h ealth a lliance for p rudent p rescribing, y ield
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HHealth ealth AAlliance for lliance for PPrudent rudent PPrescribing, rescribing, YYield ield
AAndnd UUsese of anti-microbial of anti-microbial DDrugs rugs IIn the n the TTreatment reatment of Respiratory Tract Infectionsof Respiratory Tract Infections
Proposal for EU DG Research, March 2006
Coordinator: Research Unit of General Practice, Odense, Denmark
22
40-65 %
15-20 %
35-40%
40-45%
0-2 %
20-30 % 0-5 %
0-5 %
0-5 %
Prevalence of penicillin resistant pneumococci in Europe
Use of antibiotics in Europa 2002Use of antibiotics in Europa 2002DDD/1000 persons/dayDDD/1000 persons/day
Gossens et al: Outpatient antibiotic use in Europe and association with resistance: a cross-national database study. The Lancet 2005
From: Emerging Infectious Diseases 2004;19(3):514
Penicillin-resistance in pneumococci
Linear correlation between use of antibiotics and
resistance
Resistant StrainsRare
xx
Resistant Strains Dominant
Antimicrobial Exposure
xxxx
xx
xx
xx
Selection for Antibiotic ResistanceSelection for Antibiotic Resistance
HAPPY AUDITHAPPY AUDITObjectiveObjective
to reduce the occurrence of to reduce the occurrence of bacterial resistancebacterial resistance by reducing prescribing by reducing prescribing
of unnecessary of unnecessary antibiotics for respiratory antibiotics for respiratory tract infections tract infections
by improving the use of by improving the use of appropriate antibiotics in appropriate antibiotics in suspected bacterial suspected bacterial infectionsinfections
by improving the quality by improving the quality of diagnostic procedures of diagnostic procedures for RTIs in general for RTIs in general practicepractice
102
77
309
39
31
60
- Nordic region- Denmark 102 GPs- Sweden 77 GPs
- Balticum region- Lithuania 31 GPs- Kaliningrad 39 GPs
- Region Hispano-America: - Spain 309 GPs- Argentina 60GPs
- TOTAL 618 GPs
Kick-off meeting April 2007Kick-off meeting April 2007
Project time scheduleProject time schedule
Total project period: 3 years (April 2007 – March 2010)
2007 2008 2009 2010
Analysis and conference
Second registration of Patients
First registration of Patients
X
Intervention: GPs and patients
First invitation of GPs
X
Kaliningrad
Sweden
Lithuania
Spain
Denmark
Argentina
Intervention material for Intervention material for professionalsprofessionals
Report with aggregated and individual Report with aggregated and individual resultsresults
Happy Audit GuidelinesHappy Audit Guidelines Laboratory test instructionsLaboratory test instructions
Respiratory infections in
general practice
Results from 6 countries
Reports in national language including individual results were sent to all paticipating GPs
My Practice
My Practice My Practice
Centor criteria*:Centor criteria*:
1.1. FeverFever2.2. Tender angular glands Tender angular glands 3.3. Tonsil Coatings Tonsil Coatings 4.4. Absence of cough Absence of cough
*Described by dr. Robert Centor *Described by dr. Robert Centor of the University of Alabamaof the University of Alabama
Centor criteria and probability of Centor criteria and probability of StreptococciStreptococci
Number of Centor Criteria
Probability of Streptococci
Recommandation
0 2% No test – no treatment
1 3% No test – no treatment
2 8% Test and treat
3 19% Test and treat
4 41% Test and treat
Patients with 0-1 Centor criteria should not be tested with Strep A
Use of Strep A in patients with Use of Strep A in patients with odinophagia (painful swallowing)odinophagia (painful swallowing)
Patients StrepA performed
Percentage with Strep A
Argentina 1500 33 2.2%
Denmark 1061 822 77.5%
Lithuania 803 0 0.0%
Russia 764 4 0.5%
Spain 7052 96 1.4%
Sweden 501 319 63.7%
Total 11681 1274 10.9%
Strep A test in DenmarkStrep A test in Denmark
Strep A test in SwedenStrep A test in Sweden
Carriers of StreptococciCarriers of Streptococci 5-10% of individuals are asymptomatic 5-10% of individuals are asymptomatic
carriers of streptococcicarriers of streptococci A Strep A test will show that carriers have A Strep A test will show that carriers have
streptococci streptococci even though they are not even though they are not causing symptomscausing symptoms. .
Generally, carriers should not be treated Generally, carriers should not be treated with antibioticswith antibiotics
Overuse of Strep A may lead to Overuse of Strep A may lead to inappropriate antibiotic inappropriate antibiotic
treatmentstreatments
Generally, Strep A should not be Generally, Strep A should not be performed in:performed in:
Asymptomatic carriers of StreptococciAsymptomatic carriers of Streptococci Patients with sore throat and less than 2 Patients with sore throat and less than 2
Centor criteriaCentor criteria
ConclusionConclusion
Denmark, Sweden:Denmark, Sweden: Overuse of Strep may lead to inappropriate Overuse of Strep may lead to inappropriate
antibiotic treatment and initiatives should be antibiotic treatment and initiatives should be taken to reduce overuse of Strep A testing in taken to reduce overuse of Strep A testing in general practicegeneral practice
Spain, Argentina, Lithuania, Russia:Spain, Argentina, Lithuania, Russia: Introduction of Strep A may leed to a lower Introduction of Strep A may leed to a lower
prescribing in patients with sore thorat and prescribing in patients with sore thorat and initiatives should be taken to introduce Strep A in initiatives should be taken to introduce Strep A in general practice general practice
0
20
40
60
80
100
1 2 3 4 5
EAPs/Facultatiu Objectiu >70%
”The more you use it,- the faster you lose it”
Burke JP, Lancet 1995;345:977
Collaboration in Europe about Collaboration in Europe about rational prescribing of antibioticsrational prescribing of antibiotics
CHAMPChanging behaviour of Health care
professionals And the general public towards a More Prudent use of anti-
microbial agents.
lbjerrum@health.sdu.dk
Thank you
Validation study of Validation study of Strep A in general Strep A in general practice in Barcelonapractice in Barcelona
Inclusded 182 Inclusded 182 patients with sore patients with sore throat and ≥ 2 Centor throat and ≥ 2 Centor criteriacriteria
Tests: Tests: Throat CultureThroat Culture Strep AStrep A
4444
AmigdalitisAmigdalitisLa validez de la prueba de Strep A La validez de la prueba de Strep A pare diagnosticar Estrep betahem gr Apare diagnosticar Estrep betahem gr A
Cult + Cult - Total
Strep A pos.
Strep A neg.
Pos predictive valuePPV = 38/48 = 79%
Neg predictive valueNPV = 132/134 = 98%
Specificity: 132/142 = 93%
132
10
2
38
142 40
134
48
182
Sensitivity:38/40 = 95%
Llor et al. Validación de una técnica antigénica rápida en el diagnóstico de la faringitis por esptreptococo beta-hemolitico del grupo A, Aten Primaria 2008
Nycocard CRP single testNycocard CRP single test
Axis-Shield, Axis-Shield, NorwayNorway Training through Training through
local distributorslocal distributors Instrument free Instrument free
during test periodduring test period
Development of Development of
quality indicators quality indicators for diagnosis and treatment offor diagnosis and treatment of
respiratory tract infections respiratory tract infections
in general practice in general practice
Tonsillitis/pharyngitisTonsillitis/pharyngitisNumber of patients with a positive StrepA testNumber of patients with a positive StrepA test
----------------------------------------------------------------------------------------------------------------------------------------------------Number of patients with acute tonsillitis/pharyngitis Number of patients with acute tonsillitis/pharyngitis
treated with antibiotics treated with antibiotics
Number of patients treated with narrow-spectrum penicillin Number of patients treated with narrow-spectrum penicillin (J01CE)(J01CE)
---------------------------------------------------------------------------------------Number of patients ---------------------------------------------------------------------------------------Number of patients with acute tonsillitis/pharyngitis with acute tonsillitis/pharyngitis
treated with antibioticstreated with antibiotics
Experts – to doExperts – to do
Rate to what extent they agree with the Rate to what extent they agree with the relevancerelevance of the 59 quality indicators – of the 59 quality indicators – according to: according to:
A. Reducing antimicrobial resistanceA. Reducing antimicrobial resistance
B. Clinical relevance for the patient*B. Clinical relevance for the patient*
* Reducing symptoms and/or shortening duration of the actual course * Reducing symptoms and/or shortening duration of the actual course of the diseaseof the disease
ConsensusConsensus
The item should be retained: The item should be retained:
≥ ≥ 75 % of participants scored the item ≥ 575 % of participants scored the item ≥ 5
The item should be excluded: The item should be excluded:
≥ ≥ 75 % of participants scored the item ≤ 375 % of participants scored the item ≤ 3
No consensus: No consensus: items which failed to meet either of the above criteriaitems which failed to meet either of the above criteria
The final set of indicatorsThe final set of indicators
6 6 acute sinusitisacute sinusitis 9 acute9 acute otitis mediaotitis media 6 acute tonsillitis/pharyngitis6 acute tonsillitis/pharyngitis 7 acute lower respiratory tract infection (LRTI)7 acute lower respiratory tract infection (LRTI) 1 acute respiratory tract infection (RTI)1 acute respiratory tract infection (RTI) 1 penicillin allergy1 penicillin allergy 1 acute bronchitis1 acute bronchitis 5 pneumonia 5 pneumonia 5 exacerbation of chronic obstructive pulmonary disease 5 exacerbation of chronic obstructive pulmonary disease
(COPD)(COPD)
Number of doctors
Number of patientsregistered
Number of patients treated with antibiotics
Argentina 60 4374 1780
Denmark 102 3904 1351
Lithauen 31 2706 1152
Russia 39 3685 1215
Spain 309 16751 4675
Sweden 77 1853 764
Total 618 33273 10937
ConclusionConclusion Participating GPsParticipating GPs
Estimated: 400Estimated: 400 Real number 618Real number 618
Number of consultations registeredNumber of consultations registered Estimated 20-25.000Estimated 20-25.000 Real number: 33.273Real number: 33.273
Written material completed for all partnersWritten material completed for all partners Guidelines, Patient brochures, Reports etcGuidelines, Patient brochures, Reports etc
Days with symptomsDays with symptoms
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