [PMID: 16148545 DOI: 10.1097/00042737-200510000-00003] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVE To characterize and subgroup clinical strains of Campylobacter concisus isolated from patients with gastrointestinal disease. METHODS A total of 109 C. concisus isolates from 98 patients obtained between June 1997 and December 1998 were analysed using protein profiles, conventional biochemical tube tests, ApiCampy, and susceptibility patterns by Neosensitabs and E-test. RESULTS Two groups were identified by using protein profiles. One resembled the ATCC 33237 type strain of oral origin, and a second group differing from it, particularly in the high molecular weight zone. Considerable diversity exists in the lower molecular range of the gels, also within assigned subgroups. Biochemical testing showed differences between the groups in the ability to reduce nitrate, ApiCampy testing also yielded differences between the two assigned groups, although reactions were highly heterogeneous. Resistance to erythromycin, ciprofloxacin, ampicillin, ceftriaxone and tetracycline occurred in 3%, 13%, 7%, 11% and 0% of the isolates when using Neosensitabs. The E-test yielded comparable results 7%, 5%, 0%, 2% and 3%, respectively. CONCLUSION Results indicate that C. concisus can be assigned to two broad groups based on differences in protein profiles. No distinct phenotypic marker was identified. Susceptibility patterns are not suitable for discrimination between the two assigned groups. Further studies using a polyphasic approach including the application of genetic methods are needed to assess the complex taxonomy of this potential pathogen.
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Affiliation(s)
- Rune Aabenhus
- Department of Clinical Microbiology, National University Hospital (Rigshospitalet), Denmark
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Engberg J, Bang DD, Aabenhus R, Aarestrup FM, Fussing V, Gerner-Smidt P. Campylobacter concisus: an evaluation of certain phenotypic and genotypic characteristics. Clin Microbiol Infect 2005; 11:288-95. [PMID: 15760425 DOI: 10.1111/j.1469-0691.2005.01111.x] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The clinical relevance of Campylobacter concisus in gastrointestinal disease has not been determined definitively. This study investigated the phenotypic and genotypic characteristics of 39 C. concisus isolates from Danish patients with diarrhoea, three isolates from healthy individuals and the type strain. A cytolethal distending toxin (CDT)-like effect on Vero cells was observed in 35 (90%) isolates from patients with diarrhoea, in all three isolates from healthy individuals and in the type strain. Analysis of SDS-PAGE protein profiles and PCR amplification of 23S rDNA assigned the isolates into two distinct, but discordant groups. Automated ribotyping (RiboPrinting) identified 34 distinct patterns among the 43 isolates, but cluster analysis did not separate isolates from patients with diarrhoea from isolates from healthy patients. Random amplified polymorphic DNA (RAPD) analysis with three primers identified 37 unique profiles, but requires further evaluation. The isolates obtained from healthy carriers were distinguished by cluster analysis from the isolates obtained from patients with diarrhoea. All the isolates were susceptible to 11 antimicrobial agents tested. Overall, there was considerable variability between the C. concisus isolates, but there were no clear phenotypic or genotypic differences between isolates from patients with diarrhoea and isolates from healthy carriers. Further evidence is needed to support the possible role of C. concisus as a human enteric pathogen.
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Affiliation(s)
- J Engberg
- Unit of Gastrointestinal Infections, Statens Serum Institut, Copenhagen, Denmark.
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Abstract
The importance of Campylobacter species other than C. jejuni/coli in diarrhoeal disease is largely unknown. We wished to determine the prevalence and clinical presentation of C. concisus infection in patients with enteric disease in a tertiary hospital. Stool specimens were routinely tested for the presence of Campylobacter species, by use of the filter isolation method. The medical records of the C. concisus-positive patients were reviewed. Of 224 Campylobacter isolates obtained, 110 were identified as C. concisus. Concomitant infection occurred in only 27% of cases. By means of protein profiling we assigned C. concisus into 2 groups. The predominant C. concisus group 2 was the only strain to infect immunocompetent patients and children: 71% of the infected patients were immunocompromised, the majority being adults (84%). C. concisus may be a frequent cause of diarrhoea in immunocompromised patients. Two groups of C. concisus were found and these groups possibly vary in their pathogenic potential.
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Affiliation(s)
- Rune Aabenhus
- Department of Infectious Diseases, National University Hospital, Copenhagen, Denmark
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Abstract
A total of 44 clinical isolates and the type strain of the putative pathogen Campylobacter concisus were grouped based on their reactions with plant lectins. The optimized lectin typing system used C. concisus strains proteolytically pretreated and subsequently typed by using a panel of four lectins. The system grouped all 45 strains into 13 lectin reaction patterns, leaving no strain untypeable due to autoagglutination. Lectin types were both stable and reproducible.
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Affiliation(s)
- Rune Aabenhus
- Department of Clinical Microbiology and Infectious Hygiene, National University Hospital, Copenhagen, Denmark
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