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El Feghaly RE, Jaggi P, Katz SE, Poole NM. "Give Me Five": The Case for 5 Days of Antibiotics as the Default Duration for Acute Respiratory Tract Infections. J Pediatric Infect Dis Soc 2024; 13:328-333. [PMID: 38581154 DOI: 10.1093/jpids/piae034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Accepted: 04/04/2024] [Indexed: 04/08/2024]
Abstract
Acute respiratory tract infections (ARTIs) account for most antibiotic prescriptions in pediatrics. Although US guidelines continue to recommend ≥10 days antibiotics for common ARTIs, evidence suggests that 5-day courses can be safe and effective. Academic imprinting seems to play a major role in the continued use of prolonged antibiotic durations. In this report, we discuss the evidence supporting short antibiotic courses for group A streptococcal pharyngitis, acute otitis media, and acute bacterial rhinosinusitis. We discuss the basis for prolonged antibiotic course recommendations and recent literature investigating shorter courses. Prescribers in the United States should overcome academic imprinting and follow international trends to reduce antibiotic durations for common ARTIs, where 5 days is a safe and efficacious course when antibiotics are prescribed.
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Affiliation(s)
- Rana E El Feghaly
- Department of Pediatrics, Children's Mercy Kansas City, University of Missouri Kansas City, Kansas City, Missouri, USA
| | - Preeti Jaggi
- Department of Pediatrics, Emory University, Atlanta, Georgia, USA
| | - Sophie E Katz
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Nicole M Poole
- Department of Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, Colorado, USA
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Moragas A, Sarvisé C, Gómez F, Picó-Plana E, Crispi S, Llor C. Duration of severe and moderate symptoms in pharyngitis by cause. Aten Primaria 2024; 56:102994. [PMID: 38875835 PMCID: PMC11225166 DOI: 10.1016/j.aprim.2024.102994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Revised: 05/03/2024] [Accepted: 05/07/2024] [Indexed: 06/16/2024] Open
Abstract
OBJECTIVE This study aimed to assess the cause of acute pharyngitis and determine the duration of severe and moderate symptoms based on the aetiology. DESIGN Prospective observational study. SITE: One urban health care centre. PARTICIPANTS Patients aged 15 or older with acute pharyngitis were included. INTERVENTIONS Bacterial identification was carried out in the microbiology lab using MALDI-TOF in two throat samples. Patients received a symptom diary to return after one week. MAIN MEASUREMENTS Number of days with severe symptoms, scoring 5 or more in any of the symptoms included in the symptom diary, and moderate symptoms, scoring 3 or more. RESULTS Among the 149 patients recruited, beta-haemolytic streptococcus group A (GABHS) was the most common aetiology. Symptoms and signs alone as well as the mean Centor score cannot distinguish between GABHS and other bacterial causes in patients with acute pharyngitis. However, there was a trend indicating that infections caused by Streptococcus dysgalactiae and Streptococcus agalactiae presented more severe symptoms, whereas infections attributed to the Streptococcus anginosus group, Fusobacterium spp., and those where oropharyngeal microbiota was isolated tended to have milder symptoms. S. dysgalactiae infections showed a trend towards longer severe and moderate symptom duration. CONCLUSION GABHS was the most prevalent, but group C streptococcus caused more severe and prolonged symptoms.
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Affiliation(s)
- Ana Moragas
- Department of Medicine and Surgery, Universitat Rovira i Virgili, Tarragona, Spain; University Institute in Primary Care Research Jordi Gol, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain; Jaume I Health Centre, Catalan Institute of Health, Tarragona, Spain
| | - Carolina Sarvisé
- Microbiology/Clinical Analysis Laboratori Clínic ICS Camp de Tarragona, Hospital Universitari de Tarragona Joan XXIII, Tarragona, Spain; Pere Virgili Health Research Institute (IISPV), Tarragona, Spain
| | - Frederic Gómez
- Department of Medicine and Surgery, Universitat Rovira i Virgili, Tarragona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain; Microbiology/Clinical Analysis Laboratori Clínic ICS Camp de Tarragona, Hospital Universitari de Tarragona Joan XXIII, Tarragona, Spain; Pere Virgili Health Research Institute (IISPV), Tarragona, Spain
| | - Ester Picó-Plana
- Microbiology/Clinical Analysis Laboratori Clínic ICS Camp de Tarragona, Hospital Universitari de Tarragona Joan XXIII, Tarragona, Spain; Pere Virgili Health Research Institute (IISPV), Tarragona, Spain
| | - Silvia Crispi
- Jaume I Health Centre, Catalan Institute of Health, Tarragona, Spain
| | - Carl Llor
- University Institute in Primary Care Research Jordi Gol, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain; Via Roma Health Centre, Catalan Institute of Health, Barcelona, Spain; Department of Public Health, General Practice, University of Southern Denmark, Odense, Denmark.
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3
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Bakhit M, Gamage SK, Atkins T, Glasziou P, Hoffmann T, Jones M, Sanders S. Diagnostic performance of clinical prediction rules to detect group A beta-haemolytic streptococci in people with acute pharyngitis: a systematic review. Public Health 2024; 227:219-227. [PMID: 38241903 DOI: 10.1016/j.puhe.2023.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 11/20/2023] [Accepted: 12/05/2023] [Indexed: 01/21/2024]
Abstract
OBJECTIVE To assess and compare the diagnostic performance of Clinical Prediction Rules (CPRs) developed to detect group A Beta-haemolytic streptococci in people with acute pharyngitis (or sore throat). STUDY DESIGN A systematic review. METHODS We searched PubMed, Embase and Web of Science (inception-September 2022) for studies deriving and/or validating CPRs comprised of ≥2 predictors from an individual's history or physical examination. Two authors independently screened articles, extracted data and assessed risk of bias in included studies. A meta-analysis was not possible due to heterogeneity. Instead we compared the performance of CPRs when they were validated in the same study population (head-to-head comparisons). We used a modified grading of recommendations, assessment, development, and evaluations (GRADE) approach to assess certainty of the evidence. RESULTS We included 63 studies, all judged at high risk of bias. Of 24 derived CPRs, 7 were externally validated (in 46 external validations). Five validation studies provided data for head-to-head comparison of four pairs of CPRs. Very low certainty evidence favoured the Centor CPR over the McIsaac (2 studies) and FeverPain CPRs (1 study) and found the Centor CPR was equivalent to the Walsh CPR (1 study). The AbuReesh and Steinhoff 2005 CPRs had a similar poor discriminative ability (1 study). Within and between study comparisons suggested the performance of the Centor CPR may be better in adults (>18 years). CONCLUSION Very low certainty evidence suggests a better performance of the Centor CPR. When deciding about antibiotic prescribing for pharyngitis patients, involving patients in a shared decision making discussion about the likely benefits and harms, including antibiotic resistance, is recommended. Further research of higher rigour, which compares CPRs across multiple settings, is needed.
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Affiliation(s)
- Mina Bakhit
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Australia.
| | | | - Tiffany Atkins
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Australia.
| | - Paul Glasziou
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Australia.
| | - Tammy Hoffmann
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Australia.
| | - Mark Jones
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Australia.
| | - Sharon Sanders
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Australia.
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García-Callejo FJ, Martínez-Giménez LC, Ortega-García L, López-Carbonell Z, Alba-García JR, Miñarro-Díaz C. [Design of a predictive score table for peritonsillar infection based on signs and symptoms]. Semergen 2024; 50:102076. [PMID: 37837727 DOI: 10.1016/j.semerg.2023.102076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 07/12/2023] [Accepted: 07/21/2023] [Indexed: 10/16/2023]
Abstract
BACKGROUND Peritonsillar infection (PTI) is a reason for urgent consultation due to intense throat discomfort. A delayed or inaccurate diagnosis can jeopardize the upper aerodigestive tract and be fatal in its evolution. Our objective was to develop a predictive model for the presence of IPA helping in its rapid detection. PATIENTS AND METHODS A 66-month retrospective observational study from 2017 was carried out in a county and tertiary referral hospitals, registering data from all patients diagnosed with PTI and a proportional volume of subjects with pharyngeal symptoms without PTI. Collection of clinical, exploratory and demographic data among participants. Their higher relative risk of PTI presence allowed them to be considered as variables to be tested. Development of a scoring scale for the probability of suffering from it and logistic regression analysis, obtaining the ROC curve with the best diagnostic correlation. Internal validation and estimation of the predictive values of the model. RESULTS On 348 cases of PTI, the assessment scale scored the presence of six variables: trismus (3), unilateral dysphagia-odynophagia (2), velar bulging (2), reflex otalgia (1), pharyngolalia (1) and age between 16 and 46 years (1). With a range of 0-10, a cut-off ≥6 offered a sensitivity of 96.1%, a specificity of 93.9%, and an efficiency of 94.9%. The area under the ROC curve was 0.979. CONCLUSIONS The internal validation of this model based on signs and symptoms makes it a very useful tool for early detection of PTI in otorhinolaryngology and primary care.
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Affiliation(s)
- F J García-Callejo
- Servicio de Otorrinolaringología, Hospital de Requena, Requena, Valencia, España; Consorcio Hospital General Universitario de Valencia, Valencia, España.
| | - L C Martínez-Giménez
- Servicio de Otorrinolaringología, Hospital de Requena, Requena, Valencia, España
| | - L Ortega-García
- Servicio de Otorrinolaringología, Hospital de Requena, Requena, Valencia, España
| | - Z López-Carbonell
- Consorcio Hospital General Universitario de Valencia, Valencia, España
| | - J R Alba-García
- Consorcio Hospital General Universitario de Valencia, Valencia, España
| | - C Miñarro-Díaz
- Servicio de Otorrinolaringología, Hospital de Requena, Requena, Valencia, España
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Boateng I, Stuart B, Becque T, Barrett B, Bostock J, Bruyndonckx R, Carr-Knox L, Ciccone EJ, Coenen S, Ebell M, Gillespie D, Hayward G, Hedin K, Hood K, Lau TMM, Little P, Merenstein D, Mulogo E, Ordóñez-Mena J, Muir P, Samuel K, Shaikh N, Tonner S, van der Velden AW, Verheij T, Wang K, Hay AD, Francis N. Using microbiological data to improve the use of antibiotics for respiratory tract infections: A protocol for an individual patient data meta-analysis. PLoS One 2023; 18:e0294845. [PMID: 38011202 PMCID: PMC10681295 DOI: 10.1371/journal.pone.0294845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 11/09/2023] [Indexed: 11/29/2023] Open
Abstract
BACKGROUND Resistance to antibiotics is rising and threatens future antibiotic effectiveness. 'Antibiotic targeting' ensures patients who may benefit from antibiotics receive them, while being safely withheld from those who may not. Point-of-care tests may assist with antibiotic targeting by allowing primary care clinicians to establish if symptomatic patients have a viral, bacterial, combined, or no infection. However, because organisms can be harmlessly carried, it is important to know if the presence of the virus/bacteria is related to the illness for which the patient is being assessed. One way to do this is to look for associations with more severe/prolonged symptoms and test results. Previous research to answer this question for acute respiratory tract infections has given conflicting results with studies has not having enough participants to provide statistical confidence. AIM To undertake a synthesis of IPD from both randomised controlled trials (RCTs) and observational cohort studies of respiratory tract infections (RTI) in order to investigate the prognostic value of microbiological data in addition to, or instead of, clinical symptoms and signs. METHODS A systematic search of Cochrane Central Register of Controlled Trials, Ovid Medline and Ovid Embase will be carried out for studies of acute respiratory infection in primary care settings. The outcomes of interest are duration of disease, severity of disease, repeated consultation with new/worsening illness and complications requiring hospitalisation. Authors of eligible studies will be contacted to provide anonymised individual participant data. The data will be harmonised and aggregated. Multilevel regression analysis will be conducted to determine key outcome measures for different potential pathogens and whether these offer any additional information on prognosis beyond clinical symptoms and signs. TRIAL REGISTRATION PROSPERO Registration number: CRD42023376769.
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Affiliation(s)
- Irene Boateng
- Primary Care Research Centre, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | - Beth Stuart
- Primary Care Research Centre, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
- Centre for Evaluation and Methods, Wolfson Institute of Population Health, Queen Mary University of London, London, United Kingdom
| | - Taeko Becque
- Primary Care Research Centre, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | - Bruce Barrett
- Dept of Family Medicine, University of Wisconsin, Madison, WI, United States of America
| | - Jennifer Bostock
- Primary Care Research Centre, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | - Robin Bruyndonckx
- Data Science Institute, I-BioStat, Hasselt University, Martelarenlaan, Hasselt, Belgium
| | - Lucy Carr-Knox
- Centre for Evaluation and Methods, Wolfson Institute of Population Health, Queen Mary University of London, London, United Kingdom
| | - Emily J. Ciccone
- Division of Infectious Diseases, University of North Carolina School of Medicine, Chapel Hill, North Carolina, United States of America
| | - Samuel Coenen
- Centre for General Practice, Department of Family Medicine and Population Health, University of Antwerp, Antwerp, Belgium
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute, University of Antwerp, Antwerp, Belgium
| | - Mark Ebell
- Department of Epidemiology and Biostatistics, College of Public Health, University of Georgia, Athens, Georgia, United States of America
| | - David Gillespie
- Centre for Trials Research, School of Medicine, Cardiff University, Cardiff, Wales, United Kingdom
| | - Gail Hayward
- Nuffield Department of Primary Care, University of Oxford, Oxford, United Kingdom
| | - Katarina Hedin
- Futurum, Region Jönköping County, Sweden
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Kerenza Hood
- Centre for Trials Research, School of Medicine, Cardiff University, Cardiff, Wales, United Kingdom
| | - Tin Man Mandy Lau
- Centre for Trials Research, School of Medicine, Cardiff University, Cardiff, Wales, United Kingdom
| | - Paul Little
- Primary Care Research Centre, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | - Dan Merenstein
- Dept of Family Medicine, Georgetown University, Washington DC, United States of America
| | - Edgar Mulogo
- Department of Community Health, Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Jose Ordóñez-Mena
- Nuffield Department of Primary Care, University of Oxford, Oxford, United Kingdom
| | - Peter Muir
- UK Health Security Agency South West Regional Laboratory, Southmead Hospital, Bristol, United Kingdom
| | - Kirsty Samuel
- Primary Care Research Centre, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | - Nader Shaikh
- School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Sharon Tonner
- Nuffield Department of Primary Care, University of Oxford, Oxford, United Kingdom
| | - Alike W. van der Velden
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Theo Verheij
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Kay Wang
- Primary Care Research Centre, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | - Alastair D. Hay
- Centre for Academic Primary Care, Bristol Medical School: Population Health Sciences, University of Bristol, Bristol, United Kingdom
| | - Nick Francis
- Primary Care Research Centre, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
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van Staa T, Sharma A, Palin V, Fahmi A, Cant H, Zhong X, Jury F, Gold N, Welfare W, Ashcroft D, Tsang JY, Elliott RA, Sutton C, Armitage C, Couch P, Moulton G, Tempest E, Buchan IE. Knowledge support for optimising antibiotic prescribing for common infections in general practices: evaluation of the effectiveness of periodic feedback, decision support during consultations and peer comparisons in a cluster randomised trial (BRIT2) - study protocol. BMJ Open 2023; 13:e076296. [PMID: 37607793 PMCID: PMC10445367 DOI: 10.1136/bmjopen-2023-076296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 07/12/2023] [Indexed: 08/24/2023] Open
Abstract
INTRODUCTION This project applies a Learning Healthcare System (LHS) approach to antibiotic prescribing for common infections in primary care. The approach involves iterations of data analysis, feedback to clinicians and implementation of quality improvement activities by the clinicians. The main research question is, can a knowledge support system (KSS) intervention within an LHS implementation improve antibiotic prescribing without increasing the risk of complications? METHODS AND ANALYSIS A pragmatic cluster randomised controlled trial will be conducted, with randomisation of at least 112 general practices in North-West England. General practices participating in the trial will be randomised to the following interventions: periodic practice-level and individual prescriber feedback using dashboards; or the same dashboards plus a KSS. Data from large databases of healthcare records are used to characterise heterogeneity in antibiotic uses, and to calculate risk scores for clinical outcomes and for the effectiveness of different treatment strategies. The results provide the baseline content for the dashboards and KSS. The KSS comprises a display within the electronic health record used during the consultation; the prescriber (general practitioner or allied health professional) will answer standard questions about the patient's presentation and will then be presented with information (eg, patient's risk of complications from the infection) to guide decision making. The KSS can generate information sheets for patients, conveyed by the clinicians during consultations. The primary outcome is the practice-level rate of antibiotic prescribing (per 1000 patients) with secondary safety outcomes. The data from practices participating in the trial and the dashboard infrastructure will be held within regional shared care record systems of the National Health Service in the UK. ETHICS AND DISSEMINATION Approved by National Health Service Ethics Committee IRAS 290050. The research results will be published in peer-reviewed journals and also disseminated to participating clinical staff and policy and guideline developers. TRIAL REGISTRATION NUMBER ISRCTN16230629.
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Affiliation(s)
- Tjeerd van Staa
- Centre for Health Informatics, The University of Manchester, Manchester, UK
| | | | - Victoria Palin
- Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Ali Fahmi
- Centre for Health Informatics, The University of Manchester, Manchester, UK
| | - Harriet Cant
- Centre for Health Informatics, The University of Manchester, Manchester, UK
| | - Xiaomin Zhong
- Centre for Health Informatics, The University of Manchester, Manchester, UK
| | - Francine Jury
- Centre for Health Informatics, The University of Manchester, Manchester, UK
| | - Natalie Gold
- Faculty of Philosophy, University of Oxford, Oxford, UK
| | | | - Darren Ashcroft
- NIHR School for Primary Care Research, Centre for Primary Care and Health Services Research, The University of Manchester, Manchester, UK
| | - Jung Yin Tsang
- Centre for Primary Care and Health Services Research, University of Manchester, Manchester, UK
| | - Rachel Ann Elliott
- Manchester Centre for Health Economics, The University of Manchester, Manchester, UK
| | - Christopher Sutton
- Division of Population Health, Health Services Research & Primary Care, University of Manchester, Manchester, UK
| | - Chris Armitage
- Manchester Centre for Health Psychology, University of Manchester, Manchester, UK
| | - Philip Couch
- Centre for Health Informatics, The University of Manchester, Manchester, UK
| | - Georgina Moulton
- Centre for Health Informatics, The University of Manchester, Manchester, UK
| | - Edward Tempest
- Centre for Health Informatics, The University of Manchester, Manchester, UK
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Gunnarsson RK, Ebell M, Centor R, Little P, Verheij T, Lindbaek M, Sundvall PD. Best management of patients with an acute sore throat is still best management for these patients. Infect Dis (Lond) 2023; 55:521-523. [PMID: 37198950 DOI: 10.1080/23744235.2023.2212054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 05/04/2023] [Indexed: 05/19/2023] Open
Affiliation(s)
- Ronny K Gunnarsson
- Department of Public Health and Community Medicine, General Practice/Family Medicine, Institute of Medicine, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Research, Development, Education and Innovation, Primary Health Care, Research and Development Center, Södra Älvsborg, Region Västra Götaland, Boras, Sweden
- Centre for Antibiotic Resistance Research (CARe) at University of Gothenburg, Gothenburg, Sweden
- The Primary Health Care Clinic for Homeless People, Närhälsan, Region Västra Götaland, Gothenburg, Sweden
| | - Mark Ebell
- Department of Epidemiology and Biostatistics, College of Public Health, University of Georgia, Athens, GA, USA
| | | | - Paul Little
- Primary Care Research Centre, University of Southampton, Southampton, UK
| | - Theo Verheij
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Morten Lindbaek
- Antibiotic Centre for Primary Care and Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Pär-Daniel Sundvall
- Department of Public Health and Community Medicine, General Practice/Family Medicine, Institute of Medicine, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Research, Development, Education and Innovation, Primary Health Care, Research and Development Center, Södra Älvsborg, Region Västra Götaland, Boras, Sweden
- Centre for Antibiotic Resistance Research (CARe) at University of Gothenburg, Gothenburg, Sweden
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Little P, Francis NA, Stuart B, O'Reilly G, Thompson N, Becque T, Hay AD, Wang K, Sharland M, Harnden A, Yao G, Raftery J, Zhu S, Little J, Hookham C, Rowley K, Euden J, Harman K, Coenen S, Read RC, Woods C, Butler CC, Faust SN, Leydon G, Wan M, Hood K, Whitehurst J, Richards-Hall S, Smith P, Thomas M, Moore M, Verheij T. Antibiotics for lower respiratory tract infection in children presenting in primary care: ARTIC-PC RCT. Health Technol Assess 2023; 27:1-90. [PMID: 37436003 DOI: 10.3310/dgbv3199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/13/2023] Open
Abstract
Background Antimicrobial resistance is a global health threat. Antibiotics are commonly prescribed for children with uncomplicated lower respiratory tract infections, but there is little randomised evidence to support the effectiveness of antibiotics in treating these infections, either overall or relating to key clinical subgroups in which antibiotic prescribing is common (chest signs; fever; physician rating of unwell; sputum/rattly chest; shortness of breath). Objectives To estimate the clinical effectiveness and cost-effectiveness of amoxicillin for uncomplicated lower respiratory tract infections in children both overall and in clinical subgroups. Design Placebo-controlled trial with qualitative, observational and cost-effectiveness studies. Setting UK general practices. Participants Children aged 1-12 years with acute uncomplicated lower respiratory tract infections. Outcomes The primary outcome was the duration in days of symptoms rated moderately bad or worse (measured using a validated diary). Secondary outcomes were symptom severity on days 2-4 (0 = no problem to 6 = as bad as it could be); symptom duration until very little/no problem; reconsultations for new or worsening symptoms; complications; side effects; and resource use. Methods Children were randomised to receive 50 mg/kg/day of oral amoxicillin in divided doses for 7 days, or placebo using pre-prepared packs, using computer-generated random numbers by an independent statistician. Children who were not randomised could participate in a parallel observational study. Semistructured telephone interviews explored the views of 16 parents and 14 clinicians, and the data were analysed using thematic analysis. Throat swabs were analysed using multiplex polymerase chain reaction. Results A total of 432 children were randomised (antibiotics, n = 221; placebo, n = 211). The primary analysis imputed missing data for 115 children. The duration of moderately bad symptoms was similar in the antibiotic and placebo groups overall (median of 5 and 6 days, respectively; hazard ratio 1.13, 95% confidence interval 0.90 to 1.42), with similar results for subgroups, and when including antibiotic prescription data from the 326 children in the observational study. Reconsultations for new or worsening symptoms (29.7% and 38.2%, respectively; risk ratio 0.80, 95% confidence interval 0.58 to 1.05), illness progression requiring hospital assessment or admission (2.4% vs. 2.0%) and side effects (38% vs. 34%) were similar in the two groups. Complete-case (n = 317) and per-protocol (n = 185) analyses were similar, and the presence of bacteria did not mediate antibiotic effectiveness. NHS costs per child were slightly higher (antibiotics, £29; placebo, £26), with no difference in non-NHS costs (antibiotics, £33; placebo, £33). A model predicting complications (with seven variables: baseline severity, difference in respiratory rate from normal for age, duration of prior illness, oxygen saturation, sputum/rattly chest, passing urine less often, and diarrhoea) had good discrimination (bootstrapped area under the receiver operator curve 0.83) and calibration. Parents found it difficult to interpret symptoms and signs, used the sounds of the child's cough to judge the severity of illness, and commonly consulted to receive a clinical examination and reassurance. Parents acknowledged that antibiotics should be used only when 'necessary', and clinicians noted a reduction in parents' expectations for antibiotics. Limitations The study was underpowered to detect small benefits in key subgroups. Conclusion Amoxicillin for uncomplicated lower respiratory tract infections in children is unlikely to be clinically effective or to reduce health or societal costs. Parents need better access to information, as well as clear communication about the self-management of their child's illness and safety-netting. Future work The data can be incorporated in the Cochrane review and individual patient data meta-analysis. Trial registration This trial is registered as ISRCTN79914298. Funding This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 27, No. 9. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Paul Little
- Primary Care Population Sciences and Medical Education Unit, University of Southampton, Southampton, UK
| | - Nick A Francis
- Primary Care Population Sciences and Medical Education Unit, University of Southampton, Southampton, UK
| | - Beth Stuart
- Primary Care Population Sciences and Medical Education Unit, University of Southampton, Southampton, UK
| | - Gilly O'Reilly
- Primary Care Population Sciences and Medical Education Unit, University of Southampton, Southampton, UK
| | - Natalie Thompson
- Primary Care Population Sciences and Medical Education Unit, University of Southampton, Southampton, UK
| | - Taeko Becque
- Primary Care Population Sciences and Medical Education Unit, University of Southampton, Southampton, UK
| | - Alastair D Hay
- Centre for Academic Primary Care, Bristol Medical School, Population Health Sciences, University of Bristol, Bristol, UK
| | - Kay Wang
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Michael Sharland
- Institute of Infection and Immunity, St George's University, London, UK
| | - Anthony Harnden
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Guiqing Yao
- Biostatistics Research Group, Department of Health Sciences, College of Life Sciences, University of Leicester, Leicester, UK
| | - James Raftery
- Primary Care Population Sciences and Medical Education Unit, University of Southampton, Southampton, UK
| | - Shihua Zhu
- Primary Care Population Sciences and Medical Education Unit, University of Southampton, Southampton, UK
| | - Joseph Little
- Primary Care Population Sciences and Medical Education Unit, University of Southampton, Southampton, UK
| | - Charlotte Hookham
- Primary Care Population Sciences and Medical Education Unit, University of Southampton, Southampton, UK
| | - Kate Rowley
- Centre for Academic Primary Care, Bristol Medical School, Population Health Sciences, University of Bristol, Bristol, UK
| | - Joanne Euden
- Centre for Trials Research, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
| | - Kim Harman
- Primary Care Population Sciences and Medical Education Unit, University of Southampton, Southampton, UK
| | - Samuel Coenen
- Department of Family Medicine & Population Health and Vaccine & Infectious Disease Institute, University of Antwerp, Antwerp, Belgium
| | - Robert C Read
- National Institute for Health and Care Research (NIHR) Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Catherine Woods
- Primary Care Population Sciences and Medical Education Unit, University of Southampton, Southampton, UK
| | - Christopher C Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Saul N Faust
- National Institute for Health and Care Research (NIHR) Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Geraldine Leydon
- Primary Care Population Sciences and Medical Education Unit, University of Southampton, Southampton, UK
| | - Mandy Wan
- Evelina Pharmacy, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Kerenza Hood
- Centre for Trials Research, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
| | - Jane Whitehurst
- National Institute for Health and Care Research (NIHR) Applied Research Collaboration West Midlands, Coventry, UK
| | - Samantha Richards-Hall
- Southampton Primary Care Research Centre, Primary Care Population Sciences and Medical Education Unit, University of Southampton, Southampton, UK
| | - Peter Smith
- Southampton Statistical Sciences Research Institute, University of Southampton, Southampton, UK
| | - Michael Thomas
- Primary Care Population Sciences and Medical Education Unit, University of Southampton, Southampton, UK
| | - Michael Moore
- Primary Care Population Sciences and Medical Education Unit, University of Southampton, Southampton, UK
| | - Theo Verheij
- Primary Care Population Sciences and Medical Education Unit, University of Southampton, Southampton, UK
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9
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Gunnarsson RK, Ebell M, Centor R, Little P, Verheij T, Lindbæk M, Sundvall PD. Best management of patients with an acute sore throat – a critical analysis of current evidence and a consensus of experts from different countries and traditions. Infect Dis (Lond) 2023; 55:384-395. [PMID: 36971650 DOI: 10.1080/23744235.2023.2191714] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/29/2023] Open
Abstract
BACKGROUND There is a very large body of publications discussing the management of patients with an acute sore throat. Advocates for a restrictive antibiotic policy and advocates for a more liberal use of antibiotics emphasise different and valid arguments and to date have not been able to unite in a consensus. Contradicting guidelines based on the same body of knowledge is not logical, may cause confusion and cause unwanted variation in clinical management. METHODS In multiple video meetings and email correspondence from March to November 2022 and finally in a workshop at the annual meeting for the North American Primary Care Group in November 2022, experts from different countries representing different traditions agreed on how the current evidence should be interpreted. RESULTS This critical analysis identifies that the problem can be resolved by introducing a new triage scheme considering both the acute risk for suppurative complications and sepsis as well as the long-term risk of developing rheumatic fever. CONCLUSIONS The new triage scheme may solve the long-standing problem of advocating for a restrictive use of antibiotics while also satisfying concerns that critically ill patients might be missed with severe consequences. We acknowledge that the perspective of this problem is vastly different between high- and low-income countries. Furthermore, we discuss the new trend which allows nurses and pharmacists to independently manage these patients and the increased need for safety netting required for such management.
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10
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Wächtler H, Kaduszkiewicz H, Kuhnert O, Malottki KA, Maaß S, Hedderich J, Wiese B, Donner-Banzhoff N, Hansmann-Wiest J. Influence of a guideline or an additional rapid strep test on antibiotic prescriptions for sore throat: the cluster randomized controlled trial of HALS (Hals und Antibiotika Leitlinien Strategien). BMC PRIMARY CARE 2023; 24:75. [PMID: 36941540 PMCID: PMC10029262 DOI: 10.1186/s12875-023-01987-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Accepted: 01/18/2023] [Indexed: 03/22/2023]
Abstract
BACKGROUND Pharyngitis due to Group A beta-hemolytic streptococci (GAS) is seen as the main indication for antibiotics for sore throat. In primary care settings prescription rates are much higher than the prevalence of GAS. Recommendations in international guidelines differ considerably. A German guideline suggested to consider antibiotics for patients with Centor or McIsaac scores ≥ 3, first choice being penicillin V for 7 days, and recommended analgesics for all. We investigated, if the implementation of this guideline lowers the antibiotic prescription rate, and if a rapid antigen detection strep-test (RADT) in patients with scores ≥ 3 lowers the rate further. METHODS HALS was an open pragmatic parallel group three-arm cluster-randomized controlled trial. Primary care practices in Northern Germany were randomized into three groups: Guideline (GL-group), modified guideline with a RADT for scores ≥ 3 (GL-RADT-group) or usual care (UC-group). All practices were visited and instructed by the study team (outreach visits) and supplied with material according to their group. The practices were asked to recruit 11 consecutive patients ≥ 2 years with an acute sore throat and being at least moderately impaired. A study throat swab for GAS was taken in every patient. The antibiotic prescription rate at the first consultation was the primary outcome. RESULTS From October 2010 to March 2012, 68 general practitioners in 61 practices recruited 520 patients, 516 could be analyzed for the primary endpoint. Antibiotic prescription rates did not differ between groups (p = 0.162) and were about three times higher than the GAS rate: GL-group 97/187 patients (52%; GAS = 16%), GL-RADT-group 74/172 (43%; GAS = 16%) and UC-group 68/157 (43%; GAS = 14%). In the GL-RADT-group 55% of patients had scores ≥ 3 compared to 35% in GL-group (p < 0.001). After adjustment, in the GL-RADT-group the OR was 0.23 for getting an antibiotic compared to the GL-group (p = 0.010), even though 35 of 90 patients with a negative Strep-test got an antibiotic in the GL-RADT-group. The prescription rates per practice covered the full range from 0 to 100% in all groups. CONCLUSION The scores proposed in the implemented guideline seem inappropriate to lower antibiotic prescriptions for sore throat, but better adherence of practitioners to negative RADTs should lead to fewer prescriptions. TRIAL REGISTRATION DRKS00013018, retrospectively registered 28.11.2017.
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Affiliation(s)
- Hannelore Wächtler
- Institute of General Practice, Kiel University, Michaelisstr. 5, 24105, Kiel, Germany
| | - Hanna Kaduszkiewicz
- Institute of General Practice, Kiel University, Michaelisstr. 5, 24105, Kiel, Germany.
| | - Oskar Kuhnert
- Institute of General Practice, Kiel University, Michaelisstr. 5, 24105, Kiel, Germany
| | | | - Sonja Maaß
- Institute of General Practice, Kiel University, Michaelisstr. 5, 24105, Kiel, Germany
| | - Jürgen Hedderich
- Institute of Medical Informatics and Statistics, Kiel University, University Hospital Schleswig-Holstein, Campus Kiel, Arnold-Heller-Straße 3, Haus V40, 24105, Kiel, Germany
| | - Birgitt Wiese
- IT Services Applications, Science & Laboratory, MHH Information Technology, Medizinische Hochschule Hannover (MHH), Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Norbert Donner-Banzhoff
- Department of General Practice / Family Medicine, University of Marburg, Karl-von-Frisch-Str. 4, 35043, Marburg, Germany
| | - Julia Hansmann-Wiest
- Institute of General Practice, Kiel University, Michaelisstr. 5, 24105, Kiel, Germany
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11
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Hounkpatin H, Stuart B, Zhu S, Yao G, Moore M, Löffler C, Little P, Kenealy T, Gillespie D, Francis NA, Bostock J, Becque T, Arroll B, Altiner A, Alonso-Coello P, Hay AD. Post-consultation acute respiratory tract infection recovery: a latent class-informed analysis of individual patient data. Br J Gen Pract 2023; 73:e196-e203. [PMID: 36823057 PMCID: PMC9975977 DOI: 10.3399/bjgp.2022.0229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 11/11/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND There is a lack of evidence regarding post-consultation symptom trajectories for patients with respiratory tract infections (RTIs) and whether patient characteristics can be used to predict illness duration. AIM To describe symptom trajectories in patients with RTIs, and assess baseline characteristics and adverse events associated with trajectories. DESIGN AND SETTING The study included data about 9103 adults and children from 12 primary care studies. METHOD A latent class-informed regression analysis of individual patient data from randomised controlled trials and observational cohort studies was undertaken. Post-consultation symptom trajectory (severity and duration), re-consultation with same or worsening illness, and admission to hospital were assessed. RESULTS In total, 90% of participants recovered from all symptoms by 28 days, regardless of antibiotic prescribing strategy (none, immediate, and delayed antibiotics). For studies of RTI with cough as a dominant symptom (n = 5314), four trajectories were identified: 'rapid (6 days)' (90% of participants recovered within 6 days) in 52.0%; 'intermediate (10 days)' (28.9%); 'slow progressive improvement (27 days)' (12.5%); and 'slow improvement with initial high symptom burden (27 days)' (6.6%). For cough, being aged 16-64 years (odds ratio [OR] 2.57, 95% confidence interval [CI] = 1.72 to 3.85 compared with <16 years), higher presenting illness baseline severity (OR 1.51, 95% CI = 1.12 to 2.03), presence of lung disease (OR 1.78, 95% CI = 1.44 to 2.21), and median and above illness duration before consultation (≥7 days) (OR 1.99, 95% CI = 1.68 to 2.37) were associated with slower recovery (>10 days) compared with faster recovery (≤10 days). Re-consultations and admissions to hospital for cough were higher in those with slower recovery (ORs: 2.15, 95% CI = 1.78 to 2.60 and 7.42, 95% CI = 3.49 to 15.78, respectively). CONCLUSION Older patients presenting with more severe, longer pre-consultation symptoms and chronic lung disease should be advised they are more likely to experience longer post-consultation illness durations, and that recovery rates are similar with and without antibiotics.
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Affiliation(s)
- Hilda Hounkpatin
- School of Primary Care, Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Beth Stuart
- School of Primary Care, Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Shihua Zhu
- School of Primary Care, Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Guiqing Yao
- Department of Health Science, University of Leicester, Leicester, UK
| | - Michael Moore
- School of Primary Care, Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Christin Löffler
- Institute of General Practice, Rostock University Medical Center, Rostock, Germany
| | - Paul Little
- School of Primary Care, Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Timothy Kenealy
- Department of General Practice and Primary Health Care, University of Auckland, Auckland, New Zealand
| | - David Gillespie
- Centre for Trials Research, College of Biomedical & Life Sciences, School of Medicine, Cardiff University, Cardiff, UK; Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Oxford, UK
| | - Nick A Francis
- School of Primary Care, Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Jennifer Bostock
- Division of Health and Social Care Research, King's College London, London, UK
| | - Taeko Becque
- School of Primary Care, Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Bruce Arroll
- Department of General Practice and Primary Health Care, University of Auckland, Auckland, New Zealand
| | - Attila Altiner
- Department of Health Science, University of Leicester, Leicester, UK
| | - Pablo Alonso-Coello
- Iberoamerican Cochrane Centre, Instituto de Investigación Biomédica Sant Pau (IIB Sant Pau-CIBERESP), Barcelona, Spain
| | - Alastair D Hay
- Centre for Academic Primary Care, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
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12
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Dahlén E, Collin J, Hellman J, Norman C, Nauclér P, Ternhag A. The effect of absent or deferred antibiotic treatment on complications of common infections in primary care. Int J Infect Dis 2022; 124:181-186. [DOI: 10.1016/j.ijid.2022.09.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 09/08/2022] [Accepted: 09/30/2022] [Indexed: 10/31/2022] Open
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13
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Gunnarsson R, Orda U, Elliott B, Heal C, Del Mar C. What is the optimal strategy for managing primary care patients with an uncomplicated acute sore throat? Comparing the consequences of nine different strategies using a compilation of previous studies. BMJ Open 2022; 12:e059069. [PMID: 35487741 PMCID: PMC9058799 DOI: 10.1136/bmjopen-2021-059069] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVE Identifying optimal strategies for managing patients of any age with varying risk of acute rheumatic fever (ARF) attending for an apparently uncomplicated acute sore throat, also clarifying the role of point-of-care testing (POCT) for presence of group A beta-haemolytic Streptococcus (GABHS) in these settings. DESIGN We compared outcomes of adhering to nine different strategies for managing these patients in primary healthcare. SETTING AND PARTICIPANTS The nine strategies, similar to guidelines from several countries, were tested against two validation data sets being constructs from seven prior studies. MAIN OUTCOME MEASURES The proportion of patients requiring a POCT, prescribed antibiotics, prescribed antibiotics having GABHS and finally having GABHS not prescribed antibiotics, if different strategies had been adhered to. RESULTS In a scenario with high risk of ARF, adhering to existing guidelines would risk many patients ill from GABHS left without antibiotics. Hence, using a POCT on all of these patients minimised their risk. For low-risk patients, it is reasonable to only consider antibiotics if the patient has more than low pain levels despite adequate analgesia, 3-4 Centor scores (or 2-3 FeverPAIN scores or 3-4 McIsaac scores) and a POCT confirming the presence of GABHS. This would require testing only 10%-15% of patients and prescribing antibiotics to only 3.5%-6.6%. CONCLUSIONS Patients with high or low risk for ARF needs to be managed very differently. POCT can play an important role in safely targeting the use of antibiotics for patients with an apparently uncomplicated acute sore throat.
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Affiliation(s)
- Ronny Gunnarsson
- School of Public Health and Community Medicine - General Practice/Family Medicine, Göteborgs universitet Institutionen för medicin, Goteborg, Sweden
- Research, Development, Education and Innovation, Primary Health Care, Västra Götalandsregionen, Göteborg, Sweden
- Centre for Antibiotic Resistance Research (CARe), University of Gothenburg, Göteborg, Sweden
- The primary health care clinic for homeless people, Närhälsan, Region Västra Götaland, Göteborg, Sweden
| | - Ulrich Orda
- Mount Isa Hospital, North West Hospital and Health Service, Mount Isa, Queensland, Australia
| | | | - Clare Heal
- School of Medicine and Dentistry, James Cook University, Mackay, Queensland, Australia
| | - Chris Del Mar
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
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14
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Sheridan C, Grewal K, Thompson C, Borgundvaag B, McLeod SL. Antibiotic prescribing and use of corticosteroids for the emergency department management of acute uncomplicated pharyngitis. Fam Pract 2021; 38:731-734. [PMID: 34173652 DOI: 10.1093/fampra/cmab035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Acute pharyngitis is common in the ambulatory setting. The Modified Centor score uses five criteria to predict Group A Streptococcus (GAS) infection and can be used to guide management. OBJECTIVE The objective of this study was to describe the emergency department (ED) management (throat cultures, antibiotics and corticosteroids) of acute, uncomplicated pharyngitis by Centor score. METHODS This was a retrospective chart review of adult (>17 years) patients with an ED discharge diagnosis of acute pharyngitis from January 2016 to December 2018. RESULTS Of 638 patients included, 286 (44.8%) had a Centor score of 0-1, 328 (51.4%) had a score of 2-3 and 24 (3.8%) had a score of ≥4. Of those with a Centor score of 0-1, 83 (29.0%) had a throat culture, 88 (30.8%) were prescribed antibiotics, 15 (5.2%) were positive for GAS and 74 (25.9%) received corticosteroids. Of those with a Centor score of 2-3, 156 (47.6%) had a throat culture, 220 (67.1%) were prescribed antibiotics, 44 (13.4%) were positive for GAS and 145 (44.2%) received corticosteroids. Of those with a Centor score ≥4, 14 (58.3%) had a throat culture, 18 (75.0%) were prescribed antibiotics, 7 (29.2%) were positive for GAS and 12 (50.0%) received corticosteroids. CONCLUSIONS A higher Centor score was associated with a higher risk of GAS infection, increased antibiotic prescribing and use of corticosteroids. Many patients with low Centor scores were prescribed antibiotics and had throat cultures. Further work is required to understand clinical decision-making for the management of acute pharyngitis.
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Affiliation(s)
- Conor Sheridan
- Schwartz/Reisman Emergency Medicine Institute, Sinai Health, Ontario, Canada
| | - Keerat Grewal
- Schwartz/Reisman Emergency Medicine Institute, Sinai Health, Ontario, Canada.,Department Medicine, Division of Emergency Medicine, University of Toronto, Ontario, Canada
| | - Cameron Thompson
- Schwartz/Reisman Emergency Medicine Institute, Sinai Health, Ontario, Canada
| | - Bjug Borgundvaag
- Schwartz/Reisman Emergency Medicine Institute, Sinai Health, Ontario, Canada.,Department of Family & Community Medicine, Division of Emergency Medicine, University of Toronto, Ontario, Canada
| | - Shelley L McLeod
- Schwartz/Reisman Emergency Medicine Institute, Sinai Health, Ontario, Canada.,Department of Family & Community Medicine, Division of Emergency Medicine, University of Toronto, Ontario, Canada
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15
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Little P, Francis NA, Stuart B, O'Reilly G, Thompson N, Becque T, Hay AD, Wang K, Sharland M, Harnden A, Yao G, Raftery J, Zhu S, Little J, Hookham C, Rowley K, Euden J, Harman K, Coenen S, Read RC, Woods C, Butler CC, Faust SN, Leydon G, Wan M, Hood K, Whitehurst J, Richards-Hall S, Smith P, Thomas M, Moore M, Verheij T. Antibiotics for lower respiratory tract infection in children presenting in primary care in England (ARTIC PC): a double-blind, randomised, placebo-controlled trial. Lancet 2021; 398:1417-1426. [PMID: 34562391 PMCID: PMC8542731 DOI: 10.1016/s0140-6736(21)01431-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 05/07/2021] [Accepted: 06/17/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND Antibiotic resistance is a global public health threat. Antibiotics are very commonly prescribed for children presenting with uncomplicated lower respiratory tract infections (LRTIs), but there is little evidence from randomised controlled trials of the effectiveness of antibiotics, both overall or among key clinical subgroups. In ARTIC PC, we assessed whether amoxicillin reduces the duration of moderately bad symptoms in children presenting with uncomplicated (non-pneumonic) LRTI in primary care, overall and in key clinical subgroups. METHODS ARTIC PC was a double-blind, randomised, placebo-controlled trial done at 56 general practices in England. Eligible children were those aged 6 months to 12 years presenting in primary care with acute uncomplicated LRTI judged to be infective in origin, where pneumonia was not suspected clinically, with symptoms for less than 21 days. Patients were randomly assigned in a 1:1 ratio to receive amoxicillin 50 mg/kg per day or placebo oral suspension, in three divided doses orally for 7 days. Patients and investigators were masked to treatment assignment. The primary outcome was the duration of symptoms rated moderately bad or worse (measured using a validated diary) for up to 28 days or until symptoms resolved. The primary outcome and safety were assessed in the intention-to-treat population. The trial is registered with the ISRCTN Registry (ISRCTN79914298). FINDINGS Between Nov 9, 2016, and March 17, 2020, 432 children (not including six who withdrew permission for use of their data after randomisation) were randomly assigned to the antibiotics group (n=221) or the placebo group (n=211). Complete data for symptom duration were available for 317 (73%) patients; missing data were imputed for the primary analysis. Median durations of moderately bad or worse symptoms were similar between the groups (5 days [IQR 4-11] in the antibiotics group vs 6 days [4-15] in the placebo group; hazard ratio [HR] 1·13 [95% CI 0·90-1·42]). No differences were seen for the primary outcome between the treatment groups in the five prespecified clinical subgroups (patients with chest signs, fever, physician rating of unwell, sputum or chest rattle, and short of breath). Estimates from complete-case analysis and a per-protocol analysis were similar to the imputed data analysis. INTERPRETATION Amoxicillin for uncomplicated chest infections in children is unlikely to be clinically effective either overall or for key subgroups in whom antibiotics are commonly prescribed. Unless pneumonia is suspected, clinicians should provide safety-netting advice but not prescribe antibiotics for most children presenting with chest infections. FUNDING National Institute for Health Research.
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Affiliation(s)
- Paul Little
- Primary Care Research Centre, Primary Care Population Sciences and Medical Education Unit, University of Southampton, Southampton, UK.
| | - Nick A Francis
- Primary Care Research Centre, Primary Care Population Sciences and Medical Education Unit, University of Southampton, Southampton, UK
| | - Beth Stuart
- Primary Care Research Centre, Primary Care Population Sciences and Medical Education Unit, University of Southampton, Southampton, UK
| | - Gilly O'Reilly
- Primary Care Research Centre, Primary Care Population Sciences and Medical Education Unit, University of Southampton, Southampton, UK
| | - Natalie Thompson
- Primary Care Research Centre, Primary Care Population Sciences and Medical Education Unit, University of Southampton, Southampton, UK
| | - Taeko Becque
- Primary Care Research Centre, Primary Care Population Sciences and Medical Education Unit, University of Southampton, Southampton, UK
| | - Alastair D Hay
- Centre for Academic Primary Care, Bristol Medical School, Population Health Sciences, University of Bristol, Bristol, UK
| | - Kay Wang
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Michael Sharland
- Institute of Infection and Immunity, St George's University London, London, UK
| | - Anthony Harnden
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Guiqing Yao
- Biostatistics Research Group, Department of Health Sciences, College of Life Sciences, University of Leicester, Leicester, UK
| | - James Raftery
- Health Economics Analysis Team, University of Southampton, Southampton, UK
| | - Shihua Zhu
- Health Economics Analysis Team, University of Southampton, Southampton, UK
| | - Joseph Little
- Primary Care Research Centre, Primary Care Population Sciences and Medical Education Unit, University of Southampton, Southampton, UK
| | - Charlotte Hookham
- Primary Care Research Centre, Primary Care Population Sciences and Medical Education Unit, University of Southampton, Southampton, UK
| | - Kate Rowley
- Centre for Academic Primary Care, Bristol Medical School, Population Health Sciences, University of Bristol, Bristol, UK
| | - Joanne Euden
- Centre for Trials Research, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
| | - Kim Harman
- Primary Care Research Centre, Primary Care Population Sciences and Medical Education Unit, University of Southampton, Southampton, UK
| | - Samuel Coenen
- Department of Family Medicine and Population Health and Vaccine and Infectious Disease Institute, University of Antwerp, Antwerp, Belgium
| | - Robert C Read
- Faculty of Medicine and Institute for Life Sciences, University of Southampton, Southampton, UK; National Institute of Health Research Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Catherine Woods
- Primary Care Research Centre, Primary Care Population Sciences and Medical Education Unit, University of Southampton, Southampton, UK
| | - Christopher C Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Saul N Faust
- Faculty of Medicine and Institute for Life Sciences, University of Southampton, Southampton, UK; National Institute of Health Research Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Geraldine Leydon
- Primary Care Research Centre, Primary Care Population Sciences and Medical Education Unit, University of Southampton, Southampton, UK
| | - Mandy Wan
- Evelina Pharmacy, Guy's and St Thomas NHS Foundation Trust, London, UK
| | - Kerenza Hood
- Centre for Trials Research, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
| | | | - Samantha Richards-Hall
- Primary Care Research Centre, Primary Care Population Sciences and Medical Education Unit, University of Southampton, Southampton, UK
| | - Peter Smith
- Southampton Statistical Sciences Research Institute, University of Southampton, Southampton, UK
| | - Michael Thomas
- Primary Care Research Centre, Primary Care Population Sciences and Medical Education Unit, University of Southampton, Southampton, UK
| | - Michael Moore
- Primary Care Research Centre, Primary Care Population Sciences and Medical Education Unit, University of Southampton, Southampton, UK
| | - Theo Verheij
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands
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16
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Kulik E, Stuart B, Willcox M. Predictors of rheumatic fever in sore throat patients: a systematic review and meta-analysis. Trans R Soc Trop Med Hyg 2021; 116:286-297. [PMID: 34636404 PMCID: PMC8978297 DOI: 10.1093/trstmh/trab156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 08/17/2021] [Accepted: 09/24/2021] [Indexed: 11/22/2022] Open
Abstract
Background Concerns about rheumatic fever (RF) drive antibiotic prescriptions for sore throat (ST) in endemic areas. Better guidance is needed on which patients are likely to develop RF in order to avoid misuse and overuse of antibiotics. Our aim was to identify predictive factors for RF in ST patients. Methods Multiple databases were searched to identify cohort, case–control, cross-sectional or randomised controlled trials that measured RF incidence in ST patients. An inverse variance random effects model was used to pool the data and calculate odds ratios (ORs). Results Seven studies with a total of 6890 participants were included: three RCTs and four observational studies. Factors significantly associated with RF development following ST were positive group A streptococcal (GAS) swab (OR 1.74 [95% confidence interval {CI} 1.13 to 2.69]), previous RF history (OR 13.22 [95% CI 4.86 to 35.93]) and a cardiac murmur (OR 3.55 [95% CI 1.81 to 6.94]). Many potential risk factors were not reported in any of the included studies, highlighting important evidence gaps. Conclusions ST patients in endemic areas with a positive GAS swab, previous RF history and a cardiac murmur are at increased risk of developing RF. This review identifies vital gaps in our knowledge of factors predicting RF development in ST patients. Further research is needed to develop better clinical prediction tools and rationalise antibiotic use for ST.
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Affiliation(s)
- Ellen Kulik
- School of Primary Care, Population Sciences and Medical Education, Faculty of Medicine, Aldermoor Health Centre, Aldermoor Close, Southampton SO16 5ST, UK
| | - Beth Stuart
- School of Primary Care, Population Sciences and Medical Education, Faculty of Medicine, Aldermoor Health Centre, Aldermoor Close, Southampton SO16 5ST, UK
| | - Merlin Willcox
- School of Primary Care, Population Sciences and Medical Education, Faculty of Medicine, Aldermoor Health Centre, Aldermoor Close, Southampton SO16 5ST, UK
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17
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Diagnostic accuracy of Fever-PAIN and Centor criteria for bacterial throat infection in adults with sore throat: a secondary analysis of a randomised controlled trial. BJGP Open 2021; 5:BJGPO.2021.0122. [PMID: 34551959 PMCID: PMC9447300 DOI: 10.3399/bjgpo.2021.0122] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 07/28/2021] [Indexed: 12/15/2022] Open
Abstract
Background Sore throat is a common and self-limiting condition. There remains ambiguity in stratifying patients to immediate, delayed, or no antibiotic prescriptions. The National Institute for Health and Care Excellence (NICE) recommends two clinical prediction rules (CPRs), FeverPAIN and Centor, to guide decision making. Aim To describe the diagnostic accuracy of CPRs in identifying streptococcal throat infections. Design & setting Adults presenting to UK primary care with sore throat, who did not require immediate antibiotics. Method As part of the Treatment Options without Antibiotics for Sore Throat (TOAST) trial, 565 participants, aged ≥18 years, were recruited on day of presentation to general practice. Physicians could opt to give delayed prescriptions. CPR scores were not part of the trial protocol but were calculated post hoc from baseline assessments. Diagnostic accuracy was calculated by comparing scores with throat swab cultures. Results It was found that 81/502 (16.1%) patients had group A, C, or G streptococcus cultured on throat swab. Overall diagnostic accuracy of both CPRs was poor: area under receiver operating characteristics (ROC) curve 0.62 for Centor; and 0.59 for FeverPAIN. Post-test probability of a positive or negative test was 27.3% (95% confidence interval [CI] = 6.0% to 61.0%) and 84.1% (95% CI = 80.6% to 87.2%) for FeverPAIN ≥4; versus 25.7% (95% CI = 16.2% to 37.2%) and 85.5% (95% CI = 81.8% to 88.7%) for Centor ≥3. Higher CPR scores were associated with increased delayed antibiotic prescriptions (χ2 = 8.42, P = 0.004 for FeverPAIN ≥4; χ2 = 32.0, P<0.001 for Centor ≥3). Conclusion In those who do not require immediate antibiotics in primary care, neither CPR provides a reliable way of diagnosing streptococcal throat infection. However, clinicians were more likely to give delayed prescriptions to those with higher scores.
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18
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Pallon J, Rööst M, Sundqvist M, Hedin K. The aetiology of pharyngotonsillitis in primary health care: a prospective observational study. BMC Infect Dis 2021; 21:971. [PMID: 34535115 PMCID: PMC8446737 DOI: 10.1186/s12879-021-06665-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 09/07/2021] [Indexed: 11/12/2022] Open
Abstract
Background Few studies on pharyngotonsillitis have examined the clinical presentation of different aetiologies where pathogens have been detected using molecular methods. We aimed to assess how well clinical signs and symptoms can predict (1) the presence or absence of a broad range of viruses and bacteria, and (2) reconsultations for a sore throat or a complication. Methods In this descriptive observational prospective study in primary health care 220 patients aged 15–45 with suspected pharyngotonsillitis were sampled from nose, throat and blood and screened for 20 bacteria and viruses using polymerase chain reaction (PCR), culture and serology. Odds ratios (OR) and predictive values with 95% confidence intervals (CI) were used to show association between microbiological findings and clinical signs and symptoms. Patients were followed up after 3 months by reviewing electronic medical records. Results Both cough and coryza were more common in patients with only viruses (67%) than in patients with only bacteria (21%) (p < 0.001), whereas tonsillar coating was more common in patients with only bacteria (53%) than in patients with only viruses (29%) (p = 0.006). Tonsillar coating (adjusted OR 6.0; 95% CI 2.5–14) and a lack of cough (adjusted OR 3.5; 95% CI 1.5–8.0) were significantly associated with Streptococcus pyogenes (group A streptococci; GAS) and with any bacterial finding. A Centor score of 3–4 had a positive predictive value of 49% (95% CI 42–57) for GAS and 66% (95% CI 57–74) for any bacterial findings. The use of rapid antigen detection test for GAS increased the positive predictive value for this group to 93%. Conclusions Signs and symptoms, both single and combined, were insufficient to rule in GAS or other pathogens. However, both cough and coryza were useful to rule out GAS. The results support the clinical approach of restricting rapid antigen detection testing to patients with 3–4 Centor criteria. The low carriage rate of bacteria among asymptomatic controls implied that most detections in patients represented a true infection. Supplementary Information The online version contains supplementary material available at 10.1186/s12879-021-06665-9.
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Affiliation(s)
- Jon Pallon
- Department of Clinical Sciences in Malmö, Family Medicine, Lund University, Malmö, Sweden. .,Department of Research and Development, Region Kronoberg, Växjö, Sweden. .,Department of Clinical Sciences, Malmö, Clinical Research Centre, Box 50332, 202 13, Malmö, Sweden.
| | - Mattias Rööst
- Department of Clinical Sciences in Malmö, Family Medicine, Lund University, Malmö, Sweden.,Department of Research and Development, Region Kronoberg, Växjö, Sweden
| | - Martin Sundqvist
- Department of Laboratory Medicine, Clinical Microbiology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Katarina Hedin
- Department of Clinical Sciences in Malmö, Family Medicine, Lund University, Malmö, Sweden.,Futurum, Region Jönköping County, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
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19
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Fraser H, Gallacher D, Achana F, Court R, Taylor-Phillips S, Nduka C, Stinton C, Willans R, Gill P, Mistry H. Rapid antigen detection and molecular tests for group A streptococcal infections for acute sore throat: systematic reviews and economic evaluation. Health Technol Assess 2021; 24:1-232. [PMID: 32605705 DOI: 10.3310/hta24310] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Sore throat is a common condition caused by an infection of the airway. Most cases are of a viral nature; however, a number of these infections may be caused by the group A Streptococcus bacterium. Most viral and bacterial sore throat infections resolve spontaneously within a few weeks. Point-of-care testing in primary care has been recognised as an emerging technology for aiding targeted antibiotic prescribing for sore throat in cases that do not spontaneously resolve. OBJECTIVE Systematically review the evidence for 21 point-of-care tests for detecting group A Streptococcus bacteria and develop a de novo economic model to compare the cost-effectiveness of point-of-care tests alongside clinical scoring tools with the cost-effectiveness of clinical scoring tools alone for patients managed in primary care and hospital settings. DATA SOURCES Multiple electronic databases were searched from inception to March 2019. The following databases were searched in November and December 2018 and searches were updated in March 2019: MEDLINE [via OvidSP (Health First, Rockledge, FL, USA)], MEDLINE In-Process & Other Non-Indexed Citations (via OvidSP), MEDLINE Epub Ahead of Print (via OvidSP), MEDLINE Daily Update (via OvidSP), EMBASE (via OvidSP), Cochrane Database of Systematic Reviews [via Wiley Online Library (John Wiley & Sons, Inc., Hoboken, NJ, USA)], Cochrane Central Register of Controlled Trials (CENTRAL) (via Wiley Online Library), Database of Abstracts of Reviews of Effects (DARE) (via Centre for Reviews and Dissemination), Health Technology Assessment database (via the Centre for Reviews and Dissemination), Science Citation Index and Conference Proceedings [via the Web of Science™ (Clarivate Analytics, Philadelphia, PA, USA)] and the PROSPERO International Prospective Register of Systematic Reviews (via the Centre for Reviews and Dissemination). REVIEW METHODS Eligible studies included those of people aged ≥ 5 years presenting with sore throat symptoms, studies comparing point-of-care testing with antibiotic-prescribing decisions, studies of test accuracy and studies of cost-effectiveness. Quality assessment of eligible studies was undertaken. Meta-analysis of sensitivity and specificity was carried out for tests with sufficient data. A decision tree model estimated costs and quality-adjusted life-years from an NHS and Personal Social Services perspective. RESULTS The searches identified 38 studies of clinical effectiveness and three studies of cost-effectiveness. Twenty-six full-text articles and abstracts reported on the test accuracy of point-of-care tests and/or clinical scores with biological culture as a reference standard. In the population of interest (patients with Centor/McIsaac scores of ≥ 3 points or FeverPAIN scores of ≥ 4 points), point estimates were 0.829 to 0.946 for sensitivity and 0.849 to 0.991 for specificity. There was considerable heterogeneity, even for studies using the same point-of-care test, suggesting that is unlikely that any single study will have accurately captured a test's true performance. There is some randomised controlled trial evidence to suggest that the use of rapid antigen detection tests may help to reduce antibiotic-prescribing rates. Sensitivity and specificity estimates for each test in each age group and care setting combination were obtained using meta-analyses where appropriate. Any apparent differences in test accuracy may not be attributable to the tests, and may have been caused by known differences in the studies, latent characteristics or chance. Fourteen of the 21 tests reviewed were included in the economic modelling, and these tests were not cost-effective within the current National Institute for Health and Care Excellence's cost-effectiveness thresholds. Uncertainties in the cost-effectiveness estimates included model parameter inputs and assumptions that increase the cost of testing, and the penalty for antibiotic overprescriptions. LIMITATIONS No information was identified for the elderly population or pharmacy setting. It was not possible to identify which test is the most accurate owing to the paucity of evidence. CONCLUSIONS The systematic review and the cost-effectiveness models identified uncertainties around the adoption of point-of-care tests in primary and secondary care settings. Although sensitivity and specificity estimates are promising, we have little information to establish the most accurate point-of-care test. Further research is needed to understand the test accuracy of point-of-care tests in the proposed NHS pathway and in comparable settings and patient groups. STUDY REGISTRATION The protocol of the review is registered as PROSPERO CRD42018118653. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 31. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Hannah Fraser
- Warwick Medical School, University of Warwick, Coventry, UK
| | | | - Felix Achana
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Rachel Court
- Warwick Medical School, University of Warwick, Coventry, UK
| | | | - Chidozie Nduka
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Chris Stinton
- Warwick Medical School, University of Warwick, Coventry, UK
| | | | - Paramjit Gill
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Hema Mistry
- Warwick Medical School, University of Warwick, Coventry, UK
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20
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Mponponsuo K, Church DL, Lu SJ, Viczko J, Naugler C, McDonald T, Dickinson J, Somayaji R. Age and sex-specific incidence rates of group A streptococcal pharyngitis between 2010 and 2018: a population-based study. Future Microbiol 2021; 16:1053-1062. [PMID: 34468182 DOI: 10.2217/fmb-2021-0077] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: Group A streptococcus (GAS) pharyngitis is a common clinical infection with significant morbidity but remains understudied. Materials & methods: We sought to assess the rates of testing and incidence of GAS pharyngitis in Calgary, Alberta based on age and sex. Results: A total of 1,074,154 tests were analyzed (58.8% female, mean age 24.8 years) of which 16.6% were positive. Age-standardized testing and positivity was greatest in the 5-14 years age group and lowest in persons over 75 years. Females had greater rates of testing and positivity throughout. Testing rates (incidence rate ratios: 1.40, 95% CI: 1.39-1.41) and case rates (incidence rate ratios: 1.36, 95% CI: 1.33-1.39) increased over time. Conclusion: Future studies should focus on evaluating disparities in testing and treatment outcomes to optimize the approach to this infection.
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Affiliation(s)
- Kwadwo Mponponsuo
- Department of Medicine, Calgary, AB T2N 1N4, Canada.,Cumming School of Medicine, University of Calgary, Calgary, AB T2N 1N4, Canada
| | - Deirdre L Church
- Department of Medicine, Calgary, AB T2N 1N4, Canada.,Cumming School of Medicine, University of Calgary, Calgary, AB T2N 1N4, Canada.,Department of Pathology & Laboratory Medicine, Calgary, AB T2N 1N4, Canada.,Department of Family Medicine, Calgary, AB T2N 1N4, Canada
| | - Sheng Jie Lu
- Cumming School of Medicine, University of Calgary, Calgary, AB T2N 1N4, Canada
| | - Jeannine Viczko
- Cumming School of Medicine, University of Calgary, Calgary, AB T2N 1N4, Canada.,Department of Pathology & Laboratory Medicine, Calgary, AB T2N 1N4, Canada
| | - Christopher Naugler
- Department of Medicine, Calgary, AB T2N 1N4, Canada.,Cumming School of Medicine, University of Calgary, Calgary, AB T2N 1N4, Canada.,Department of Community Health Sciences, Calgary, AB T2N 1N4, Canada.,Department of Pathology & Laboratory Medicine, Calgary, AB T2N 1N4, Canada.,Department of Family Medicine, Calgary, AB T2N 1N4, Canada
| | - Terrance McDonald
- Cumming School of Medicine, University of Calgary, Calgary, AB T2N 1N4, Canada.,Department of Family Medicine, Calgary, AB T2N 1N4, Canada
| | - James Dickinson
- Cumming School of Medicine, University of Calgary, Calgary, AB T2N 1N4, Canada.,Department of Family Medicine, Calgary, AB T2N 1N4, Canada
| | - Ranjani Somayaji
- Department of Medicine, Calgary, AB T2N 1N4, Canada.,Cumming School of Medicine, University of Calgary, Calgary, AB T2N 1N4, Canada.,Department of Community Health Sciences, Calgary, AB T2N 1N4, Canada.,Department of Microbiology, Immunology & Infectious Disease, Calgary, AB T2N 1N4, Canada
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21
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van Staa TP, Palin V, Brown B, Welfare W, Li Y, Ashcroft DM. The Safety of Delayed Versus Immediate Antibiotic Prescribing for Upper Respiratory Tract Infections. Clin Infect Dis 2021; 73:e394-e401. [PMID: 32594104 PMCID: PMC8282258 DOI: 10.1093/cid/ciaa890] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 06/24/2020] [Indexed: 12/15/2022] Open
Abstract
Background This study aimed to evaluate the clinical safety of delayed antibiotic prescribing for upper respiratory tract infections (URTIs), which is recommended in treatment guidelines for less severe cases. Methods Two population-based cohort studies used the English Clinical Practice Research Databank and Welsh Secure Anonymized Information Linkage, containing electronic health records from primary care linked to hospital admission records. Patients with URTI and prescriptions of amoxicillin, clarithromycin, doxycycline, erythromycin, or phenoxymethylpenicillin were identified. Patients were stratified according to delayed and immediate prescribing relative to URTI diagnosis. Outcome of interest was infection-related hospital admission after 30 days. Results The population included 1.82 million patients with an URTI and antibiotic prescription; 91.7% had an antibiotic at URTI diagnosis date (immediate) and 8.3% had URTI diagnosis in 1–30 days before (delayed). Delayed antibiotic prescribing was associated with a 52% increased risk of infection-related hospital admissions (adjusted hazard ratio, 1.52; 95% confidence interval, 1.43–1.62). The probability of delayed antibiotic prescribing was unrelated to predicted risks of hospital admission. Analyses of the number needed to harm showed considerable variability across different patient groups (median with delayed antibiotic prescribing, 1357; 2.5% percentile, 295; 97.5% percentile, 3366). Conclusions This is the first large population-based study examining the safety of delayed antibiotic prescribing. Waiting to treat URTI was associated with increased risk of hospital admission, although delayed antibiotic prescribing was used similarly between high- and low-risk patients. There is a need to better target delayed antibiotic prescribing to URTI patients with lower risks of complications.
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Affiliation(s)
- Tjeerd Pieter van Staa
- Centre for Health Informatics, Division of Informatics, Imaging, and Data Science, School of Health Sciences, Faculty of Biology, Medicine, and Health, The University of Manchester, Manchester, United Kingdom.,Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Victoria Palin
- Centre for Health Informatics, Division of Informatics, Imaging, and Data Science, School of Health Sciences, Faculty of Biology, Medicine, and Health, The University of Manchester, Manchester, United Kingdom
| | - Benjamin Brown
- Centre for Health Informatics, Division of Informatics, Imaging, and Data Science, School of Health Sciences, Faculty of Biology, Medicine, and Health, The University of Manchester, Manchester, United Kingdom
| | - William Welfare
- Public Health England North West, Manchester, United Kingdom
| | - Yan Li
- Centre for Health Informatics, Division of Informatics, Imaging, and Data Science, School of Health Sciences, Faculty of Biology, Medicine, and Health, The University of Manchester, Manchester, United Kingdom
| | - Darren M Ashcroft
- Centre for Pharmacoepidemiology and Drug Safety, School of Health Sciences, Faculty of Biology, Medicine, and Health, The University of Manchester, Manchester, United Kingdom.,NIHR Greater Manchester Patient Safety Translational Research Centre, School of Health Sciences, Faculty of Biology, Medicine, and Health, The University of Manchester, Manchester, United Kingdom
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22
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Gulliford MC, Charlton J, Boiko O, Winter JR, Rezel-Potts E, Sun X, Burgess C, McDermott L, Bunce C, Shearer J, Curcin V, Fox R, Hay AD, Little P, Moore MV, Ashworth M. Safety of reducing antibiotic prescribing in primary care: a mixed-methods study. HEALTH SERVICES AND DELIVERY RESEARCH 2021. [DOI: 10.3310/hsdr09090] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Background
The threat of antimicrobial resistance has led to intensified efforts to reduce antibiotic utilisation, but serious bacterial infections are increasing in frequency.
Objectives
To estimate the risks of serious bacterial infections in association with lower antibiotic prescribing and understand stakeholder views with respect to safe antibiotic reduction.
Design
Mixed-methods research was undertaken, including a qualitative interview study of patient and prescriber views that informed a cohort study and a decision-analytic model, using primary care electronic health records. These three work packages were used to design an application (app) for primary care prescribers.
Data sources
The Clinical Practice Research Datalink.
Setting
This took place in UK general practices.
Participants
A total of 706 general practices with 66.2 million person-years of follow-up from 2002 to 2017 and antibiotic utilisation evaluated for 671,830 registered patients. The qualitative study included 31 patients and 30 health-care professionals from primary care.
Main outcome measures
Sepsis and localised bacterial infections.
Results
Patients were concerned about antimicrobial resistance and the side effects, as well as the benefits, of antibiotic treatment. Prescribers viewed the onset of sepsis as the most concerning potential outcome of reduced antibiotic prescribing. More than 40% of antibiotic prescriptions in primary care had no coded indication recorded across both Vision® and EMIS® practice systems. Antibiotic prescribing rates varied widely between general practices, but there was no evidence that serious bacterial infections were less frequent at higher prescribing practices (adjusted rate ratio for 20% increase in prescribing 1.03, 95% confidence interval 1.00 to 1.06; p = 0.074). The probability of sepsis was lower if an antibiotic was prescribed at an infection consultation, and the number of antibiotic prescriptions required to prevent one episode of sepsis (i.e. the number needed to treat) decreased with age. For those aged 0–4 years, the number needed to treat was 29,773 (95% uncertainty interval 18,458 to 71,091) in boys and 27,014 (95% uncertainty interval 16,739 to 65,709) in girls. For those aged > 85 years, the number needed to treat was 262 (95% uncertainty interval 236 to 293) in men and 385 (95% uncertainty interval 352 to 421) in women. Frailty was associated with a greater risk of sepsis and a smaller number needed to treat. For severely frail patients aged 55–64 years, the number needed to treat was 247 (95% uncertainty interval 156 to 459) for men and 343 (95% uncertainty interval 234 to 556) for women. At all ages, the probability of sepsis was greatest for urinary tract infection, followed by skin infection and respiratory tract infection. The numbers needed to treat were generally smaller for the period 2014–17, when sepsis was diagnosed more frequently. The results are available using an app that we developed to provide primary care prescribers with stratified risk estimates during infection consultations.
Limitations
Analyses were based on non-randomised comparisons. Infection episodes and antibiotic prescribing are poorly documented in primary care.
Conclusions
Antibiotic treatment is generally associated with lower risks, but the most serious bacterial infections remain infrequent even without antibiotic treatment. This research identifies risk strata in which antibiotic prescribing can be more safely reduced.
Future work
The software developed from this research may be further developed and investigated for antimicrobial stewardship effect.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 9. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Martin C Gulliford
- School of Population Health and Environmental Sciences, King’s College London, London, UK
- National Institute for Health Research Biomedical Research Centre, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Judith Charlton
- School of Population Health and Environmental Sciences, King’s College London, London, UK
| | - Olga Boiko
- School of Population Health and Environmental Sciences, King’s College London, London, UK
| | - Joanne R Winter
- School of Population Health and Environmental Sciences, King’s College London, London, UK
- National Institute for Health Research Biomedical Research Centre, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Emma Rezel-Potts
- School of Population Health and Environmental Sciences, King’s College London, London, UK
- National Institute for Health Research Biomedical Research Centre, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Xiaohui Sun
- School of Population Health and Environmental Sciences, King’s College London, London, UK
| | - Caroline Burgess
- School of Population Health and Environmental Sciences, King’s College London, London, UK
| | - Lisa McDermott
- School of Population Health and Environmental Sciences, King’s College London, London, UK
| | - Catey Bunce
- School of Population Health and Environmental Sciences, King’s College London, London, UK
- National Institute for Health Research Biomedical Research Centre, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - James Shearer
- School of Population Health and Environmental Sciences, King’s College London, London, UK
| | - Vasa Curcin
- School of Population Health and Environmental Sciences, King’s College London, London, UK
| | - Robin Fox
- Bicester Health Centre, Bicester, UK
| | - Alastair D Hay
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, UK
| | - Paul Little
- Primary Care Research Group, University of Southampton, Southampton, UK
| | - Michael V Moore
- Primary Care Research Group, University of Southampton, Southampton, UK
| | - Mark Ashworth
- School of Population Health and Environmental Sciences, King’s College London, London, UK
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23
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Stuart B, Hounkpatin H, Becque T, Yao G, Zhu S, Alonso-Coello P, Altiner A, Arroll B, Böhning D, Bostock J, Bucher HC, Chao J, de la Poza M, Francis N, Gillespie D, Hay AD, Kenealy T, Löffler C, McCormick DP, Mas-Dalmau G, Muñoz L, Samuel K, Moore M, Little P. Delayed antibiotic prescribing for respiratory tract infections: individual patient data meta-analysis. BMJ 2021; 373:n808. [PMID: 33910882 PMCID: PMC8080136 DOI: 10.1136/bmj.n808] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/15/2021] [Indexed: 01/04/2023]
Abstract
OBJECTIVE To assess the overall effect of delayed antibiotic prescribing on average symptom severity for patients with respiratory tract infections in the community, and to identify any factors modifying this effect. DESIGN Systematic review and individual patient data meta-analysis. DATA SOURCES Cochrane Central Register of Controlled Trials, Ovid Medline, Ovid Embase, EBSCO CINAHL Plus, and Web of Science. ELIGIBILITY CRITERIA FOR STUDY SELECTION Randomised controlled trials and observational cohort studies in a community setting that allowed comparison between delayed versus no antibiotic prescribing, and delayed versus immediate antibiotic prescribing. MAIN OUTCOME MEASURES The primary outcome was the average symptom severity two to four days after the initial consultation measured on a seven item scale (ranging from normal to as bad as could be). Secondary outcomes were duration of illness after the initial consultation, complications resulting in admission to hospital or death, reconsultation with the same or worsening illness, and patient satisfaction rated on a Likert scale. RESULTS Data were obtained from nine randomised controlled trials and four observational studies, totalling 55 682 patients. No difference was found in follow-up symptom severity (seven point scale) for delayed versus immediate antibiotics (adjusted mean difference -0.003, 95% confidence interval -0.12 to 0.11) or delayed versus no antibiotics (0.02, -0.11 to 0.15). Symptom duration was slightly longer in those given delayed versus immediate antibiotics (11.4 v 10.9 days), but was similar for delayed versus no antibiotics. Complications resulting in hospital admission or death were lower with delayed versus no antibiotics (odds ratio 0.62, 95% confidence interval 0.30 to 1.27) and delayed versus immediate antibiotics (0.78, 0.53 to 1.13). A significant reduction in reconsultation rates (odds ratio 0.72, 95% confidence interval 0.60 to 0.87) and an increase in patient satisfaction (adjusted mean difference 0.09, 0.06 to 0.11) were observed in delayed versus no antibiotics. The effect of delayed versus immediate antibiotics and delayed versus no antibiotics was not modified by previous duration of illness, fever, comorbidity, or severity of symptoms. Children younger than 5 years had a slightly higher follow-up symptom severity with delayed antibiotics than with immediate antibiotics (adjusted mean difference 0.10, 95% confidence interval 0.03 to 0.18), but no increased severity was found in the older age group. CONCLUSIONS Delayed antibiotic prescribing is a safe and effective strategy for most patients, including those in higher risk subgroups. Delayed prescribing was associated with similar symptom duration as no antibiotic prescribing and is unlikely to lead to poorer symptom control than immediate antibiotic prescribing. Delayed prescribing could reduce reconsultation rates and is unlikely to be associated with an increase in symptoms or illness duration, except in young children. STUDY REGISTRATION PROSPERO CRD42018079400.
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Affiliation(s)
- Beth Stuart
- Academic Unit of Primary Care, Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Hilda Hounkpatin
- Academic Unit of Primary Care, Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Taeko Becque
- Academic Unit of Primary Care, Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Guiqing Yao
- Biostatistics Research Group, Department of Health Sciences, College of Life Sciences, University of Leicester, Leicester, UK
| | - Shihua Zhu
- Academic Unit of Primary Care, Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Pablo Alonso-Coello
- Iberoamerican Cochrane Centre, Instituto de Investigación Biomédica Sant Pau (IIB Sant Pau-CIBERESP), Barcelona, Spain
| | - Attila Altiner
- Institute of General Practice, Rostock University Medical Center, Rostock, Germany
| | - Bruce Arroll
- Department of General Practice and Primary Health Care, University of Auckland, Auckland, New Zealand
| | - Dankmar Böhning
- Southampton Statistical Sciences Research Institute, University of Southampton, Southampton, UK
| | - Jennifer Bostock
- Division of Health and Social Care Research, King's College London, London, UK
| | - Heiner C Bucher
- Basel Institute for Clinical Epidemiology and Biostatistics (CEB), University Hospital Basel and University of Basel, Switzerland
| | - Jennifer Chao
- Pediatric Emergency Medicine, State University of New York Downstate, Brooklyn, New York, USA
| | - Mariam de la Poza
- Institut Català de la Salut, CAP Doctor Carles Ribas, Foc 112, Barcelona, Spain
| | - Nick Francis
- Academic Unit of Primary Care, Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton, UK
| | - David Gillespie
- Centre for Trials Research, School of Medicine, College of Biomedical & Life Sciences, Cardiff University, Cardiff, UK
| | - Alastair D Hay
- Centre for Academic Primary Care, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Timothy Kenealy
- Department of General Practice and Primary Health Care, University of Auckland, Auckland, New Zealand
| | - Christin Löffler
- Institute of General Practice, Rostock University Medical Center, Rostock, Germany
| | - David P McCormick
- Department of Pediatrics, University of Texas Medical Branch at Galveston, Galveston, TX, USA
| | - Gemma Mas-Dalmau
- Instituto de Investigación Biomédica Sant Pau (IIB Sant Pau), Barcelona, Spain
| | - Laura Muñoz
- Agència de Qualitat i Avaluació Sanitàries de Catalunya (AQuAS), Barcelona, Spain
| | - Kirsty Samuel
- ASPIRE PPI Panel, Leeds Institute for Health Sciences, University of Leeds, Leeds, UK
| | - Michael Moore
- Academic Unit of Primary Care, Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Paul Little
- Academic Unit of Primary Care, Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton, UK
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Stuart B, Brotherwood H, Van't Hoff C, Brown A, van den Bruel A, Hay AD, Moore M, Little P. Exploring the appropriateness of antibiotic prescribing for common respiratory tract infections in UK primary care. J Antimicrob Chemother 2021; 75:236-242. [PMID: 31637421 DOI: 10.1093/jac/dkz410] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 08/13/2019] [Accepted: 08/29/2019] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVES To use illness severity scores to evaluate the appropriateness of antibiotic prescribing in UK general practice. METHODS We describe variations in practice prescribing rates, taking account of illness severity. We used three scores in three studies to measure severity: 'FeverPAIN' in an adult acute sore throat cohort (n=12 829), the '3C score' in an adult acute lower respiratory tract infection cohort (n=28 883) and the STARWAVe score in an acute cough and respiratory infection children's cohort (n=8394). We calculated median ORs to quantify practice-level variation in prescribing rates, adjusted for illness severity. RESULTS There was substantial variability in practice prescribing rates (ranges of 0%-97%, 7%-100% and 0%-75% in the three cohorts, respectively). There was evidence that higher prescribing practices saw a higher proportion of unwell patients. At the individual level, patients who were more unwell were more likely to receive a prescription, but prescribing levels for those with low scores were still high. The median OR was 2.5 (95% credible interval=2.2-2.9) in the sore throat data set, 2.9 (95% credible interval=2.6-3.2) in the adult cough data set and 2.1 (95% credible interval=1.8-2.4) in the children's cough data set. CONCLUSIONS Higher prescribing practices may see more unwell patients with high illness severity scores, but the differences in scores account for a minority of between-practice prescribing variation. There is likely to be scope for further reductions in antibiotic prescribing among patients with low illness severity scores. Further research is needed to explore the additional factors that account for variation in prescribing levels.
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Affiliation(s)
- Beth Stuart
- University of Southampton, Primary Care Medical Group, PCPS Unit, Aldermoor Health Centre, Southampton, UK
| | - Hannah Brotherwood
- University of Southampton, Primary Care Medical Group, PCPS Unit, Aldermoor Health Centre, Southampton, UK
| | - Catherine Van't Hoff
- University of Southampton, Primary Care Medical Group, PCPS Unit, Aldermoor Health Centre, Southampton, UK
| | - Alastair Brown
- University of Southampton, Primary Care Medical Group, PCPS Unit, Aldermoor Health Centre, Southampton, UK
| | | | - Alastair D Hay
- Centre for Academic Primary Care, Bristol Medical School: Population Health Sciences, University of Bristol, Bristol, UK
| | - Michael Moore
- University of Southampton, Primary Care Medical Group, PCPS Unit, Aldermoor Health Centre, Southampton, UK
| | - Paul Little
- University of Southampton, Primary Care Medical Group, PCPS Unit, Aldermoor Health Centre, Southampton, UK
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ENT UK coronavirus disease 2019 adult tonsillitis and quinsy guidelines: translating guidance into practice. The Journal of Laryngology & Otology 2021; 135:579-583. [PMID: 33653421 PMCID: PMC8144819 DOI: 10.1017/s0022215121000682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES This study examined the uptake of ENT UK coronavirus disease 2019 adult tonsillitis and quinsy guidelines at our tertiary centre, and assessed perceived barriers to uptake. METHODS A retrospective case series of tonsillitis and quinsy patients was analysed in two arms: before and after the introduction of new ENT UK management guidelines. A survey assessed perceptions and practice differences between ENT and emergency department doctors. RESULTS Each study arm examined 82 patients. Following the introduction of new ENT UK guidelines, ENT clinicians demonstrated significant changes in practice, unlike their emergency department counterparts. Survey results from emergency department doctors highlighted a lack of appreciation of guideline change and identified barriers to guideline uptake. CONCLUSION The introduction of new management guidelines for tonsillitis and quinsy patients during the pandemic resulted in disparate uptake within ENT and emergency department departments at the tertiary centre. Clearer dissemination to all affected clinicians is paramount for future rapidly introduced changes to practice, to ensure clinician safety.
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van Bodegraven B, Palin V, Mistry C, Sperrin M, White A, Welfare W, Ashcroft DM, van Staa TP. Infection-related complications after common infection in association with new antibiotic prescribing in primary care: retrospective cohort study using linked electronic health records. BMJ Open 2021; 11:e041218. [PMID: 33452190 PMCID: PMC7813359 DOI: 10.1136/bmjopen-2020-041218] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 11/17/2020] [Accepted: 12/29/2020] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Determine the association of incident antibiotic prescribing levels for common infections with infection-related complications and hospitalisations by comparing high with low prescribing general practitioner practices. DESIGN RETROSPECTIVE COHORT STUDY Retrospective cohort study. DATA SOURCE UK primary care records from the Clinical Practice Research Datalink (CPRD GOLD) and SAIL Databank (SAIL) linked with Hospital Episode Statistics (HES) data, including 546 CPRD, 346 CPRD-HES and 338 SAIL-HES practices. EXPOSURES Initial general practice visit for one of six common infections and the proportion of antibiotic prescribing in each practice. MAIN OUTCOME MEASURES Incidence of infection-related complications (as recorded in general practice) or infection-related hospital admission within 30 days after consultation for a common infection. RESULTS A practice with 10.4% higher antibiotic prescribing (the IQR) was associated with a 5.7% lower rate of infection-related hospital admissions (adjusted analysis, 95% CI 3.3% to 8.0%). The association varied by infection with larger associations in hospital admissions with lower respiratory tract infection (16.1%; 95% CI 12.4% to 19.7%) and urinary tract infection (14.7%; 95% CI 7.6% to 21.1%) and smaller association in hospital admissions for upper respiratory tract infection (6.5%; 95% CI 3.5% to 9.5%) The association of antibiotic prescribing levels and hospital admission was largest in patients aged 18-39 years (8.6%; 95% CI 4.0% to 13.0%) and smallest in the elderly aged 75+ years (0.3%; 95% CI -3.4% to 3.9%). CONCLUSIONS There is an association between lower levels of practice level antibiotic prescribing and higher infection-related hospital admissions. Indiscriminately reducing antibiotic prescribing may lead to harm. Greater focus is needed to optimise antibiotic use by reducing inappropriate antibiotic prescribing and better targeting antibiotics to patients at high risk of infection-related complications.
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Affiliation(s)
- Birgitta van Bodegraven
- Health e-Research Centre, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Victoria Palin
- Health e-Research Centre, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Chirag Mistry
- Health e-Research Centre, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Matthew Sperrin
- Health e-Research Centre, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Andrew White
- NHS Greater Manchester Shared Service, Oldham, UK
| | | | - Darren M Ashcroft
- Centre for Pharmacoepidemiology and Drug Safety, NIHR Greater Manchester Patient Safety Translational Research Centre, School of Health Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre (MAHSC), The University of Manchester, Manchester, UK
| | - Tjeerd Pieter van Staa
- Health e-Research Centre, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
- Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, the Netherlands
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27
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Weishaupt R, Bächler A, Feldhaus S, Lang G, Klein P, Schoop R. Safety and Dose-Dependent Effects of Echinacea for the Treatment of Acute Cold Episodes in Children: A Multicenter, Randomized, Open-Label Clinical Trial. CHILDREN (BASEL, SWITZERLAND) 2020; 7:E292. [PMID: 33333722 PMCID: PMC7765151 DOI: 10.3390/children7120292] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 12/08/2020] [Accepted: 12/11/2020] [Indexed: 11/16/2022]
Abstract
Background: Due to the frequency and severity of cold symptoms in children, and the risk of associated complications, effective treatments are urgently needed. Here we evaluated the safety profile and treatment benefits of Echinacea in children with acute cold and flu symptoms. Methods: A total of 79 children (4-12 years) were randomized to a treatment regimen of three or five times daily Echinaforce Junior tablets (total of 1200 or 2000 mg Echinacea extract, EFJ) for the prospective treatment of upcoming cold and flu episodes at first signs. Parents recorded respiratory symptoms daily during episodes in their child and physicians and parents subjectively rated tolerability. Results: EFJ was used to treat 130 cold episodes in 68 children and was very well tolerated by more than 96% positive physician's ratings. EFJ-treated cold episodes lasted 7.5 days on average, with nine out of 10 episodes being fully resolved after 10 days. Five EFJ tablets daily reduced the average episode duration by up to 1.7 days (p < 0.02) in comparison to three EFJ tablets daily regimen. Effective symptom resolution finally contributed to a low antibiotic prescription rate in this study of 4.6%. Conclusions: EFJ tablets present a valuable option for the treatment of acute cold episodes in children showing a wide safety margin and increased therapeutic benefits at five tablets daily.
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Affiliation(s)
| | - Arnold Bächler
- Pediatric Practice, Notkerstrasse 14, 9000 St. Gallen, Switzerland;
| | - Simon Feldhaus
- Paramed Ambulatory, Paramed AG, Haldenstrasse 1, 6340 Baar, Switzerland;
| | - Günter Lang
- General Practice, Burgstrasse 112, 4125 Riehen, Switzerland;
| | - Peter Klein
- d.s.h. Statistical Services GmbH, Turmbergweg 5, 85296 Rohrbach, Germany;
| | - Roland Schoop
- A. Vogel AG, Grünaustrasse 4, 9325 Roggwil, Switzerland;
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28
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Morrell L, Buchanan J, Roope LSJ, Pouwels KB, Butler CC, Hayhoe B, Moore MV, Tonkin-Crine S, McLeod M, Robotham JV, Walker AS, Wordsworth S. Delayed Antibiotic Prescription by General Practitioners in the UK: A Stated-Choice Study. Antibiotics (Basel) 2020; 9:E608. [PMID: 32947965 PMCID: PMC7558347 DOI: 10.3390/antibiotics9090608] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 09/10/2020] [Accepted: 09/14/2020] [Indexed: 12/15/2022] Open
Abstract
Delayed antibiotic prescription in primary care has been shown to reduce antibiotic consumption, without increasing risk of complications, yet is not widely used in the UK. We sought to quantify the relative importance of factors affecting the decision to give a delayed prescription, using a stated-choice survey among UK general practitioners. Respondents were asked whether they would provide a delayed or immediate prescription in fifteen hypothetical consultations, described by eight attributes. They were also asked if they would prefer not to prescribe antibiotics. The most important determinants of choice between immediate and delayed prescription were symptoms, duration of illness, and the presence of multiple comorbidities. Respondents were more likely to choose a delayed prescription if the patient preferred not to have antibiotics, but consultation length had little effect. When given the option, respondents chose not to prescribe antibiotics in 51% of cases, with delayed prescription chosen in 21%. Clinical features remained important. Patient preference did not affect the decision to give no antibiotics. We suggest that broader dissemination of the clinical evidence supporting use of delayed prescription for specific presentations may help increase appropriate use. Establishing patient preferences regarding antibiotics may help to overcome concerns about patient acceptance. Increasing consultation length appears unlikely to affect the use of delayed prescription.
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Affiliation(s)
- Liz Morrell
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford OX3 7LF, UK; (J.B.); (L.S.J.R.); (K.B.P.); (S.W.)
| | - James Buchanan
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford OX3 7LF, UK; (J.B.); (L.S.J.R.); (K.B.P.); (S.W.)
- NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford OX2 6GG, UK; (C.C.B.); (S.T.-C.); (A.S.W.)
- NIHR Biomedical Research Centre Oxford, John Radcliffe Hospital, University of Oxford, Oxford OX3 9DU, UK
| | - Laurence S. J. Roope
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford OX3 7LF, UK; (J.B.); (L.S.J.R.); (K.B.P.); (S.W.)
- NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford OX2 6GG, UK; (C.C.B.); (S.T.-C.); (A.S.W.)
- NIHR Biomedical Research Centre Oxford, John Radcliffe Hospital, University of Oxford, Oxford OX3 9DU, UK
| | - Koen B. Pouwels
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford OX3 7LF, UK; (J.B.); (L.S.J.R.); (K.B.P.); (S.W.)
- NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford OX2 6GG, UK; (C.C.B.); (S.T.-C.); (A.S.W.)
| | - Christopher C. Butler
- NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford OX2 6GG, UK; (C.C.B.); (S.T.-C.); (A.S.W.)
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK
| | - Benedict Hayhoe
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, London W2 1PG, UK;
| | - Michael V. Moore
- Primary Care, Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton SO17 1BJ, UK;
| | - Sarah Tonkin-Crine
- NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford OX2 6GG, UK; (C.C.B.); (S.T.-C.); (A.S.W.)
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK
| | - Monsey McLeod
- NIHR Health Protection Research Unit in Healthcare-Associated Infections and Antimicrobial Resistance, Imperial College London, London SW7 2AZ, UK;
- Centre for Medication Safety and Service Quality, Pharmacy Department, Imperial College Healthcare NHS Trust, London W2 1NY, UK
- NIHR Imperial Patient Safety Translational Research Centre, Imperial College London, London SW7 2AZ, UK
| | - Julie V. Robotham
- Modelling and Economics Unit, National Infection Service, Public Health England, London SE1 8UG, UK;
| | - A. Sarah Walker
- NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford OX2 6GG, UK; (C.C.B.); (S.T.-C.); (A.S.W.)
- NIHR Biomedical Research Centre Oxford, John Radcliffe Hospital, University of Oxford, Oxford OX3 9DU, UK
- Nuffield Department of Medicine, University of Oxford, Oxford OX3 7BN, UK
| | - Sarah Wordsworth
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford OX3 7LF, UK; (J.B.); (L.S.J.R.); (K.B.P.); (S.W.)
- NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford OX2 6GG, UK; (C.C.B.); (S.T.-C.); (A.S.W.)
- NIHR Biomedical Research Centre Oxford, John Radcliffe Hospital, University of Oxford, Oxford OX3 9DU, UK
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Gulliford MC, Juszczyk D, Prevost AT, Soames J, McDermott L, Sultana K, Wright M, Fox R, Hay AD, Little P, Moore M, Yardley L, Ashworth M, Charlton J. Electronically delivered interventions to reduce antibiotic prescribing for respiratory infections in primary care: cluster RCT using electronic health records and cohort study. Health Technol Assess 2020; 23:1-70. [PMID: 30900550 DOI: 10.3310/hta23110] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Unnecessary prescribing of antibiotics in primary care is contributing to the emergence of antimicrobial drug resistance. OBJECTIVES To develop and evaluate a multicomponent intervention for antimicrobial stewardship in primary care, and to evaluate the safety of reducing antibiotic prescribing for self-limiting respiratory infections (RTIs). INTERVENTIONS A multicomponent intervention, developed as part of this study, including a webinar, monthly reports of general practice-specific data for antibiotic prescribing and decision support tools to inform appropriate antibiotic prescribing. DESIGN A parallel-group, cluster randomised controlled trial. SETTING The trial was conducted in 79 general practices in the UK Clinical Practice Research Datalink (CPRD). PARTICIPANTS All registered patients were included. MAIN OUTCOME MEASURES The primary outcome was the rate of antibiotic prescriptions for self-limiting RTIs over the 12-month intervention period. COHORT STUDY A separate population-based cohort study was conducted in 610 CPRD general practices that were not exposed to the trial interventions. Data were analysed to evaluate safety outcomes for registered patients with 45.5 million person-years of follow-up from 2005 to 2014. RESULTS There were 41 intervention trial arm practices (323,155 patient-years) and 38 control trial arm practices (259,520 patient-years). There were 98.7 antibiotic prescriptions for RTIs per 1000 patient-years in the intervention trial arm (31,907 antibiotic prescriptions) and 107.6 per 1000 patient-years in the control arm (27,923 antibiotic prescriptions) [adjusted antibiotic-prescribing rate ratio (RR) 0.88, 95% confidence interval (CI) 0.78 to 0.99; p = 0.040]. There was no evidence of effect in children aged < 15 years (RR 0.96, 95% CI 0.82 to 1.12) or adults aged ≥ 85 years (RR 0.97, 95% CI 0.79 to 1.18). Antibiotic prescribing was reduced in adults aged between 15 and 84 years (RR 0.84, 95% CI 0.75 to 0.95), that is, one antibiotic prescription was avoided for every 62 patients (95% CI 40 to 200 patients) aged 15-84 years per year. Analysis of trial data for 12 safety outcomes, including pneumonia and peritonsillar abscess, showed no evidence that these outcomes might be increased as a result of the intervention. The analysis of data from non-trial practices showed that if a general practice with an average list size of 7000 patients reduces the proportion of RTI consultations with antibiotics prescribed by 10%, then 1.1 (95% CI 0.6 to 1.5) more cases of pneumonia per year and 0.9 (95% CI 0.5 to 1.3) more cases of peritonsillar abscesses per decade may be observed. There was no evidence that mastoiditis, empyema, meningitis, intracranial abscess or Lemierre syndrome were more frequent at low-prescribing practices. LIMITATIONS The research was based on electronic health records that may not always provide complete data. The number of practices included in the trial was smaller than initially intended. CONCLUSIONS This study found evidence that, overall, general practice antibiotic prescribing for RTIs was reduced by this electronically delivered intervention. Antibiotic prescribing rates were reduced for adults aged 15-84 years, but not for children or the senior elderly. FUTURE WORK Strategies for antimicrobial stewardship should employ stratified interventions that are tailored to specific age groups. Further research into the safety of reduced antibiotic prescribing is also needed. TRIAL REGISTRATION Current Controlled Trials ISRCTN95232781. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 11. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Martin C Gulliford
- School of Population Health and Environmental Sciences, King's College London, London, UK.,NIHR Biomedical Research Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Dorota Juszczyk
- School of Population Health and Environmental Sciences, King's College London, London, UK.,NIHR Biomedical Research Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - A Toby Prevost
- School of Population Health and Environmental Sciences, King's College London, London, UK.,NIHR Biomedical Research Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK.,School of Public Health, Imperial College London, London, UK
| | - Jamie Soames
- Clinical Practice Research Datalink, Medicines and Healthcare products Regulatory Agency, London, UK
| | - Lisa McDermott
- School of Population Health and Environmental Sciences, King's College London, London, UK
| | - Kirin Sultana
- Clinical Practice Research Datalink, Medicines and Healthcare products Regulatory Agency, London, UK
| | - Mark Wright
- Clinical Practice Research Datalink, Medicines and Healthcare products Regulatory Agency, London, UK
| | | | - Alastair D Hay
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Paul Little
- Primary Care Research Group, University of Southampton, Southampton, UK
| | - Michael Moore
- Primary Care Research Group, University of Southampton, Southampton, UK
| | - Lucy Yardley
- Department of Psychology, University of Southampton, Southampton, UK.,School of Psychological Science, University of Bristol, Bristol, UK
| | - Mark Ashworth
- School of Population Health and Environmental Sciences, King's College London, London, UK
| | - Judith Charlton
- School of Population Health and Environmental Sciences, King's College London, London, UK
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31
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Affiliation(s)
- Roseanne A Ressner
- Walter Reed National Military Medical Center, Infectious Diseases, 8901 Wisconsin Ave, Bethesda, MD 20889
- Uniformed Services University of the Health Sciences, Medicine, 4301 Jones Bridge Rd, Bethesda, MD 20814
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Greer R, Althaus T, Ling C, Intralawan D, Nedsuwan S, Thaipadungpanit J, Wangrangsimakul T, Butler C, Day N, Lubell Y. Prevalence of Group A Streptococcus in Primary Care Patients and the Utility of C-Reactive Protein and Clinical Scores for Its Identification in Thailand. Am J Trop Med Hyg 2020; 102:377-383. [PMID: 31889507 PMCID: PMC7008346 DOI: 10.4269/ajtmh.19-0502] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Accepted: 11/11/2019] [Indexed: 01/21/2023] Open
Abstract
Pharyngitis is usually caused by a viral infection for which antibiotics are often unnecessarily prescribed, adding to the burden of antimicrobial resistance. Identifying who needs antibiotics is challenging; microbiological confirmation and clinical scores are used but have limitations. In a cross-sectional study nested within a randomized controlled trial, we estimated the prevalence and antibiotic susceptibility profiles of group A Streptococcus (GAS) in patients presenting to primary care with a sore throat and fever in northern Thailand. We then evaluated the use of C-reactive protein (CRP) and clinical scores (Centor and FeverPAIN) to identify the presence of GAS. One hundred sixty-nine patients were enrolled, of whom 35 (20.7%) had β-hemolytic Streptococci (BHS) isolated from throat swab culture, and 11 (6.5%) had GAS. All GAS isolates were sensitive to penicillin G. The median CRP of those without BHS isolation was 10 mg/L (interquartile range [IQR] ≤ 8-18), compared with 18 mg/L (IQR 9-71, P = 0.0302) for those with GAS and 14 mg/L (IQR ≤ 8-38, P = 0.0516) for those with any BHS isolated. However, there were no significant relationships between CRP > 8 mg/L (P = 0.112), Centor ≥ 3 (P = 0.212), and FeverPAIN ≥ 4 (P = 1.000), and the diagnosis of GAS compared with no BHS isolation. Identifying who requires antibiotics for pharyngitis remains challenging and necessitates further larger studies. C-reactive protein testing alone, although imperfect, can reduce prescribing compared with routine care. Targeted CRP testing through clinical scoring may be the most cost-effective approach to ruling out GAS infection.
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Affiliation(s)
- Rachel Greer
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
| | - Thomas Althaus
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
| | - Clare Ling
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Daranee Intralawan
- Social and Preventive Medicine Department, Chiang Rai Regional Hospital, Chiang Rai, Thailand
| | - Supalert Nedsuwan
- Social and Preventive Medicine Department, Chiang Rai Regional Hospital, Chiang Rai, Thailand
| | - Janjira Thaipadungpanit
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Tri Wangrangsimakul
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
| | - Christopher Butler
- Clinical Trials Unit, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Nicolas Day
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
| | - Yoel Lubell
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
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33
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Gong CL, Zangwill KM, Hay JW, Meeker D, Doctor JN. Behavioral Economics Interventions to Improve Outpatient Antibiotic Prescribing for Acute Respiratory Infections: a Cost-Effectiveness Analysis. J Gen Intern Med 2019; 34:846-854. [PMID: 29740788 PMCID: PMC6544688 DOI: 10.1007/s11606-018-4467-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Revised: 03/06/2018] [Accepted: 04/13/2018] [Indexed: 01/13/2023]
Abstract
BACKGROUND Behavioral economics interventions have been shown to effectively reduce the rates of inappropriate antibiotic prescriptions for acute respiratory infections (ARIs). OBJECTIVE To determine the cost-effectiveness of three behavioral economic interventions designed to reduce inappropriate antibiotic prescriptions for ARIs. DESIGN Thirty-year Markov model from the US societal perspective with inputs derived from the literature and CDC surveillance data. SUBJECTS Forty-five-year-old adults with signs and symptoms of ARI presenting to a healthcare provider. INTERVENTIONS (1) Provider education on guidelines for the appropriate treatment of ARIs; (2) Suggested Alternatives, which utilizes computerized clinical decision support to suggest non-antibiotic treatment choices in lieu of antibiotics; (3) Accountable Justification, which mandates free-text justification into the patient's electronic health record when antibiotics are prescribed; and (4) Peer Comparison, which sends a periodic email to prescribers about his/her rate of inappropriate antibiotic prescribing relative to clinician colleagues. MAIN MEASURES Discounted costs, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios. KEY RESULTS Each intervention has lower costs but higher QALYs compared to provider education. Total costs for each intervention were $178.21, $173.22, $172.82, and $172.52, and total QALYs were 14.68, 14.73, 14.74, and 14.74 for the control, Suggested Alternatives, Accountable Justification, and Peer Comparison groups, respectively. Results were most sensitive to the quality-of-life of the uninfected state, and the likelihood and costs for antibiotic-associated adverse events. CONCLUSIONS Behavioral economics interventions can be cost-effective strategies for reducing inappropriate antibiotic prescriptions by reducing healthcare resource utilization.
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Affiliation(s)
- Cynthia L Gong
- University of Southern California Leonard D. Schaeffer Center for Health Policy & Economics, Los Angeles, CA, USA.
| | - Kenneth M Zangwill
- Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Los Angeles, CA, USA
| | - Joel W Hay
- University of Southern California Leonard D. Schaeffer Center for Health Policy & Economics, Los Angeles, CA, USA
| | - Daniella Meeker
- University of Southern California Leonard D. Schaeffer Center for Health Policy & Economics, Los Angeles, CA, USA.,University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Jason N Doctor
- University of Southern California Leonard D. Schaeffer Center for Health Policy & Economics, Los Angeles, CA, USA
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Moore M, Stuart B, Lown M, Van den Bruel A, Smith S, Knox K, Thompson MJ, Little P. Predictors of Adverse Outcomes in Uncomplicated Lower Respiratory Tract Infections. Ann Fam Med 2019; 17:231-238. [PMID: 31085527 PMCID: PMC6827627 DOI: 10.1370/afm.2386] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 01/31/2019] [Accepted: 02/28/2019] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Presentation with acute lower respiratory tract infection (LRTI) in primary care is common. The aim of this study was to help clinicians treat patients presenting with LRTI in primary care by identifying those at risk of serious adverse outcomes (death, admission, late-onset pneumonia). METHODS In a prospective cohort study of patients presenting with LRTI symptoms, patient characteristics and clinical findings were recorded and adverse events identified over 30 days by chart review. Multivariable logistic regression analyses identified predictors of adverse outcomes. RESULTS Participants were recruited from 522 UK practices in 2009-2013. The analysis was restricted to the 28,846 adult patients not referred immediately to the hospital. Serious adverse outcomes occurred in 325/28,846 (1.1%). Eight factors were independently predictive; these characterized symptom severity (absence of coryza, fever, chest pain, and clinician-assessed severity), patient vulnerability (age >65 years, comorbidity), and physiological impact (oxygen saturation <95%, low blood pressure). In aggregate, the 8 features had moderate predictive value (area under the receiver operating characteristic curve 0.71, 95% CI, 0.68-0.74); the 4% of patients with ≥5 features had an approximately 1 in 17 (5.7%) risk of serious adverse outcomes, the 35% with 3 or 4 features had an intermediate risk (1 in 50, 2.0%), and the 61% with ≤2 features had a low (1 in 200, 0.5%) risk. CONCLUSIONS In routine practice most patients presenting with LRTI in primary care can be identified as at intermediate or low risk of serious outcome.
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Affiliation(s)
- Michael Moore
- University of Southampton, Primary Care and Population Sciences, Aldermoor Health Centre, Southampton, United Kingdom
| | - Beth Stuart
- University of Southampton, Primary Care and Population Sciences, Aldermoor Health Centre, Southampton, United Kingdom
| | - Mark Lown
- University of Southampton, Primary Care and Population Sciences, Aldermoor Health Centre, Southampton, United Kingdom
| | - Ann Van den Bruel
- University of Oxford, Nuffield Department of Primary Health Care Sciences, Radcliffe Observatory Quarter, Oxford, United Kingdom
| | - Sue Smith
- University of Oxford, Nuffield Department of Primary Health Care Sciences, Radcliffe Observatory Quarter, Oxford, United Kingdom
| | - Kyle Knox
- University of Oxford, Nuffield Department of Primary Health Care Sciences, Radcliffe Observatory Quarter, Oxford, United Kingdom
| | | | - Paul Little
- University of Southampton, Primary Care and Population Sciences, Aldermoor Health Centre, Southampton, United Kingdom
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Frost HM, Fritsche TR, Hall MC. Beta-Hemolytic Nongroup A Streptococcal Pharyngitis in Children. J Pediatr 2019; 206:268-273.e1. [PMID: 30528760 DOI: 10.1016/j.jpeds.2018.10.048] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 10/09/2018] [Accepted: 10/24/2018] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To evaluate the epidemiology, clinical features, and antibiotic prescribing patterns for nongroup A streptococci (NGAS) in children. STUDY DESIGN Throat cultures obtained for pharyngitis were assessed at a large community-based health system over 10 years. Epidemiologic and clinical features of children with NGAS were compared with children with group A Streptococcus (GAS) and negative cultures. Antibiotic prescribing patterns were evaluated. RESULTS A total of 224 328 rapid streptococcal antigen tests and 116 578 throat cultures were performed. Clinical analysis was completed for 602 GAS-positive patients, 535 NGAS-positive patients, and 480 patients with negative cultures. Incidence of NGAS did not vary annually or by season but increased with age from 2% at ≤5 years to 7% at 18 years of age. Patients with NGAS were more likely than those with negative cultures to have tonsillar exudate (20.3% vs 13.1%, P = .003) and enlarged tonsils (28.6% vs 19.3%, P < .001). Modified Centor scores did not differ between groups (score ≥2, P = 1.0; score ≥3, P = .50). Patients with GAS were more likely than those with NGAS to have fever (32.6% vs 24.5%, P = .003), palatal petechiae (14.0% vs 3.1%, P < .001), and modified Centor score ≥2 (47.8% vs 27.1%; P < .001). Of patients with NGAS, 65% were prescribed antibiotics. CONCLUSIONS NGAS likely exist in both carriage and infectious states and incidence increases with age. Infections associated with NGAS are milder than with GAS, and complications are rare. Laboratory reporting of NGAS results in high antibiotic use, despite current recommendations against treatment.
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Affiliation(s)
- Holly M Frost
- Department of Pediatrics, University of Colorado, Aurora, CO; Department of Pediatrics, Denver Health and Hospital Authority, Denver, CO; Marshfield Clinic Research Institute, Marshfield, WI.
| | - Thomas R Fritsche
- Marshfield Clinic Research Institute, Marshfield, WI; Department of Pathology, Marshfield Clinic Health System, Marshfield, WI
| | - Matthew C Hall
- Department of Medicine, Division of Infectious Diseases, Marshfield Clinic Health System, Marshfield, WI
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Wilcox CR, Stuart B, Leaver H, Lown M, Willcox M, Moore M, Little P. Effectiveness of the probiotic Streptococcus salivarius K12 for the treatment and/or prevention of sore throat: a systematic review. Clin Microbiol Infect 2019; 25:673-680. [PMID: 30616011 DOI: 10.1016/j.cmi.2018.12.031] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Revised: 12/21/2018] [Accepted: 12/23/2018] [Indexed: 01/12/2023]
Abstract
BACKGROUND Sore throat resulting from pharyngotonsillitis is one of the commonest reasons for primary care consultation and inappropriate antibiotic prescription and finding effective alternative treatments is important. OBJECTIVES To review the evidence for using the probiotic Streptococcus salivarius K12 (SsK12) for the prevention or treatment of pharyngotonsillitis. DATA SOURCES PubMed, Embase, CINAHL and Cochrane Library. STUDY ELIGIBILITY CRITERIA Randomized controlled trials (RCTs). PARTICIPANTS Adults or children. INTERVENTIONS SsK12 as active treatment or prophylaxis, against pharyngotonsillitis. METHODS Literature search. RESULTS Four articles were identified (1846 participants). All were deemed to be of poor quality using the Cochrane risk-of-bias assessment. Two trials studied SsK12 prophylaxis for streptococcal pharyngitis (children without history of recurrence). One compared daily administration of SsK12 to no treatment over 6 months (n = 222, age 33-45 months), reporting significantly lower incidence in the SsK12 group (16.2% vs. 48.6%, p < 0.01), whereas another placebo-controlled RCT over four school terms (n = 1314, 5-14 years) found no significant difference (7.8% vs. 8.8%, p 0.34) with SsK12 (administered on school days). Another trial found daily SsK12 to significantly protect children (n = 250, 6-7 years) against chronic adenoiditis exacerbation over 3 months compared to no treatment (71.7% vs. 100%, p < 0.0001). The one placebo-controlled RCT in adults that studied the use of SsK12 for acute pharyngotonsillitis (concurrently with penicillin) showed no significant benefit. In all trials, SsK12 was safe and well tolerated. CONCLUSIONS SsK12 appears safe and well tolerated. However, further RCTs are required to establish its role as a prophylactic therapy, particularly among patients experiencing frequent exacerbations of pharyngitis. In the acute setting, SsK12 is unlikely to be effective if given concurrently with antibiotics; however, further RCTs should establish its role as an alternative to antibiotics in nonsevere cases or when prescribed after antibiotic therapy for the prevention of disease recurrence and/or secondary infection.
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Affiliation(s)
- C R Wilcox
- NIHR Clinical Research Facility, University Hospital Southampton NHS Foundation Trust, UK; Department of Primary Care and Population Sciences, Aldermoor Health Centre, University of Southampton, Southampton, UK.
| | - B Stuart
- Department of Primary Care and Population Sciences, Aldermoor Health Centre, University of Southampton, Southampton, UK
| | - H Leaver
- Department of Primary Care and Population Sciences, Aldermoor Health Centre, University of Southampton, Southampton, UK
| | - M Lown
- Department of Primary Care and Population Sciences, Aldermoor Health Centre, University of Southampton, Southampton, UK
| | - M Willcox
- Department of Primary Care and Population Sciences, Aldermoor Health Centre, University of Southampton, Southampton, UK
| | - M Moore
- Department of Primary Care and Population Sciences, Aldermoor Health Centre, University of Southampton, Southampton, UK
| | - P Little
- Department of Primary Care and Population Sciences, Aldermoor Health Centre, University of Southampton, Southampton, UK
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Llor C, Moragas A, Cordoba G. [Twenty-five myths in infectious diseases in primary care associated with overdiagnosis and overtreatment]. Aten Primaria 2018; 50 Suppl 2:57-64. [PMID: 30270191 PMCID: PMC6836970 DOI: 10.1016/j.aprim.2018.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Accepted: 09/10/2018] [Indexed: 11/17/2022] Open
Abstract
Overdiagnosis and overprescribing is common in current clinical practice of infectious diseases in primary care. On the basis of studies published in the medical literature we identify my means of a non-systematic review a total of 25 myths associated with the diagnosis and treatment and present the literature pertaining to each myth. These myths result in extraneous testing (overdiagnosis) and excessive antimicrobial treatment (overtreatment). Most of these myths are ingrained among general practitioners in our country. Not only should these myths be debunked from our clinical practice, but they should also be reversed, and we encourage our readers to critically appraise their practice when it comes down to the misconceptions treated in this manuscript. We attempt to give guidance to clinicians facing these frequent clinical scenarios.
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Affiliation(s)
- Carles Llor
- Centro de Salud Via Roma, Barcelona, España; Grupo de Trabajo de Enfermedades Infecciosas de la semFYC.
| | - Ana Moragas
- Universitat Rovira i Virgili. Centro de Salud Jaume I, Tarragona, España
| | - Gloria Cordoba
- Centro de Investigación y Educación en Medicina Familiar, Instituto de Salud Pública, Universidad de Copenhague, Copenhague, Dinamarca
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Oliver J, Malliya Wadu E, Pierse N, Moreland NJ, Williamson DA, Baker MG. Group A Streptococcus pharyngitis and pharyngeal carriage: A meta-analysis. PLoS Negl Trop Dis 2018; 12:e0006335. [PMID: 29554121 PMCID: PMC5875889 DOI: 10.1371/journal.pntd.0006335] [Citation(s) in RCA: 81] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2017] [Revised: 03/29/2018] [Accepted: 02/21/2018] [Indexed: 01/22/2023] Open
Abstract
Objective Antibiotic treatment of Group A Streptococcus (GAS) pharyngitis is important in acute rheumatic fever (ARF) prevention, however clinical guidelines for prescription vary. GAS carriers with acute viral infections may receive antibiotics unnecessarily. This review assessed the prevalence of GAS pharyngitis and carriage in different settings. Methods A random-effects meta-analysis was performed. Prevalence estimates for GAS+ve pharyngitis, serologically-confirmed GAS pharyngitis and asymptomatic pharyngeal carriage were generated. Findings were stratified by age group, recruitment method and country income level. Medline and EMBASE databases were searched for relevant literature published between 1 January 1946 and 7 April 2017. Studies reporting prevalence data on GAS+ve or serologically-confirmed GAS pharyngitis that stated participants exhibited symptoms of pharyngitis or upper respiratory tract infection (URTI) were included. Included studies reporting the prevalence of asymptomatic GAS carriage needed to state participants were asymptomatic. Results 285 eligible studies were identified. The prevalence of GAS+ve pharyngitis was 24.1% (95% CI: 22.6–25.6%) in clinical settings (which used ‘passive recruitment’ methods), but less in sore throat management programmes (which used ‘active recruitment’, 10.0%, 8.1–12.4%). GAS+ve pharyngitis was more prevalent in high-income countries (24.3%, 22.6–26.1%) compared with low/middle-income countries (17.6%, 14.9–20.7%). In clinical settings, approximately 10% of children swabbed with a sore throat have serologically-confirmed GAS pharyngitis, but this increases to around 50–60% when the child is GAS culture-positive. The prevalence of serologically-confirmed GAS pharyngitis was 10.3% (6.6–15.7%) in children from high-income countries and their asymptomatic GAS carriage prevalence was 10.5% (8.4–12.9%). A lower carriage prevalence was detected in children from low/middle income countries (5.9%, 4.3–8.1%). Conclusions In active sore throat management programmes, if the prevalence of GAS detection approaches the asymptomatic carriage rate (around 6–11%), there may be little benefit from antibiotic treatment as the majority of culture-positive patients are likely carriers. Treating sore throats caused by Group A Streptococcus infections (GAS pharyngitis) with antibiotics is important for preventing acute rheumatic fever (ARF). It is impossible to distinguish patients with true GAS pharyngitis infections from GAS carriers with pharyngitis caused by viral infections when throat swab culturing alone is used to diagnose GAS pharyngitis. Carriers are not likely to benefit from antibiotic treatment, but may receive treatment unnecessarily. Reported rates of GAS pharyngitis and carriage vary considerably depending on the setting. Thus it is difficult to ascertain which groups are likely to benefit significantly from active sore throat management programmes which treat GAS pharyngitis in order to prevent ARF. We performed a meta-analysis to estimate the prevalence of GAS pharyngitis and asymptomatic carriage in different settings. Approximately 10% of all children swabbed for a sore throat in clinical settings have true GAS pharyngitis, but this increases to around 55% if the children have GAS detected in their throat using swab cultures. In active sore throat management programmes, the prevalence of GAS detection is lower than in clinical settings and if it declines towards 8% (the asymptomatic carriage level), there may be little benefit in treating GAS culture-positive patients with antibiotics.
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Affiliation(s)
- Jane Oliver
- University of Otago Wellington, Newtown, Wellington, New Zealand
| | | | - Nevil Pierse
- University of Otago Wellington, Newtown, Wellington, New Zealand
| | - Nicole J. Moreland
- Maurice Wilkins Centre and School of Medical Sciences, University of Auckland, Auckland, New Zealand
| | - Deborah A. Williamson
- University of Otago Wellington, Newtown, Wellington, New Zealand
- Department of Microbiology and Immunology, University of Melbourne, Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
| | - Michael G. Baker
- University of Otago Wellington, Newtown, Wellington, New Zealand
- * E-mail:
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Gottlieb M, Long B, Koyfman A. Clinical Mimics: An Emergency Medicine-Focused Review of Streptococcal Pharyngitis Mimics. J Emerg Med 2018. [PMID: 29523424 DOI: 10.1016/j.jemermed.2018.01.031] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Pharyngitis is a common disease in the emergency department (ED). Despite a relatively low incidence of complications, there are many dangerous conditions that can mimic this disease and are essential for the emergency physician to consider. OBJECTIVE This article provides a review of the evaluation and management of group A β-hemolytic Streptococcal (GABHS) pharyngitis, as well as important medical conditions that can mimic this disease. DISCUSSION GABHS pharyngitis often presents with fever, sore throat, tonsillar exudates, and anterior cervical lymphadenopathy. History and physical examination are insufficient for the diagnosis. The Centor criteria or McIsaac score can help risk stratify patients for subsequent testing or treatment. Antibiotics may reduce symptom duration and suppurative complications, but the effect is small. Rheumatic fever is uncommon in developed countries, and shared decision making is recommended if antibiotics are used for this indication. Oral analgesics and topical anesthetics are important for symptom management. Physicians should consider alternate diagnoses that may mimic GABHS pharyngitis, which can include epiglottitis, infectious mononucleosis, Kawasaki disease, acute retroviral syndrome, Lemierre's syndrome, Ludwig's angina, peritonsillar abscess, retropharyngeal abscess, and viral pharyngitis. A focused history and physical examination can help differentiate these conditions. CONCLUSIONS GABHS may present similarly to other benign and potentially deadly diseases. Diagnosis and treatment of pharyngitis should be based on clinical evaluation. Consideration of pharyngitis mimics is important in the evaluation and management of ED patients.
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Affiliation(s)
- Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, Illinois
| | - Brit Long
- Department of Emergency Medicine, San Antonio Military Medical Center, Fort Sam Houston, Texas
| | - Alex Koyfman
- Department of Emergency Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas
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Moore M, Stuart B, Little P, Smith S, Thompson MJ, Knox K, van den Bruel A, Lown M, Mant D. Predictors of pneumonia in lower respiratory tract infections: 3C prospective cough complication cohort study. Eur Respir J 2017; 50:50/5/1700434. [PMID: 29167296 PMCID: PMC5724402 DOI: 10.1183/13993003.00434-2017] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 08/16/2017] [Indexed: 12/22/2022]
Abstract
The aim was to aid diagnosis of pneumonia in those presenting with lower respiratory tract symptoms in routine primary care. A cohort of 28 883 adult patients with acute cough attributed to lower respiratory tract infections (LRTIs) was recruited from 5222 UK practices in 2009–13. Symptoms, signs and treatment were recorded at presentation and subsequent events followed-up for 30 days by chart review. The predictive value of patient characteristics, presenting symptoms and clinical findings for the diagnosis of pneumonia in the first 7 days was established. Of the 720 out of 28 883 (2.5.%) radiographed within 1 week of the index consultation, 115 (16.0%; 0.40% of 28 883) were assigned a definite or probable pneumonia diagnosis. The significant independent predictors of radiograph-confirmed pneumonia were temperature >37.8°C (RR 2.6; 95% CI 1.5–4.8), crackles on auscultation (RR 1.8; 1.1–3.0), oxygen saturation <95% (RR 1.7; 1.0–3.1) and pulse >100·min–1 (RR 1.9; 1.1–3.2). Most patients with pneumonia (99/115, 86.1%) exhibited at least one of these four clinical signs; the positive predictive value of having at least one of these signs was 20.2% (95% CI 17.3–23.1). In routine practice, radiograph-confirmed pneumonia as a short-term complication of LRTI is very uncommon (one in 270). Pulse oximetry may aid the diagnosis of pneumonia in this setting. Pulse oximetry probably has a role in the diagnosis of pneumonia in the communityhttp://ow.ly/QpWc30fVM2j
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Affiliation(s)
- Michael Moore
- University of Southampton, Primary Care Medical Group, Aldermoor Health Centre, Southampton, UK
| | - Beth Stuart
- University of Southampton, Primary Care Medical Group, Aldermoor Health Centre, Southampton, UK
| | - Paul Little
- University of Southampton, Primary Care Medical Group, Aldermoor Health Centre, Southampton, UK
| | - Sue Smith
- Nuffield Department of Primary Health Care Sciences, University of Oxford, Oxford, UK
| | | | - Kyle Knox
- Nuffield Department of Primary Health Care Sciences, University of Oxford, Oxford, UK
| | - Anne van den Bruel
- Nuffield Department of Primary Health Care Sciences, University of Oxford, Oxford, UK
| | - Mark Lown
- University of Southampton, Primary Care Medical Group, Aldermoor Health Centre, Southampton, UK
| | - David Mant
- Nuffield Department of Primary Health Care Sciences, University of Oxford, Oxford, UK
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Weckmann G, Hauptmann-Voß A, Baumeister SE, Klötzer C, Chenot JF. Efficacy of AMC/DCBA lozenges for sore throat: A systematic review and meta-analysis. Int J Clin Pract 2017; 71. [PMID: 28869700 DOI: 10.1111/ijcp.13002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Accepted: 08/08/2017] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Lozenges containing Amylmetacresol and 2,4-Dichlorobenzylalcohol (AMC/DCBA, eg Strepsils® ) are marketed as a remedy for acute sore throat. This over-the-counter formulation has antiseptic and local anaesthetic qualities. OBJECTIVES The objective of this systematic review and meta-analysis is to evaluate the efficacy and safety of AMC/DCBA for the relief of pain associated with acute uncomplicated sore throat. METHODS A systematic review of Literature was conducted using databases Medline, Embase and Cochrane to identify randomised controlled trials comparing AMC/DCBA against placebo or alternative local treatment options for acute uncomplicated sore throat. An additional hand search was performed. Two reviewers independently assessed citations for relevance, inclusion criteria and risk of bias. Meta-analysis was performed on included trials and standardised mean differences (SMD; dCohen ) with 95% confidence intervals (CIs) were calculated. RESULTS The literature search yielded 77 citations, 3 of which met the inclusion criteria. AMC/DCBA lozenges (0.6 mg Amylmetacresol, 1.2 mg 2, 4-Dichlorobenzylalcohol) were compared with unflavoured, non-medicated lozenges. The AMC/DCBA formulation additionally contained lidocaine in one and flavouring additives in another trial. A total of 660 adults participated in the included trials. Primary outcome was reduction in pain intensity against baseline, 2 hours after intervention compared with placebo group. Fixed effects meta-analysis resulted in a standardised mean difference in pain intensity of -0.6 (-0.75; -0.45) on an 11-point ordinal rating scale, favouring the AMC/DCBA lozenges. Secondary outcomes were sore throat relief, difficulty swallowing and throat numbness. No serious side effects were reported, whereas mild side effects like headache, cough, nasal congestion and irritation of the oral cavity, were reported in up to 16% of subjects in both groups. All included trials were sponsored by a manufacturer of AMC/DCBA containing lozenges. CONCLUSIONS Lozenges with AMC/DCBA can be a safe treatment option to relieve pain in patients with uncomplicated sore throat looking for local treatment options and valuing the modest additional effect compared with non-medicated lozenges. Registration: PROSPERO CRD42015008826.
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Affiliation(s)
- Gesine Weckmann
- Department of General Practice, Institute for Community Medicine, University Medicine Greifswald, Germany
| | - Anke Hauptmann-Voß
- Department of General Practice, Institute for Community Medicine, University Medicine Greifswald, Germany
| | - Sebastian E Baumeister
- Division of Epidemiology, Department of Sport and Health Sciences, Technical University of Munich, Germany
- Institute for Community Medicine, SHIP/KEF Clinical-Epidemiological Research, University Medicine Greifswald, Germany
| | - Christine Klötzer
- Department of General Practice, Institute for Community Medicine, University Medicine Greifswald, Germany
| | - Jean-François Chenot
- Department of General Practice, Institute for Community Medicine, University Medicine Greifswald, Germany
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Aertgeerts B, Agoritsas T, Siemieniuk RAC, Burgers J, Bekkering GE, Merglen A, van Driel M, Vermandere M, Bullens D, Okwen PM, Niño R, van den Bruel A, Lytvyn L, Berg-Nelson C, Chua S, Leahy J, Raven J, Weinberg M, Sadeghirad B, Vandvik PO, Brignardello-Petersen R. Corticosteroids for sore throat: a clinical practice guideline. BMJ 2017; 358:j4090. [PMID: 28931507 PMCID: PMC6284245 DOI: 10.1136/bmj.j4090] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Bert Aertgeerts
- Academic Centre for General Practice, Department of Public Health and Primary Care, KU Leuven, Belgium
- CEBAM, Belgian Centre for Evidence-Based Medicine, Cochrane Belgium, Leuven, Belgium
| | - Thomas Agoritsas
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada L8S 4L8
- Division General Internal Medicine & Division of Clinical Epidemiology, University Hospitals of Geneva, CH-1211, Geneva, Switzerland
| | - Reed A C Siemieniuk
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada L8S 4L8
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jako Burgers
- Dutch College of General Practitioners, Utrecht, The Netherlands
- School CAPHRI, Department Family Medicine, Maastricht, The Netherlands
| | - Geertruida E Bekkering
- Academic Centre for General Practice, Department of Public Health and Primary Care, KU Leuven, Belgium
- CEBAM, Belgian Centre for Evidence-Based Medicine, Cochrane Belgium, Leuven, Belgium
| | - Arnaud Merglen
- Division of General Pediatrics, University Hospitals of Geneva & Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Mieke van Driel
- Primary Care Clinical Unit, Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Mieke Vermandere
- Academic Centre for General Practice, Department of Public Health and Primary Care, KU Leuven, Belgium
| | - Dominique Bullens
- Pediatric Immunology, Department of microbiology and immunology, KU Leuven, Belgium
- Pediatric allergy, Clinical division of pediatrics UZ Leuven, Leuven, Belgium
| | - Patrick Mbah Okwen
- Bali District Hospital, Bali and Centre for Development of Best practices in Health Yaounde, Cameroon
| | - Ricardo Niño
- Otorhinolaryngology-Head and Neck Surgery, Clinica del Country, Bogota, Colombia
| | - Ann van den Bruel
- NIHR Oxford Diagnostic Evidence Cooperative, Oxford, UK
- Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Lyubov Lytvyn
- Oslo University Hospital, Forskningsveien 2b, Blindern 0317 Oslo, Norway
| | - Carla Berg-Nelson
- The Society for Participatory Medicine, Newburyport, MA 01950-1183, USA
- Arizona Senior Academy, Tucson, AZ 85747, USA
| | - Shunjie Chua
- MOH Holdings, 1 Maritime Square, Singapore, Singapore 099253
| | | | | | | | - Behnam Sadeghirad
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada L8S 4L8
- HIV/STI Surveillance Research Center, and WHO Collaborating Center for HIV Surveillance, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
| | - Per O Vandvik
- Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- Department of Medicine, Innlandet Hospital Trust - division Gjøvik, Norway
| | - Romina Brignardello-Petersen
- CEBAM, Belgian Centre for Evidence-Based Medicine, Cochrane Belgium, Leuven, Belgium
- Faculty of Dentistry, Universidad de Chile, Santiago, Chile
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Moore M, Stuart B, Hobbs FR, Butler CC, Hay AD, Campbell J, Delaney BC, Broomfield S, Barratt P, Hood K, Everitt HA, Mullee M, Williamson I, Mant D, Little P. Symptom response to antibiotic prescribing strategies in acute sore throat in adults: the DESCARTE prospective cohort study in UK general practice. Br J Gen Pract 2017; 67:e634-e642. [PMID: 28808075 PMCID: PMC5569743 DOI: 10.3399/bjgp17x692321] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Accepted: 05/15/2017] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND A delayed or 'just in case' prescription has been identified as having potential to reduce antibiotic use in sore throat. AIM To determine the symptomatic outcome of acute sore throat in adults according to antibiotic prescription strategy in routine care. DESIGN AND SETTING A secondary analysis of the DESCARTE (Decision rule for the Symptoms and Complications of Acute Red Throat in Everyday practice) prospective cohort study comprising adults aged ≥16 years presenting with acute sore throat (≤2 weeks' duration) managed with treatment as usual in primary care in the UK. METHOD A random sample of 2876 people from the full cohort were requested to complete a symptom diary. A brief clinical proforma was used to collect symptom severity and examination findings at presentation. Outcome details were collected by notes review and a detailed symptom diary. The primary outcome was poorer 'global' symptom control (defined as longer than the median duration or higher than median symptom severity). Analyses controlled for confounding by indication (propensity to prescribe antibiotics). RESULTS A total of 1629/2876 (57%) of those requested returned a symptom diary, of whom 1512 had information on prescribing strategy. The proportion with poorer global symptom control was greater in those not prescribed antibiotics 398/587 (68%) compared with those prescribed immediate antibiotics 441/728 (61%) or delayed antibiotic prescription 116/197 59%); adjusted risk ratio (RR) (95% confidence intervals [CI]): immediate RR 0.87 (95% CI = 0.70 to 0.96), P = 0.006; delayed RR 0.88 (95% CI = 0.78 to 1.00), P = 0.042. CONCLUSION In the routine care of adults with sore throat, a delayed antibiotic strategy confers similar symptomatic benefits to immediate antibiotics compared with no antibiotics. If a decision is made to prescribe an antibiotic, a delayed antibiotic strategy is likely to yield similar symptomatic benefit to immediate antibiotics.
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Affiliation(s)
- Michael Moore
- Primary Care and Population Sciences Division, University of Southampton
| | - Beth Stuart
- Primary Care and Population Sciences Division, University of Southampton
| | - Fd Richard Hobbs
- Nuffield Department of Primary Care Health Sciences, University of Oxford
| | - Chris C Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford
| | - Alastair D Hay
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol
| | | | - Brendan C Delaney
- Department of Surgery and Cancer, Imperial College, St Mary's Hospital, London
| | - Sue Broomfield
- Primary Care and Population Sciences Division, University of Southampton
| | - Paula Barratt
- Primary Care and Population Sciences Division, University of Southampton
| | - Kerenza Hood
- Centre for trials research, South East Wales Trials Unit, Institute of Primary Care and Public Health, School of Medicine, Cardiff University
| | - Hazel A Everitt
- Primary Care and Population Sciences Division, University of Southampton
| | - Mark Mullee
- Primary Care and Population Sciences Division, University of Southampton
| | - Ian Williamson
- Primary Care and Population Sciences Division, University of Southampton
| | - David Mant
- Nuffield Department of Primary Care Health Sciences, University of Oxford
| | - Paul Little
- Primary Care and Population Sciences Division, University of Southampton
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Influence of the duration of penicillin prescriptions on outcomes for acute sore throat in adults: the DESCARTE prospective cohort study in UK general practice. Br J Gen Pract 2017; 67:e623-e633. [PMID: 28808076 DOI: 10.3399/bjgp17x692333] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Accepted: 05/15/2017] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Guidelines recommend 10-day treatment courses for acute sore throat, but shorter courses may be used in practice. AIM To determine whether antibiotic duration predicts adverse outcome of acute sore throat in adults in routine care. DESIGN AND SETTING A secondary analysis of the DESCARTE (Decision rule for the Symptoms and Complications of Acute Red Throat in Everyday practice) prospective cohort study of 12 829 adults presenting in UK general practice with acute sore throat. METHOD A brief clinical proforma was used to collect symptom severity and examination findings at presentation. Outcomes were collected by notes review, a sample also completed a symptom diary. The primary outcome was re-consultation with new/non-resolving symptoms within 1 month. The secondary outcome was 'global' poorer symptom control (longer than the median duration or higher than median severity). RESULTS Antibiotics were prescribed for 62% (7872/12 677) of participants. The most commonly prescribed antibiotic was phenoxymethylpenicillin (76%, 5656/7474) and prescription durations were largely for 5 (20%), 7 (57%), or 10 (22%) days. Compared with 5-day courses, those receiving longer courses were less likely to re-consult with new or non-resolving symptoms (5 days 15.3%, 7 days 13.9%, 10 days 12.2%, 7-day course adjusted risk ratio (RR) 0.92 [95% confidence interval [CI] = 0.76 to 1.11] and 10-days RR 0.86 [95% CI = 0.59 to 1.23]) but these differences did not reach statistical significance. CONCLUSION In adults prescribed antibiotics for sore throat, the authors cannot rule out a small advantage in terms of reduced re-consultation for a 10-day course of penicillin, but the effect is likely to be small.
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Llor C, Alkorta Gurrutxaga M, de la Flor I Bru J, Bernárdez Carracedo S, Cañada Merino JL, Bárcena Caamaño M, Serrano Martino C, Cots Yago JM. [Recommendations for the use of rapid diagnosis techniques in respiratory infections in primary care]. Aten Primaria 2017; 49:426-437. [PMID: 28623011 PMCID: PMC6875920 DOI: 10.1016/j.aprim.2017.03.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2017] [Accepted: 03/06/2017] [Indexed: 01/22/2023] Open
Abstract
Respiratory tract infections rank first as causes of adult and paediatric infectious morbidity in primary care in Spain. These infections are usually self-limiting and are mainly caused by viruses. However, a high percentage of unnecessary antibiotic prescription is reported. Point-of-care tests are biomedical tests, which can be used near the patient, without interference of a laboratory. The use of these tests, many of which have been recently developed, is rapidly increasing in general practice. Notwithstanding, we must mull over whether they always contribute to an effective and high-quality diagnostic process by primary care clinicians. We present a set of criteria that can be used by clinicians and discuss the pros and cons of the instruments available for the management of respiratory tract infections and how to use them appropriately.
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Affiliation(s)
- Carles Llor
- Grupo de Trabajo de Enfermedades Infecciosas de la Sociedad Española de Medicina Familiar y Comunitaria (SemFYC), Centro de Salud Via Roma, Barcelona, España.
| | - Miriam Alkorta Gurrutxaga
- Grupo de Estudio de Infección en la Atención Primaria de la Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica (GEIAP-SEIMC), Servicio de Microbiología, Hospital de Donostia, Osakidetza, Donostia, España
| | - Josep de la Flor I Bru
- Grupo de Trabajo de Tecnologías Diagnósticas de la Sociedad Española de Pediatría Extrahospitalaria y Atención Primaria (SEPEAP), Centro de Salud El Serral, Institut Català de la Salut, Sant Vicenç dels Horts, España
| | - Sílvia Bernárdez Carracedo
- Grupo de Trabajo de Tecnologías Diagnósticas de la Sociedad Española de Pediatría Extrahospitalaria y Atención Primaria (SEPEAP), Centro de Salud Dr. Robert, Institut Català de la Salut, Badalona, España
| | - José Luis Cañada Merino
- Grupo de Trabajo de Enfermedades Infecciosas, Medicina Tropical y del Viajero de la Sociedad Española de Médicos de Atención Primaria (SEMERGEN), Sendagile orokorra erretirodun, Osakidetza, Getxo, España
| | - Mario Bárcena Caamaño
- Grupo de Trabajo de Patología Infecciosa del Aparato Respiratorio de la Sociedad Española de Médicos Generales y de Familia (SEMG), Centro de Salud Valdefierro, Zaragoza, España
| | - Carmen Serrano Martino
- Grupo de Estudio de Infección en la Atención Primaria de la Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica (GEIAP-SEIMC), Hospital San Juan de Dios, Bormujos, Sevilla, España
| | - Josep Maria Cots Yago
- Grupo de Trabajo de Enfermedades Infecciosas de la Sociedad Española de Medicina Familiar y Comunitaria (SemFYC), Universidad de Barcelona, Centro de Salud La Marina, Institut Català de la Salut, Barcelona, España
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Llor C, Vilaseca I, Lehrer-Coriat E, Boleda X, Cañada JL, Moragas A, Cots JM. Survey of Spanish general practitioners' attitudes toward management of sore throat: an internet-based questionnaire study. BMC FAMILY PRACTICE 2017; 18:21. [PMID: 28193184 PMCID: PMC5307696 DOI: 10.1186/s12875-017-0597-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Accepted: 02/08/2017] [Indexed: 12/23/2022]
Abstract
Background The management of sore throat varies widely in Europe. The objective of this study was to gain insight into clinicians’ perceptions on the current management of sore throat in Spain. Methods Cross-sectional, internet-based questionnaire study answered from July to September 2013. General practitioners (GPs) affiliated with the two largest scientific societies of primary care were invited to participate in the study. Questions were asked about physician knowledge, the use of current national guidelines for sore throat management, and management in two clinical scenarios, depicting a young adult with sore throat and: 1. cough, coriza with or without fever, and 2. fever without cough and coriza. Results The questionnaire was completed by 1476 GPs (5%) and 12.7% declared using rapid antigen detection tests. Antibiotics were considered by 18.8% of the GPs in the first scenario and by 32% in the second scenario (p < 0.001). The antibiotics most commonly mentioned by GPs were amoxicillin and amoxicillin + clavulanate (52.7 and 31.2%, respectively) whereas penicillin V was only prescribed in 11.9% of the cases. The drugs most commonly considered in both scenarios were analgesics and anti-inflammatory drugs. Antitussives, decongestants and expectorants were more commonly prescribed in cases of suspected viral infection (p < 0.001). Conclusions GPs have misconceptions as to the indications for using rapid antigen detection tests and prescribing drugs in the management of sore throat. These results suggest that guidelines are seldom followed since one in five GPs declared giving antibiotics for patients with a suspected viral infection and the use of second-choice antibiotics seems considerable.
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Affiliation(s)
- Carl Llor
- Primary Healthcare Centre Via Roma, Barcelona, Spain.
| | - Isabel Vilaseca
- Department of Otorhinolaringology, Hospital Clínic of Barcelona, Barcelona, Spain.,Faculty of Medicine, University of Barcelona, Barcelona, Spain
| | | | - Xavier Boleda
- Pharmacy Arizcun (Group on respiratory diseases, Sociedad Española de Farmacia Comunitaria), Sant Pere de Ribes, Spain
| | - José L Cañada
- Primary Healthcare Centre Algorta (Group on Infectious Diseases SEMERGEN), Getxo, Vizcaya, Spain
| | - Ana Moragas
- Primary Healthcare Centre Jaume I, University Rovira i Virgili, Tarragona, Spain
| | - Josep M Cots
- Primary Healthcare Centre La Marina (Group on Infectious Diseases, semFYC), University of Barcelona, Barcelona, Spain
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Hay AD, Redmond NM, Turnbull S, Christensen H, Thornton H, Little P, Thompson M, Delaney B, Lovering AM, Muir P, Leeming JP, Vipond B, Stuart B, Peters TJ, Blair PS. Development and internal validation of a clinical rule to improve antibiotic use in children presenting to primary care with acute respiratory tract infection and cough: a prognostic cohort study. THE LANCET. RESPIRATORY MEDICINE 2016; 4:902-910. [PMID: 27594440 PMCID: PMC5080970 DOI: 10.1016/s2213-2600(16)30223-5] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Revised: 07/11/2016] [Accepted: 07/15/2016] [Indexed: 12/21/2022]
Abstract
BACKGROUND Antimicrobial resistance is a serious threat to public health, with most antibiotics prescribed in primary care. General practitioners (GPs) report defensive antibiotic prescribing to mitigate perceived risk of future hospital admission in children with respiratory tract infections. We developed a clinical rule aimed to reduce clinical uncertainty by stratifying risk of future hospital admission. METHODS 8394 children aged between 3 months and 16 years presenting with acute cough (for ≤28 days) and respiratory tract infection were recruited to a prognostic cohort study from 247 general practitioner practices in England. Exposure variables included demographic characteristics, parent-reported symptoms, and physical examination signs. The outcome was hospital admission for respiratory tract infection within 30 days, collected using a structured, blinded review of medical records. FINDINGS 8394 (100%) children were included in the analysis, with 78 (0·9%, 95% CI 0·7%-1·2%) admitted to hospital: 15 (19%) were admitted on the day of recruitment (day 1), 33 (42%) on days 2-7; and 30 (39%) on days 8-30. Seven characteristics were independently associated (p<0·01) with hospital admission: age <2 years, current asthma, illness duration of 3 days or less, parent-reported moderate or severe vomiting in the previous 24 h, parent-reported severe fever in the previous 24 h or a body temperature of 37·8°C or more at presentation, clinician-reported intercostal or subcostal recession, and clinician-reported wheeze on auscultation. The area under the receiver operating characteristic (AUROC) curve for the coefficient-based clinical rule was 0·82 (95% CI 0·77-0·87, bootstrap validated 0·81). Assigning one point per characteristic, a points-based clinical rule consisting of short illness, temperature, age, recession, wheeze, asthma, and vomiting (mnemonic STARWAVe; AUROC 0·81, 0·76-0·85) distinguished three hospital admission risk strata: very low (0·3%, 0·2-0·4%) with 1 point or less, normal (1·5%, 1·0-1·9%) with 2 or 3 points, and high (11·8%, 7·3-16·2%) with 4 points or more. INTERPRETATION Clinical characteristics can distinguish children at very low, normal, and high risk of future hospital admission for respiratory tract infection and could be used to reduce antibiotic prescriptions in primary care for children at very low risk. FUNDING National Institute for Health Research (NIHR).
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Affiliation(s)
- Alastair D Hay
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK.
| | - Niamh M Redmond
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Sophie Turnbull
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Hannah Christensen
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Hannah Thornton
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Paul Little
- Primary Care and Population Sciences Unit, University of Southampton, Aldermoor Health Centre, Southampton, UK
| | - Matthew Thompson
- Department of Family Medicine, University of Washington, Seattle, WA, USA
| | - Brendan Delaney
- Department of Surgery and Cancer, Imperial College London, Saint Mary's Hospital, London, UK
| | - Andrew M Lovering
- Bristol Centre for Antimicrobial Research and Evaluation, North Bristol NHS Trust, Southmead Hospital, Bristol, UK
| | - Peter Muir
- Specialist Virology Centre, Public Health Laboratory Bristol, Public Health England, Myrtle Road, Bristol, UK
| | - John P Leeming
- Bristol Centre for Antimicrobial Research and Evaluation, North Bristol NHS Trust, Southmead Hospital, Bristol, UK
| | - Barry Vipond
- Specialist Virology Centre, Public Health Laboratory Bristol, Public Health England, Myrtle Road, Bristol, UK
| | - Beth Stuart
- Primary Care and Population Sciences Unit, University of Southampton, Aldermoor Health Centre, Southampton, UK
| | - Tim J Peters
- School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Peter S Blair
- School of Social and Community Medicine, University of Bristol, Bristol, UK
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Sheppard JP, Martin U, Gill P, Stevens R, McManus RJ. Prospective Register Of patients undergoing repeated OFfice and Ambulatory Blood Pressure Monitoring (PROOF-ABPM): protocol for an observational cohort study. BMJ Open 2016; 6:e012607. [PMID: 27799244 PMCID: PMC5093685 DOI: 10.1136/bmjopen-2016-012607] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
INTRODUCTION The diagnosis and management of hypertension depends on accurate measurement of blood pressure (BP) in order to target antihypertensive treatment appropriately. Most BP measurements take place in a clinic setting, but it has long been recognised that readings taken out-of-office (via home or ambulatory monitoring) estimate true underlying BP more accurately. Recent studies have shown that the change in clinic BP over multiple readings is a significant predictor of the difference between clinic and out-of-office BP. Used in combination with patient characteristics, this change has been shown to accurately predict a patient's out-of-office BP level. The present study proposes to collect real-life BP data to prospectively validate this new prediction tool in routine clinical practice. METHODS AND ANALYSIS A prospective, multicentre observational cohort design will be used, recruiting patients from primary and secondary care. All patients attending participating centres for ambulatory BP monitoring will be eligible to participate. Anonymised clinical data will be collected from all eligible patients, who will be invited to give informed consent to permit identifiable data to be collected for data linkage to external outcome registries. Descriptive statistics will be used to calculate the sensitivity, specificity, positive and negative predictive values of the out-of-office BP prediction tool. Area under the receiver operator characteristic curve statistics will be used to examine model performance. ETHICS AND DISSEMINATION Ethical approval for this study has been obtained from the National Research. Ethics Service Committee South Central-Oxford A (reference; 15/SC/0184), and site-specific R&D approval has been acquired from the relevant NHS trusts. All findings will be presented at relevant conferences and published in peer-reviewed journals, on the study website and disseminated in lay and social media where appropriate.
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Affiliation(s)
- James P Sheppard
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Una Martin
- School of Clinical and Experimental Medicine, University of Birmingham, Birmingham, UK
| | - Paramjit Gill
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Richard Stevens
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Richard J McManus
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Gulliford MC, Moore MV, Little P, Hay AD, Fox R, Prevost AT, Juszczyk D, Charlton J, Ashworth M. Safety of reduced antibiotic prescribing for self limiting respiratory tract infections in primary care: cohort study using electronic health records. BMJ 2016; 354:i3410. [PMID: 27378578 PMCID: PMC4933936 DOI: 10.1136/bmj.i3410] [Citation(s) in RCA: 91] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To determine whether the incidence of pneumonia, peritonsillar abscess, mastoiditis, empyema, meningitis, intracranial abscess, and Lemierre's syndrome is higher in general practices that prescribe fewer antibiotics for self limiting respiratory tract infections (RTIs). DESIGN Cohort study. SETTING 610 UK general practices from the UK Clinical Practice Research Datalink. PARTICIPANTS Registered patients with 45.5 million person years of follow-up from 2005 to 2014. EXPOSURES Standardised proportion of RTI consultations with antibiotics prescribed for each general practice, and rate of antibiotic prescriptions for RTIs per 1000 registered patients. MAIN OUTCOME MEASURES Incidence of pneumonia, peritonsillar abscess, mastoiditis, empyema, meningitis, intracranial abscess, and Lemierre's syndrome, adjusting for age group, sex, region, deprivation fifth, RTI consultation rate, and general practice. RESULTS From 2005 to 2014 the proportion of RTI consultations with antibiotics prescribed decreased from 53.9% to 50.5% in men and from 54.5% to 51.5% in women. From 2005 to 2014, new episodes of meningitis, mastoiditis, and peritonsillar abscess decreased annually by 5.3%, 4.6%, and 1.0%, respectively, whereas new episodes of pneumonia increased by 0.4%. Age and sex standardised incidences for pneumonia and peritonsillar abscess were higher for practices in the lowest fourth of antibiotic prescribing compared with the highest fourth. The adjusted relative risk increases for a 10% reduction in antibiotic prescribing were 12.8% (95% confidence interval 7.8% to 17.5%, P<0.001) for pneumonia and 9.9% (5.6% to 14.0%, P<0.001) for peritonsillar abscess. If a general practice with an average list size of 7000 patients reduces the proportion of RTI consultations with antibiotics prescribed by 10%, then it might observe 1.1 (95% confidence interval 0.6 to 1.5) more cases of pneumonia each year and 0.9 (0.5 to 1.3) more cases of peritonsillar abscess each decade. Mastoiditis, empyema, meningitis, intracranial abscess, and Lemierre's syndrome were similar in frequency at low prescribing and high prescribing practices. CONCLUSIONS General practices that adopt a policy to reduce antibiotic prescribing for RTIs might expect a slight increase in the incidence of treatable pneumonia and peritonsillar abscess. No increase is likely in mastoiditis, empyema, bacterial meningitis, intracranial abscess, or Lemierre's syndrome. Even a substantial reduction in antibiotic prescribing was predicted to be associated with only a small increase in numbers of cases observed overall, but caution might be required in subgroups at higher risk of pneumonia.
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Affiliation(s)
- Martin C Gulliford
- Department of Primary Care and Public Health Sciences, King's College London, Guy's Campus, London SE1 1UL, UK
| | - Michael V Moore
- Academic Unit for Primary Care and Population Sciences, University of Southampton, Southampton, UK
| | - Paul Little
- Academic Unit for Primary Care and Population Sciences, University of Southampton, Southampton, UK
| | - Alastair D Hay
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Robin Fox
- The Health Centre, Bicester, Oxford, UK
| | - A Toby Prevost
- Department of Primary Care and Public Health Sciences, King's College London, Guy's Campus, London SE1 1UL, UK
| | - Dorota Juszczyk
- Department of Primary Care and Public Health Sciences, King's College London, Guy's Campus, London SE1 1UL, UK
| | - Judith Charlton
- Department of Primary Care and Public Health Sciences, King's College London, Guy's Campus, London SE1 1UL, UK
| | - Mark Ashworth
- Department of Primary Care and Public Health Sciences, King's College London, Guy's Campus, London SE1 1UL, UK
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Monedero Mira MJ, Sales MB, Domingo CG, Monedero Mira MJ, Saura BP, Mallen GR, Porcar LT. Tratamiento empírico de las infecciones del adulto. FMC : FORMACION MEDICA CONTINUADA EN ATENCION PRIMARIA 2016; 23:9-71. [PMID: 32288498 PMCID: PMC7144499 DOI: 10.1016/j.fmc.2015.12.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Revised: 12/15/2015] [Accepted: 12/20/2015] [Indexed: 12/12/2022]
Affiliation(s)
- María José Monedero Mira
- Médico especialista en Medicina Familiar y Comunitaria, CS Rafalafena, Castellón. Profesor asociado de Medicina, Facultad de Ciencias de la Salud, Universitat Jaume I, Castellón, España
| | - Manuel Batalla Sales
- Médico especialista en Medicina Familiar y Comunitaria, CS Rafalafena, Castellón. Profesor asociado de Medicina, Facultad de Ciencias de la Salud, Universitat Jaume I, Castellón, España
| | | | - María José Monedero Mira
- Médico especialista en Medicina Familiar y Comunitaria, CS Rafalafena, Castellón. Profesor asociado de Medicina, Facultad de Ciencias de la Salud, Universitat Jaume I, Castellón, España
| | - Belén Persiva Saura
- Médico especialista en Medicina Familiar y Comunitaria, CS Rafalafena, Castellón, España
| | | | - Lledó Tárrega Porcar
- Médico especialista en Medicina Familiar y Comunitaria, CS Rafalafena, Castellón, España
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