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Kornfält Isberg H, Hedin K, Melander E, Mölstad S, Beckman A. Uncomplicated urinary tract infection in primary health care: presentation and clinical outcome. Infect Dis (Lond) 2020; 53:94-101. [PMID: 33073654 DOI: 10.1080/23744235.2020.1834138] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [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: 01/13/2023] Open
Abstract
BACKGROUND Uncomplicated urinary tract infection (UTI) causes bothersome symptoms among women and is a leading cause for antibiotic prescribing in primary healthcare (PHC). METHODS A prospective observational study in eight different PHC centres in Sweden including 192 women with symptoms of uncomplicated UTI. Questionnaires and symptom diaries were used to retrieve patient data. All urine samples were analysed with urine culture and susceptibility testing. The aim was to describe the clinical presentation of symptoms in uncomplicated UTI in relation to bacterial findings in urine and to describe the course and duration of symptoms in relation to anamnestic factors, bacterial findings and antibiotic treatment. RESULTS Median symptom duration before seeking care was four days (IQR 1-7). Restrictions in daily life related to symptoms of uncomplicated UTI were reported by the majority (74%) of respondents. The median number of days concerning any symptom after consultation was 4.0 days (IQR 2.0-5.0) for patients treated with antibiotics, and 6.5 days (IQR 3.0-10.0) for patients not treated with antibiotics. There was an association between longer symptom duration after consultation and age over 50 years, relative risk (RR) 1.76 (95% CI 1.25-2.49). Antibiotic treatment RR 0.47 (95% CI 0.27-0.81) was associated with reported shorter duration of symptoms. CONCLUSIONS Women visiting primary health care with symptoms indicating uncomplicated UTI have symptoms for several days before seeking care and after consulting. A majority of patients feel restricted in their daily activities due to uncomplicated UTI. Older women and women not treated with antibiotics have the longest symptom duration after consultation.
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Affiliation(s)
| | - Katarina Hedin
- Department of Clinical Sciences, Family Medicine Malmö, Lund University, Malmö, Sweden.,Futurum, Jönköping, Sweden.,Department of Health, Medicine and Caring Sciences, Linköping University, Jönköping, Sweden
| | - Eva Melander
- Regional Center for Communicable Disease Control, Malmö, Sweden.,Department of Translational Medicine, Lund University, Malmö, Sweden
| | - Sigvard Mölstad
- Department of Clinical Sciences, Family Medicine Malmö, Lund University, Malmö, Sweden
| | - Anders Beckman
- Department of Clinical Sciences, Family Medicine Malmö, Lund University, Malmö, Sweden
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Kornfält Isberg H, Hedin K, Melander E, Mölstad S, Cronberg O, Engström S, Lindbäck H, Neumark T, Ekman GS, Beckman A. Different antibiotic regimes in men diagnosed with lower urinary tract infection - a retrospective register-based study. Scand J Prim Health Care 2020; 38:291-299. [PMID: 32686974 PMCID: PMC7470089 DOI: 10.1080/02813432.2020.1794409] [Citation(s) in RCA: 4] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVE To compare the proportion of therapy failure, recurrence and complications within 30 days after consultation between men diagnosed with lower urinary tract infection (UTI) treated with narrow-spectrum antibiotics (nitrofurantoin or pivmecillinam) and broad-spectrum antibiotics (fluoroquinolones or trimethoprim or trimethoprim/sulfamethoxazole). DESIGN A retrospective cohort study based on data derived from electronic medical records between January 2012 and December 2015. SETTING Primary health care and hospital care in five different counties in Sweden. Patients: A total of 16,555 men aged between 18 and 79 years diagnosed with lower UTI. MAIN OUTCOME MEASURES Treatment with narrow-spectrum antibiotics was compared with broad-spectrum antibiotics regarding therapy failure, recurrence and complications within 30 days. RESULTS The median age of included men was 65 IQR (51-72) years. Narrow-spectrum antibiotics were prescribed in 8457 (40%) and broad-spectrum antibiotics in 12,667 (60%) cases, respectively. Therapy failure was registered in 192 (0.9%), recurrence in 1277 (6%) and complications in 121 (0.6%) cases. Therapy failure and recurrence were more common in patients treated with narrow-spectrum antibiotics and trimethoprim (p < 0.001), but no such difference could be detected regarding complications. CONCLUSION There was no difference in incidence of complications within 30 days between men treated with narrow- or broad-spectrum antibiotics. Patients prescribed broad-spectrum antibiotics had lower odds of reconsultation because of therapy failure and recurrence. From current data, treatment with narrow-spectrum antibiotics seems to be an optimal choice regarding preventing complications when treating men with lower UTI. KEY POINTS Complications such as pyelonephritis and sepsis are uncommon in men diagnosed with lower urinary tract infection treated with antibiotics. There was no difference in incidence of complications among men diagnosed with lower urinary tract infection treated with narrow- or broad-spectrum antibiotics. In spite of higher incidence of therapy failure and recurrence, treatment with narrow-spectrum antibiotics seems to be an optimal choice regarding preventing complications when treating men diagnosed with lower UTI.
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Affiliation(s)
- Helena Kornfält Isberg
- Department of Clinical Sciences, Family Medicine Malmö, Lund University, Malmö, Sweden
- CONTACT Helena Kornfält Isberg Department of Clinical Sciences, Family Medicine Malmö, Lund University, Malmö, Sweden
| | - Katarina Hedin
- Department of Clinical Sciences, Family Medicine Malmö, Lund University, Malmö, Sweden
- Futurum, Region Jönköping County and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Eva Melander
- Regional Center for Communicable Disease Control, Malmö, Sweden
- Department of Translational Medicine, Lund University, Malmö, Sweden
| | - Sigvard Mölstad
- Department of Clinical Sciences, Family Medicine Malmö, Lund University, Malmö, Sweden
| | - Olof Cronberg
- Department of Clinical Sciences, Family Medicine Malmö, Lund University, Malmö, Sweden
- Department of Research and Development, Region Kronoberg, Växjö, Sweden
| | - Sven Engström
- Futurum, Region Jönköping County and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Heidi Lindbäck
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Thomas Neumark
- Regional Executive Officer's Staff – Coordination of Health Care, Kalmar, Sweden
| | | | - Anders Beckman
- Department of Clinical Sciences, Family Medicine Malmö, Lund University, Malmö, Sweden
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Skoog Ståhlgren G, Tyrstrup M, Edlund C, Giske CG, Mölstad S, Norman C, Rystedt K, Sundvall PD, Hedin K. Penicillin V four times daily for five days versus three times daily for 10 days in patients with pharyngotonsillitis caused by group A streptococci: randomised controlled, open label, non-inferiority study. BMJ 2019; 367:l5337. [PMID: 31585944 PMCID: PMC6776830 DOI: 10.1136/bmj.l5337] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
OBJECTIVE To determine whether total exposure to penicillin V can be reduced while maintaining adequate clinical efficacy when treating pharyngotonsillitis caused by group A streptococci. DESIGN Open label, randomised controlled non-inferiority study. SETTING 17 primary healthcare centres in Sweden between September 2015 and February 2018. PARTICIPANTS Patients aged 6 years and over with pharyngotonsillitis caused by group A streptococci and three or four Centor criteria (fever ≥38.5°C, tender lymph nodes, coatings of the tonsils, and absence of cough). INTERVENTIONS Penicillin V 800 mg four times daily for five days (total 16 g) compared with the current recommended dose of 1000 mg three times daily for 10 days (total 30 g). MAIN OUTCOME MEASURES Primary outcome was clinical cure five to seven days after the end of antibiotic treatment. The non-inferiority margin was prespecified to 10 percentage points. Secondary outcomes were bacteriological eradication, time to relief of symptoms, frequency of relapses, complications and new tonsillitis, and patterns of adverse events. RESULTS Patients (n=433) were randomly allocated to the five day (n=215) or 10 day (n=218) regimen. Clinical cure in the per protocol population was 89.6% (n=181/202) in the five day group and 93.3% (n=182/195) in the 10 day group (95% confidence interval -9.7 to 2.2). Bacteriological eradication was 80.4% (n=156/194) in the five day group and 90.7% (n=165/182) in the 10 day group. Eight and seven patients had relapses, no patients and four patients had complications, and six and 13 patients had new tonsillitis in the five day and 10 day groups, respectively. Time to relief of symptoms was shorter in the five day group. Adverse events were mainly diarrhoea, nausea, and vulvovaginal disorders; the 10 day group had higher incidence and longer duration of adverse events. CONCLUSIONS Penicillin V four times daily for five days was non-inferior in clinical outcome to penicillin V three times daily for 10 days in patients with pharyngotonsillitis caused by group A streptococci. The number of relapses and complications did not differ between the two intervention groups. Five day treatment with penicillin V four times daily might be an alternative to the currently recommended 10 day regimen. TRIAL REGISTRATION EudraCT 2015-001752-30; ClinicalTrials.gov NCT02712307.
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Affiliation(s)
- Gunilla Skoog Ståhlgren
- Unit for Antibiotics and Infection Control, The Public Health Agency of Sweden, SE 171 82 Solna, Sweden
| | - Mia Tyrstrup
- Lundbergsgatan Primary Health Care Centre, Malmö, Sweden
- Department of Clinical Sciences in Malmö, Family Medicine, Lund University, Malmö, Sweden
| | - Charlotta Edlund
- Unit for Antibiotics and Infection Control, The Public Health Agency of Sweden, SE 171 82 Solna, Sweden
| | - Christian G Giske
- Division of Clinical Microbiology, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
- Department of Clinical Microbiology, Karolinska University Hospital, Stockholm, Sweden
| | - Sigvard Mölstad
- Department of Clinical Sciences in Malmö, Family Medicine, Lund University, Malmö, Sweden
| | | | - Karin Rystedt
- Närhälsan Södra Ryd Primary Health Care Center, Skövde, Sweden
- Department of Public Health and Community Medicine/Primary Health Care, Institute of Medicine, Sahlgrenska Academy at the University of Gothenburg, Göteborg, Sweden
| | - Pär-Daniel Sundvall
- Department of Public Health and Community Medicine/Primary Health Care, Institute of Medicine, Sahlgrenska Academy at the University of Gothenburg, Göteborg, Sweden
- Research and Development Primary Health Care, Region Västra Götaland, R & D Center Södra Älvsborg, Borås, Sweden
| | - Katarina Hedin
- Department of Clinical Sciences in Malmö, Family Medicine, Lund University, Malmö, Sweden
- Futurum, Region Jönköping County and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
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Westerlind B, Östgren CJ, Mölstad S, Midlöv P, Hägg S. Use of non-benzodiazepine hypnotics is associated with falls in nursing home residents: a longitudinal cohort study. Aging Clin Exp Res 2019; 31:1087-1095. [PMID: 30341643 DOI: 10.1007/s40520-018-1056-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Accepted: 10/13/2018] [Indexed: 01/25/2023]
Abstract
BACKGROUND Falls and related injuries are common among older people, and several drug classes are considered to increase fall risk. AIMS This study aimed to investigate the association between the use of certain drug classes and falls in older nursing home residents in Sweden, and relate these to different age groups. METHODS Information on falls that occurred in the previous year and regular use of possible fall risk drugs including non-benzodiazepine hypnotics (zopiclone and zolpidem) was collected from 331 nursing home residents during 2008-2011. Over the following 6 months, the occurrence of serious falls, requiring a physician visit or hospital care, was registered. Association between serious falls and drug use was compared between an older (≥ 85 years) and a younger group. RESULTS An increased fall risk (Downton Fall Risk Index ≥ 3) was found in 93% of the study subjects (aged 65-101 years). Baseline data indicated an association between falls that occurred in the previous year and regular use of non-benzodiazepine hypnotics (p = 0.005), but not with the other studied drug classes. During the following 6 months, an association between use of non-benzodiazepine hypnotics and serious falls in the older group (p = 0.017, odds ratio 4.311) was found. No association was found between the other studied drug classes and serious falls. DISCUSSION These results indicate an association between falls and the use of non-benzodiazepine hypnotics, compounds that previously have been considered generally well-tolerated in older people. CONCLUSIONS Caution is advocated when using non-benzodiazepine hypnotics regularly in older people living in nursing homes.
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Kornfält Isberg H, Hedin K, Melander E, Mölstad S, Beckman A. Increased adherence to treatment guidelines in patients with urinary tract infection in primary care: A retrospective study. PLoS One 2019; 14:e0214572. [PMID: 30921411 PMCID: PMC6438509 DOI: 10.1371/journal.pone.0214572] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 03/17/2019] [Indexed: 11/28/2022] Open
Abstract
Background Urinary tract infection (UTI) is common in primary care and leads to a high number of antibiotic prescriptions. Antimicrobial resistance is a global health problem; better antimicrobial prescribing is one way to limit antimicrobial resistance. We aimed to describe the number of consultations for patients diagnosed with lower urinary tract infection (LUTI) and pyelonephritis and changes in prescribing of antibiotics to men and women with LUTI and pyelonephritis in Swedish PHC between the years 2008 and 2013. Methods We performed a descriptive study of changes in UTI diagnosis and antibiotic prescribing in UTI for the years 2008, 2010 and 2013. The Primary Care Record of Infections in Sweden, a database regarding diagnosis linked antibiotic prescribing in primary care, was analyzed concerning data for men and women of all ages regarding UTI visits and antibiotic prescribing. The results were analyzed in relation to current national guidelines. Results There was a variability in consultation incidence for LUTI with an increase between 2008 and 2010 and a decrease between 2010 and 2013, resulting in a slight rise in consultation incidence between 2008 and 2013. The use of recommended nitrofurantoin or pivmecillinam in LUTI in women increased from 54% in 2008 to 69% in 2013. Fluoroquinolones or trimethoprim were prescribed in 24% of LUTI cases in women in 2008 and in 7% of cases in 2013. Prescriptions of pivmecillinam or nitrofurantoin in male LUTI cases increased from 13% in 2008 to 31% in 2013. Fluoroquinolones or trimethoprim were prescribed in 54% of male LUTI cases in 2008 and 32% in 2013. Conclusions Swedish GPs seem to follow national guidelines in the treatment of LUTI in women. In male LUTI cases, the prescriptions of fluoroquinolones remain high and further research is needed to follow prescription patterns and enhance more prudent prescribing to this group of patients.
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Affiliation(s)
- Helena Kornfält Isberg
- Department of Clinical Sciences, Malmö, Family Medicine, Lund University, Malmö, Sweden
- * E-mail:
| | - Katarina Hedin
- Department of Clinical Sciences, Malmö, Family Medicine, Lund University, Malmö, Sweden
- Futurum, Region Jönköping County, Jönköping, Sweden
- Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Eva Melander
- Regional Centre for Communicable Disease Control, Malmö, Sweden
- Department of Translational Medicine, Lund University, Malmö, Sweden
| | - Sigvard Mölstad
- Department of Clinical Sciences, Malmö, Family Medicine, Lund University, Malmö, Sweden
| | - Anders Beckman
- Department of Clinical Sciences, Malmö, Family Medicine, Lund University, Malmö, Sweden
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Kornfält Isberg H, Melander E, Hedin K, Mölstad S, Beckman A. Uncomplicated urinary tract infections in Swedish primary care; etiology, resistance and treatment. BMC Infect Dis 2019; 19:155. [PMID: 30760219 PMCID: PMC6375206 DOI: 10.1186/s12879-019-3785-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [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] [Received: 06/15/2018] [Accepted: 02/06/2019] [Indexed: 11/29/2022] Open
Abstract
Background Uncomplicated urinary tract infection (uUTI) is common and a majority of patients are prescribed antibiotics. There is little knowledge about antibiotic resistance in urine samples from patients with uUTI in primary health care (PHC). The aim was to describe antibiotic treatment, bacterial findings, the prevalence of resistant E.coli and factors associated with antibiotic resistance. The aim was also to compare the prevalence of resistant E.coli in clinical practice with the prevalence of resistant E.coli in routine microbiological laboratory data. Methods This observational study in PHC setting started in November 2014 and ended in March 2016. Women aged 17 years and older with symptoms indicating uUTI from eight PHCs were included. Questionnaires were used to retrieve anamnestic data. All urine samples were sent to the local laboratory of microbiology for diagnostic analysis and susceptibility testing. Proportions of resistant E.coli were compared with corresponding data from the regional laboratory. Results Urine cultures were analysed in 304 women with a median age of 46 (IQR 32–66) years. Bacterial growth was found in 243 (80%) of urine samples, and E.coli in 72% of the positive samples. A total of 80% of detected E.coli isolates were susceptible to all tested antimicrobials and resistance rates to ciprofloxacin were lower than reported from the local clinical laboratory. Antibiotic treatment within the last year was independently associated with antibiotic resistant E.coli in the urine sample adjusted OR 4.97 (95% CI 2.04–12.06). A total of 74% of the women were treated with antibiotics. The most prescribed was pivmecillinam followed by nitrofurantoin. Conclusions Antibiotic resistance in E.coli was low. Antibiotic treatment within the last year was associated with antibiotic resistant E.coli. Data from the clinical microbiology laboratory indicates that laboratory data may overestimate antibiotic resistance and lead to an unnecessary change in empiric antibiotic treatment of uUTI in primary care. The empirically prescribed antibiotics, were inline with Swedish treatment recommendations for uUTI.
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Affiliation(s)
- Helena Kornfält Isberg
- Department of Clinical Sciences, Malmö, Family Medicine, Lund University, Malmö, Sweden.
| | - Eva Melander
- Regional Centre for Communicable Disease Control, Malmö, Sweden.,Department of Translational Medicine, Lund University, Malmö, Sweden
| | - Katarina Hedin
- Department of Clinical Sciences, Malmö, Family Medicine, Lund University, Malmö, Sweden.,Futurum, Region Jönköping County and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Sigvard Mölstad
- Department of Clinical Sciences, Malmö, Family Medicine, Lund University, Malmö, Sweden
| | - Anders Beckman
- Department of Clinical Sciences, Malmö, Family Medicine, Lund University, Malmö, Sweden
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Mölstad S, Löfmark S, Carlin K, Erntell M, Aspevall O, Blad L, Hanberger H, Hedin K, Hellman J, Norman C, Skoog G, Stålsby-Lundborg C, Tegmark Wisell K, Åhrén C, Cars O. Lessons learnt during 20 years of the Swedish strategic programme against antibiotic resistance. Bull World Health Organ 2017; 95:764-773. [PMID: 29147057 PMCID: PMC5677604 DOI: 10.2471/blt.16.184374] [Citation(s) in RCA: 105] [Impact Index Per Article: 15.0] [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: 01/30/2017] [Revised: 07/07/2017] [Accepted: 08/14/2017] [Indexed: 11/27/2022] Open
Abstract
Increasing use of antibiotics and rising levels of bacterial resistance to antibiotics are a challenge to global health and development. Successful initiatives for containing the problem need to be communicated and disseminated. In Sweden, a rapid spread of resistant pneumococci in the southern part of the country triggered the formation of the Swedish strategic programme against antibiotic resistance, also known as Strama, in 1995. The creation of the programme was an important starting point for long-term coordinated efforts to tackle antibiotic resistance in the country. This paper describes the main strategies of the programme: committed work at the local and national levels; monitoring of antibiotic use for informed decision-making; a national target for antibiotic prescriptions; surveillance of antibiotic resistance for local, national and global action; tracking resistance trends; infection control to limit spread of resistance; and communication to raise awareness for action and behavioural change. A key element for achieving long-term changes has been the bottom-up approach, including working closely with prescribers at the local level. The work described here and the lessons learnt could inform countries implementing their own national action plans against antibiotic resistance.
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Affiliation(s)
- Sigvard Mölstad
- Department of Clinical Sciences, Lund University, Jan Waldenströmsg 35, 20502, Malmö, Sweden
| | - Sonja Löfmark
- Department of Monitoring and Evaluation, Public Health Agency of Sweden, Solna, Sweden
| | - Karin Carlin
- Department of Monitoring and Evaluation, Public Health Agency of Sweden, Solna, Sweden
| | - Mats Erntell
- Department of Communicable Disease Control, County of Halland, Halmstad, Sweden
| | - Olov Aspevall
- Department of Monitoring and Evaluation, Public Health Agency of Sweden, Solna, Sweden
| | - Lars Blad
- Department of Communicable Disease Control, County of Värmland, Karlstad, Sweden
| | - Håkan Hanberger
- Division of Infectious Disease, Department of Clinical and Experimental Medicine, Faculty of Medicine, Linköping, Sweden
| | - Katarina Hedin
- Department of Clinical Sciences, General Practice/Family Medicine, Lund University, Malmö, Sweden
| | - Jenny Hellman
- Department of Monitoring and Evaluation, Public Health Agency of Sweden, Solna, Sweden
| | - Christer Norman
- Department of Monitoring and Evaluation, Public Health Agency of Sweden, Solna, Sweden
| | - Gunilla Skoog
- Department of Monitoring and Evaluation, Public Health Agency of Sweden, Solna, Sweden
| | - Cecilia Stålsby-Lundborg
- Global Health Systems and Policy: Medicines, Focusing Antibiotics, Department of Public Health, Stockholm, Sweden
| | | | - Christina Åhrén
- Department of Infectious Diseases, Institution of Biomedicine, Sahlgrenska Academy, Gothenburg, Sweden
| | - Otto Cars
- Department of Monitoring and Evaluation, Public Health Agency of Sweden, Solna, Sweden
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Tyrstrup M, Melander E, Hedin K, Beckman A, Mölstad S. Children with respiratory tract infections in Swedish primary care; prevalence of antibiotic resistance in common respiratory tract pathogens and relation to antibiotic consumption. BMC Infect Dis 2017; 17:603. [PMID: 28870173 PMCID: PMC5583975 DOI: 10.1186/s12879-017-2703-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Accepted: 08/22/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The majority of antibiotics consumed in developed countries are prescribed in primary care. However, little is known about resistance levels in the primary care population. METHOD Nasopharyngeal cultures were obtained from children, 0-10 years of age, seeking care at their Primary Health Care Centre with symptoms of respiratory tract infection. Parental questionnaires were used to retrieve information about the child's previous antibiotic consumption. RESULT Cultures from 340 children were gathered. The level of resistant Haemophilus influenzae was low and the prevalence of penicillin non-susceptible pneumococci (PNSP MIC ≥ 0.125 mg/L) was 6% compared to 10% (p = 0.31) in corresponding cultures from children diagnosed at the local clinical microbiology laboratory. Antibiotic treatment within the previous 4 weeks predisposed for resistant bacteria in the nasopharynx, OR: 3.08, CI 95% (1.13-8.42). CONCLUSION Low prevalence of PNSP supports the use of phenoxymethylpenicillin as empirical treatment for childhood upper respiratory tract infections attending primary care in our setting. It is important that studies on resistance are performed in primary care populations to evaluate data from microbiological laboratories. Recent antibiotic treatment increases risk of bacterial resistance in children and continuous work to reduce unnecessary antibiotic prescribing should be prioritised.
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Affiliation(s)
- Mia Tyrstrup
- Department of Clinical Sciences, Family Medicine, Lund University, Malmö, Sweden.
| | - Eva Melander
- Department of Translational Medicine, Lund University, Malmö, Sweden
- Regional Centre for Communicable Disease Control, Malmö, Skåne County, Sweden
| | - Katarina Hedin
- Department of Clinical Sciences, Family Medicine, Lund University, Malmö, Sweden
- Futurum- Academy for Health and Care, Region Jönköping County, Sweden
| | - Anders Beckman
- Department of Clinical Sciences, Family Medicine, Lund University, Malmö, Sweden
| | - Sigvard Mölstad
- Department of Clinical Sciences, Family Medicine, Lund University, Malmö, Sweden
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Westerlind B, Östgren CJ, Mölstad S, Midlöv P. Prevalence and predictive importance of anemia in Swedish nursing home residents - a longitudinal study. BMC Geriatr 2016; 16:206. [PMID: 27912734 PMCID: PMC5134278 DOI: 10.1186/s12877-016-0375-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [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] [Subscribe] [Scholar Register] [Received: 04/09/2016] [Accepted: 11/23/2016] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Anemia is common in elderly people and especially in nursing home residents. Few studies have been performed on the consequences of anemia in a nursing home population. This study explored the prevalence of anemia in nursing homes in Sweden, including risk factors and mortality associated with anemia or hemoglobin (Hb) decline. METHODS Three hundred ninety patients from 12 nursing homes were included during 2008-2011. Information about medication, blood samples, questionnaire responses and information about physical and social activities was recorded. The baseline characteristics of the patients were compared for subjects with and without anemia. Vital status was ascertained during the following 7 years from baseline to compare the survival. Hb levels <120 g/L in women and <130 g/L in men were used to define anemia. For 220 of the subjects Hb change during one year was registered and the quartiles in Hb change were compared in terms of baseline characteristics and mortality. RESULTS The prevalence of anemia at baseline was 52% among men and 32% among women. The men with anemia had a two-year mortality significantly higher (61%) than the men without anemia (29%, p = 0.001) but there was no statistical difference in two-year survival in women. In anemic men there was a higher mortality (Hazard Ratio = 1.58) during a total follow-up period of up to 7 years after adjustment for age, increased B-type natriuretic peptide (BNP) and decreased estimated Glomerular Filtration Rate (eGFR). Among men, but not women, we found baseline correlations between anemia and elevated BNP (>100 ng/L) and severely reduced eGFR (<30 ml/min). When the lowest quartile of Hb change (decline > 9 g/L) was compared with the highest (improvement > 6 g/L) the mortality was higher in the lowest quartile (p = 0.03). CONCLUSIONS Anemia is common in nursing home residents in Sweden, especially among men for whom it is related to higher mortality. A rapid Hb drop is associated with higher mortality. Regardless of earlier Hb values, monitoring Hb regularly in a nursing home population seems important for catching rapid Hb decline correlated with higher mortality.
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Affiliation(s)
- Björn Westerlind
- Department of Geriatrics, County Hospital Ryhov, Region Jönköping County, Jönköping, Sweden
| | - Carl Johan Östgren
- Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Sigvard Mölstad
- Department of Clinical Sciences in Malmö, Center for Primary Health Care Research, Lund University, Malmö, Sweden
| | - Patrik Midlöv
- Department of Clinical Sciences in Malmö, Center for Primary Health Care Research, Lund University, Malmö, Sweden
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Tyrstrup M, Beckman A, Mölstad S, Engström S, Lannering C, Melander E, Hedin K. Reduction in antibiotic prescribing for respiratory tract infections in Swedish primary care- a retrospective study of electronic patient records. BMC Infect Dis 2016; 16:709. [PMID: 27887585 PMCID: PMC5124268 DOI: 10.1186/s12879-016-2018-9] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [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] [Received: 10/14/2015] [Accepted: 11/11/2016] [Indexed: 11/25/2022] Open
Abstract
Background Swedish studies on antibiotic use in primary care have been based on one-week registrations of infections. In order to study adherence to guidelines, analyses based on large databases that provide information on diagnosis linked prescriptions, are needed. This study describes trends in management of infections in Swedish primary care particularly with regards to antibiotic prescribing and adherence to national guidelines. Methods A descriptive study of Sweden’s largest database regarding diagnosis linked antibiotic prescription data, the Primary care Record of Infections in Sweden (PRIS), for the years 2008, 2010 and 2013. Results Although the consultation rate for all infections remained around 30% each year, antibiotic prescribing rates decreased significantly over the years from 53.7% in 2008, to 45.5% in 2010, to 38.6% in 2013 (p = .032). The antibiotic prescribing rate for respiratory tract infections (RTIs) decreased from 40.5% in 2008 to 24.9% in 2013 while those for urinary tract infections and skin and soft tissue infections were unchanged. For most RTI diagnoses there was a decrease in prescription rate from 2008 to 2013, particularly for the age group 0–6 years. Phenoxymethylpenicillin (PcV) was the antibiotic most often prescribed, followed by tetracycline. Tonsillitis and acute otitis media were the two RTI diagnoses with the highest number of prescriptions per 1000 patient years (PY). For these diagnoses an increase in adherence to national guidelines was seen, with regards to treatment frequency, choice of antibiotics and use of rapid antigen detection test. The frequency in antibiotic prescribing varied greatly between different Primary Healthcare Centres (PHCCs). Conclusion Falling numbers of consultations and decreased antibiotic prescription rates for RTIs have reduced the antibiotic use in Swedish primary care substantially. Overprescribing of antibiotics could still be suspected due to large variability in prescribing frequency, especially for acute bronchitis and sinusitis. Continuous evaluation of diagnosis linked prescribing data and feedback to doctors is essential in order to achieve a more prudent antibiotic use. Electronic supplementary material The online version of this article (doi:10.1186/s12879-016-2018-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Mia Tyrstrup
- Department of Clinical Sciences, Family Medicine, Lund University, Malmö, Sweden.
| | - Anders Beckman
- Department of Clinical Sciences, Family Medicine, Lund University, Malmö, Sweden
| | - Sigvard Mölstad
- Department of Clinical Sciences, Family Medicine, Lund University, Malmö, Sweden
| | - Sven Engström
- Unit of Research and Development in Primary Care, Jönköping, Sweden
| | | | - Eva Melander
- Department of Infection Control, Malmö, Skåne County, Sweden.,Department of translational medicine, Lund University, Malmö, Sweden
| | - Katarina Hedin
- Department of Clinical Sciences, Family Medicine, Lund University, Malmö, Sweden.,Department of Research and Development, Region Kronoberg, Växjö, Sweden
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11
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Rådholm K, Festin K, Falk M, Midlöv P, Mölstad S, Östgren CJ. Blood pressure and all-cause mortality: a prospective study of nursing home residents. Age Ageing 2016; 45:826-832. [PMID: 27496923 DOI: 10.1093/ageing/afw122] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Accepted: 05/25/2016] [Indexed: 01/11/2023] Open
Abstract
AIM to explore the natural course of blood pressure development and its relation to mortality in a nursing home cohort. METHODS a cohort of 406 nursing home residents in south east Sweden was followed prospectively for 30 months. Participants were divided into four groups based on systolic blood pressure (SBP) at baseline. Data were analysed using a Cox regression model with all-cause mortality as the outcome measurement; paired Student t-tests were used to evaluate blood pressure development over time. RESULTS during follow-up, 174 (43%) people died. Participants with SBP < 120 mmHg had a hazard ratio for mortality of 1.56 (95% confidence interval, 1.08-2.27) compared with those with SBP 120-139 mmHg, adjusted for age and sex. Risk of malnutrition or present malnutrition was most common in participants with SBP < 120 mmHg; risk of malnutrition or present malnutrition estimated using the Mini Nutritional Assessment was found in 78 (71%). The levels of SBP decreased over time independent of changes in anti-hypertensive medication. CONCLUSIONS in this cohort of nursing home residents, low SBP was associated with increased all-cause mortality. SBP decreased over time; this was not associated with altered anti-hypertensive treatment. The clinical implication from this study is that there is a need for systematic drug reviews in elderly persons in nursing homes, paying special attention to those with low SBP.
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Affiliation(s)
- Karin Rådholm
- Department of Medical and Health Sciences, Primary care, Linköping University, Linköping SE-581 83, Sweden
| | - Karin Festin
- Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Magnus Falk
- Division of Community Medicine, Primary Care, Department of Medicine and Health Sciences, Faculty of Health Sciences, Department of Local Care Central, County Council of Östergötland, Linköping University, Linköping, Sweden
| | - Patrik Midlöv
- Department of Clinical Sciences, Lund University Malmö, Sweden
| | - Sigvard Mölstad
- Department of Clinical Sciences, Lund University Malmö, Sweden
| | - Carl Johan Östgren
- Department of Medical and Health Sciences, Primary care, Linköping University, Linköping SE-581 83, Sweden
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12
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Skoog G, Edlund C, Giske CG, Mölstad S, Norman C, Sundvall PD, Hedin K. A randomized controlled study of 5 and 10 days treatment with phenoxymethylpenicillin for pharyngotonsillitis caused by streptococcus group A - a protocol study. BMC Infect Dis 2016; 16:484. [PMID: 27618925 PMCID: PMC5020538 DOI: 10.1186/s12879-016-1813-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [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] [Received: 06/30/2016] [Accepted: 08/30/2016] [Indexed: 01/24/2023] Open
Abstract
Background In 2014 the Swedish government assigned to The Public Health Agency of Sweden to conduct studies to evaluate optimal use of existing antibiotic agents. The aim is to optimize drug use and dosing regimens to improve the clinical efficacy. The present study was selected following a structured prioritizing process by independent experts. Methods This phase IV study is a randomized, open-label, multicenter study with non-inferiority design regarding the therapeutic use of penicillin V with two parallel groups. The overall aim is to study if the total exposure with penicillin V can be reduced from 1000 mg three times daily for 10 days to 800 mg four times daily for 5 days when treating Streptococcus pyogenes (Lancefield group A) pharyngotonsillitis. Patients will be recruited from 17 primary health care centers in Sweden. Adult men and women, youth and children ≥6 years of age who consult for sore throat and is judged to have a pharyngotonsillitis, with 3–4 Centor criteria and a positive rapid test for group A streptococci, will be included in the study. The primary outcome is clinical cure 5–7 days after discontinuation of antibiotic treatment. Follow-up controls will be done by telephone after 1 and 3 months. Throat symptoms, potential relapses and complications will be monitored, as well as adverse events. Patients (n = 432) will be included during 2 years. Discussion In the era of increasing antimicrobial resistance and the shortage of new antimicrobial agents it is necessary to revisit optimal usage of old antibiotics. Old antimicrobial drugs are often associated with inadequate knowledge on pharmacokinetics and pharmacodynamics and lack of optimized dosing regimens based on randomized controlled clinical trials. If a shorter and more potent treatment regimen is shown to be equivalent with the normal 10 day regimen this can imply great advantages for both patients (adherence, adverse events, resistance) and the community (resistance, drug costs). Trial registration EudraCT number 2015-001752-30. Protocol FoHM/Tonsillit2015 date 22 June 2015, version 2. Approved by MPA of Sweden 3 July 2015, Approved by Regional Ethical Review Board in Lund, 25 June 2015.
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Affiliation(s)
- Gunilla Skoog
- Unit for Antibiotics and Infection Control, The Public Health Agency of Sweden, Solna, Sweden. .,Department of Medicine Solna, Division of Infectious Diseases, Karolinska Institute, Stockholm, Sweden.
| | - Charlotta Edlund
- Unit for Antibiotics and Infection Control, The Public Health Agency of Sweden, Solna, Sweden.,Department of Medicine Solna, Division of Infectious Diseases, Karolinska Institute, Stockholm, Sweden
| | - Christian G Giske
- Division of Clinical Microbiology, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden.,Department of Clinical Microbiology, Karolinska University Hospital, Stockholm, Sweden
| | - Sigvard Mölstad
- Department of Clinical Sciences, Malmö, Family Medicine, Lund University, Lund, Sweden
| | - Christer Norman
- Unit for Antibiotics and Infection Control, The Public Health Agency of Sweden, Solna, Sweden.,Salem Primary Health Care Center (PHCC), Säbytorgsvägen 6, SE-144 30, Rönninge, Sweden
| | - Pär-Daniel Sundvall
- Närhälsan Research and Development Primary Health Care, Region Västra Götaland, R & D Center Södra Älvsborg, Sven Eriksonsplatsen 4, SE-503 38, Borås, Sweden.,Department of Public Health and Community Medicine/Primary Health Care, Institute of Medicine, Sahlgrenska Academy at the University of Gothenburg, Box 454, SE-405 30, Göteborg, Sweden
| | - Katarina Hedin
- Department of Clinical Sciences, Malmö, Family Medicine, Lund University, Lund, Sweden.,Department of Research and Development, Region Kronoberg, Växjö, Sweden
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13
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Strandberg EL, Brorsson A, André M, Gröndal H, Mölstad S, Hedin K. Interacting factors associated with Low antibiotic prescribing for respiratory tract infections in primary health care - a mixed methods study in Sweden. BMC Fam Pract 2016; 17:78. [PMID: 27430895 PMCID: PMC4950701 DOI: 10.1186/s12875-016-0494-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [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: 02/24/2016] [Accepted: 07/13/2016] [Indexed: 11/12/2022]
Abstract
Background Prescribing of antibiotics for common infections varies widely, and there is no medical explanation. Systematic reviews have highlighted factors that may influence antibiotic prescribing and that this is a complex process. It is unclear how factors interact and how the primary care organization affects diagnostic procedures and antibiotic prescribing. Therefore, we sought to explore and understand interactions between factors influencing antibiotic prescribing for respiratory tract infections in primary care. Methods Our mixed methods design was guided by the Triangulation Design Model according to Creswell. Quantitative and qualitative data were collected in parallel. Quantitative data were collected by prescription statistics, questionnaires to patients, and general practitioners’ audit registrations. Qualitative data were collected through observations and semi-structured interviews. Results From the analysis of the data from the different sources an overall theme emerged: A common practice in the primary health care centre is crucial for low antibiotic prescribing in line with guidelines. Several factors contribute to a common practice, such as promoting management and leadership, internalized guidelines including inter-professional discussions, the general practitioner’s diagnostic process, nurse triage, and patient expectation. These factors were closely related and influenced each other. The results showed that knowledge must be internalized and guidelines need to be normative for the group as well as for every individual. Conclusions Low prescribing is associated with adapted and transformed guidelines within all staff, not only general practitioners. Nurses’ triage and self-care advice played an important role. Encouragement from the management level stimulated inter-professional discussions about antibiotic prescribing. Informal opinion moulders talking about antibiotic prescribing was supported by the managers. Finally, continuous professional development activities were encouraged for up-to-date knowledge.
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Affiliation(s)
- Eva Lena Strandberg
- Department of Clinical Sciences, Malmö, Family Medicine, Lund University, Malmö, Sweden. .,Blekinge Centre of Competence, Blekinge County Council, Karlskrona, Sweden.
| | - Annika Brorsson
- Department of Clinical Sciences, Malmö, Family Medicine, Lund University, Malmö, Sweden.,Center for Primary Health Care Research, Malmö, Skåne Region, Sweden
| | - Malin André
- Department of Medicine and Health Sciences, Family Medicine, Linköping University, Linköping, Sweden.,Department of Public Health and Caring Sciences - Family Medicine and Preventive Medicine, Uppsala University, Uppsala, Sweden
| | - Hedvig Gröndal
- Department of Sociology Uppsala, Uppsala University, Uppsala, Sweden
| | - Sigvard Mölstad
- Department of Clinical Sciences, Malmö, Family Medicine, Lund University, Malmö, Sweden
| | - Katarina Hedin
- Department of Clinical Sciences, Malmö, Family Medicine, Lund University, Malmö, Sweden.,Department of Research and Development, Region Kronoberg, Växjö, Sweden
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14
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Malhotra-Kumar S, Van Heirstraeten L, Coenen S, Lammens C, Adriaenssens N, Kowalczyk A, Godycki-Cwirko M, Bielicka Z, Hupkova H, Lannering C, Mölstad S, Fernandez-Vandellos P, Torres A, Parizel M, Ieven M, Butler CC, Verheij T, Little P, Goossens H. Impact of amoxicillin therapy on resistance selection in patients with community-acquired lower respiratory tract infections: a randomized, placebo-controlled study. J Antimicrob Chemother 2016; 71:3258-3267. [PMID: 27353466 DOI: 10.1093/jac/dkw234] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Revised: 05/09/2016] [Accepted: 05/16/2016] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES To determine the effect of amoxicillin treatment on resistance selection in patients with community-acquired lower respiratory tract infections in a randomized, placebo-controlled trial. METHODS Patients were prescribed amoxicillin 1 g, three times daily (n = 52) or placebo (n = 50) for 7 days. Oropharyngeal swabs obtained before, within 48 h post-treatment and at 28-35 days were assessed for proportions of amoxicillin-resistant (ARS; amoxicillin MIC ≥2 mg/L) and -non-susceptible (ANS; MIC ≥0.5 mg/L) streptococci. Alterations in amoxicillin MICs and in penicillin-binding-proteins were also investigated. ITT and PP analyses were conducted. RESULTS ARS and ANS proportions increased 11- and 2.5-fold, respectively, within 48 h post-amoxicillin treatment compared with placebo [ARS mean increase (MI) 9.46, 95% CI 5.57-13.35; ANS MI 39.87, 95% CI 30.96-48.78; P < 0.0001 for both]. However, these differences were no longer significant at days 28-35 (ARS MI -3.06, 95% CI -7.34 to 1.21; ANS MI 4.91, 95% CI -4.79 to 14.62; P > 0.1588). ARS/ANS were grouped by pbp mutations. Group 1 strains exhibited significantly lower amoxicillin resistance (mean MIC 2.8 mg/L, 95% CI 2.6-3.1) than group 2 (mean MIC 9.3 mg/L, 95% CI 8.1-10.5; P < 0.0001). Group 2 strains predominated immediately post-treatment (61.07%) and although decreased by days 28-35 (30.71%), proportions remained higher than baseline (18.70%; P = 0.0004). CONCLUSIONS By utilizing oropharyngeal streptococci as model organisms this study provides the first prospective, experimental evidence that resistance selection in patients receiving amoxicillin is modest and short-lived, probably due to 'fitness costs' engendered by high-level resistance-conferring mutations. This evidence further supports European guidelines that recommend amoxicillin when an antibiotic is indicated for community-acquired lower respiratory tract infections.
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Affiliation(s)
- Surbhi Malhotra-Kumar
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium
| | - Liesbet Van Heirstraeten
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium
| | - Samuel Coenen
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium.,Centre for General Practice, Department of Primary and Interdisciplinary care (ELIZA), University of Antwerp, Antwerp, Belgium
| | - Christine Lammens
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium
| | - Niels Adriaenssens
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium.,Centre for General Practice, Department of Primary and Interdisciplinary care (ELIZA), University of Antwerp, Antwerp, Belgium
| | - Anna Kowalczyk
- Department of Family and Community Medicine, Medical University of Lodz, Lodz, Poland
| | - Maciek Godycki-Cwirko
- Department of Family and Community Medicine, Medical University of Lodz, Lodz, Poland
| | - Zuzana Bielicka
- Clinical Research Associates and Consultants, Bratislava, Slovakia
| | - Helena Hupkova
- Institute of Microbiology, Faculty of Medicine, Comenius University Bratislava, Bratislava, Slovakia
| | | | - Sigvard Mölstad
- Department of Clinical Sciences, Lund University, Lund, Sweden
| | | | | | - Maxim Parizel
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium
| | - Margareta Ieven
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium
| | - Chris C Butler
- Cardiff University, Cardiff, UK.,Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
| | - Theo Verheij
- University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Herman Goossens
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium
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15
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Bolmsjö BB, Mölstad S, Gallagher M, Chalmers J, Östgren CJ, Midlöv P. Risk factors and consequences of decreased kidney function in nursing home residents: A longitudinal study. Geriatr Gerontol Int 2016; 17:791-797. [DOI: 10.1111/ggi.12789] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Revised: 02/16/2016] [Accepted: 02/24/2016] [Indexed: 01/04/2023]
Affiliation(s)
| | - Sigvard Mölstad
- Department of Clinical Sciences; Lund University; Malmö Sweden
| | - Martin Gallagher
- The George Institute for Global Health; Sydney Medical School, University of Sydney; NSW Australia
| | - John Chalmers
- The George Institute for Global Health; Sydney Medical School, University of Sydney; NSW Australia
| | - Carl Johan Östgren
- Department of Medical and Health Sciences, Primary Care; Linköping University; Linköping Sweden
| | - Patrik Midlöv
- Department of Clinical Sciences; Lund University; Malmö Sweden
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16
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Lannering C, Ernsth Bravell M, Midlöv P, Östgren CJ, Mölstad S. Factors related to falls, weight-loss and pressure ulcers - more insight in risk assessment among nursing home residents. J Clin Nurs 2016; 25:940-50. [DOI: 10.1111/jocn.13154] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/05/2015] [Indexed: 12/18/2022]
Affiliation(s)
| | - Marie Ernsth Bravell
- Institute of Gerontology; School of Health Sciences; Jönköping University; Jönköping Sweden
| | - Patrik Midlöv
- Department of Clinical Sciences in Malmö, General Practice/Family Medicine; Lund University; Malmö Sweden
| | - Carl-Johan Östgren
- Department of Medical and Health Sciences, General Practice; Linköping University; Linköping Sweden
| | - Sigvard Mölstad
- Department of Clinical Sciences in Malmö, General Practice/Family Medicine; Lund University; Malmö Sweden
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17
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Hallgren J, Ernsth Bravell M, Mölstad S, Östgren CJ, Midlöv P, Dahl Aslan AK. Factors associated with increased hospitalisation risk among nursing home residents in Sweden: a prospective study with a three-year follow-up. Int J Older People Nurs 2015; 11:130-9. [DOI: 10.1111/opn.12107] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2014] [Accepted: 08/13/2015] [Indexed: 12/01/2022]
Affiliation(s)
- Jenny Hallgren
- Institute of Gerontology; School of Health and Welfare; Jönköping University; Jönköping Sweden
- Regional Development Council of Jönköping County; Jönköping Sweden
| | - Marie Ernsth Bravell
- Institute of Gerontology; School of Health and Welfare; Jönköping University; Jönköping Sweden
| | - Sigvard Mölstad
- Department of Clinical Sciences; Lund University; Malmö Sweden
| | - Carl Johan Östgren
- Department of Medical and Health Sciences; Linköping University; Linköping Sweden
| | - Patrik Midlöv
- Department of Clinical Sciences; Lund University; Malmö Sweden
| | - Anna K. Dahl Aslan
- Institute of Gerontology; School of Health and Welfare; Jönköping University; Jönköping Sweden
- Department of Medical Epidemiology and Biostatistics; Karolinska Institutet; Stockholm Sweden
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18
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Mölstad S, Sundvall PD, Hedin K, André M. [Comment regarding Group A Streptococcus: Manage throat infections according to the current recommendations]. Lakartidningen 2015; 112:DRUT. [PMID: 26485140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Affiliation(s)
- Sigvard Mölstad
- Institutionen för kliniska vetenskaper - Allmänmedicin Malmö, Sweden Institutionen för kliniska vetenskaper - Allmänmedicin Malmö, Sweden
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19
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Tell D, Engström S, Mölstad S. Adherence to guidelines on antibiotic treatment for respiratory tract infections in various categories of physicians: a retrospective cross-sectional study of data from electronic patient records. BMJ Open 2015; 5:e008096. [PMID: 26179648 PMCID: PMC4513445 DOI: 10.1136/bmjopen-2015-008096] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To study how prescription patterns concerning respiratory tract infections differ between interns, residents, younger general practitioners (GPs), older GPs and locums. DESIGN Retrospective study of structured data from electronic patient records. SETTING Data were obtained from 53 health centres and 3 out-of-hours units in Jönköping County, Sweden, through their common electronic medical record database. PARTICIPANTS All physicians working in primary care during the 2-year study period (1 November 2010 to 31 October 2012). OUTCOME MEASURES Physicians' adherence to current guidelines for respiratory tract infections regarding the use of antibiotics. RESULTS We found considerable differences in prescribing patterns between physician categories. The recommended antibiotic, phenoxymethylpenicillin, was more often prescribed by interns, residents and younger GPs, while older GPs and locums to a higher degree prescribed broad-spectrum antibiotics. The greatest differences were seen when the recommendation in guidelines was to refrain from antibiotics, as for acute bronchitis. Interns and residents most often followed guidelines, while compliance in descending order was: young GPs, older GPs and locums. We also noticed that male doctors were somewhat overall more restrictive with antibiotics than female doctors. CONCLUSIONS In general, primary care doctors followed national guidelines on choice of antibiotics when treating respiratory tract infections in children but to a lesser degree when treating adults. Refraining from antibiotics seems harder. Adherence to national guidelines could be improved, especially for acute bronchitis and pneumonia. This was especially true for older GPs and locums whose prescription patterns were distant from the prevailing guidelines.
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Affiliation(s)
- David Tell
- Råslätt Health Care Centre, Jönköping, Sweden
| | - Sven Engström
- Primary Care Research and Development Unit, Futurum, Jönköping, Sweden
| | - Sigvard Mölstad
- Department of Clinical Sciences, General Practice, Lund University, Lund, Sweden
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20
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Abstract
BACKGROUND Studies of antibiotic prescribing related to diagnosis comparing prescribers trained abroad with those trained in Sweden are lacking. OBJECTIVES To determine whether general practices (GPs) and GP residents trained abroad had different prescribing patterns for antibiotics for common infections than those trained in Sweden using retrospective data from electronic patient records from primary health care in Kalmar County, Sweden. METHODS Consultations with an infection diagnosis, both with and without the prescription of antibiotics to 67 GPs and residents trained in Western Europe outside Sweden and other countries, were compared with a matched control group trained in Sweden. RESULTS For 1 year, 44101 consultations of patients with an infection diagnosis and 16276 prescriptions of antibiotics were registered. Foreign-trained physicians had 20% more visits compared with physicians trained in Sweden. The prescription of antibiotics per visit and physician in the respective groups, and independent of diagnosis, did not significantly differ between groups, when scaled down from number of consultations to number of prescribing physicians. CONCLUSIONS There were minor and non-significant differences in antibiotic prescribing comparing GPs and residents trained abroad and in Sweden, most likely the result of an adaptation to Swedish conditions. Nevertheless, no group prescribed antibiotics in accordance to national guidelines. The results suggest that interventions are needed to reduce irrational antibiotic prescribing patterns, targeting all physicians working in Swedish primary health care.
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Affiliation(s)
- Thomas Neumark
- Primary Health Centre, Lindsdal, Kalmar, Department of Planning, Division of Pharmacotherapy, Kalmar County Council, Kalmar,
| | - Lars Brudin
- Department of Clinical Physiology, Kalmar County Hospital, Kalmar and
| | - Sigvard Mölstad
- Department of Clinical Sciences, General Practice, Lund University, Malmö, Sweden
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21
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Persson LG, Lingfors H, Nilsson M, Mölstad S. The possibility of lifestyle and biological risk markers to predict morbidity and mortality in a cohort of young men after 26 years follow-up. BMJ Open 2015; 5:e006798. [PMID: 25948404 PMCID: PMC4431125 DOI: 10.1136/bmjopen-2014-006798] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVES To study the association between lifestyle and biological risk markers measured at one occasion, morbidity and mortality from cardiovascular disease (CVD) and cancer, and morbidity from diabetes approximately 26 years later. DESIGN A follow-up study of a cohort of men, 33-42 years old at baseline. SETTING Primary healthcare centre in Sweden. PARTICIPANTS All 757 men, living in the community of Habo in Sweden in 1985, and all 652 of these participating in a health examination in 1985-1987. INTERVENTIONS Health profile and a health dialogue with a nurse. A doctor invited the high-risk group to further dialogue and examination. Intervention programmes were carried out in the primary healthcare centre and in cooperation with local associations. MAIN OUTCOME MEASURES CVD and cancer diagnoses from the Swedish National Board of Health and Welfare. Data from pharmacy registers of sold drugs concerning diabetes mellitus. RESULTS The participants were divided in three groups based on summarised risk points from lifestyle (smoking, physical activity, alcohol consumption) and biological risk markers (body mass index (BMI), blood pressure, serum cholesterol) selected from the health profile. Comparisons were done between these groups. The group with the lowest summarised total risk points had a significantly lower risk for CVD and cancer compared with the group with the highest summarised risk points. The group with the lowest risk points concerning lifestyle had a significantly lower risk for CVD, and the group with lowest risk points for biological risk markers had a significantly lower risk for both CVD and cancer compared with the groups with the highest risk points. Smoking and serum cholesterol were the most important risk factors. In association to diabetes, BMI and smoking were the most important risk factors. CONCLUSIONS Risk factors measured on one occasion seemed to be able to predict CVD, cancer and diabetes 26 years later.
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Affiliation(s)
- Lars-Göran Persson
- Futurum, Health Care Centre of Habo and Unit for Research and Development in Primary Health Care, Jönköping, Sweden
| | - Hans Lingfors
- Futurum, Health Care Centre of Habo and Unit for Research and Development in Primary Health Care, Jönköping, Sweden
| | - Mats Nilsson
- Primary Health Care, Futurum County Council of Jönköping, Jönköping, Sweden
| | - Sigvard Mölstad
- Department of Clinical Sciences, General Practice, Lund University, Malmö, Sweden
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Pikkemaat M, Melander O, Mölstad S, Garberg G, Boström KB. C-peptide concentration, mortality and vascular complications in people with Type 2 diabetes. The Skaraborg Diabetes Register. Diabet Med 2015; 32:85-9. [PMID: 25354243 DOI: 10.1111/dme.12608] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [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] [Received: 02/25/2014] [Revised: 08/11/2014] [Accepted: 10/07/2014] [Indexed: 12/17/2022]
Abstract
AIM To study the prognosis of patients with newly diagnosed Type 2 diabetes in primary care in relation to their baseline C-peptide concentration. METHODS C-peptide concentrations were determined in 399 patients aged < 65 years with newly diagnosed Type 2 diabetes using the Skaraborg Diabetes Register, Sweden. Data on cardiovascular complications and death were extracted from national registers and a local study of retinopathy. Statistical analyses were performed using Cox regression. RESULTS An analysis of C-peptide concentrations in quartiles, after adjusting for confounders, showed that patients in the highest quartile had a 2.75-fold higher risk of death from all causes compared with those in the lowest quartile (CI 1.17-6.47). By contrast, C-peptide concentration was not associated with the incidence of cardiovascular events or the development of retinopathy. CONCLUSIONS Measurement of C-peptide concentration at diagnosis could help identify patients who are at high risk and who presumably would benefit from more intensive treatment.
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Affiliation(s)
- M Pikkemaat
- Husensjö Health Care Centre, Helsingborg, Sweden; Centre for Primary Health Care Research, Department of Clinical Sciences in Malmö, Lund University, Skövde, Sweden
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Persson LG, Lingfors H, Nilsson M, Mölstad S. Lifestyle, Biological Risk Markers, Morbidity and Mortality in a Cohort of Men 33 - 42 Years Old at Baseline, after 24-Year Follow-Up of a Primary Health Care Intervention. ACTA ACUST UNITED AC 2015. [DOI: 10.4236/ojpm.2015.53011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Vik I, Bollestad M, Grude N, Bærheim A, Mölstad S, Bjerrum L, Lindbæk M. Ibuprofen versus mecillinam for uncomplicated cystitis--a randomized controlled trial study protocol. BMC Infect Dis 2014; 14:693. [PMID: 25516016 PMCID: PMC4273435 DOI: 10.1186/s12879-014-0693-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2014] [Accepted: 12/10/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Although uncomplicated cystitis is often self-limiting, most such patients will be prescribed antibiotic treatment. We are investigating whether treatment of cystitis with an NSAID is as effective as an antibiotic in achieving symptomatic resolution. METHODS/DESIGN This is a randomized, controlled, double blind trial following the principles of Good Clinical Practice. Women between the ages of 18 to 60 presenting with symptoms of uncomplicated cystitis are screened for eligibility. 500 women from four sites in Norway, Sweden and Denmark are allocated to treatment with 600 mg ibuprofen three times a day or 200 mg mecillinam three times a day for three days. Allocation is conducted using block randomization. The primary outcome is the number of patients who feel cured by day four as recorded in a diary. Adverse events will be handled and reported in accordance with Good Clinical Practice. DISCUSSION If treatment of uncomplicated cystitis with ibuprofen is as effective as mecillinam for symptom relief, we can potentially reduce the use of antibiotics on a global scale. TRIAL REGISTRATION EudraCTnr: 2012-002776-14. ClinicalTrials.gov: NCT01849926.
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Affiliation(s)
- Ingvild Vik
- Antibiotic Centre of Primary Care, Department of General Practice, Institute of Health and Society, University of Oslo, Pb 1130, Blindern, 0318, Oslo, Norway. .,Department of General Practice, Oslo Accident and Emergency Out Patient Clinic, Storgata 40, 0182, Oslo, Norway.
| | - Marianne Bollestad
- Antibiotic Centre of Primary Care, Department of General Practice, Institute of Health and Society, University of Oslo, Pb 1130, Blindern, 0318, Oslo, Norway. .,Division of Medicine, Stavanger University Hospital, Pb 8100, 4068, Stavanger, Norway.
| | - Nils Grude
- Antibiotic Centre of Primary Care, Department of General Practice, Institute of Health and Society, University of Oslo, Pb 1130, Blindern, 0318, Oslo, Norway. .,Department of Medical Microbiology, Vestfold Hospital Trust, Pb 2168, 3103, Tønsberg, Norway.
| | - Anders Bærheim
- Department of Global Public Health and Primary Care, University of Bergen, Pb 7804, 5018, Bergen, Norway.
| | - Sigvard Mölstad
- Department of Clinical Sciences, Malmoe, General Practice, University of Lund, box 117, 221 00, Lund, Sweden.
| | - Lars Bjerrum
- Department of Public Health, University of Copenhagen, Pb 2099, 1014, Copenhagen, Denmark.
| | - Morten Lindbæk
- Antibiotic Centre of Primary Care, Department of General Practice, Institute of Health and Society, University of Oslo, Pb 1130, Blindern, 0318, Oslo, Norway.
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Sundvall PD, Elm M, Ulleryd P, Mölstad S, Rodhe N, Jonsson L, Andersson B, Hahn-Zoric M, Gunnarsson R. Interleukin-6 concentrations in the urine and dipstick analyses were related to bacteriuria but not symptoms in the elderly: a cross sectional study of 421 nursing home residents. BMC Geriatr 2014; 14:88. [PMID: 25117748 PMCID: PMC4137105 DOI: 10.1186/1471-2318-14-88] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2014] [Accepted: 07/24/2014] [Indexed: 11/18/2022] Open
Abstract
Background Up to half the residents of nursing homes for the elderly have asymptomatic bacteriuria (ABU), which should not be treated with antibiotics. A complementary test to discriminate between symptomatic urinary tract infections (UTI) and ABU is needed, as diagnostic uncertainty is likely to generate significant antibiotic overtreatment. Previous studies indicate that Interleukin-6 (IL-6) in the urine might be suitable as such a test. The aim of this study was to investigate the association between laboratory findings of bacteriuria, IL-6 in the urine, dipstick urinalysis and newly onset symptoms among residents of nursing homes. Methods In this cross sectional study, voided urine specimens for culture, urine dipstick and IL-6 analyses were collected from all residents capable of providing a voided urine sample, regardless of the presence of symptoms. Urine specimens and symptom forms were provided from 421 residents of 22 nursing homes. The following new or increased nonspecific symptoms occurring during the previous month were registered; fatigue, restlessness, confusion, aggressiveness, loss of appetite, frequent falls and not being herself/himself, as well as symptoms from the urinary tract; dysuria, urinary urgency and frequency. Results Recent onset of nonspecific symptoms was common among elderly residents of nursing homes (85/421). Urine cultures were positive in 32% (135/421), Escherichia coli was by far the most common bacterial finding. Residents without nonspecific symptoms had positive urine cultures as often as those with nonspecific symptoms with a duration of up to one month. Residents with positive urine cultures had higher concentrations of IL-6 in the urine (p < 0.001). However, among residents with positive urine cultures there were no differences in IL-6 concentrations or dipstick findings between those with or without nonspecific symptoms. Conclusions Nonspecific symptoms among elderly residents of nursing homes are unlikely to be caused by bacteria in the urine. This study could not establish any clinical value of using dipstick urinalysis or IL-6 in the urine to verify if bacteriuria was linked to nonspecific symptoms.
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Affiliation(s)
- Pär-Daniel Sundvall
- Research and Development Unit, Primary Health Care in Southern Älvsborg County, Sven Eriksonsplatsen 4, SE-503 38 Borås, Sweden.
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Samefors M, Östgren CJ, Mölstad S, Lannering C, Midlöv P, Tengblad A. Vitamin D deficiency in elderly people in Swedish nursing homes is associated with increased mortality. Eur J Endocrinol 2014; 170:667-75. [PMID: 24520134 DOI: 10.1530/eje-13-0855] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [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: 11/08/2022]
Abstract
OBJECTIVE Institutionalised elderly people at northern latitudes may be at elevated risk for vitamin D deficiency. In addition to osteoporosis-related disorders, vitamin D deficiency may influence several medical conditions conferring an increased mortality risk. The aim of this study was to explore the prevalence of vitamin D deficiency and its association with mortality. DESIGN The Study of Health and Drugs in the Elderly (SHADES) is a prospective cohort study among elderly people (>65 years) in 11 nursing homes in Sweden. METHODS We analysed the levels of 25-hydroxyvitamin D₃ (25(OH)D₃) at baseline. Vital status of the subjects was ascertained and hazard ratios (HRs) for mortality according to 25(OH)D₃ quartiles were calculated. RESULTS We examined 333 study participants with a mean follow-up of 3 years. A total of 147 (44%) patients died within this period. Compared with the subjects in Q4 (25(OH)D₃ >48 nmol/l), HR (with 95% CI) for mortality was 2.02 (1.31-3.12) in Q1 (25(OH)D₃ <29 nmol/l) (P<0.05); 2.03 (1.32-3.14) in Q2 (25(OH)D₃ 30-37 nmol/l) (P<0.05) and 1.6 (1.03-2.48) in Q3 (25(OH)D₃ 38-47 nmol/l) (P<0.05). The mean 25(OH)D₃ concentration was 40.2 nmol/l (S.D. 16.0) and 80% had 25(OH)D₃ below 50 nmol/l. The vitamin D levels decreased from baseline to the second and third measurements. CONCLUSIONS Vitamin D deficiency was highly prevalent and associated with increased mortality among the elderly in Swedish nursing homes. Strategies are needed to prevent, and maybe treat, vitamin D deficiency in the elderly in nursing homes and the benefit of vitamin D supplementation should be evaluated in randomised clinical trials.
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Affiliation(s)
- Maria Samefors
- Department of Medical and Health Sciences, Linköping University, SE-581 83 Linköping, Sweden
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Sundvall PD, Elm M, Gunnarsson R, Mölstad S, Rodhe N, Jonsson L, Ulleryd P. Antimicrobial resistance in urinary pathogens among Swedish nursing home residents remains low: a cross-sectional study comparing antimicrobial resistance from 2003 to 2012. BMC Geriatr 2014; 14:30. [PMID: 24625344 PMCID: PMC3975149 DOI: 10.1186/1471-2318-14-30] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [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] [Subscribe] [Scholar Register] [Received: 10/23/2013] [Accepted: 03/06/2014] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND There are several risk factors for the colonisation, infection and spreading of antibiotic resistant bacteria among elderly residents of nursing homes. An updated estimate of the native prevalence of antimicrobial resistance in uropathogens among Swedish nursing home residents is needed. METHODS Urine specimens were collected for culture and antimicrobial susceptibility testing against mecillinam, ampicillin, cefadroxil, trimethoprim, nitrofurantoin and quinolones from the residents of 32 and 22 nursing homes, respectively. The residents were capable of providing a voided urine sample in 2003 and 2012. In 2012 urine specimens were also collected from residents with urinary catheters. Any antibiotic treatment during the previous month was registered in 2003 as well as hospitalisation and any antibiotic treatment during the previous six months in 2012. RESULTS The proportion of positive urine cultures was 32% (207/651) in voided urine specimens in 2003, 35% (147/421) in 2012, and 46% (27/59) in urine samples from catheters in 2012. Escherichia coli (E. coli) was the most commonly occurring bacteria.Resistance rates in E. coli (voided urine specimens) in 2012 were; ampicillin 21%, trimethoprim 12%, mecillinam 7.7%, ciprofloxacin 3.4%, cefadroxil 2.6% and nitrofurantoin 0.85%. There were no significant changes in the average resistance rates in E. coli for antibiotics tested 2003-2012.In 2012, two isolates of E. coli produced extended spectrum beta-lactamase enzymes (ESBL) and one with plasmid mediated AmpC production.Any antibiotic treatment during the previous month increased the risk for resistance in E. coli, adjusted for age and gender; for mecillinam with an odds ratio (OR) of 7.1 (2.4-21; p = 0.00049), ampicillin OR 5.2 (2.4-11; p = 0.000036), nalidixic acid OR 4.6 (1.4-16; p = 0.014) and trimethoprim OR 3.9 (1.6-9.2; p = 0.0023). Hospitalisation during the previous six months increased the risk for antibiotic resistance in E. coli to ampicillin, ciprofloxacin and any antimicrobial tested, adjusted for age, gender and antibiotic treatments during the previous six months. CONCLUSIONS The average rates of antimicrobial resistance were low and did not increase between 2003 and 2012 in E. coli urinary isolates among Swedish nursing home residents. Antibiotic treatment during the previous month and hospitalisation during the previous six months predicted higher resistance rates.
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Affiliation(s)
- Pär-Daniel Sundvall
- Research and Development Unit, Primary Health Care in Southern Älvsborg County, Sven Eriksonsplatsen 4, SE-503 38, Borås, Sweden
- Department of Public Health and Community Medicine, Institute of Medicine, the Sahlgrenska Academy, University of Gothenburg, Box 100, SE-405 30 Gothenburg, Sweden
- Sandared Primary Health Care Centre, Sandared, Sweden
| | - Marie Elm
- Health Care Unit, Borås Municipality, Våglängdsgatan 21 B, SE-507 41 Borås, Sweden
| | - Ronny Gunnarsson
- Research and Development Unit, Primary Health Care in Southern Älvsborg County, Sven Eriksonsplatsen 4, SE-503 38, Borås, Sweden
- Department of Public Health and Community Medicine, Institute of Medicine, the Sahlgrenska Academy, University of Gothenburg, Box 100, SE-405 30 Gothenburg, Sweden
- Cairns Clinical School, School of Medicine and Dentistry, James Cook University, Cairns Base Hospital, PO Box 902, Cairns, QLD 4870, Australia
| | - Sigvard Mölstad
- Department of Clinical Sciences, General Practice, Lund University, CRC, Hus 28, Plan 11, Jan Waldenströms gata 35, Malmö, SE-205 02, Sweden
| | - Nils Rodhe
- Centre for Clinical Research, Dalarna, Sweden and Falu Vårdcentral, Södra Mariegatan 18, SE-791 70 Falun, Sweden
- Department of Public Health and Caring Sciences, Family Medicine, Uppsala University, Uppsala, Sweden
| | - Lars Jonsson
- Bio Imaging and Laboratory Medicine Unit, Södra Älvsborg Hospital, SE-501 82 Borås, SE-501 82, Sweden
| | - Peter Ulleryd
- Department of Infectious Diseases, Institute of Biomedicine, the Sahlgrenska Academy, University of Gothenburg, Sweden and Department of Communicable Disease Control, Västra Götalandsregionen, SE-501 82 Borås, Sweden
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Gunnarsson R, Mölstad S. [Updated guidelines for acute pharyngotonsillitis provides good support. But more research is needed on Fusobacterium necrophorum]. Lakartidningen 2014; 111:78. [PMID: 24552008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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Hedin K, Brorsson A, Mölstad S, Strandberg EL. Antibiotics and near-patient testing: Differences in habits between physicians completing or discontinuing a medical audit. Health (London) 2014. [DOI: 10.4236/health.2014.62022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Milos V, Jakobsson U, Westerlund T, Melander E, Mölstad S, Midlöv P. Theory-based interventions to reduce prescription of antibiotics--a randomized controlled trial in Sweden. Fam Pract 2013; 30:634-40. [PMID: 23960104 DOI: 10.1093/fampra/cmt043] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Upper respiratory tract infections (URTIs) are the most common reason for consulting a GP and for receiving an antibiotic prescription, although evidence shows poor benefit but rather increasing antibiotic resistance. Interventions addressing physicians have to take into consideration the complexity of prescribing behaviour. OBJECTIVE To study whether interventions based on behavioural theories can reduce the prescribing of antibiotics against URTIs in primary care. Setting and subjects. GPs at 19 public primary health care centres in southern Sweden. METHODS We performed a randomized controlled study using two behavioural theory-based interventions, the persuasive communication intervention (PCI) and the graded task intervention (GTI), which emerged from social cognitive theory and operant learning theory. GPs were randomized to a control group or one of two intervention groups (PCI and GTI). MAIN OUTCOME MEASURES Changes in the rate of prescription of antibiotics against URTIs in primary care patients of all ages and in patients aged 0-6 years. RESULTS No significant differences were seen in the prescription rates before and after the interventions when patients of all ages were analysed together. However, for patients aged 0-6 years, there was a significant lower prescription rate in the PCI group (P = 0.037), but not the GTI group, after intervention. CONCLUSION Theory-based interventions have limited impact on reducing the prescription of antibiotics against URTIs in primary care. Future studies are needed to draw firm conclusions about their effects.
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Affiliation(s)
- Veronica Milos
- Primärvården Skåne, Laröd Health Care Centre, Helsingborg
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Bolmsjö BB, Mölstad S, Östgren CJ, Midlöv P. Prevalence and treatment of heart failure in Swedish nursing homes. BMC Geriatr 2013; 13:118. [PMID: 24188665 PMCID: PMC4228246 DOI: 10.1186/1471-2318-13-118] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2013] [Accepted: 10/28/2013] [Indexed: 12/03/2022] Open
Abstract
Background Since the burden of care for elderly patients with heart failure (HF) can be decreased by therapeutic measures, it is important that such patients are identified correctly. This study explores the prevalence of HF in nursing homes in Sweden, with special consideration of the risk of failure to diagnose HF in the study population. A second aim is to explore medication and the adherence to guidelines for the treatment of HF. Methods 429 patients from 11 nursing homes were included during 2008–2011. Information about diagnoses and medications from patient records, blood samples, questionnaire responses and blood pressure measurements were collected. The baseline characteristics of the patients, their medications and one-year mortality were identified and then compared regarding HF diagnosis and B-type natriuretic peptide (BNP) levels. A BNP level of >100 ng/L was used to identify potential cases of HF. Results The point prevalence of HF diagnosis in the medical records in the study population was 15.4%. With the recommended cut-off value for BNP, up to 196 subjects in the study population (45.7%) qualified for further screening of potential HF. The subjects in the HF and non-HF groups were similar with the exception of mean age, BNP levels and Mini Mental State Examination results which were higher in the HF group, and the eGFR and blood pressure, which were lower when HF. The subjects with higher BNP values were older and had lower eGFR, Hb, diastolic blood pressure and BMI. The subjects with HF diagnoses were in many cases not treated according to the guidelines. Loop diuretics were often used without concomitant ACE inhibitors or angiotensin receptor blockers. The subjects without HF diagnoses in the medical records at inclusion but with BNP values >100 ng/L had less appropriate HF medication. The one-year mortality was 52.9% in the population with HF. Conclusions Our study suggests that the estimated prevalence of HF in nursing homes in Sweden would increase if BNP measurements were used to select patients for further examinations. The pharmacological treatment of HF varied substantially, as did adherence to guidelines.
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Affiliation(s)
- Beata Borgström Bolmsjö
- Department of Clinical Sciences in Malmö, Center for Primary Health Care Research, Lund University, Malmö, Sweden.
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Nord M, Engström S, Mölstad S. [Very varied prescription of antibiotics in primary care. Low adherence to guidelines in throat infections, as shown by diagnosis based data]. Lakartidningen 2013; 110:1282-1284. [PMID: 23951882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Affiliation(s)
- Maria Nord
- Bankeryds vårdcentral, Jönköpings läns landsting.
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Little P, Stuart B, Moore M, Coenen S, Butler CC, Godycki-Cwirko M, Mierzecki A, Chlabicz S, Torres A, Almirall J, Davies M, Schaberg T, Mölstad S, Blasi F, De Sutter A, Kersnik J, Hupkova H, Touboul P, Hood K, Mullee M, O'Reilly G, Brugman C, Goossens H, Verheij T. Amoxicillin for acute lower-respiratory-tract infection in primary care when pneumonia is not suspected: a 12-country, randomised, placebo-controlled trial. Lancet Infect Dis 2012; 13:123-9. [PMID: 23265995 DOI: 10.1016/s1473-3099(12)70300-6] [Citation(s) in RCA: 150] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Lower-respiratory-tract infection is one of the most common acute illnesses managed in primary care. Few placebo-controlled studies of antibiotics have been done, and overall effectiveness (particularly in subgroups such as older people) is debated. We aimed to compare the benefits and harms of amoxicillin for acute lower-respiratory-tract infection with those of placebo both overall and in patients aged 60 years or older. METHODS Patients older than 18 years with acute lower-respiratory-tract infections (cough of ≤28 days' duration) in whom pneumonia was not suspected were randomly assigned (1:1) to either amoxicillin (1 g three times daily for 7 days) or placebo by computer-generated random numbers. Our primary outcome was duration of symptoms rated "moderately bad" or worse. Secondary outcomes were symptom severity in days 2-4 and new or worsening symptoms. Investigators and patients were masked to treatment allocation. This trial is registered with EudraCT (2007-001586-15), UKCRN Portfolio (ID 4175), ISRCTN (52261229), and FWO (G.0274.08N). FINDINGS 1038 patients were assigned to the amoxicillin group and 1023 to the placebo group. Neither duration of symptoms rated "moderately bad" or worse (hazard ratio 1.06, 95% CI 0.96-1.18; p=0.229) nor mean symptom severity (1.69 with placebo vs 1.62 with amoxicillin; difference -0.07 [95% CI -0.15 to 0.007]; p=0.074) differed significantly between groups. New or worsening symptoms were significantly less common in the amoxicillin group than in the placebo group (162 [15.9%] of 1021 patients vs 194 [19.3%] of 1006; p=0.043; number needed to treat 30). Cases of nausea, rash, or diarrhoea were significantly more common in the amoxicillin group than in the placebo group (number needed to harm 21, 95% CI 11-174; p=0.025), and one case of anaphylaxis was noted with amoxicillin. Two patients in the placebo group and one in the amoxicillin group needed to be admitted to hospital; no study-related deaths were noted. We noted no evidence of selective benefit in patients aged 60 years or older (n=595). INTERPRETATION When pneumonia is not suspected clinically, amoxicillin provides little benefit for acute lower-respiratory-tract infection in primary care both overall and in patients aged 60 years or more, and causes slight harms. FUNDING European Commission Framework Programme 6, UK National Institute for Health Research, Barcelona Ciberde Enfermedades Respiratorias, and Research Foundation Flanders.
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Affiliation(s)
- Paul Little
- Primary Care and Population Sciences Division, University of Southampton, Southampton, UK.
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van Vugt S, Broekhuizen L, Zuithoff N, de Jong P, Butler C, Hood K, Coenen S, Goossens H, Little P, Almirall J, Blasi F, Chlabicz S, Davies M, Godycki-Cwirko M, Hupkova H, Kersnik J, Mierzecki A, Mölstad S, Moore M, Schaberg T, De Sutter A, Torres A, Touboul P, Verheij T. Incidental chest radiographic findings in adult patients with acute cough. Ann Fam Med 2012; 10:510-5. [PMID: 23149527 PMCID: PMC3495924 DOI: 10.1370/afm.1384] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [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: 12/20/2022] Open
Abstract
PURPOSE Imaging may produce unexpected or incidental findings with consequences for patients and ordering of future investigations. Chest radiography in patients with acute cough is among the most common reasons for imaging in primary care, but data on associated incidental findings are lacking. We set out to describe the type and prevalence of incidental chest radiography findings in primary care patients with acute cough. METHODS We report on data from a cross-sectional study in 16 European primary care networks on 3,105 patients with acute cough, all of whom were undergoing chest radiography as part of a research study workup. Apart from assessment for specified signs of pneumonia and acute bronchitis, local radiologists were asked to evaluate any additional finding on the radiographs. For the 2,823 participants with good-quality chest radiographs, these findings were categorized according to clinical relevance based on previous research evidence and analyzed for type and prevalence by network, sex, age, and smoking status. RESULTS Incidental findings were reported in 19% of all participants, and ranged from 0% to 25% by primary care network, with the network being an independent contributor (P <.001). Of all participants 3% had clinically relevant incidental findings. Suspected nodules and shadows were reported in 1.8%. Incidental findings were more common is older participants and smokers (P <. 001). CONCLUSIONS Clinically relevant incidental findings on chest radiographs in primary care adult patients with acute cough are uncommon, and prevalence varies by setting.
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Affiliation(s)
- Saskia van Vugt
- University Medical Center Utrecht, Julius Center for Health Sciences and Primary Care, Utrecht, the Netherlands.
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Olofsson M, Toepfer M, Östgren CJ, Midlöv P, Matussek A, Lindgren PE, Mölstad S. Low level of antimicrobial resistance in Escherichia coli among Swedish nursing home residents. ACTA ACUST UNITED AC 2012; 45:117-23. [DOI: 10.3109/00365548.2012.717232] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Johansson RM, Malmvall BE, Andersson-Gäre B, Larsson B, Erlandsson I, Sund-Levander M, Rensfelt G, Mölstad S, Christensson L. Guidelines for preventing urinary retention and bladder damage during hospital care. J Clin Nurs 2012; 22:347-55. [DOI: 10.1111/j.1365-2702.2012.04229.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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Cars O, Mölstad S, Norman C, Ternhag A, André M, Erntell M. [National recommendations for the treatment of pharyngotonsillitis are valid]. Lakartidningen 2012; 109:108-109. [PMID: 22451987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
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Pettersson E, Vernby A, Mölstad S, Lundborg CS. Can a multifaceted educational intervention targeting both nurses and physicians change the prescribing of antibiotics to nursing home residents? A cluster randomized controlled trial. J Antimicrob Chemother 2011; 66:2659-66. [PMID: 21893568 DOI: 10.1093/jac/dkr312] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES To assess the impact of a multifaceted educational intervention concerning treatment of infections in the nursing home setting. METHODS We used a cluster randomized controlled trial. Fifty-eight nursing homes in Sweden were randomly assigned either to educational intervention or control. The intervention consisted of small educational group sessions with nurses and physicians, feedback on prescribing, presentation of guidelines and written materials. The primary outcome was the proportion of quinolones prescribed for lower urinary tract infection (UTI) in women. Secondary outcomes were for all infections: number of UTIs per resident, proportion of recorded infections treated with an antibiotic, proportion of infections handled by physicians as 'wait and see', and for lower UTI in women, proportion of nitrofurantoin. RESULTS Of the 58 nursing homes, 46 completed the study. A total of 702 and 540 infections were recorded pre- and post-intervention. The proportion of quinolones decreased significantly in the intervention and control groups, by -0.196 (9/93 to 36/123) and -0.224 (4/66 to 31/109), respectively [95% confidence interval (CI) -0.338, -0.054 and -0.394, -0.054], but the difference between intervention and control groups was not significant, with an absolute risk reduction of 0.028 (95% CI -0.193, 0.249). The changes in proportion of infections treated with antibiotics and proportion of infections handled by physicians as 'wait and see' was significant in comparison with controls: -0.124 (95% CI -0.228, -0.019) and 0.143 (95% CI 0.047, 0.240). No intervention effect could be seen for the other outcomes. CONCLUSIONS The educational intervention had no effect on the primary outcome, but decreased the overall prescribing of antibiotics.
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Affiliation(s)
- Eva Pettersson
- Division of Global Health (IHCAR), Department of Public Health Sciences, Karolinska Institutet, Nobels väg 9, SE-171 77 Stockholm, Sweden.
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Olofsson M, Lindgren PE, Ostgren CJ, Midlöv P, Mölstad S. Colonization with Staphylococcus aureus in Swedish nursing homes: a cross-sectional study. ACTA ACUST UNITED AC 2011; 44:3-8. [PMID: 21867472 DOI: 10.3109/00365548.2011.598875] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Screening for bacterial colonization among risk populations could provide better estimates of the volume of the bacteria-related disease reservoir and the level of antimicrobial resistance, than do conventional laboratory reports. METHODS Two hundred and one participants at 10 Swedish nursing homes were screened for colonization with Staphylococcus aureus between January and October 2009. Of the 201 participants, 61 (30%) were male. The median age was 86 y. All participants were systematically sampled from the nasal mucosa, the pharyngeal mucosa, the groin, and active skin lesions, if any. RESULTS Ninety-nine of 199 participants (50%) were colonized with S. aureus. The colonization rate was 34% for the nose, 35% for throat, 10% for groin, and 54% for active skin lesions. An antibiotic-resistant S. aureus isolate was identified in 8.5% of all participants regardless of colonization status. A total of 24 resistant isolates were detected, and 21 of these were resistant to fluoroquinolones. There was no case of colonization with methicillin-resistant S. aureus (MRSA). CONCLUSIONS The presence of resistant isolates was generally low, and the greater part of the resistance was fluoroquinolone-related. To achieve reasonable precision, screening programmes of this kind must include samples from both the nose and throat, and, although low, the prevalence of antimicrobial resistance in Swedish nursing homes still calls for reflection on how to use the fluoroquinolones wisely.
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Neumark T, Ekblom M, Brudin L, Groth A, Eliasson I, Mölstad S, Petersson AC, Törngren A. Spontaneously draining acute otitis media in children: an observational study of clinical findings, microbiology and clinical course. ACTA ACUST UNITED AC 2011; 43:891-8. [PMID: 21736512 DOI: 10.3109/00365548.2011.591820] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES To study the outcome of acute otitis media (AOM) with otorrhoea in children managed initially without antibiotics, in relation to bacterial and clinical findings, and to identify those who may benefit from antibiotics. METHODS Otherwise healthy, not otitis prone children aged 2-16 y, presenting with AOM with spontaneous otorrhoea, were recruited from primary care and followed at selected ear, nose and throat (ENT) clinics. Specimens for bacterial investigations were obtained; symptoms were registered on a daily basis. The main outcomes measured were the frequency of children treated with antibiotics due to persisting AOM within 9 days in relation to clinical and bacteriological findings, and new AOM within 3 months. RESULTS Twelve of 71 children who completed the trial received antibiotics during the first 9 days due to lack of improvement. One received antibiotics after 16 days due to relapsing AOM and 6 received antibiotics after 30 days due to new AOM. At 2-4 days following inclusion, over 70% of children showed normalized eardrum status and markedly reduced secretion. Alloiococcus otitidis was found in 23 samples, Streptococcus pneumoniae in 12, Streptococcus pyogenes in 6, and Fusobacterium nucleatum in 5. Mycoplasma pneumoniae, Chlamydia pneumoniae, and Fusobacterium necrophorum were not detected. Antibiotics were prescribed more extensively to children with a pulsating eardrum and abundant purulent secretion. All children with S. pyogenes received antibiotics, whereas children with only A. otitidis did not. CONCLUSIONS The results suggest that antibiotics are indicated in AOM with otorrhoea and the presence of abundant purulent secretion, a pulsating eardrum, or the presence of S. pyogenes. The presence of only A. otitidis was not associated with a more prolonged course or the need for antibiotics.
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Ernsth Bravell M, Westerlind B, Midlöv P, Östgren CJ, Borgquist L, Lannering C, Mölstad S. How to assess frailty and the need for care? Report from the Study of Health and Drugs in the Elderly (SHADES) in community dwellings in Sweden. Arch Gerontol Geriatr 2011; 53:40-5. [DOI: 10.1016/j.archger.2010.06.011] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2010] [Revised: 06/14/2010] [Accepted: 06/16/2010] [Indexed: 01/14/2023]
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Bjerrum L, Munck A, Gahrn-Hansen B, Hansen MP, Jarbol DE, Cordoba G, Llor C, Cots JM, Hernández S, López-Valcárcel BG, Pérez A, Caballero L, von der Heyde W, Radzeviciene R, Jurgutis A, Reutskiy A, Egorova E, Strandberg EL, Ovhed I, Mölstad S, Stichele RV, Benko R, Vlahovic-Palcevski V, Lionis C, Rønning M. Health Alliance for prudent antibiotic prescribing in patients with respiratory tract infections (HAPPY AUDIT) -impact of a non-randomised multifaceted intervention programme. BMC Fam Pract 2011; 12:52. [PMID: 21689406 PMCID: PMC3146837 DOI: 10.1186/1471-2296-12-52] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/25/2011] [Accepted: 06/20/2011] [Indexed: 11/17/2022]
Abstract
Background Excessive use of antibiotics is worldwide the most important reason for development of antimicrobial resistance. As antibiotic resistance may spread across borders, high prevalence countries may serve as a source of bacterial resistance for countries with a low prevalence. Therefore, bacterial resistance is an important issue with a potential serious impact on all countries. Initiatives have been taken to improve the quality of antibiotic prescribing in primary care, but only few studies have been designed to determine the effectiveness of multifaceted strategies across countries with different practice setting. The aim of this study was to evaluate the impact of a multifaceted intervention targeting general practitioners (GPs) and patients in six countries with different health organization and different prevalence of antibiotic resistance. Methods GPs from two Nordic countries, two Baltic Countries and two Hispano-American countries registered patients with respiratory tract infections (RTIs) in 2008 and 2009. After first registration they received individual prescriber feedback and they were offered an intervention programme that included training courses, clinical guidelines, posters for waiting rooms, patient brochures and access to point of care tests (Strep A and C-Reactive Protein). Antibiotic prescribing rates were compared before and after the intervention. Results A total of 440 GPs registered 47011 consultations; 24436 before the intervention (2008) and 22575 after the intervention (2009). After the intervention, the GPs significantly reduced the percentage of consultations resulting in an antibiotic prescription. In patients with lower RTI the GPs in Lithuania reduced the prescribing rate by 42%, in Russia by 25%, in Spain by 25%, and in Argentina by 9%. In patients with upper RTIs, the corresponding reductions in the antibiotic prescribing rates were in Lithania 20%, in Russia 15%, in Spain 9%, and in Argentina 5%. Conclusion A multifaceted intervention programme targeting GPs and patients and focusing on improving diagnostic procedures in patients with RTIs may lead to a marked reduction in antibiotic prescribing. The pragmatic before-after design used may suffer from some limitations and the reduction in antibiotic prescribing could be influenced by factors not related to the intervention.
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Affiliation(s)
- Lars Bjerrum
- Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark.
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Nilsson S, Mölstad S, Karlberg C, Karlsson JE, Persson LG. No connection between the level of exposition to statins in the population and the incidence/mortality of acute myocardial infarction: an ecological study based on Sweden's municipalities. J Negat Results Biomed 2011; 10:6. [PMID: 21609438 PMCID: PMC3127855 DOI: 10.1186/1477-5751-10-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2010] [Accepted: 05/24/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Randomised controlled trials have shown an excellent preventive effect of statins on ischemic heart disease. Our objective was to investigate if a relation can be detected between acute myocardial infarction- (AMI) mortality or incidence and statin utilisation, for men and women in different age-groups on a population basis. RESULTS The utilisation rate of statins increased almost three times for both men and women between 1998 and 2002. During 1998-2000 the incidence of AMI decreased clearly for men but only slightly for women. Mortality decreased from 1998 to 2002. The change in statin utilisation from 1998 to 2000 showed no correlation to the change in AMI mortality from 2000 to 2002. Statin utilisation and AMI- incidence or mortality showed no correlations when adjusting for socio-economic deprivation, antidiabetic drugs and geographic coordinates. CONCLUSIONS Despite a widespread and increasing utilisation of statins, no correlation to the incidence or mortality of AMI could be detected. Other factors than increased statin treatment should be analysed especially when discussing the allocation of public resources.
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Affiliation(s)
- Staffan Nilsson
- Division of Community Medicine, Department of Medicine and Health Sciences, Faculty of Health Sciences, Linköping University, Linköping, Sweden.
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Axelsson I, Mölstad S. [Less antibiotics should be given in otitis. Active expectancy for 1-12 years old--antibiotics for teenagers and adults]. Lakartidningen 2011; 108:1044-1045. [PMID: 21815330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
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Ernsth-Bravell M, Mölstad S. Easy-to-use definition of frailty for guiding care decisions in elderly individuals: probability or utopia? ACTA ACUST UNITED AC 2010. [DOI: 10.2217/ahe.10.68] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Affiliation(s)
- Marie Ernsth-Bravell
- Institute of gerontology, School of Health Sciences, Jönköping University, Box 1026, SE-551 11 Jönköping, Sweden
| | - Sigvard Mölstad
- Unit of Research and Development in Primary care, Futurum, Jönköping, Sweden
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Jakobsen KA, Melbye H, Kelly MJ, Ceynowa C, Mölstad S, Hood K, Butler CC. Influence of CRP testing and clinical findings on antibiotic prescribing in adults presenting with acute cough in primary care. Scand J Prim Health Care 2010; 28:229-36. [PMID: 20704523 PMCID: PMC3444795 DOI: 10.3109/02813432.2010.506995] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE Respiratory tract infections are the most common indication for antibiotic prescribing in primary care. The value of clinical findings in lower respiratory tract infection (LRTI) is known to be overrated. This study aimed to determine the independent influence of a point of care test (POCT) for C-reactive protein (CRP) on the prescription of antibiotics in patients with acute cough or symptoms suggestive of LRTI, and how symptoms and chest findings influence the decision to prescribe when the test is and is not used. DESIGN Prospective observational study of presentation and management of acute cough/LRTI in adults. SETTING Primary care research networks in Norway, Sweden, and Wales. SUBJECTS Adult patients contacting their GP with symptoms of acute cough/LRTI. MAIN OUTCOME MEASURES Predictors of antibiotic prescribing were evaluated in those tested and those not tested with a POCT for CRP using logistic regression and receiver operating characteristic (ROC) curve analysis. RESULTS A total of 803 patients were recruited in the three networks. Among the 372 patients tested with a POCT for CRP, the CRP value was the strongest independent predictor of antibiotic prescribing, with an odds ratio (OR) of CRP ≥ 50 mg/L of 98.1. Crackles on auscultation and a patient preference for antibiotics perceived by the GP were the strongest predictors of antibiotic prescribing when the CRP test was not used. CONCLUSIONS The CRP result is a major influence in the decision whether or not to prescribe antibiotics for acute cough. Clinicians attach less weight to discoloured sputum and abnormal lung sounds when a CRP value is available. CRP testing could prevent undue reliance on clinical features that poorly predict benefit from antibiotic treatment.
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Norman C, Mölstad S. [Bacterial skin and soft tissue infections in primary health care. Less antibiotics in view of new recommendations]. Lakartidningen 2010; 107:2961-2963. [PMID: 21213606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
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Hedin K, Andre M, Håkansson A, Mölstad S, Rodhe N, Petersson C. Infectious morbidity in 18-month-old children with and without older siblings. Fam Pract 2010; 27:507-12. [PMID: 20558499 DOI: 10.1093/fampra/cmq041] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Infections are the most commonly reported health problems in children. Younger age and day care outside the home are two factors of importance for infectious morbidity. The influence of siblings on infectious symptoms is not clear. OBJECTIVES To compare families with one child and families with more than one child in terms of reported infectious symptoms, physician consultations and antibiotic prescriptions. METHODS A prospective population-based survey was performed. During 1 month, all infectious symptoms, physician consultations and antibiotic prescriptions for 18-month-old children were noted by the parents. The 789 families also answered questions about socio-economic factors, numbers of siblings in the family and type of day care. RESULTS No difference in number of symptom days was found between children with and without older siblings. Neither could we find any significance in terms of having older siblings in relation to physician consultations and antibiotic prescriptions. CONCLUSIONS The results of our study indicate that having older siblings not was important in relation to number of symptoms days, physician consultations or antibiotic prescriptions for 18-month-old children in Sweden today. Changes in social activities and attitudes towards antibiotic prescription may explain our different findings as compared with previous Swedish studies and studies from other countries.
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Affiliation(s)
- Katarina Hedin
- Unit of Research and Development, Kronoberg County Council, Växjö, Sweden.
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Butler CC, Hood K, Kelly MJ, Goossens H, Verheij T, Little P, Melbye H, Torres A, Mölstad S, Godycki-Cwirko M, Almirall J, Blasi F, Schaberg T, Edwards P, Rautakorpi UM, Hupkova H, Wood J, Nuttall J, Coenen S. Treatment of acute cough/lower respiratory tract infection by antibiotic class and associated outcomes: a 13 European country observational study in primary care. J Antimicrob Chemother 2010; 65:2472-8. [PMID: 20852271 DOI: 10.1093/jac/dkq336] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Acute cough/lower respiratory tract infection (LRTI) is one of the commonest reasons for consulting and antibiotic prescribing. There are theoretical reasons why treatment with particular antibiotic classes may aid recovery more than others, but empirical, pragmatic evidence is lacking. We investigated whether treatment with a particular antibiotic class (amoxicillin) was more strongly associated with symptom score resolution and time to patients reporting recovery than each of eight other antibiotic classes or no antibiotic treatment for acute cough/LRTI. METHODS Clinicians recorded history, examination findings, symptom severity and antibiotic treatment for 3402 patients in a 13 country prospective observational study of adults presenting in 14 primary care research networks with acute cough/LRTI. 2714 patients completed a symptom score daily for up to 28 days and recorded the day on which they felt recovered. A three-level autoregressive moving average model (1,1) model investigated logged daily symptom scores to analyse symptom resolution. A two-level survival model analysed time to reported recovery. Clinical presentation was controlled for using clinician-recorded symptoms, sputum colour, temperature, age, co-morbidities, smoking status and duration of illness prior to consultation. RESULTS Compared with amoxicillin, no antibiotic class (and no antibiotic treatment) was associated with clinically relevant improved symptom resolution (all coefficients in the range -0.02 to 0.01 and all P values greater than 0.12). No antibiotic class (and no antibiotic treatment) was associated with faster time to recovery than amoxicillin. CONCLUSIONS Treatment by antibiotic class was not associated with symptom resolution or time to recovery in adults presenting to primary care with acute cough/LRTI.
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Affiliation(s)
- Christopher C Butler
- Department of Primary Care and Public Health, School of Medicine, Cardiff University, Cardiff, UK
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Neumark T, Brudin L, Mölstad S. Use of rapid diagnostic tests and choice of antibiotics in respiratory tract infections in primary healthcare--a 6-y follow-up study. ACTA ACUST UNITED AC 2010; 42:90-6. [PMID: 19902992 DOI: 10.3109/00365540903352932] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The aim of this retrospective study of electronic patient records in primary health care in Kalmar County, Sweden, was to describe consultations for respiratory tract infections (RTIs) in relation to age, choice of antibiotics and the use of rapid diagnostic tests. During the period 1999-2005, 240,445 visits for RTI were recorded. Children aged <2 y and especially those aged 2-16 y with acute otitis media (AOM), showed decreasing consultations between 2000 and 2005. The consultations for sore throat declined during the study period in all age groups and in 65% of these, antibiotics were prescribed, primarily penicillin V (82%). In sore throat, a positive Strep-A test result was followed by antibiotic prescription in about 92% of cases; when negative, the antibiotic prescription rate was 40%. C-reactive protein (CRP) was analyzed in 36% of all consultations for RTI. In common cold and acute bronchitis, the prescription rates of antibiotics rose with rising CRP. The results show that near-patient tests were used extensively, but often not in accordance with the guidelines. Antibiotic use decreased mainly as a consequence of declined visiting frequencies. This indicates that the new guidelines for AOM and sore throat may have influenced patient consultation habits more than physician prescribing habits.
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Affiliation(s)
- Thomas Neumark
- Lindsdals Primary Health Centre, Förlösavägen 4, Kalmar, Sweden.
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