Download L Bjerrum

Health Alliance for Prudent Prescribing, Yield
And Use of anti-microbial Drugs In the Treatment
of Respiratory Tract Infections
Proposal for EU DG Research, March 2006
Coordinator: Research Unit of General Practice, Odense, Denmark
Prevalence of penicillin resistant
pneumococci in Europe
0-5 %
0-2 %
20-30 %
0-5 %
0-5 %
35-40%
15-20 %
40-65 %
40-45%
2
Use of antibiotics in Europa 2002
DDD/1000 persons/day
Gossens et al: Outpatient antibiotic use in Europe and association with resistance: a cross-national database study.
The Lancet 2005
Penicillin-resistance
in pneumococci
Linear correlation between
use of antibiotics and
resistance
From: Emerging Infectious Diseases 2004;19(3):514
Selection for Antibiotic Resistance
Resistant Strains
Rare
Antimicrobial
Exposure
Resistant Strains
Dominant
HAPPY AUDIT
Objective
 to reduce the occurrence of
bacterial resistance
 by reducing prescribing
of unnecessary
antibiotics for respiratory
tract infections
 by improving the use of
appropriate antibiotics in
suspected bacterial
infections
 by improving the quality
of diagnostic procedures
for RTIs in general
practice
60
77
31
102
39
-
-
-
-
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
309
Kick-off meeting April 2007
Project time schedule
2007
2008
X
X
2009
2010
Analysis and conference
Second registration of Patients
Intervention: GPs and patients
First registration of Patients
First invitation of GPs
Total project period: 3 years (April 2007 – March 2010)
Kaliningrad
Sweden
Lithuania
Spain
Denmark
Argentina
Intervention material for
professionals
 Report with aggregated and individual
results
 Happy Audit Guidelines
 Laboratory test instructions
Reports in national
language including
individual results were sent
to all paticipating GPs
Respiratory
infections in
general practice
Results from
6 countries
My Practice
My Practice
My Practice
Centor criteria*:
1.
2.
3.
4.
Fever
Tender angular glands
Tonsil Coatings
Absence of cough
*Described by dr. Robert Centor
of the University of Alabama
Centor criteria and probability of
Streptococci
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
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%
11681
1274
10.9%
Total
Strep A test in Denmark
Strep A test in Sweden
Carriers of Streptococci
 5-10% of individuals are asymptomatic
carriers of streptococci
 A Strep A test will show that carriers have
streptococci even though they are not
causing symptoms.
 Generally, carriers should not be treated
with antibiotics
Overuse of Strep A may lead to
inappropriate antibiotic
treatments
 Generally, Strep A should not be
performed in:
 Asymptomatic carriers of Streptococci
 Patients with sore throat and less than 2
Centor criteria
100
80
60
40
20
0
1
2
EAPs/Facultatiu
3
4
5
Objectiu >70%
Conclusion
 Denmark, Sweden:
 Overuse of Strep may lead to inappropriate
antibiotic treatment and initiatives should be
taken to reduce overuse of Strep A testing in
general practice
 Spain, Argentina, Lithuania, Russia:
 Introduction of Strep A may leed to a lower
prescribing in patients with sore thorat and
initiatives should be taken to introduce Strep A
in general practice
”The more you use it,
- the faster you lose it”
Burke JP, Lancet 1995;345:977
www.happyaudit.org
Collaboration in Europe about
rational prescribing of antibiotics
CHAMP
Changing behaviour of Health care
professionals And the general public
towards a More Prudent use of antimicrobial agents.
Thank you
[email protected]
Validation study of
Strep A in general
practice in Barcelona
 Inclusded 182
patients with sore
throat and ≥ 2 Centor
criteria
 Tests:
 Throat Culture
 Strep A
44
Amigdalitis
La validez de la prueba de Strep A
pare diagnosticar Estrep betahem gr A
Cult +
Cult -
Total
Strep A pos.
38
10
48
Strep A neg.
2
132
134
40
142
182
Sensitivity:
38/40 = 95%
Pos predictive value
PPV = 38/48 = 79%
Neg predictive value
NPV = 132/134 = 98%
Specificity:
132/142 = 93%
Llor et al. Validación de una técnica antigénica rápida en el diagnóstico de la faringitis por esptreptococo betahemolitico del grupo A, Aten Primaria 2008
Nycocard CRP single test
 Axis-Shield,
Norway
 Training through
local distributors
 Instrument free
during test period
Development of
quality indicators
for diagnosis and treatment of
respiratory tract infections
in general practice
Tonsillitis/pharyngitis
Number of patients with a positive StrepA test
-------------------------------------------------------------------------Number of patients with acute tonsillitis/pharyngitis
treated with antibiotics
Number of patients treated with narrow-spectrum penicillin (J01CE)
---------------------------------------------------------------------------------------Number of patients
with acute tonsillitis/pharyngitis
treated with antibiotics
Experts – to do
 Rate to what extent they agree with the
relevance of the 59 quality indicators –
according to:
A. Reducing antimicrobial resistance
B. Clinical relevance for the patient*
* Reducing symptoms and/or shortening duration of the actual course
of the disease
Consensus
The item should be retained:
≥ 75 % of participants scored the item ≥ 5
The item should be excluded:
≥ 75 % of participants scored the item ≤ 3
No consensus:
items which failed to meet either of the above criteria
The final set of indicators









6 acute sinusitis
9 acute otitis media
6 acute tonsillitis/pharyngitis
7 acute lower respiratory tract infection (LRTI)
1 acute respiratory tract infection (RTI)
1 penicillin allergy
1 acute bronchitis
5 pneumonia
5 exacerbation of chronic obstructive pulmonary disease
(COPD)
Number of
doctors
Number of patients
registered
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
77
1853
764
618
33273
10937
Sweden
Total
Conclusion
 Participating GPs
 Estimated: 400
 Real number 618
 Number of consultations registered
 Estimated 20-25.000
 Real number: 33.273
 Written material completed for all partners
 Guidelines, Patient brochures, Reports etc
Days with symptoms