1
|
Butler CC. Democratising the design and delivery of large-scale randomised, controlled clinical trials in primary care: A personal view. Eur J Gen Pract 2024; 30:2293702. [PMID: 38180050 PMCID: PMC10773679 DOI: 10.1080/13814788.2023.2293702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 12/04/2023] [Indexed: 01/06/2024] Open
Abstract
BACKGROUND Rapid identification of effective treatments for use in the community during a pandemic is vital for the well-being of individuals and the sustainability of healthcare systems and society. Furthermore, identifying treatments that do not work reduces research wastage, spares people unnecessary side effects, rationalises the cost of purchasing and stockpiling medication, and reduces inappropriate medication use. Nevertheless, only a small minority of therapeutic trials for SARS-CoV-2 infections have been in primary care: most opened too late, struggled to recruit, and few produced actionable results. Participation in research is often limited by where one lives or receives health care, and trial participants may not represent those for whom the treatments are intended. INNOVATIVE TRIALS The ALIC4E, PRINCIPLE and the ongoing PANORAMIC trial have randomised over 40,500 people with COVID-19. This personal view describes how these trials have innovated in: trial design (by using novel adaptive platform designs); trial delivery (by complementing traditional site-based recruitment ('the patient comes to the research') with mechanisms to enable sick, infectious people to participate without having to leave home ('taking research to the people'), and by addressing the 'inverse research participation law,' which highlights disproportionate barriers faced by those who have the most to contribute, and benefit from, research, and; in transforming the evidence base by evaluating nine medicines to support guidelines and care decisions world-wide for COVID-19 and contribute to antimicrobial stewardship. CONCLUSION The PRINCIPLE and PANORAMIC trials represent models of innovation and inclusivity, and exemplify the potential of primary care to lead the way in addressing pressing global health challenges.
Collapse
Affiliation(s)
- Christopher C. Butler
- Nuffield Department of Primary Care Health Sciences, Primary Care Clinical Trials Unit, University of Oxford, Oxford, United Kingdom
| |
Collapse
|
2
|
Dorward J, Sookrajh Y, Lessells R, Bulo E, Bodley N, Singh L, Moodley P, Samsunder N, Drain PK, Hayward G, Butler CC, Garrett N. Viremia and HIV Drug Resistance Among People Receiving Dolutegravir Versus Efavirenz-Based First-Line Antiretroviral Therapy. J Acquir Immune Defic Syndr 2024; 95:e8-e11. [PMID: 38489494 PMCID: PMC10927299 DOI: 10.1097/qai.0000000000003385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2024]
Abstract
Supplemental Digital Content is Available in the Text.
Collapse
Affiliation(s)
- Jienchi Dorward
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu–Natal, Durban, South Africa
| | | | - Richard Lessells
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu–Natal, Durban, South Africa
- KwaZulu-Natal Research and Innovation Sequencing Platform (KRISP), University of KwaZulu-Natal, Durban, South Africa
| | - Elliot Bulo
- eThekwini Municipality Health Unit, Durban, South Africa
| | - Nicola Bodley
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu–Natal, Durban, South Africa
| | - Lavanya Singh
- KwaZulu-Natal Research and Innovation Sequencing Platform (KRISP), University of KwaZulu-Natal, Durban, South Africa
| | - Pravikrishnen Moodley
- Department of Virology, University of KwaZulu-Natal and National Health Laboratory Service, Inkosi Albert Luthuli Central Hospital, KwaZulu-Natal, South Africa
| | - Natasha Samsunder
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu–Natal, Durban, South Africa
| | - Paul K. Drain
- Department of Global Health, Schools of Medicine and Public Health, University of Washington, Seattle, WA
- Department of Medicine, School of Medicine, University of Washington, Seattle, WA
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, WA; and
| | - Gail Hayward
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Christopher C. Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Nigel Garrett
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu–Natal, Durban, South Africa
- Discipline of Public Health Medicine, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| |
Collapse
|
3
|
Hayward G, Mort S, Hay AD, Moore M, Thomas NPB, Cook J, Robinson J, Williams N, Maeder N, Edeson R, Franssen M, Grabey J, Glogowska M, Yang Y, Allen J, Butler CC. d-Mannose for Prevention of Recurrent Urinary Tract Infection Among Women: A Randomized Clinical Trial. JAMA Intern Med 2024:2817488. [PMID: 38587819 PMCID: PMC11002776 DOI: 10.1001/jamainternmed.2024.0264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 12/12/2023] [Indexed: 04/09/2024]
Abstract
Importance Recurrent urinary tract infection (UTI) is a common debilitating condition in women, with limited prophylactic options. d-Mannose has shown promise in trials based in secondary care, but effectiveness in placebo-controlled studies and community settings has not been established. Objective To determine whether d-mannose taken for 6 months reduces the proportion of women with recurrent UTI experiencing a medically attended UTI. Design, Setting, and Participants This 2-group, double-blind randomized placebo-controlled trial took place across 99 primary care centers in the UK. Participants were recruited between March 28, 2019, and January 31, 2020, with 6 months of follow-up. Participants were female, 18 years or older, living in the community, and had evidence in their primary care record of consultations for at least 2 UTIs in the preceding 6 months or 3 UTIs in 12 months. Invitation to participate was made by their primary care center. A total of 7591 participants were approached, 830 responded, and 232 were ineligible or did not proceed to randomization. Statistical analysis was reported in December 2022. Intervention Two grams daily of d-mannose powder or matched volume of placebo powder. Main Outcomes and Measures The primary outcome measure was the proportion of women experiencing at least 1 further episode of clinically suspected UTI for which they contacted ambulatory care within 6 months of study entry. Secondary outcomes included symptom duration, antibiotic use, time to next medically attended UTI, number of suspected UTIs, and UTI-related hospital admissions. Results Of 598 women eligible (mean [range] age, 58 [18-93] years), 303 were randomized to d-mannose (50.7%) and 295 to placebo (49.3%). Primary outcome data were available for 583 participants (97.5%). The proportion contacting ambulatory care with a clinically suspected UTI was 150 of 294 (51.0%) in the d-mannose group and 161 of 289 (55.7%) in the placebo group (risk difference, -5%; 95% CI, -13% to 3%; P = .26). Estimates were similar in per protocol analyses, imputation analyses, and preplanned subgroups. There were no statistically significant differences in any secondary outcome measures. Conclusions and Relevance In this randomized clinical trial, daily d-mannose did not reduce the proportion of women with recurrent UTI in primary care who experienced a subsequent clinically suspected UTI. d-Mannose should not be recommended for prophylaxis in this patient group. Trial Registration isrctn.org Identifier: ISRCTN13283516.
Collapse
Affiliation(s)
- Gail Hayward
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, England, United Kingdom
| | - Sam Mort
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, England, United Kingdom
| | - Alastair D. Hay
- Centre for Academic Primary Care, NIHR School for Primary Care Research, Bristol Medical School: Population Health Sciences, University of Bristol, Bristol, England, United Kingdom
| | - Michael Moore
- Primary Care Research Centre, Primary Care, Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton, England, United Kingdom
| | - Nicholas P. B. Thomas
- Windrush Medical Practice, Witney, England, United Kingdom
- NIHR Clinical Research Network Thames Valley and South Midlands, Oxford, England, United Kingdom
| | - Johanna Cook
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, England, United Kingdom
| | - Jared Robinson
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, England, United Kingdom
| | - Nicola Williams
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, England, United Kingdom
| | - Nicola Maeder
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, England, United Kingdom
| | - Rebecca Edeson
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, England, United Kingdom
| | - Marloes Franssen
- Oxford Trauma and Emergency Care, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford University, England, United Kingdom
| | - Jenna Grabey
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, England, United Kingdom
| | - Margaret Glogowska
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, England, United Kingdom
| | - Yaling Yang
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, England, United Kingdom
| | - Julie Allen
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, England, United Kingdom
| | - Christopher C. Butler
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, England, United Kingdom
| |
Collapse
|
4
|
Hayward G, Yu LM, Little P, Gbinigie O, Shanyinde M, Harris V, Dorward J, Saville BR, Berry N, Evans PH, Thomas NPB, Patel MG, Richards D, Hecke OV, Detry MA, Saunders C, Fitzgerald M, Robinson J, Latimer-Bell C, Allen J, Ogburn E, Grabey J, de Lusignan S, Hobbs FR, Butler CC. Ivermectin for COVID-19 in adults in the community (PRINCIPLE): An open, randomised, controlled, adaptive platform trial of short- and longer-term outcomes. J Infect 2024; 88:106130. [PMID: 38431155 PMCID: PMC10981761 DOI: 10.1016/j.jinf.2024.106130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 02/20/2024] [Accepted: 02/22/2024] [Indexed: 03/05/2024]
Abstract
BACKGROUND The evidence for whether ivermectin impacts recovery, hospital admissions, and longer-term outcomes in COVID-19 is contested. The WHO recommends its use only in the context of clinical trials. METHODS In this multicentre, open-label, multi-arm, adaptive platform randomised controlled trial, we included participants aged ≥18 years in the community, with a positive SARS-CoV-2 test, and symptoms lasting ≤14 days. Participants were randomised to usual care, usual care plus ivermectin tablets (target 300-400 μg/kg per dose, once daily for 3 days), or usual care plus other interventions. Co-primary endpoints were time to first self-reported recovery, and COVID-19 related hospitalisation/death within 28 days, analysed using Bayesian models. Recovery at 6 months was the primary, longer term outcome. TRIAL REGISTRATION ISRCTN86534580. FINDINGS The primary analysis included 8811 SARS-CoV-2 positive participants (median symptom duration 5 days), randomised to ivermectin (n = 2157), usual care (n = 3256), and other treatments (n = 3398) from June 23, 2021 to July 1, 2022. Time to self-reported recovery was shorter in the ivermectin group compared with usual care (hazard ratio 1·15 [95% Bayesian credible interval, 1·07 to 1·23], median decrease 2.06 days [1·00 to 3·06]), probability of meaningful effect (pre-specified hazard ratio ≥1.2) 0·192). COVID-19-related hospitalisations/deaths (odds ratio 1·02 [0·63 to 1·62]; estimated percentage difference 0% [-1% to 0·6%]), serious adverse events (three and five respectively), and the proportion feeling fully recovered were similar in both groups at 6 months (74·3% and 71·2% respectively (RR = 1·05, [1·02 to 1·08]) and also at 3 and 12 months. INTERPRETATION Ivermectin for COVID-19 is unlikely to provide clinically meaningful improvement in recovery, hospital admissions, or longer-term outcomes. Further trials of ivermectin for SARS-Cov-2 infection in vaccinated community populations appear unwarranted. FUNDING UKRI/National Institute of Health Research (MC_PC_19079).
Collapse
Affiliation(s)
- Gail Hayward
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Ly-Mee Yu
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Paul Little
- Primary Care Research Centre, University of Southampton, Southampton, UK
| | - Oghenekome Gbinigie
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Milensu Shanyinde
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Victoria Harris
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Jienchi Dorward
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK; Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa
| | - Benjamin R Saville
- Berry Consultants, TX, USA; Department of Biostatistics, Vanderbilt University School of Medicine, TN, USA
| | | | - Philip H Evans
- College of Medicine and Health, University of Exeter, Exeter, UK; National Institute for Health Research (NIHR) Clinical Research Network, National Institute for Health Research, London, UK
| | - Nicholas P B Thomas
- National Institute for Health Research (NIHR) Clinical Research Network, National Institute for Health Research, London, UK
| | - Mahendra G Patel
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Duncan Richards
- Royal College of General Practitioners, London, UK; Oxford Clinical Trials Research Unit, Botnar Research Centre, University of Oxford, Oxford, UK
| | - Oliver V Hecke
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | | | | | - Jared Robinson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | - Julie Allen
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Emma Ogburn
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Jenna Grabey
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Simon de Lusignan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Fd Richard Hobbs
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK.
| | - Christopher C Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK.
| |
Collapse
|
5
|
Dorward J, Govender K, Moodley P, Lessells R, Samsunder N, Sookrajh Y, Fanshawe TR, Turner PJ, Butler CC, Drain PK, Hayward GN, Garrett N. Urine tenofovir and dried blood spot tenofovir diphosphate concentrations and viraemia in people taking efavirenz and dolutegravir-based antiretroviral therapy. AIDS 2024; 38:697-702. [PMID: 38126342 PMCID: PMC7615742 DOI: 10.1097/qad.0000000000003818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 12/02/2023] [Accepted: 12/11/2023] [Indexed: 12/23/2023]
Abstract
OBJECTIVE We aimed to determine whether urine tenofovir (TFV) and dried blood spot (DBS) tenofovir diphosphate (TFV-DP) concentrations are associated with concurrent HIV viraemia. DESIGN Cross-sectional study among people with HIV (PWH) receiving tenofovir disoproxil fumarate (TDF)-based antiretroviral therapy (ART). METHODS We used dual tandem liquid chromatography and mass spectrometry to measure urine TFV and DBS TFV-DP concentrations, and evaluated their associations with concurrent viraemia at least 1000 copies/ml using logistic regression models. In exploratory analyses, we used receiver operating curves (ROCs) to estimate optimal urine TFV and DBS TFV-DP thresholds to predict concurrent viraemia. RESULTS Among 124 participants, 68 (54.8%) were women, median age was 39 years [interquartile range (IQR) 34-45] and 74 (59.7%) were receiving efavirenz versus 50 (40.3%) receiving dolutegravir. Higher concentrations of urine TFV [1000 ng/ml increase, odds ratio (OR) 0.97 95% CI 0.94-0.99, P = 0.005] and DBS TFV-DP (100 fmol/punch increase, OR 0.76, 95% CI 0.67-0.86, P < 0.001) were associated with lower odds of viraemia. There was evidence that these associations were stronger among people receiving dolutegravir than among people receiving efavirenz (urine TFV, P = 0.072; DBS TFV-DP, P = 0.003). Nagelkerke pseudo- R2 for the DBS TFV-DP models was higher for the urine TFV models, demonstrating a stronger relationship between DBS TFV-DP and viraemia. Among people receiving dolutegravir, a DBS TFV-DP concentration of 483 fmol/punch had 88% sensitivity and 85% specificity to predict concurrent viraemia ≥1000 copies/ml. CONCLUSION Among PWH receiving TDF-based ART, urine TFV concentrations, and in particular DBS TFV-DP concentrations, were strongly associated with concurrent viraemia, especially among people receiving dolutegravir.
Collapse
Affiliation(s)
- Jienchi Dorward
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu–Natal
| | | | - Pravikrishnen Moodley
- Department of Virology, University of KwaZulu-Natal and National Health Laboratory Service, Inkosi Albert Luthuli Central Hospital, KwaZulu-Natal
| | - Richard Lessells
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu–Natal
- KwaZulu-Natal Research and Innovation Sequencing Platform (KRISP), University of KwaZulu-Natal, Durban
| | - Natasha Samsunder
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu–Natal
| | | | - Thomas R. Fanshawe
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Philip J. Turner
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Christopher C. Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Paul K. Drain
- Department of Global Health, Schools of Medicine and Public Health
- Department of Medicine, School of Medicine
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, USA
| | - Gail N. Hayward
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Nigel Garrett
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu–Natal
- Discipline of Public Health Medicine, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| |
Collapse
|
6
|
Png ME, Harris V, Grabey J, Hart ND, Jani BD, Butler D, Carson-Stevens A, Coates M, Cureton L, Dobson M, Dorward J, Evans P, Francis N, Gbinigie OA, Hayward G, Holmes J, Hood K, Khoo S, Ahmed H, Lown M, Mckenna M, Mort S, Nguyen-Van-Tam J, Rahman N, Richards DB, Thomas N, van Hecke O, Hobbs FR, Little P, Yu LM, Butler CC, Petrou S. Cost-utility analysis of molnupiravir plus usual care versus usual care alone as early treatment for community-based adults with COVID-19 and increased risk of adverse outcomes in the UK PANORAMIC trial. Br J Gen Pract 2024:BJGP.2023.0444. [PMID: 38228357 DOI: 10.3399/bjgp.2023.0444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 11/20/2023] [Indexed: 01/18/2024] Open
Abstract
BACKGROUND The cost-effectiveness of molnupiravir, an oral antiviral for early treatment of SARS-CoV-2, has not been established in vaccinated populations. AIM To evaluate the cost-effectiveness of molnupiravir relative to usual care alone among mainly vaccinated community-based people at higher risk of severe outcomes from COVID-19 over six months. DESIGN AND SETTING Economic evaluation of the PANORAMIC trial in the UK. METHOD A cost-utility analysis that adopted a UK National Health Service and personal social services perspective and a six-month time horizon was performed using PANORAMIC trial data. Cost-effectiveness was expressed in terms of incremental cost per quality-adjusted life year (QALY) gained. Sensitivity and subgroup analyses assessed the impacts of uncertainty and heterogeneity. Threshold analysis explored the price for molnupiravir consistent with likely reimbursement. RESULTS In the base case analysis, molnupiravir had higher mean costs of £449 (95% confidence interval [CI] 445 to 453) and higher mean QALYs of 0.0055 (95% CI 0.004 to 0.007) than usual care (mean incremental cost per QALY of £81190). Sensitivity and subgroup analyses showed similar results, except those aged ≥75 years with a 55% probability of being cost-effective at a £30000 per QALY threshold. Molnupiravir would have to be priced around £147 per course to be cost-effective at a £15000 per QALY threshold. CONCLUSION Molnupiravir at the current cost of £513 per course is unlikely to be cost-effective relative to usual care over a six-month time horizon among mainly vaccinated COVID-19 patients at increased risk of adverse outcomes, except those aged ≥75 years.
Collapse
Affiliation(s)
- May Ee Png
- University of Oxford, Nuffield Department of Primary Care Health Sciences, Oxford, United Kingdom
| | - Victoria Harris
- University of Oxford, Nuffield Department of Primary Care Health Sciences, Oxford, United Kingdom
| | - Jenna Grabey
- University of Oxford, Nuffield Department of Primary Care Health Sciences, Oxford, United Kingdom
| | - Nigel David Hart
- Queen's University Belfast, Centre for Medical Education, Belfast, United Kingdom
| | - Bhautesh Dinesh Jani
- University of Glasgow College of Medical Veterinary and Life Sciences, Institute of Health and wellbeing, Glasgow, United Kingdom
| | - Daniel Butler
- Queen's University Belfast, Centre for Medical Education, Belfast, United Kingdom
| | - Andrew Carson-Stevens
- Cardiff University, Division of Population Medicine, School of Medicine, Cardiff, United Kingdom
| | - Maria Coates
- University of Oxford, Nuffield Department of Primary Care Health Sciences, Oxford, United Kingdom
| | - Lucy Cureton
- University of Oxford, Nuffield Department of Primary Care Health Sciences, Oxford, United Kingdom
| | - Melissa Dobson
- University of Oxford, Oxford Respiratory Trials Unit, Oxford, United Kingdom
| | - Jienchi Dorward
- University of Oxford, Nuffield Department of Primary Care Health Sciences, Oxford, United Kingdom
- University of KwaZulu-Natal, Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban, South Africa
| | - Philip Evans
- University of Exeter, Faculty of Health and Life Sciences, Exeter, United Kingdom
- University of Leeds, National Institute of Health and Care Research (NIHR) Clinical Research Network (CRN), Leeds, United Kingdom
| | - Nick Francis
- University of Southampton, Primary Care Research Centre, Southampton, United Kingdom
| | | | - Gail Hayward
- University of Oxford, Nuffield Department of Primary Care Health Sciences, Oxford, United Kingdom
| | - Jane Holmes
- University of Oxford, Nuffield Department of Primary Care Health Sciences, Oxford, United Kingdom
| | - Kerenza Hood
- Cardiff University, Centre for Trials Research, Cardiff, United Kingdom
| | - Saye Khoo
- University of Liverpool, Department of Pharmacology, Liverpool, United Kingdom
| | - Haroon Ahmed
- Cardiff University, Division of Population Medicine, School of Medicine, Cardiff, United Kingdom
| | - Mark Lown
- University of Southampton, Primary Care Research Centre, Southampton, United Kingdom
| | - Micheal Mckenna
- University of Oxford, Nuffield Department of Primary Care Health Sciences, Oxford, United Kingdom
| | - Sam Mort
- University of Oxford, Nuffield Department of Primary Care Health Sciences, Oxford, United Kingdom
| | | | - Najib Rahman
- University of Oxford, Oxford Respiratory Trials Unit, Oxford, United Kingdom
- NIHR Oxford Biomedical Research Centre, Oxford, United Kingdom
- University of Oxford, Chinese Academy of Medicine Oxford Institute, Oxford, United Kingdom
| | - Duncan B Richards
- University of Oxford, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford, United Kingdom
| | - Nicholas Thomas
- Windrush Medical Practice, Witney, United Kingdom
- National Institute for Health and Care Research Applied Research Collaboration Oxford and Thames Valley, Oxford, United Kingdom
- Royal College of General Practitioners, London, United Kingdom
| | - Oliver van Hecke
- University of Oxford, Nuffield Department of Primary Care Health Sciences, Oxford, United Kingdom
| | - Fd Richard Hobbs
- University of Oxford, Nuffield Department of Primary Care Health Sciences, Oxford, United Kingdom
| | - Paul Little
- University of Southampton, Primary Care Research Centre, Southampton, United Kingdom
| | - Ly-Mee Yu
- University of Oxford, Nuffield Department of Primary Care Health Sciences, Oxford, United Kingdom
| | - Christopher C Butler
- University of Oxford, Nuffield Department of Primary Care Health Sciences, Oxford, United Kingdom
| | - Stavros Petrou
- University of Oxford, Nuffield Department of Primary Care Health Sciences, Oxford, United Kingdom
| |
Collapse
|
7
|
Santillo M, Tonkin-Crine S, Wang K, Butler CC, Wanat M. Management of asthma in primary care in the changing context of the COVID-19 pandemic: a qualitative longitudinal study with patients. Br J Gen Pract 2023; 73:e903-e914. [PMID: 37429732 PMCID: PMC10355814 DOI: 10.3399/bjgp.2022.0581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 04/04/2023] [Indexed: 07/12/2023] Open
Abstract
BACKGROUND The COVID-19 pandemic dramatically affected asthma monitoring in primary care, but exploration of patients' views and their experiences of managing their asthma and seeking help from primary care during the pandemic has been limited. AIM To investigate patients' experiences of asthma management in the community during the COVID-19 pandemic. DESIGN AND SETTING A qualitative longitudinal study using semi-structured interviews with patients from four GP practices across diverse regions including Thames Valley, Greater Manchester, Yorkshire, and North West Coast. METHOD Interviews were undertaken with patients with asthma, who were usually managed in primary care. The interviews were audiorecorded, transcribed, and analysed using inductive temporal thematic analysis and a trajectory approach. RESULTS Forty-six interviews were conducted with 18 patients over an 8-month period that covered contrasting stages of the COVID-19 pandemic. Patients felt less vulnerable as the pandemic subsided, but the process of making sense of risk was dynamic and influenced by multiple factors. Patients relied on self-management strategies, but felt that routine asthma reviews should still have been conducted during the pandemic and highlighted that they had limited opportunities to discuss their asthma with health professionals. Patients with well-controlled symptoms felt that remote reviews were largely satisfactory, but still thought face-to-face reviews were necessary for certain aspects, such as physical examination and patient-led discussions of sensitive or broader issues associated with asthma, including mental health. CONCLUSION The dynamic nature of patients' perception of risk throughout the pandemic highlighted the need for greater clarity regarding personal risk. Having an opportunity to discuss their asthma is important to patients, even when access to face-to-face consultations in primary care is more restricted than usual.
Collapse
Affiliation(s)
- Marta Santillo
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford
| | - Sarah Tonkin-Crine
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford
| | - Kay Wang
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford
| | - Christopher C Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford
| | - Marta Wanat
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford
| |
Collapse
|
8
|
van der Velden AW, Shanyinde M, Bongard E, Böhmer F, Chlabicz S, Colliers A, García-Sangenís A, Malania L, Pauer J, Tomacinschii A, Yu LM, Loens K, Ieven M, Verheij TJ, Goossens H, Vellinga A, Butler CC. Clinical diagnosis of SARS-CoV-2 infection: An observational study of respiratory tract infection in primary care in the early phase of the pandemic. Eur J Gen Pract 2023; 29:2270707. [PMID: 37870070 PMCID: PMC10990254 DOI: 10.1080/13814788.2023.2270707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 10/04/2023] [Indexed: 10/24/2023] Open
Abstract
BACKGROUND Early in the COVID-19 pandemic, GPs had to distinguish SARS-CoV-2 from other aetiologies in patients presenting with respiratory tract infection (RTI) symptoms on clinical grounds and adapt management accordingly. OBJECTIVES To test the diagnostic accuracy of GPs' clinical diagnosis of a SARS-CoV-2 infection in a period when COVID-19 was a new disease. To describe GPs' management of patients presenting with RTI for whom no confirmed diagnosis was available. To investigate associations between patient and clinical features with a SARS-CoV-2 infection. METHODS In April 2020-March 2021, 876 patients (9 countries) were recruited when they contacted their GP with symptoms of an RTI of unknown aetiology. A swab was taken at baseline for later analysis. Aetiology (PCR), diagnostic accuracy of GPs' clinical SARS-CoV-2 diagnosis, and patient management were explored. Factors related to SARS-CoV-2 infection were determined by logistic regression modelling. RESULTS GPs suspected SARS-CoV-2 in 53% of patients whereas 27% of patients tested positive for SARS-CoV-2. True-positive patients (23%) were more intensively managed for follow-up, antiviral prescribing and advice than true-negatives (42%). False negatives (5%) were under-advised, particularly for social distancing and isolation. Older age (OR: 1.02 (1.01-1.03)), male sex (OR: 1.68 (1.16-2.41)), loss of taste/smell (OR: 5.8 (3.7-9)), fever (OR: 1.9 (1.3-2.8)), muscle aches (OR: 2.1 (1.5-3)), and a known risk factor for COVID-19 (travel, health care worker, contact with proven case; OR: 2.7 (1.8-4)) were predictive of SARS-CoV-2 infection. Absence of loss of taste/smell, fever, muscle aches and a known risk factor for COVID-19 correctly excluded SARS-CoV-2 in 92.3% of patients, whereas presence of 3, or 4 of these variables correctly classified SARS-CoV-2 in 57.7% and 87.1%. CONCLUSION Correct clinical diagnosis of SARS-CoV-2 infection, without POC-testing available, appeared to be complicated.
Collapse
Affiliation(s)
- Alike W. van der Velden
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Milensu Shanyinde
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Emily Bongard
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Femke Böhmer
- Institute of General Practice, Rostock University Medical Center, Rostock, Germany
| | - Slawomir Chlabicz
- Department of Family Medicine, Medical University of Bialystok, Bialystok, Poland
| | - Annelies Colliers
- Department of Family Medicine & Population Health, University of Antwerp, Antwerp, Belgium
| | - Ana García-Sangenís
- Institut Universitari d‘Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain
| | - Lile Malania
- National Center for Disease Control and Public Health, Tbilisi and Arner Science Management LLC, Tbilisi, Georgia
| | | | - Angela Tomacinschii
- University Clinic of Primary Medical Assistance of State University of Medicine and Pharmacy “N. Testemițanu”, Chişinǎu, The Republic of Moldova
| | - Ly-Mee Yu
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Katherine Loens
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute, University of Antwerp, Antwerp, Belgium
| | - Margareta Ieven
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute, University of Antwerp, Antwerp, Belgium
| | - Theo J. Verheij
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Herman Goossens
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute, University of Antwerp, Antwerp, Belgium
| | - Akke Vellinga
- School of Public Health, Physiotherapy and Sports Science, University College Dublin (UCD), Dublin, Ireland
| | - Christopher C. Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| |
Collapse
|
9
|
Salaun B, De Smedt J, Vernhes C, Moureau A, Öner D, Bastian AR, Janssens M, Balla-Jhagjhoorsingh S, Aerssens J, Lambert C, Coenen S, Butler CC, Drysdale SB, Wildenbeest JG, Pollard AJ, Openshaw PJM, Bont L. T cells, more than antibodies, may prevent symptoms developing from respiratory syncytial virus infections in older adults. Front Immunol 2023; 14:1260146. [PMID: 37936699 PMCID: PMC10627235 DOI: 10.3389/fimmu.2023.1260146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 09/25/2023] [Indexed: 11/09/2023] Open
Abstract
Introduction The immune mechanisms supporting partial protection from reinfection and disease by the respiratory syncytial virus (RSV) have not been fully characterized. In older adults, symptoms are typically mild but can be serious in patients with comorbidities when the infection extends to the lower respiratory tract. Methods This study formed part of the RESCEU older-adults prospective-cohort study in Northern Europe (2017-2019; NCT03621930) in which a thousand participants were followed over an RSV season. Peripheral-blood samples (taken pre-season, post-season, during illness and convalescence) were analyzed from participants who (i) had a symptomatic acute respiratory tract infection by RSV (RSV-ARTI; N=35) or (ii) asymptomatic RSV infection (RSV-Asymptomatic; N=16). These analyses included evaluations of antibody (Fc-mediated-) functional features and cell-mediated immunity, in which univariate and machine-learning (ML) models were used to explore differences between groups. Results Pre-RSV-season peripheral-blood biomarkers were predictive of symptomatic RSV infection. T-cell data were more predictive than functional antibody data (area under receiver operating characteristic curve [AUROC] for the models were 99% and 76%, respectively). The pre-RSV season T-cell phenotypes which were selected by the ML modelling and which were more frequent in RSV-Asymptomatic group than in the RSV-ARTI group, coincided with prominent phenotypes identified during convalescence from RSV-ARTI (e.g., IFN-γ+, TNF-α+ and CD40L+ for CD4+, and IFN-γ+ and 4-1BB+ for CD8+). Conclusion The evaluation and statistical modelling of numerous immunological parameters over the RSV season suggests a primary role of cellular immunity in preventing symptomatic RSV infections in older adults.
Collapse
Affiliation(s)
| | | | | | | | - Deniz Öner
- Biomarkers Infectious Diseases, Janssen Pharmaceutica NV, Beerse, Belgium
| | | | | | | | - Jeroen Aerssens
- Biomarkers Infectious Diseases, Janssen Pharmaceutica NV, Beerse, Belgium
| | | | - Samuel Coenen
- Centre for General Practice, Department of Family Medicine and Population Health (FAMPOP), University of Antwerp, Antwerp, Belgium
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium
| | - Christopher C. Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Simon B. Drysdale
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, and the National Institute for Health and care Research (NIHR) Oxford Biomedical Research Centre, Oxford, United Kingdom
| | - Joanne G. Wildenbeest
- Department of Paediatric Infectious Diseases and Immunology, Wilhelmina Children’s Hospital, University Medical Center Utrecht, Utrecht, Netherlands
| | - Andrew J. Pollard
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, and the National Institute for Health and care Research (NIHR) Oxford Biomedical Research Centre, Oxford, United Kingdom
| | - Peter J. M. Openshaw
- National Heart and Lung Institute , Imperial College London, London, United Kingdom
| | - Louis Bont
- Department of Paediatric Infectious Diseases and Immunology, Wilhelmina Children’s Hospital, University Medical Center Utrecht, Utrecht, Netherlands
- ReSViNET Foundation, Julius Clinical, Zeist, Netherlands
| |
Collapse
|
10
|
Armitage KF, Porter CE, Ahmed S, Cook J, Boards J, Bongard E, Butler CC, Corfield K, Davoudianfar M, Galal U, Howard P, Mujica-Mota R, Saman R, Santillo M, Savic S, Shinkins B, Tonkin-Crine S, Wanat M, West RM, Yu LM, Pavitt S, Sandoe JAT. Penicillin allergy status and its effect on antibiotic prescribing, patient outcomes and antimicrobial resistance (ALABAMA): protocol for a multicentre, parallel-arm, open-label, randomised pragmatic trial. BMJ Open 2023; 13:e072253. [PMID: 37666558 PMCID: PMC10481831 DOI: 10.1136/bmjopen-2023-072253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 07/07/2023] [Indexed: 09/06/2023] Open
Abstract
INTRODUCTION Incorrect penicillin allergy records are recognised as an important barrier to the safe treatment of infection and affect an estimated 2.7 million people in England. Penicillin allergy records are associated with worse health outcome and antimicrobial resistance. The ALlergy AntiBiotics And Microbial resistAnce (ALABAMA) trial aims to determine if an intervention package, centred around a penicillin allergy assessment pathway (PAAP) initiated in primary care, is safe and effective in improving patient health outcomes and antibiotic prescribing. METHODS AND ANALYSIS The ALABAMA trial is a multicentre, parallel-arm, open-label, randomised pragmatic trial with a nested pilot study. Adults (≥18 years) with a penicillin allergy record and who have received antibiotics in the previous 24 months will be eligible for participation. Between 1592 and 2090 participants will be recruited from participating National Health Service general practices in England. Participants will be randomised to either usual care or intervention to undergo a pre-emptive PAAP using a 1:1 allocation ratio. The primary outcome measure is the percentage of treatment response failures within 28 days of an index prescription. 2090 and 1592 participants are estimated to provide 90% and 80% power, respectively, to detect a clinically important absolute difference of 7.9% in primary outcome at 1 year between groups. The trial includes a mixed-methods process evaluation and cost-effectiveness evaluation. ETHICS AND DISSEMINATION This trial has been approved by London Bridge Research Ethics Committee (ref: 19/LO/0176). It will be conducted in compliance with Good Clinical Practice guidelines according to the Declaration of Helsinki. Informed consent will be obtained from all subjects involved in the study. The primary trial results will be submitted for publication to an international, peer-reviewed journal. TRIAL REGISTRATION ISRCTN20579216.
Collapse
Affiliation(s)
- Kelsey Fiona Armitage
- Nuffield Department of Primary Care Health Sciences, Clinical Trials Unit, University of Oxford, Oxford, UK
| | - Catherine E Porter
- Dental Translational and Clinical Research Unit, School of Dentistry, University of Leeds, Leeds, West Yorkshire, UK
| | - Shadia Ahmed
- Leeds Teaching Hospitals NHS Trust, Leeds, Leeds, UK
- Leeds Institute of Medical Research, School of Medicine, University of Leeds, Leeds, UK
| | - Johanna Cook
- Nuffield Department of Primary Care Health Sciences, Clinical Trials Unit, University of Oxford, Oxford, UK
| | - Jenny Boards
- Leeds Teaching Hospitals NHS Trust, Leeds, Leeds, UK
| | - Emily Bongard
- Nuffield Department of Primary Care Health Sciences, Clinical Trials Unit, University of Oxford, Oxford, UK
| | - Christopher C Butler
- Nuffield Department of Primary Care Health Sciences, Clinical Trials Unit, University of Oxford, Oxford, UK
| | - Kate Corfield
- Nuffield Department of Primary Care Health Sciences, Clinical Trials Unit, University of Oxford, Oxford, UK
| | - Mina Davoudianfar
- Nuffield Department of Primary Care Health Sciences, Clinical Trials Unit, University of Oxford, Oxford, UK
| | - Ushma Galal
- Nuffield Department of Primary Care Health Sciences, Clinical Trials Unit, University of Oxford, Oxford, UK
| | - Philip Howard
- School of Healthcare, University of Leeds, Leeds, UK
- NHS England, Leeds, UK
| | - Ruben Mujica-Mota
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Razan Saman
- Leeds Teaching Hospitals NHS Trust, Leeds, Leeds, UK
| | - Marta Santillo
- Nuffield Department of Primary Care Health Sciences, Clinical Trials Unit, University of Oxford, Oxford, UK
| | - Sinisa Savic
- Clinical Immunology and Allergy, University of Leeds Leeds Institute of Medical Research at St James's, Leeds, UK
| | - Bethany Shinkins
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Sarah Tonkin-Crine
- Nuffield Department of Primary Care Health Sciences, Clinical Trials Unit, University of Oxford, Oxford, UK
| | - Marta Wanat
- Nuffield Department of Primary Care Health Sciences, Clinical Trials Unit, University of Oxford, Oxford, UK
| | - Robert M West
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Ly-Mee Yu
- Nuffield Department of Primary Care Health Sciences, Clinical Trials Unit, University of Oxford, Oxford, UK
| | - Sue Pavitt
- Dental Translational and Clinical Research Unit, School of Dentistry, University of Leeds, Leeds, West Yorkshire, UK
| | - Jonathan A T Sandoe
- Leeds Institute of Medical Research, School of Medicine, University of Leeds, Leeds, UK
| |
Collapse
|
11
|
Dorward J, Lessells R, Govender K, Moodley P, Samsunder N, Sookrajh Y, Turner P, Butler CC, Hayward G, Gandhi M, Drain PK, Garrett N. Diagnostic accuracy of a point-of-care urine tenofovir assay, and associations with HIV viraemia and drug resistance among people receiving dolutegravir and efavirenz-based antiretroviral therapy. J Int AIDS Soc 2023; 26:e26172. [PMID: 37735860 PMCID: PMC10514373 DOI: 10.1002/jia2.26172] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 09/05/2023] [Indexed: 09/23/2023] Open
Abstract
INTRODUCTION Novel point-of-care assays which measure urine tenofovir (TFV) concentrations may have a role in improving adherence monitoring for people living with HIV (PLHIV) receiving antiretroviral therapy (ART). However, further studies of their diagnostic accuracy, and whether results are associated with viraemia and drug resistance, are needed to guide their use, particularly in the context of the global dolutegravir rollout. METHODS We conducted a cross-sectional evaluation among PLHIV receiving first-line ART containing tenofovir disoproxil fumarate at enrolment into a randomized trial in two South African public sector clinics. We calculated the diagnostic accuracy of the Abbott point-of-care immunoassay to detect urine TFV compared to liquid chromatography-tandem mass spectrometry (LC-MS/MS). We evaluated the association between point-of-care urine TFV results and self-reported adherence, viraemia ≥1000 copies/ml and HIV drug resistance, among people receiving either efavirenz or dolutegravir-based ART. RESULTS Between August 2020 and March 2022, we enrolled 124 participants. The median age was 39 (IQR 34-45) years, 55% were women, 74 (59.7%) were receiving efavirenz and 50 (40.3%) dolutegravir. The sensitivity and specificity of the immunoassay to detect urine TFV ≥1500 ng/ml compared to LC-MS/MS were 96.1% (95% CI 90.0-98.8) and 95.2% (75.3-100.0), respectively. Urine TFV results were associated with short (p<0.001) and medium-term (p = 0.036) self-reported adherence. Overall, 44/124 (35.5%) had viraemia, which was associated with undetectable TFV in those receiving efavirenz (OR 6.01, 1.27-39.0, p = 0.014) and dolutegravir (OR 25.7, 4.20-294.8, p<0.001). However, in those with viraemia while receiving efavirenz, 8/27 (29.6%) had undetectable urine TFV, compared to 11/17 (64.7%) of those receiving dolutegravir. Drug resistance was detected in 23/27 (85.2%) of those receiving efavirenz and only 1/16 (6.3%) of those receiving dolutegravir. There was no association between urine TFV results and drug resistance. CONCLUSIONS Among PLHIV receiving ART, a rapid urine TFV immunoassay can be used to accurately monitor urine TFV levels compared to the gold standard of LC-MS/MS. Undetectable point-of-care urine TFV results were associated with viraemia, particularly among people receiving dolutegravir. TRIAL REGISTRATION Pan-African Clinical Trials Registry: PACTR202001785886049.
Collapse
Affiliation(s)
- Jienchi Dorward
- Nuffield Department of Primary Care Health SciencesUniversity of OxfordOxfordUK
- Centre for the AIDS Programme of Research in South Africa (CAPRISA)University of KwaZulu–NatalDurbanSouth Africa
| | - Richard Lessells
- Centre for the AIDS Programme of Research in South Africa (CAPRISA)University of KwaZulu–NatalDurbanSouth Africa
- KwaZulu‐Natal Research and Innovation Sequencing Platform (KRISP)University of KwaZulu‐NatalDurbanSouth Africa
| | | | - Pravi Moodley
- Department of VirologyUniversity of KwaZulu‐Natal and National Health Laboratory Service, Inkosi Albert Luthuli Central HospitalKwaZulu‐NatalSouth Africa
| | - Natasha Samsunder
- Centre for the AIDS Programme of Research in South Africa (CAPRISA)University of KwaZulu–NatalDurbanSouth Africa
| | | | - Phil Turner
- Nuffield Department of Primary Care Health SciencesUniversity of OxfordOxfordUK
| | | | - Gail Hayward
- Nuffield Department of Primary Care Health SciencesUniversity of OxfordOxfordUK
| | - Monica Gandhi
- Division of HIVInfectious Disease, and Global MedicineDepartment of MedicineUniversity of California, San Francisco (UCSF)San FranciscoCaliforniaUSA
| | - Paul K. Drain
- Department of Global Health, Schools of Medicine and Public HealthUniversity of WashingtonSeattleWashingtonUSA
- Department of Medicine, School of MedicineUniversity of WashingtonSeattleWashingtonUSA
- Department of Epidemiology, School of Public HealthUniversity of WashingtonSeattleWashingtonUSA
| | - Nigel Garrett
- Centre for the AIDS Programme of Research in South Africa (CAPRISA)University of KwaZulu–NatalDurbanSouth Africa
- Discipline of Public Health Medicine, School of Nursing and Public HealthUniversity of KwaZulu‐NatalDurbanSouth Africa
| |
Collapse
|
12
|
Gillespie D, Wootton M, Ray R, Calder PC, Mandy Lau TM, Owen-Jones E, Lowe R, Davies L, Richards J, Hood K, Castro-Herrera V, Davies J, Francis NA, Hobbs FDR, Lown M, Moore M, Shepherd V, Butler CC. Gut microbiology of UK care home residents: a cross-sectional analysis from a randomised controlled trial. Clin Microbiol Infect 2023:S1198-743X(23)00362-2. [PMID: 37595801 DOI: 10.1016/j.cmi.2023.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 07/28/2023] [Accepted: 08/01/2023] [Indexed: 08/20/2023]
Abstract
OBJECTIVE To describe the prevalence of potentially clinically relevant gut pathogens and associations with the carriage of resistant organisms in UK care home residents. METHODS Stool samples were collected pre-randomisation from care home residents participating in a randomised placebo-controlled trial. Cultivable clinically relevant bacteria were analysed. Antimicrobial susceptibility testing was performed by agar dilution (amoxicillin, co-amoxiclav, gentamicin, trimethoprim, nitrofurantoin, and ciprofloxacin). We also aimed to detect resistance to third-generation cephalosporins, carbapenems, and vancomycin. RESULTS Stool samples were available for 159/310 residents participating in the trial (51%) from 23 care homes between 2016 and 2018. In total, 402 bacterial isolates were cultured from 158 stool samples and 29 different species were cultured. The five most common species were Escherichia coli (155/158, 98%), Pseudomonas aeruginosa (40/158, 25%), Enterococcus faecalis (35/158, 22%), Enterococcus faecium (30/158, 19%), and Proteus mirabilis (25/158, 16%). Enterobacterales isolates were cultured from 157 samples (99%), and resistance to at least one of the tested antimicrobials was found in 119 of these (76%). There were high levels of variation in outcomes by care home. DISCUSSION We demonstrated that care home residents harbour significant levels of antimicrobial-resistant organisms in their stool. This work emphasises the importance of both enhanced infection control practices and antimicrobial stewardship programmes to support the appropriate use of antimicrobials in this setting.
Collapse
Affiliation(s)
- David Gillespie
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom; Centre for Trials Research, School of Medicine, College of Biomedical & Life Sciences, Cardiff University, Cardiff, United Kingdom.
| | - Mandy Wootton
- Specialist Antimicrobial Chemotherapy Unit, Public Health Wales Microbiology Cardiff, Cardiff, United Kingdom
| | - Ruby Ray
- Centre for Trials Research, School of Medicine, College of Biomedical & Life Sciences, Cardiff University, Cardiff, United Kingdom
| | - Philip C Calder
- Human Development and Health, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | - Tin Man Mandy Lau
- Centre for Trials Research, School of Medicine, College of Biomedical & Life Sciences, Cardiff University, Cardiff, United Kingdom
| | - Eleri Owen-Jones
- Centre for Trials Research, School of Medicine, College of Biomedical & Life Sciences, Cardiff University, Cardiff, United Kingdom
| | - Rachel Lowe
- Centre for Trials Research, School of Medicine, College of Biomedical & Life Sciences, Cardiff University, Cardiff, United Kingdom
| | - Leanne Davies
- Specialist Antimicrobial Chemotherapy Unit, Public Health Wales Microbiology Cardiff, Cardiff, United Kingdom
| | - Jennifer Richards
- Specialist Antimicrobial Chemotherapy Unit, Public Health Wales Microbiology Cardiff, Cardiff, United Kingdom
| | - Kerenza Hood
- Centre for Trials Research, School of Medicine, College of Biomedical & Life Sciences, Cardiff University, Cardiff, United Kingdom
| | - Vivian Castro-Herrera
- Human Development and Health, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | - Jane Davies
- Centre for Trials Research, School of Medicine, College of Biomedical & Life Sciences, Cardiff University, Cardiff, United Kingdom
| | - Nick A Francis
- Primary Care, Population Sciences and Medical Education, University of Southampton, Southampton, UK
| | - F D Richard Hobbs
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Mark Lown
- Human Development and Health, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | - Michael Moore
- Primary Care, Population Sciences and Medical Education, University of Southampton, Southampton, UK
| | - Victoria Shepherd
- Centre for Trials Research, School of Medicine, College of Biomedical & Life Sciences, Cardiff University, Cardiff, United Kingdom
| | - Christopher C Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| |
Collapse
|
13
|
Gbinigie O, Ogburn E, Allen J, Dorward J, Dobson M, Madden TA, Yu LM, Lowe DM, Rahman N, Petrou S, Richards D, Hood K, Patel M, Saville BR, Marion J, Holmes J, Png ME, Hayward G, Lown M, Harris V, Jani B, Hart N, Khoo S, Rutter H, Chalk J, Standing JF, Breuer J, Lavallee L, Hadley E, Cureton L, Benysek M, Andersson MI, Francis N, Thomas NPB, Evans P, van Hecke O, Koshkouei M, Coates M, Barrett S, Bateman C, Davies J, Raymundo-Wood I, Ustianowski A, Nguyen-Van-Tam J, Carson-Stevens A, Hobbs R, Little P, Butler CC. Platform adaptive trial of novel antivirals for early treatment of COVID-19 In the community (PANORAMIC): protocol for a randomised, controlled, open-label, adaptive platform trial of community novel antiviral treatment of COVID-19 in people at increased risk of more severe disease. BMJ Open 2023; 13:e069176. [PMID: 37550022 PMCID: PMC10407406 DOI: 10.1136/bmjopen-2022-069176] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Accepted: 07/03/2023] [Indexed: 08/09/2023] Open
Abstract
INTRODUCTION There is an urgent need to determine the safety, effectiveness and cost-effectiveness of novel antiviral treatments for COVID-19 in vaccinated patients in the community at increased risk of morbidity and mortality from COVID-19. METHODS AND ANALYSIS PANORAMIC is a UK-wide, open-label, prospective, adaptive, multiarm platform, randomised clinical trial that evaluates antiviral treatments for COVID-19 in the community. A master protocol governs the addition of new antiviral treatments as they become available, and the introduction and cessation of existing interventions via interim analyses. The first two interventions to be evaluated are molnupiravir (Lagevrio) and nirmatrelvir/ritonavir (Paxlovid). ELIGIBILITY CRITERIA community-dwelling within 5 days of onset of symptomatic COVID-19 (confirmed by PCR or lateral flow test), and either (1) aged 50 years and over, or (2) aged 18-49 years with qualifying comorbidities. Registration occurs via the trial website and by telephone. Recruitment occurs remotely through the central trial team, or in person through clinical sites. Participants are randomised to receive either usual care or a trial drug plus usual care. Outcomes are collected via a participant-completed daily electronic symptom diary for 28 days post randomisation. Participants and/or their Trial Partner are contacted by the research team after days 7, 14 and 28 if the diary is not completed, or if the participant is unable to access the diary. The primary efficacy endpoint is all-cause, non-elective hospitalisation and/or death within 28 days of randomisation. Multiple prespecified interim analyses allow interventions to be stopped for futility or superiority based on prespecified decision criteria. A prospective economic evaluation is embedded within the trial. ETHICS AND DISSEMINATION Ethical approval granted by South Central-Berkshire REC number: 21/SC/0393; IRAS project ID: 1004274. Results will be presented to policymakers and at conferences, and published in peer-reviewed journals. TRIAL REGISTRATION NUMBER ISRCTN30448031; EudraCT number: 2021-005748-31.
Collapse
Affiliation(s)
- Oghenekome Gbinigie
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Emma Ogburn
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Julie Allen
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Jienchi Dorward
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- Centre for the Aids Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa
| | - Melissa Dobson
- Nuffield Department of Medicine, Oxford Respiratory Trials Unit, Oxford, UK
| | | | - Ly-Mee Yu
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - David M Lowe
- University College London, Institute of Immunity and Transplantation, London, UK
| | - Najib Rahman
- Nuffield Department of Medicine, Oxford Respiratory Trials Unit, Oxford, UK
- NIHR Oxford Biomedical Research Centre, Oxford, UK
- Chinese Academy of Medicine Oxford Institute, University of Oxford, Oxford, UK
| | - Stavros Petrou
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Duncan Richards
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
| | - Kerenza Hood
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Mahendra Patel
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Benjamin R Saville
- Berry Consultants, Austin, Texas, USA
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | | - Jane Holmes
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - May Ee Png
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Gail Hayward
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Mark Lown
- Primary Care Research Centre, University of Southampton, Southampton, UK
| | - Victoria Harris
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Bhautesh Jani
- General Practice and Primary Care, School of Health and Wellbeing, MVLS, University of Glasgow, Glasgow, UK
| | - Nigel Hart
- School of Medicine, Dentistry and Biomedical Sciences - Centre for Public Health, Queen's University Belfast, Belfast, UK
| | - Saye Khoo
- Department of Pharmacology, University of Liverpool, Liverpool, UK
| | - Heather Rutter
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Jem Chalk
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Joseph F Standing
- Infection Inflammation and Immunology, UCL Great Ormond Street Institute of Child Health Population Policy and Practice, London, UK
- Department of Pharmacy, Great Ormond Street Hospital for Children, London, UK
| | - Judith Breuer
- Infection Inflammation and Immunology, UCL Great Ormond Street Institute of Child Health Population Policy and Practice, London, UK
| | - Layla Lavallee
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Elizabeth Hadley
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Lucy Cureton
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Magdalena Benysek
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Monique I Andersson
- Department of Microbiology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Nick Francis
- Primary Care Research Centre, University of Southampton, Southampton, UK
| | - Nicholas P B Thomas
- Windrush Medical Practice, Witney, UK
- Thames Valley and South Midlands Clinical Research Network, National Institute for Health and Care Research, Oxford, UK
- Royal College of General Practitioners, London, UK
| | - Philip Evans
- Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
- National Institute for Health Research Clinical Research Network, London, UK
| | - Oliver van Hecke
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Mona Koshkouei
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Maria Coates
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Sarah Barrett
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Clare Bateman
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Jennifer Davies
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Ivy Raymundo-Wood
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Andrew Ustianowski
- Regional Infectious Diseases Unit, North Manchester General Hospital, Manchester, UK
| | - Jonathan Nguyen-Van-Tam
- Lifespan and Population Health Unit, University of Nottingham School of Medicine, Nottingham, UK
| | | | - Richard Hobbs
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Paul Little
- Primary Care Research Centre, University of Southampton, Southampton, UK
| | - Christopher C Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| |
Collapse
|
14
|
Greer RC, Althaus T, Dittrich S, Butler CC, Cheah PY, Wangrangsimakul T, Smithuis FM, Day NP, Lubell Y. The impact of C-reactive protein testing on treatment-seeking behavior and patients' attitudes toward their care in Myanmar and Thailand. Healthc Low Resour Settings 2023; 11:11278. [PMID: 38332803 PMCID: PMC7615608 DOI: 10.4081/hls.2023.11278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2024] Open
Abstract
C-reactive protein (CRP) point-of-care testing can reduce antibiotic prescribing in primary care patients with febrile and respiratory illness, yet little is known about its effects on treatment-seeking behavior. If patients go on to source antibiotics elsewhere, the impact of CRP testing will be limited. A randomized controlled trial assessed the impact of CRP testing on antibiotic prescriptions in Myanmar and Thai primary care patients with a febrile illness. Here we report patients' treatment-seeking behavior before and during the two-week study period. Self-reported antibiotic use is compared against urine antibacterial activity. Patients' opinions towards CRP testing were evaluated. Antibiotic use before study enrolment was reported by 5.4% while antimicrobial activity was detected in 20.8% of samples tested. During the study period, 14.8% of the patients sought additional healthcare, and 4.3% sourced their own antibiotics. Neither were affected by CRP testing. Overall, patients' satisfaction with their care and CRP testing was high. CRP testing did not affect patients' treatment-seeking behavior during the study period whilst modestly reducing antibiotic prescriptions. CRP testing appears to be acceptable to patients and their caregivers.
Collapse
Affiliation(s)
- Rachel C. Greer
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Thomas Althaus
- The Department of Health Action, Monaco, Monaco
- Monaco Scientific Centre, Monaco, Monaco
| | - Sabine Dittrich
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- FIND, global alliance for diagnostic, Geneva, Switzerland
- Deggendorf Institute of Technology, European-Campus Rottal Inn, Pfarrkirchen, Germany
| | - Christopher C. Butler
- Clinical Trials Unit, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Phaik Yeong Cheah
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- The Ethox Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Tri Wangrangsimakul
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Frank M. Smithuis
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Myanmar Oxford Clinical Research Unit, Yangon, Myanmar
- Medical Action Myanmar, Yangon, Myanmar
| | - Nicolas P.J. Day
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Yoel Lubell
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| |
Collapse
|
15
|
Fanshawe TR, Judge RK, Mort S, Butler CC, Hayward GN. Evidence-based appraisal of two guidelines for the diagnosis of suspected, uncomplicated urinary tract infections in primary care: a diagnostic accuracy validation study. J Antimicrob Chemother 2023:dkad212. [PMID: 37401673 PMCID: PMC10393881 DOI: 10.1093/jac/dkad212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 06/23/2023] [Indexed: 07/05/2023] Open
Abstract
OBJECTIVES Given the lack of accurate rapid diagnostics for urinary tract infection (UTI) in women, many countries have developed guidelines aiming to support appropriate antibiotic prescribing, but some guidelines have not been validated. We performed a diagnostic accuracy validation study of two guidelines: Public Health England (GW-1263) and Scottish Intercollegiate Guidelines Network (SIGN160). METHODS We used data from women with symptoms suggestive of uncomplicated UTI from a randomized controlled trial comparing urine collection devices. Symptom information was recorded via baseline questionnaire and primary care assessment. Women provided urine samples for dipstick testing and culture. We calculated the number within each risk category of diagnostic flowcharts who had positive/mixed growth/no significant growth urine culture. Results were presented as positive/negative predictive values, with 95% CIs. RESULTS Of women aged under 65 years, 311/509 (61.1%, 95% CI 56.7%-65.3%) classified to the highest risk category (recommended to consider immediate antibiotic prescribing) and 80/199 (40.2%, 95% CI 33.4%-47.4%) classified to the lowest risk category (recommended to reassure that UTI is less likely) by the GW-1263 guideline (n = 810) had positive culture. For the SIGN160 guideline (n = 814), the proportion with positive culture ranged from 60/82 (73.2%, 95% CI 62.1%-82.1%) in those for whom immediate treatment was indicated to 33/76 (43.4%, 95% CI 32.3%-55.3%) in those recommended a self-care/waiting strategy. CONCLUSIONS Clinicians should be aware of the potential for diagnostic error when using diagnostic guidelines for managing uncomplicated UTI and making antimicrobial prescribing decisions. Infection cannot be excluded on the basis of symptoms and dipstick testing alone.
Collapse
Affiliation(s)
- Thomas R Fanshawe
- Nuffield Department of Primary Care Health Sciences, Unversity of Oxford, Oxford, UK
| | - Rebecca K Judge
- Nuffield Department of Primary Care Health Sciences, Unversity of Oxford, Oxford, UK
| | - Sam Mort
- Nuffield Department of Primary Care Health Sciences, Unversity of Oxford, Oxford, UK
| | - Christopher C Butler
- Nuffield Department of Primary Care Health Sciences, Unversity of Oxford, Oxford, UK
| | - Gail N Hayward
- Nuffield Department of Primary Care Health Sciences, Unversity of Oxford, Oxford, UK
| |
Collapse
|
16
|
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] [What about the content of this article? (0)] [Affiliation(s)] [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.
Collapse
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
| |
Collapse
|
17
|
Hoste ME, Wanat M, Gobat N, Anastasaki M, Böhmer F, Chlabicz S, Colliers A, Farrell K, Karkana MN, Kinsman J, Lionis C, Marcinowicz L, Reinhardt K, Skoglund I, Sundvall PD, Vellinga A, Goossens H, Butler CC, van der Velden A, Tonkin-Crine S, Anthierens S. The experiences of patients ill with COVID-19-like symptoms and the role of testing for SARS-CoV-2 in supporting them: A qualitative study in eight European countries during the first wave of the pandemic. Eur J Gen Pract 2023:2212904. [PMID: 37248990 DOI: 10.1080/13814788.2023.2212904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023] Open
Abstract
BACKGROUND Access to testing during the first wave of the COVID-19 pandemic was limited, impacting patients with COVID-19-like symptoms. Current qualitative studies have been limited to one country or were conducted outside Europe. OBJECTIVES To explore - in eight European countries - the experiences of patients consulting in primary care with COVID-19-like symptoms during the first wave of the pandemic. METHODS Sixty-six semi-structured interviews, informed by a topic guide, were conducted by telephone or in person between April and July 2020. Patients with COVID-19-like symptoms were purposively recruited in primary care sites in eight countries and sampled based on age, gender, and symptom presentation. Deductive and inductive thematic analysis techniques were used to develop a framework representing data across settings. Data adequacy was attained by collecting rich data. RESULTS Seven themes were identified, which described the experiences of patients consulting. Two themes are reported in this manuscript describing the role of COVID-19 testing in this experience. Patients described significant distress due to their symptoms, especially those at higher risk of complications from COVID-19, and those with severe symptoms. Patients wanted access to testing to identify the cause of their illness and minimise the burden of managing uncertainty. Some patients testing positive for COVID-19 assumed they would be immune from future infection. CONCLUSION Patients experiencing novel and severe symptoms, particularly those with comorbidities, experienced a significant emotional and psychological burden due to concerns about COVID-19. Testing provided reassurance over health status and helped patients identify which guidance to follow. Testing positive for SARS-CoV-2 led to some patients thinking they were immune from future infection, thus influencing subsequent behaviour.
Collapse
Affiliation(s)
- Melanie E Hoste
- 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
| | - Marta Wanat
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Nina Gobat
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Marilena Anastasaki
- Faculty of Medicine, Clinic of Social and Family Medicine, University of Crete, Crete, Greece
| | - Femke Böhmer
- Institute of General Practice, Rostock University Medical Center, Rostock, Germany
| | - Sławomir Chlabicz
- Department of Family Medicine, Medical University of Białystok, Białystok, Poland
| | - Annelies Colliers
- Department of Family Medicine and Population Health, University of Antwerp, Antwerp, Belgium
| | - Karen Farrell
- School of Medicine, National University of Ireland, Galway, Ireland
| | | | - John Kinsman
- European Centre for Disease Prevention and Control (ECDC), Solna, Sweden
| | - Christos Lionis
- Faculty of Medicine, Clinic of Social and Family Medicine, University of Crete, Crete, Greece
| | - Ludmila Marcinowicz
- Department of Obstetrics, Gynaecology and Maternity Care, Medical University of Białystok, Białystok, Poland
| | - Katrin Reinhardt
- Institute of General Practice, Rostock University Medical Center, Rostock, Germany
| | - Ingmarie Skoglund
- General Practice/Family Medicine, Primary Health Care, School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Research, Development, Education and Innovation, Primary Health Care, Region Västra Götaland, Sweden
| | - Pär-Daniel Sundvall
- General Practice/Family Medicine, Primary Health Care, School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Research, Development, Education and Innovation, Primary Health Care, Region Västra Götaland, Sweden
| | - Akke Vellinga
- School of Public Health, Physiotherapy and Sports Science, University College Dublin, Dublin, Ireland
| | - Herman Goossens
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute, University of Antwerp, Antwerp, Belgium
- Laboratory of Clinical Microbiology, Antwerp University Hospital, Edegem, Belgium
| | - Christopher C Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford in Partnership with Public Health England, Oxford, UK
| | - Alike van der Velden
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Sarah Tonkin-Crine
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford in Partnership with Public Health England, Oxford, UK
| | - Sibyl Anthierens
- Department of Family Medicine and Population Health, University of Antwerp, Antwerp, Belgium
| |
Collapse
|
18
|
Dorward J, Sookrajh Y, Khubone T, van der Molen J, Govender R, Phakathi S, Lewis L, Bottomley C, Maraj M, Lessells RJ, Naidoo K, Butler CC, Van Heerden R, Garrett N. Implementation and outcomes of dolutegravir-based first-line antiretroviral therapy for people with HIV in South Africa: a retrospective cohort study. Lancet HIV 2023; 10:e284-e294. [PMID: 37001536 PMCID: PMC10288006 DOI: 10.1016/s2352-3018(23)00047-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 02/02/2023] [Accepted: 02/08/2023] [Indexed: 03/30/2023]
Abstract
BACKGROUND There are few data assessing the uptake of first-line dolutegravir among men and women living with HIV in low-income and middle-income countries, and subsequent clinical outcomes in non-trial settings. We aimed to determine dolutegravir uptake in women, and the effect of dolutegravir on clinical outcomes in routine care in South Africa. METHODS In this cohort study, we analysed deidentified data from adults receiving first-line antiretroviral therapy (ART) at 59 South African clinics from Dec 1, 2019, to Feb 28, 2022, using two distinct cohorts. In the initiator cohort, we used Poisson regression models to assess the outcome of initiation with dolutegravir-based ART by gender, and associations between dolutegravir use and the outcomes of 12-month retention in care and viral suppression at less than 50 copies per mL. In the transition cohort, comprising adults who received non-dolutegravir-based first-line ART in December, 2019, we used Cox proportional hazards models to assess the outcome of transition to first-line dolutegravir by gender. We then used time-dependent propensity score matching to compare the outcomes of subsequent 12-month retention in care and viral suppression between people who transitioned to dolutegravir and those who had not yet transitioned at the same timepoint. In both the initiation and transition cohort, the primary viral load analysis was an intention-to-treat analysis, with a secondary as-treated analysis that excluded people who changed their ART regimen after baseline. FINDINGS In the initiator cohort, between Dec 1, 2019, and Feb 28, 2022, 45 392 people were initiated on ART. 23 945 (52·8%) of 45 392 were non-pregnant women, 4780 (10·5%) were pregnant women, and 16 667 (36·7%) were men. The median participant age was 31·0 years (IQR 26·0-38·0) and 2401 (5·3%) were receiving tuberculosis treatment at time of ART initiation. 31 264 (68·9%) of 45 392 people were initiated on dolutegravir, 14 102 (31·1%) on efavirenz, and 26 (0·1%) on nevirapine. In a univariable Poisson regression model, pregnant women (risk ratio [RR] 0·57, 95% CI 0·49 to 0·66; risk difference -35·4%, 95% CI -42·3 to -28·5) and non-pregnant women (RR 0·78, 0·74 to 0·82; risk difference -18·4%, -21·6 to -15·2) were less likely to be initiated on dolutegravir than were men. In Poisson models adjusted for age, gender (including pregnancy), time, tuberculosis status, and initiation CD4 count, people initiated on dolutegravir were more likely to be retained in care at 12 months (adjusted RR 1·09, 95% CI 1·04 to 1·14; adjusted risk difference 5·2%, 2·2 to 8·4) and virally suppressed (adjusted RR 1·04, 95% CI 1·01 to 1·06; adjusted risk difference 3·1%, 1·2 to 5·1) compared with those initiated on non-dolutegravir-based regimens. For the transition cohort, on Dec 1, 2019, 180 956 people were receiving non-dolutegravir-based first-line ART at the study clinics, of whom 124 168 (68·6%) were women. The median age was 38 years (IQR 32-45), and the median time on ART was 3·9 years (2·0-6·4) years, with most people receiving efavirenz (178 624 [98·7%] people) and tenofovir (178 148 [98·4%]). By Feb 28, 2022, 121 174 (67·0%) of 180 956 people had transitioned to first-line dolutegravir at a median of 283 days (IQR 203-526). In a univariable Cox regression model the hazard of being transitioned to dolutegravir was lower in women than in men (hazard ratio 0·56, 95% CI 0·56 to 0·57). Among 92 318 propensity score matched people, the likelihood of retention in care was higher among the dolutegravir group compared with matched controls (adjusted RR 1·03, 95% CI 1·02 to 1·03; risk difference 2·5%, 95% CI 2·1 to 2·9). In the dolutegravir group, 33 423 (90·5%) of 36 920 people were suppressed at less than 50 copies per mL compared with 31 648 (89·7%) of 35 299 matched controls (adjusted RR 1·01, 95% CI 1·00 to 1·02; risk difference 0·8%, 95% CI 0·3 to 1·4). INTERPRETATION Women were less likely to receive dolutegravir than men. As dolutegravir was associated with improved outcomes, roll-out should continue, with a particular emphasis on inclusion of women. FUNDING Wellcome Trust, Africa Oxford Initiative, International Association of Providers of AIDS Care, and Bill & Melinda Gates Foundation. TRANSLATION For the isiZulu translation of the abstract see Supplementary Materials section.
Collapse
Affiliation(s)
- Jienchi Dorward
- Centre for the AIDS Programme of Research in South Africa, University of KwaZulu-Natal, Durban, South Africa; Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK.
| | - Yukteshwar Sookrajh
- eThekwini Municipality Health Unit, eThekwini Municipality, Durban, South Africa
| | - Thokozani Khubone
- eThekwini Municipality Health Unit, eThekwini Municipality, Durban, South Africa
| | - Johan van der Molen
- Centre for the AIDS Programme of Research in South Africa, University of KwaZulu-Natal, Durban, South Africa
| | - Riona Govender
- Health Informatics Directorate, South African National Department of Health, Pretoria, South Africa
| | - Sifiso Phakathi
- Health Informatics Directorate, South African National Department of Health, Pretoria, South Africa
| | - Lara Lewis
- Centre for the AIDS Programme of Research in South Africa, University of KwaZulu-Natal, Durban, South Africa
| | | | - Munthra Maraj
- eThekwini Municipality Health Unit, eThekwini Municipality, Durban, South Africa
| | - Richard J Lessells
- Centre for the AIDS Programme of Research in South Africa, University of KwaZulu-Natal, Durban, South Africa; KwaZulu-Natal Research and Innovation Sequencing Platform, University of KwaZulu-Natal, Durban, South Africa
| | - Kogieleum Naidoo
- Centre for the AIDS Programme of Research in South Africa, University of KwaZulu-Natal, Durban, South Africa; South African Medical Research Council-Centre for the AIDS Programme of Research in South Africa-TB-HIV Pathogenesis and Treatment Research Unit, University of KwaZulu-Natal Nelson R Mandela School of Medicine, Durban, South Africa
| | - Christopher C Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Rose Van Heerden
- eThekwini Municipality Health Unit, eThekwini Municipality, Durban, South Africa
| | - Nigel Garrett
- Centre for the AIDS Programme of Research in South Africa, University of KwaZulu-Natal, Durban, South Africa; Discipline of Public Health Medicine, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| |
Collapse
|
19
|
Dorward J, Sookrajh Y, Lessells R, Bulo E, Naidoo J, Naidoo K, Bodley N, Khanyile M, Van Vuuren CJ, Moodley P, Samsunder N, Lewis L, Drain PK, Hayward G, Butler CC, Garrett N. Point-of-care viral load testing to manage HIV viraemia during the rollout of dolutegravir-based ART in South Africa: a randomised feasibility study (POwER). J Acquir Immune Defic Syndr 2023:00126334-990000000-00227. [PMID: 37120720 DOI: 10.1097/qai.0000000000003212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
Abstract
BACKGROUND Data is required regarding the feasibility of conducting a randomised trial of point-of-care viral load (VL) testing to guide management of HIV viraemia, and to provide estimates of effect to guide potential future trial design. SETTING Two public South African clinics during the dolutegravir-based antiretroviral therapy (ART) rollout. METHODS We randomised adults receiving first-line ART, with recent VL ≥1000 copies/mL, in a 1:1 ratio to receive point-of-care Xpert HIV-1 VL versus standard-of-care laboratory VL testing, after 12 weeks. Feasibility outcomes included proportions of eligible patients enrolled and completing follow-up, and VL process outcomes. Estimates of effect were assessed using the trial primary outcome of VL <50 copies/mL after 24 weeks. RESULTS From August 2020-March 2022 we enrolled 80 eligible participants, an estimated 24% of those eligible. 47/80 (58.8%) were women, and median age was 38.5 years (IQR 33-45). 44/80 (55.0%) were receiving dolutegravir and 36/80 (465.0%) were receiving efavirenz. After 12 weeks, point-of-care participants received VL results after median 3.1 hours (IQR 2.6-3.8), versus 7 days (IQR 6-8, p<0.001) in standard-of-care. 12-week follow-up VL was ≥1000 copies/mL in 13/39 (33.3%) point-of-care participants and in 16/41 (39.0%) standard-of-care participants; 11/13 (84.6%) and 12/16 (75.0%) switched to second-line ART respectively. After 24 weeks, 76/80 (95.0%) completed follow-up. 27/39 (69.2% [95%CI 53.4-81.4]) point-of-care participants achieved VL <50 copies/ml versus 29/40 (72.5% [57.0-83.9]) standard-of-care participants. Point-of-care participants had median 3 (IQR 3-4) clinic visits versus 4 (IQR 4-5) in standard-of-care (p<0.001). CONCLUSIONS It was feasible to conduct a trial of point-of-care VL testing to manage viraemia. Point-of-care VL lead to quicker results and fewer clinical visits, but estimates of 24-week VL suppression were similar between arms.
Collapse
Affiliation(s)
- Jienchi Dorward
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa
| | | | - Richard Lessells
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa
- KwaZulu-Natal Research and Innovation Sequencing Platform (KRISP), University of KwaZulu-Natal, Durban, South Africa
| | - Elliot Bulo
- eThekwini Municipality Health Unit, Durban, South Africa
| | - Jessica Naidoo
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa
| | - Keshani Naidoo
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa
| | - Nicola Bodley
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa
| | - Mlungisi Khanyile
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa
| | - Claudia Jansen Van Vuuren
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa
| | - Pravikrishnen Moodley
- Department of Virology, University of KwaZulu-Natal and National Health Laboratory Service, Inkosi Albert Luthuli Central Hospital, KwaZulu-Natal, South Africa
| | - Natasha Samsunder
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa
| | - Lara Lewis
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa
| | - Paul K Drain
- Department of Global Health, Schools of Medicine and Public Health, University of Washington, Seattle, USA
- Department of Medicine, School of Medicine, University of Washington, Seattle, USA
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, USA
| | - Gail Hayward
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Christopher C Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Nigel Garrett
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa
- Discipline of Public Health Medicine, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| |
Collapse
|
20
|
Vellinga A, Luke-Currier A, Garzón-Orjuela N, Aabenhus R, Anastasaki M, Balan A, Böhmer F, Lang VB, Chlabicz S, Coenen S, García-Sangenís A, Kowalczyk A, Malania L, Tomacinschii A, van der Linde SR, Bongard E, Butler CC, Goossens H, van der Velden AW. Disease-Specific Quality Indicators for Outpatient Antibiotic Prescribing for Respiratory Infections (ESAC Quality Indicators) Applied to Point Prevalence Audit Surveys in General Practices in 13 European Countries. Antibiotics (Basel) 2023; 12:antibiotics12030572. [PMID: 36978439 PMCID: PMC10044809 DOI: 10.3390/antibiotics12030572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 02/23/2023] [Accepted: 03/10/2023] [Indexed: 03/17/2023] Open
Abstract
Up to 80% of antibiotics are prescribed in the community. An assessment of prescribing by indication will help to identify areas where improvement can be made. A point prevalence audit study (PPAS) of consecutive respiratory tract infection (RTI) consultations in general practices in 13 European countries was conducted in January–February 2020 (PPAS-1) and again in 2022 (PPAS-4). The European Surveillance of Antibiotic Consumption quality indicators (ESAC-QI) were calculated to identify where improvements can be made. A total of 3618 consultations were recorded for PPAS-1 and 2655 in PPAS-4. Bacterial aetiology was suspected in 26% (PPAS-1) and 12% (PPAS-4), and an antibiotic was prescribed in 30% (PPAS-1) and 16% (PPAS-4) of consultations. The percentage of adult patients with bronchitis who receive an antibiotic should, according to the ESAC-QI, not exceed 30%, which was not met by participating practices in any country except Denmark and Spain. For patients (≥1) with acute upper RTI, less than 20% should be prescribed an antibiotic, which was achieved by general practices in most countries, except Ireland (both PPAS), Croatia (PPAS-1), and Greece (PPAS-4) where prescribing for acute or chronic sinusitis (0–20%) was also exceeded. For pneumonia in adults, prescribing is acceptable for 90–100%, and this is lower in most countries. Prescribing for tonsillitis (≥1) exceeded the ESAC-QI (0–20%) in all countries and was 69% (PPAS-1) and 75% (PPAS-4). In conclusion, ESAC-QI applied to PPAS outcomes allows us to evaluate appropriate antibiotic prescribing by indication and benchmark general practices and countries.
Collapse
Affiliation(s)
- Akke Vellinga
- School of Public Health, Physiotherapy and Sports Science, University College Dublin, D04 V1W8 Dublin, Ireland
- Correspondence:
| | - Addiena Luke-Currier
- School of Public Health, Physiotherapy and Sports Science, University College Dublin, D04 V1W8 Dublin, Ireland
| | - Nathaly Garzón-Orjuela
- School of Public Health, Physiotherapy and Sports Science, University College Dublin, D04 V1W8 Dublin, Ireland
| | - Rune Aabenhus
- Research Unit for General Practice, Department of Public Health, University of Copenhagen, DK-2200 Copenhagen, Denmark
| | - Marilena Anastasaki
- Department of Social Medicine, School of Medicine, University of Crete, 71003 Heraklion, Greece
| | - Anca Balan
- Balan Medfam Srl, 400064 Cluj Napoca, Romania
| | - Femke Böhmer
- Institute of General Practice, Rostock University Medical Center, 18057 Rostock, Germany
| | - Valerija Bralić Lang
- Department of Family Medicine, “Andrija Stampar” School of Public Health, School of Medicine, University of Zagreb, 10020 Zagreb, Croatia
| | - Slawomir Chlabicz
- Department of Family Medicine, Medical University of Bialystok, 15-089 Bialystok, Poland
| | - Samuel Coenen
- Department of Family Medicine & Population Health, University of Antwerp, 2610 Antwerp, Belgium
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute, University of Antwerp, 2610 Antwerp, Belgium
| | - Ana García-Sangenís
- Institut Universitari d’Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), 08007 Barcelona, Spain
- Centro de investigación Biomédica en Red Enfermedades Infecciosas (CIBERINFEC), 28029 Madrid, Spain
| | - Anna Kowalczyk
- Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Lodz, 92-213 Lodz, Poland
| | - Lile Malania
- National Center for Disease Control and Public Health, Tbilisi and Arner Science Management LLC, 0190 Tbilisi, Georgia
| | - Angela Tomacinschii
- University Clinic of Primary Medical Assistance, State University of Medicine and Pharmacy “Nicolae Testemițanu”, MD-2004 Chişinǎu, Moldova
| | - Sanne R. van der Linde
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Universiteitsweg 100, 3584 CG Utrecht, The Netherlands
| | - Emily Bongard
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX1 4BH, UK
| | - Christopher C. Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX1 4BH, UK
| | - Herman Goossens
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute, University of Antwerp, 2610 Antwerp, Belgium
| | - Alike W. van der Velden
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Universiteitsweg 100, 3584 CG Utrecht, The Netherlands
| |
Collapse
|
21
|
Butler CC, Hobbs FDR, Gbinigie OA, Rahman NM, Hayward G, Richards DB, Dorward J, Lowe DM, Standing JF, Breuer J, Khoo S, Petrou S, Hood K, Nguyen-Van-Tam JS, Patel MG, Saville BR, Marion J, Ogburn E, Allen J, Rutter H, Francis N, Thomas NPB, Evans P, Dobson M, Madden TA, Holmes J, Harris V, Png ME, Lown M, van Hecke O, Detry MA, Saunders CT, Fitzgerald M, Berry NS, Mwandigha L, Galal U, Mort S, Jani BD, Hart ND, Ahmed H, Butler D, McKenna M, Chalk J, Lavallee L, Hadley E, Cureton L, Benysek M, Andersson M, Coates M, Barrett S, Bateman C, Davies JC, Raymundo-Wood I, Ustianowski A, Carson-Stevens A, Yu LM, Little P. Molnupiravir plus usual care versus usual care alone as early treatment for adults with COVID-19 at increased risk of adverse outcomes (PANORAMIC): an open-label, platform-adaptive randomised controlled trial. Lancet 2023; 401:281-293. [PMID: 36566761 PMCID: PMC9779781 DOI: 10.1016/s0140-6736(22)02597-1] [Citation(s) in RCA: 141] [Impact Index Per Article: 141.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 11/21/2022] [Accepted: 11/29/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND The safety, effectiveness, and cost-effectiveness of molnupiravir, an oral antiviral medication for SARS-CoV-2, has not been established in vaccinated patients in the community at increased risk of morbidity and mortality from COVID-19. We aimed to establish whether the addition of molnupiravir to usual care reduced hospital admissions and deaths associated with COVID-19 in this population. METHODS PANORAMIC was a UK-based, national, multicentre, open-label, multigroup, prospective, platform adaptive randomised controlled trial. Eligible participants were aged 50 years or older-or aged 18 years or older with relevant comorbidities-and had been unwell with confirmed COVID-19 for 5 days or fewer in the community. Participants were randomly assigned (1:1) to receive 800 mg molnupiravir twice daily for 5 days plus usual care or usual care only. A secure, web-based system (Spinnaker) was used for randomisation, which was stratified by age (<50 years vs ≥50 years) and vaccination status (yes vs no). COVID-19 outcomes were tracked via a self-completed online daily diary for 28 days after randomisation. The primary outcome was all-cause hospitalisation or death within 28 days of randomisation, which was analysed using Bayesian models in all eligible participants who were randomly assigned. This trial is registered with ISRCTN, number 30448031. FINDINGS Between Dec 8, 2021, and April 27, 2022, 26 411 participants were randomly assigned, 12 821 to molnupiravir plus usual care, 12 962 to usual care alone, and 628 to other treatment groups (which will be reported separately). 12 529 participants from the molnupiravir plus usual care group, and 12 525 from the usual care group were included in the primary analysis population. The mean age of the population was 56·6 years (SD 12·6), and 24 290 (94%) of 25 708 participants had had at least three doses of a SARS-CoV-2 vaccine. Hospitalisations or deaths were recorded in 105 (1%) of 12 529 participants in the molnupiravir plus usual care group versus 98 (1%) of 12 525 in the usual care group (adjusted odds ratio 1·06 [95% Bayesian credible interval 0·81-1·41]; probability of superiority 0·33). There was no evidence of treatment interaction between subgroups. Serious adverse events were recorded for 50 (0·4%) of 12 774 participants in the molnupiravir plus usual care group and for 45 (0·3%) of 12 934 in the usual care group. None of these events were judged to be related to molnupiravir. INTERPRETATION Molnupiravir did not reduce the frequency of COVID-19-associated hospitalisations or death among high-risk vaccinated adults in the community. FUNDING UK National Institute for Health and Care Research.
Collapse
Affiliation(s)
- Christopher C Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK.
| | - F D Richard Hobbs
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Oghenekome A Gbinigie
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Najib M Rahman
- Oxford Respiratory Trials Unit, Nuffield Department of Medicine, University of Oxford, Oxford, UK; Chinese Academy of Medical Sciences Oxford Institute, University of Oxford, Oxford, UK; Oxford National Institute for Health and Care Research Biomedical Research Centre, Oxford, UK
| | - Gail Hayward
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Duncan B Richards
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Jienchi Dorward
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK; Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa
| | - David M Lowe
- Institute of Immunity and Transplantation, University College London, London, UK
| | - Joseph F Standing
- Infection, Inflammation and Immunology, UCL Great Ormond Street Institute of Child Health, London, UK; Department of Pharmacy, Great Ormond Street Hospital for Children, London, UK
| | - Judith Breuer
- Infection, Inflammation and Immunology, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Saye Khoo
- Department of Pharmacology, University of Liverpool, Liverpool, UK
| | - Stavros Petrou
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Kerenza Hood
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | | | - Mahendra G Patel
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Benjamin R Saville
- Berry Consultants, Austin, TX, USA; Department of Biostatistics, Vanderbilt School of Medicine, Nashville, TN, USA
| | | | - Emma Ogburn
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Julie Allen
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Heather Rutter
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Nick Francis
- Primary Care Research Centre, University of Southampton, Southampton, UK
| | - Nicholas P B Thomas
- Windrush Medical Practice, Witney, UK; National Institute for Health and Care Research Clinical Research Network: Thames Valley and South Midlands, Oxford, UK; Royal College of General Practitioners, London, UK
| | - Philip Evans
- Faculty of Health and Life Sciences, University of Exeter, Exeter, UK; National Institute for Health and Care Research Clinical Research Network, Leeds, UK
| | - Melissa Dobson
- Oxford Respiratory Trials Unit, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | | | - Jane Holmes
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Victoria Harris
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - May Ee Png
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Mark Lown
- Primary Care Research Centre, University of Southampton, Southampton, UK
| | - Oliver van Hecke
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | | | | | | | - Lazaro Mwandigha
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Ushma Galal
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Sam Mort
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Bhautesh D Jani
- General Practice and Primary Care, School of Health and Wellbeing, College of Medical, Veterinary & Life Sciences, University of Glasgow, Glasgow, UK
| | - Nigel D Hart
- School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - Haroon Ahmed
- Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Daniel Butler
- School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - Micheal McKenna
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Jem Chalk
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Layla Lavallee
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Elizabeth Hadley
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Lucy Cureton
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Magdalena Benysek
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Monique Andersson
- Department of Microbiology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Maria Coates
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Sarah Barrett
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Clare Bateman
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Jennifer C Davies
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Ivy Raymundo-Wood
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Andrew Ustianowski
- and Regional Infectious Diseases Unit, North Manchester General Hospital, Manchester, UK
| | | | - Ly-Mee Yu
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Paul Little
- Primary Care Research Centre, University of Southampton, Southampton, UK
| |
Collapse
|
22
|
Gbinigie OA, Boylan AM, Butler CC, Heneghan CJ, Tonkin-Crine S. Enhancing opportunistic recruitment and retention in primary care trials: lessons learned from a qualitative study embedded in the Cranberry for Urinary Tract Infection (CUTI) feasibility trial. BMC Prim Care 2022; 23:184. [PMID: 35883016 PMCID: PMC9315325 DOI: 10.1186/s12875-022-01796-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 07/12/2022] [Indexed: 11/12/2022]
Abstract
Background Opportunistic recruitment in primary care is challenging due to the inherent unpredictability of incident conditions, and workload and time pressures. Many clinical trials do not recruit to target, leading to equivocal answers to research questions. Learning from the experiences of patients and recruiters to trials of incident conditions has the potential to improve recruitment and retention to future trials, thereby enhancing the quality and impact of research findings. The aim of this research was to learn from the trial experiences of UTI patients and recruiters to the Cranberry for UTI (CUTI) trial, to help plan an adequately powered trial of similar design. Methods One-to-one semi-structured interviews were embedded within the CUTI feasibility trial, an open-label, randomised feasibility trial of cranberry extract for symptoms of acute, uncomplicated Urinary Tract Infection (UTI) in primary care. Interviews were conducted with a sample of: CUTI trial participants; non-CUTI trial UTI patients; and, recruiters to the CUTI trial. Verbatim transcripts were analysed thematically. Results Twenty-six patients with UTI and eight recruiters (nurses and GPs) to the CUTI trial were interviewed. Three themes were developed around: reasons for participating in research; barriers to opportunistic recruitment; and, UTI patients’ experiences of trial procedures. Recruiters found that targeted electronic prompts directed at healthcare practitioners based in clinics where patients with incident conditions were likely to present (e.g. minor illness clinic) were more effective than generic prompts (e.g. desk prompts) at filtering patients from their usual clinical pathway to research clinics. Using a script to explain the delayed antibiotic trial group to patients was found to be helpful, and may have served to boost recruitment. For UTI patients, using an electronic diary to rate their symptoms was considered an acceptable medium, and often preferable to using a paper diary or mobile phone application. Conclusions The use of targeted prompts directed at clinicians, a script to explain trial groups that may be deemed less desirable, and an appropriate diary format for patient-reported outcomes, may help to improve trial recruitment and retention. Supplementary Information The online version contains supplementary material available at 10.1186/s12875-022-01796-7.
Collapse
|
23
|
Hassoun-Kheir N, van Werkhoven CH, Dunning J, Jaenisch T, van Beek J, Bielicki J, Butler CC, Francois B, Harbarth S, Hernandez Padilla AC, Horby P, Koopmans M, Lee J, Rodriguez-Baño J, Tacconelli E, Themistocleous Y, van der Velden AW, Bonten M, Goossens H, de Kraker ME. Perpetual observational studies: new strategies to support efficient implementation of observational studies and randomized trials in infectious diseases. Clin Microbiol Infect 2022; 28:1528-1532. [PMID: 35940566 PMCID: PMC9354481 DOI: 10.1016/j.cmi.2022.07.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 07/25/2022] [Accepted: 07/26/2022] [Indexed: 01/26/2023]
Affiliation(s)
- Nasreen Hassoun-Kheir
- Infection Control Program, Geneva University Hospitals and Faculty of Medicine, Geneva Switzerland
| | - C. Henri van Werkhoven
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Jake Dunning
- Pandemic Sciences Institute, University of Oxford, Oxford, UK
| | - Thomas Jaenisch
- Heidelberg Institute of Global Health (HIGH), Heidelberg University Hospital, Heidelberg, Germany
| | - Janko van Beek
- Department of Viroscience, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Julia Bielicki
- Institute for Infection and Immunity, St George's, University of London, London, UK,Infection Prevention and Control, Universitäts-Kinderspital Beider Basel, Basel, Switzerland
| | | | - Bruno Francois
- Medical-Surgical Intensive Care Unit and Inserm CIC 1435 & UMR 1092, CHU Limoges, Limoges, France
| | - Stephan Harbarth
- Infection Control Program, Geneva University Hospitals and Faculty of Medicine, Geneva Switzerland
| | - Ana C. Hernandez Padilla
- Medical-Surgical Intensive Care Unit and Inserm CIC 1435 & UMR 1092, CHU Limoges, Limoges, France
| | - Peter Horby
- Pandemic Sciences Institute, University of Oxford, Oxford, UK
| | - Marion Koopmans
- Department of Viroscience, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands,Pandemic and Disaster Preparedness Research Centre, Rotterdam, the Netherlands
| | - James Lee
- Pandemic Sciences Institute, University of Oxford, Oxford, UK
| | - Jesús Rodriguez-Baño
- Infectious Diseases and Microbiology, Hospital Universitario Virgen Macarena, Department of Medicine, University of Sevilla, Biomedicine Institute of Sevilla (IBiS), CSIC, Sevilla, Spain,Centro de Investigación Biomédica en Red en Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
| | | | | | - Alike W. van der Velden
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Marc Bonten
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Herman Goossens
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute, University of Antwerp, Antwerp, Belgium
| | - Marlieke E.A. de Kraker
- Infection Control Program, Geneva University Hospitals and Faculty of Medicine, Geneva Switzerland,Corresponding author. Marlieke E.A. de Kraker, Infection Control Program, Geneva University Hospitals and Faculty of Medicine, Gabrielle-Perret-Gentil 4, 1205 Geneva, Switzerland
| | | |
Collapse
|
24
|
Goggin K, Hurley EA, Lee BR, Bradley-Ewing A, Bickford C, Pina K, Donis de Miranda E, Yu D, Weltmer K, Linnemayr S, Butler CC, Newland JG, Myers AL. Let's Talk About Antibiotics: a randomised trial of two interventions to reduce antibiotic misuse. BMJ Open 2022; 12:e049258. [PMID: 36410835 PMCID: PMC9680140 DOI: 10.1136/bmjopen-2021-049258] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Children with acute respiratory tract infections (ARTIs) receive ≈11.4 million unnecessary antibiotic prescriptions annually. A noted contributor is inadequate parent-clinician communication, however, efforts to reduce overprescribing have only indirectly targeted communication or been impractical. OBJECTIVES Compare two feasible (higher vs lower intensity) interventions for enhancing parent-clinician communication on the rate of inappropriate antibiotic prescribing. DESIGN Multisite, parallel group, cluster randomised comparative effectiveness trial. Data collected between March 2017 and March 2019. SETTING Academic and private practice outpatient clinics. PARTICIPANTS Clinicians (n=41, 85% of eligible approached) and 1599 parent-child dyads (ages 1-5 years with ARTI symptoms, 71% of eligible approached). INTERVENTIONS All clinicians received 20 min ARTI diagnosis and treatment education. Higher intensity clinicians received an additional 50 min communication skills training. All parents viewed a 90 second antibiotic education video. MAIN OUTCOMES AND MEASURES Inappropriate antibiotic treatment was assessed via blinded medical record review by study clinicians and a priori defined as prescriptions for the wrong diagnosis or use of the wrong agent. Secondary outcomes were revisits, adverse drug reactions (both assessed 2 weeks after the visit) and parent ratings of provider communication, shared decision-making and visit satisfaction (assessed at end of the visit on Likert-type scales). RESULTS Most clinicians completed the study (n=38, 93%), were doctors (n=25, 66%), female (n=30, 78%) and averaged 8 years in practice. All parent-child dyad provided data for the main outcome (n=855 (54%) male, n=1043 (53%) <2 years). Inappropriate antibiotic prescribing was similar among patients who consulted with a higher intensity (54/696, 7.8%) versus a lower intensity (85/904, 9.4%) clinician. A generalised linear mixed effect regression model (adjusted for the two-stage nested design, clinician type, clinic setting and clinician experience) revealed that the odds of receiving inappropriate antibiotic treatment did not significantly vary by group (AOR 0.99, 95% CI: 0.52 to 1.89, p=0.98). Secondary outcomes of revisits and adverse reactions did not vary between arms, and parent ratings of satisfaction with quality of parent-provider communication (5/5), shared decision making (9/10) and visit satisfaction (5/5) were similarly high in both arms. CONCLUSIONS AND RELEVANCE Rate of inappropriate prescribing was low in both arms. Clinician education coupled with parent education may be sufficient to yield low inappropriate antibiotic prescribing rates. The absence of a significant difference between groups indicates that communication principles previously thought to drive inappropriate prescribing may need to be re-examined or may not have as much of an impact in practices where prescribing has improved in recent years. TRIAL REGISTRATION NUMBER NCT03037112.
Collapse
Affiliation(s)
- Kathy Goggin
- Health Services and Outcomes Research, Children's Mercy Hospitals and Clinics, Kansas City, Missouri, USA
- School of Medicine, University of Missouri - Kansas City, Kansas City, MO, USA
- School of Pharmacy, University of Missouri - Kansas City, Kansas City, MO, USA
| | - Emily A Hurley
- Health Services and Outcomes Research, Children's Mercy Hospitals and Clinics, Kansas City, Missouri, USA
- School of Medicine, University of Missouri - Kansas City, Kansas City, MO, USA
| | - Brian R Lee
- Health Services and Outcomes Research, Children's Mercy Hospitals and Clinics, Kansas City, Missouri, USA
- School of Medicine, University of Missouri - Kansas City, Kansas City, MO, USA
| | - Andrea Bradley-Ewing
- Health Services and Outcomes Research, Children's Mercy Hospitals and Clinics, Kansas City, Missouri, USA
- School of Medicine, University of Missouri - Kansas City, Kansas City, MO, USA
| | - Carey Bickford
- Health Services and Outcomes Research, Children's Mercy Hospitals and Clinics, Kansas City, Missouri, USA
| | - Kimberly Pina
- Health Services and Outcomes Research, Children's Mercy Hospitals and Clinics, Kansas City, Missouri, USA
| | - Evelyn Donis de Miranda
- Health Services and Outcomes Research, Children's Mercy Hospitals and Clinics, Kansas City, Missouri, USA
| | - David Yu
- Sunflower Medical Group, Kansas City, Kansas, USA
| | - Kirsten Weltmer
- School of Medicine, University of Missouri - Kansas City, Kansas City, MO, USA
- General Academic Pediatrics, Children's Mercy Hospitals and Clinics, Kansas City, MO, USA
| | | | - Christopher C Butler
- Nuffield Department of Primary Health Care Sciences, University of Oxford, Oxford, UK
| | - Jason G Newland
- Division of Infectious Diseases, Department of Pediatrics, Washington University in St. Louis, St. Louis, MO, USA
| | - Angela L Myers
- Pediatric Infectious Diseases, Children's Mercy Hospitals and Clinics, Kansas City, MO, USA
| |
Collapse
|
25
|
Li X, Bilcke J, van der Velden AW, Bruyndonckx R, Coenen S, Bongard E, de Paor M, Chlabicz S, Godycki-Cwirko M, Francis N, Aabenhus R, Bucher HC, Colliers A, De Sutter A, Garcia-Sangenis A, Glinz D, Harbin NJ, Kosiek K, Lindbæk M, Lionis C, Llor C, Mikó-Pauer R, Radzeviciene Jurgute R, Seifert B, Sundvall PD, Touboul Lundgren P, Tsakountakis N, Verheij TJ, Goossens H, Butler CC, Beutels P. Cost-effectiveness of adding oseltamivir to primary care for influenza-like-illness: economic evaluation alongside the randomised controlled ALIC 4E trial in 15 European countries. Eur J Health Econ 2022:10.1007/s10198-022-01521-2. [PMID: 36131214 DOI: 10.1007/s10198-022-01521-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 08/23/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Oseltamivir is usually not often prescribed (or reimbursed) for non-high-risk patients consulting for influenza-like-illness (ILI) in primary care in Europe. We aimed to evaluate the cost-effectiveness of adding oseltamivir to usual primary care in adults/adolescents (13 years +) and children with ILI during seasonal influenza epidemics, using data collected in an open-label, multi-season, randomised controlled trial of oseltamivir in 15 European countries. METHODS Direct and indirect cost estimates were based on patient reported resource use and official country-specific unit costs. Health-Related Quality of Life was assessed by EQ-5D questionnaires. Costs and quality adjusted life-years (QALY) were bootstrapped (N = 10,000) to estimate incremental cost-effectiveness ratios (ICER), from both the healthcare payers' and the societal perspectives, with uncertainty expressed through probabilistic sensitivity analysis and expected value for perfect information (EVPI) analysis. Additionally, scenario (self-reported spending), comorbidities subgroup and country-specific analyses were performed. RESULTS The healthcare payers' expected ICERs of oseltamivir were €22,459 per QALY gained in adults/adolescents and €13,001 in children. From the societal perspective, oseltamivir was cost-saving in adults/adolescents, but the ICER is €8,344 in children. Large uncertainties were observed in subgroups with comorbidities, especially for children. The expected ICERs and extent of decision uncertainty varied between countries (EVPI ranged €1-€35 per patient). CONCLUSION Adding oseltamivir to primary usual care in Europe is likely to be cost-effective for treating adults/adolescents and children with ILI from the healthcare payers' perspective (if willingness-to-pay per QALY gained > €22,459) and cost-saving in adults/adolescents from a societal perspective.
Collapse
Affiliation(s)
- Xiao Li
- Centre for Health Economics Research and Modelling Infectious Diseases (CHERMID), Vaccine and Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Campus Drie Eiken, room D.S.221, Universiteitsplein 1, 2610, Antwerp, Belgium.
| | - Joke Bilcke
- Centre for Health Economics Research and Modelling Infectious Diseases (CHERMID), Vaccine and Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Campus Drie Eiken, room D.S.221, Universiteitsplein 1, 2610, Antwerp, Belgium
| | - Alike W van der Velden
- Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht, The Netherlands
| | - Robin Bruyndonckx
- Interuniversity Institute for Biostatistics and Statistical Bioinformatics (I-BIOSTAT), Data Science Institute (DSI), Hasselt University, Hasselt, Belgium
- Laboratory of Medical Microbiology, Vaccine and Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium
| | - Samuel Coenen
- Laboratory of Medical Microbiology, Vaccine and Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium
- Department of Family Medicine and Population Health (FAMPOP), University of Antwerp, Antwerp, Belgium
| | - Emily Bongard
- The Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Muirrean de Paor
- RCSI Department of General Practice, 123 St Stephens Green, Dublin 2, Ireland
| | - Slawomir Chlabicz
- Department of Family Medicine, Medical University of Bialystok, Białystok, Poland
| | | | - Nick Francis
- School of Primary Care, Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Rune Aabenhus
- Section and Research Unit of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Heiner C Bucher
- Division of Infectious Diseases and Hospital Hygiene, Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Basel, Switzerland
| | - Annelies Colliers
- Department of Family Medicine and Population Health (FAMPOP), University of Antwerp, Antwerp, Belgium
| | - An De Sutter
- Department of Public Health and Primary Care (Centre for Family Medicine), Gent University, Gent, Belgium
| | - Ana Garcia-Sangenis
- University Institute in Primary Care Research Jordi Gol, Via Roma Health Centre, Barcelona, Spain
| | - Dominik Glinz
- Department of Clinical Research, Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Basel, Switzerland
| | - Nicolay J Harbin
- Department of General Practice, Antibiotic Center for Primary Care, Institute of Health and Society, University of Oslo, Oslo, Norway
| | | | - Morten Lindbæk
- Research Leader Antibiotic Centre for Primary Care, Department of General Practice, University of Oslo, Oslo, Norway
| | - Christos Lionis
- General Practice and Primary Health Care at the School of Medicine, University of Crete, Crete, Greece
| | - Carl Llor
- University Institute in Primary Care Research Jordi Gol, Via Roma Health Centre, Barcelona, Spain
- Research Unit for General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | | | | | - Bohumil Seifert
- Institute of General Practice, First Faculty of Medicine, Charles University in Prague, Prague, Czech Republic
| | - Pär-Daniel Sundvall
- General Practice/Family Medicine, School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Research, Education, Development and Innovation, Primary Health Care, Region Västra Götaland, Sandared, Sweden
| | | | | | - Theo J Verheij
- Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht, The Netherlands
| | - Herman Goossens
- Department of Family Medicine and Population Health (FAMPOP), University of Antwerp, Antwerp, Belgium
| | - Christopher C Butler
- The Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Philippe Beutels
- Centre for Health Economics Research and Modelling Infectious Diseases (CHERMID), Vaccine and Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Campus Drie Eiken, room D.S.221, Universiteitsplein 1, 2610, Antwerp, Belgium
| |
Collapse
|
26
|
van der Pol S, Jansen DEMC, van der Velden AW, Butler CC, Verheij TJM, Friedrich AW, Postma MJ, van Asselt ADI. The Opportunity of Point-of-Care Diagnostics in General Practice: Modelling the Effects on Antimicrobial Resistance. Pharmacoeconomics 2022; 40:823-833. [PMID: 35764913 PMCID: PMC9243781 DOI: 10.1007/s40273-022-01165-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 05/29/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVES Antimicrobial resistance (AMR) is a public health threat associated with antibiotic consumption. Community-acquired acute respiratory tract infections (CA-ARTIs) are a major driver of antibiotic consumption in primary care. We aimed to quantify the investments required for a large-scale rollout of point-of care (POC) diagnostic testing in Dutch primary care, and the impact on AMR due to reduced use of antibiotics. METHODS We developed an individual-based model that simulates consultations for CA-ARTI at GP practices in the Netherlands and compared a scenario where GPs test all CA-ARTI patients with a hypothetical diagnostic strategy to continuing the current standard-of-care for the years 2020-2030. We estimated differences in costs and future AMR rates caused by testing all patients consulting for CA-ARTI with a hypothetical diagnostic strategy, compared to the current standard-of-care in GP practices. RESULTS Compared to the current standard-of-care, the diagnostic algorithm increases the total costs of GP consultations for CA-ARTI by 9% and 19%, when priced at €5 and €10, respectively. The forecast increase in Streptococcus pneumoniae resistance against penicillins can be partly restrained by the hypothetical diagnostic strategy from 3.8 to 3.5% in 2030, albeit with considerable uncertainty. CONCLUSIONS Our results show that implementing a hypothetical diagnostic strategy for all CA-ARTI patients in primary care raises the costs of consultations, while lowering antibiotic consumption and AMR. Novel health-economic methods to assess and communicate the potential benefits related to AMR may be required for interventions with limited gains for individual patients, but considerable potential related to antibiotic consumption and AMR.
Collapse
Affiliation(s)
- Simon van der Pol
- Department of Health Sciences, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
- Health-Ecore, Zeist, The Netherlands.
| | - Danielle E M C Jansen
- Department of General Practice and Elderly Care Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Department of Sociology, Interuniversity Center for Social Science Theory and Methodology (ICS), University of Groningen, Groningen, The Netherlands
| | - Alike W van der Velden
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Christopher C Butler
- Nuffield Department of Primary Care and Public Health, School of Medicine, Cardiff Sciences, University, Cardiff of Oxford, Oxford, UK
| | - Theo J M Verheij
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Alex W Friedrich
- Department of Medical Microbiology and Infection Control, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Institute of European Prevention Networks in Infection Control, University Hospital Münster, Münster, Germany
| | - Maarten J Postma
- Department of Health Sciences, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Health-Ecore, Zeist, The Netherlands
- Department of Economics, Econometrics and Finance, University of Groningen, Groningen, The Netherlands
| | - Antoinette D I van Asselt
- Department of Health Sciences, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| |
Collapse
|
27
|
Butler CC. Response to Dal-Ré and Holm's ethical concern regarding the UK PANORAMIC COVID-19 trial by the PANORAMIC Investigators. Br J Clin Pharmacol 2022; 88:3542. [PMID: 35266567 PMCID: PMC9111443 DOI: 10.1111/bcp.15299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 02/28/2022] [Indexed: 11/29/2022] Open
|
28
|
Dorward J, Yu LM, Hayward G, Saville BR, Gbinigie O, Van Hecke O, Ogburn E, Evans PH, Thomas NP, Patel MG, Richards D, Berry N, Detry MA, Saunders C, Fitzgerald M, Harris V, Shanyinde M, de Lusignan S, Andersson MI, Butler CC, Hobbs FR. Colchicine for COVID-19 in the community (PRINCIPLE): a randomised, controlled, adaptive platform trial. Br J Gen Pract 2022; 72:e446-e455. [PMID: 35440469 PMCID: PMC9037186 DOI: 10.3399/bjgp.2022.0083] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 03/02/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Colchicine has been proposed as a COVID-19 treatment. AIM To determine whether colchicine reduces time to recovery and COVID-19-related admissions to hospital and/or deaths among people in the community. DESIGN AND SETTING Prospective, multicentre, open-label, multi-arm, randomised, controlled, adaptive platform trial (PRINCIPLE). METHOD Adults aged ≥65 years or ≥18 years with comorbidities or shortness of breath, and unwell for ≤14 days with suspected COVID-19 in the community, were randomised to usual care, usual care plus colchicine (500 µg daily for 14 days), or usual care plus other interventions. The co-primary endpoints were time to first self-reported recovery and admission to hospital/death related to COVID-19, within 28 days, analysed using Bayesian models. RESULTS The trial opened on 2 April 2020. Randomisation to colchicine started on 4 March 2021 and stopped on 26 May 2021 because the prespecified time to recovery futility criterion was met. The primary analysis model included 2755 participants who were SARS-CoV-2 positive, randomised to colchicine (n = 156), usual care (n = 1145), and other treatments (n = 1454). Time to first self-reported recovery was similar in the colchicine group compared with usual care with an estimated hazard ratio of 0.92 (95% credible interval (CrI) = 0.72 to 1.16) and an estimated increase of 1.4 days in median time to self-reported recovery for colchicine versus usual care. The probability of meaningful benefit in time to recovery was very low at 1.8%. COVID-19-related admissions to hospital/deaths were similar in the colchicine group versus usual care, with an estimated odds ratio of 0.76 (95% CrI = 0.28 to 1.89) and an estimated difference of -0.4% (95% CrI = -2.7 to 2.4). CONCLUSION Colchicine did not improve time to recovery in people at higher risk of complications with COVID-19 in the community.
Collapse
Affiliation(s)
- Jienchi Dorward
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK; Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa
| | - Ly-Mee Yu
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Gail Hayward
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Benjamin R Saville
- Berry Consultants, Texas, TX, US; Department of Biostatistics, Vanderbilt University School of Medicine, Tennessee, TN, US
| | - Oghenekome Gbinigie
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Oliver Van Hecke
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Emma Ogburn
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Philip H Evans
- College of Medicine and Health, University of Exeter, Exeter, UK; National Institute for Health Research (NIHR) Clinical Research Network, NIHR, London, UK
| | | | - Mahendra G Patel
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Duncan Richards
- Oxford Clinical Trials Research Unit, Botnar Research Centre, University of Oxford, Oxford, UK
| | | | | | | | | | - Victoria Harris
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Milensu Shanyinde
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Simon de Lusignan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK; Royal College of General Practitioners, London, UK
| | | | - Christopher C Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Fd Richard Hobbs
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | |
Collapse
|
29
|
Wanat M, Santillo M, Galal U, Davoudianfar M, Bongard E, Savic S, Savic L, Porter C, Fielding J, Butler CC, Pavitt S, Sandoe J, Tonkin-Crine S. Mixed-methods evaluation of a behavioural intervention package to identify and amend incorrect penicillin allergy records in UK general practice. BMJ Open 2022; 12:e057471. [PMID: 36691248 PMCID: PMC9171226 DOI: 10.1136/bmjopen-2021-057471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 05/11/2022] [Indexed: 01/27/2023] Open
Abstract
OBJECTIVES About 6% of the UK general practice population has a record of a penicillin allergy but fewer than 10% of these are likely to be truly allergic. In the ALABAMA (Allergy Antibiotics and Microbial resistance) feasibility trial, primary care patients with penicillin allergy were randomised to penicillin allergy assessment pathway or usual care to assess the effect on health outcomes. A behavioural intervention package was developed to aid delabelling. This study aimed to investigate patients' and clinicians' views of penicillin allergy testing (PAT). DESIGN We conducted a mixed-methods process evaluation embedded within the ALABAMA trial, which included a clinician survey, a patient survey (at baseline and follow-up) and semistructured interviews with patients and clinicians. SETTINGS The study was conducted in primary care, as part of the feasibility stage of the ALABAMA trial. PARTICIPANTS Patients and primary care clinicians. RESULTS Clinicians (N=53; 52.2%) were positive about PAT and its potential value but did not have previous experience of referring patients for a PAT and were unsure whether patients would take penicillin after a negative allergy test. Patients (N=36; 46%) were unsure whether they were severely allergic to penicillin and did not fear a severe allergic reaction to penicillin. Clinician interviews showed that they were already aware of the benefit of PAT. Interviews with patients suggested the importance of safety as patients valued having numerous opportunities to address their concerns about safety of the test. CONCLUSIONS This study highlights the positive effects of the ALABAMA behavioural intervention for both patients and clinicians. TRIAL REGISTRATION NUMBER NCT04108637; ISRCTN20579216; Pre-results.
Collapse
Affiliation(s)
- Marta Wanat
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
| | - Marta Santillo
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
| | - Ushma Galal
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
| | - Mina Davoudianfar
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
| | - Emily Bongard
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
| | - Sinisa Savic
- University of Leeds and Leeds Teaching Hospitals NHS Trust, Faculty of Medicine and Health, Leeds, UK
| | - Louise Savic
- University of Leeds and Leeds Teaching Hospitals NHS Trust, Faculty of Medicine and Health, Leeds, UK
| | - Catherine Porter
- Healthcare Associated Infection Group, University of Leeds and Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Joanne Fielding
- Healthcare Associated Infection Group, University of Leeds and Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Christopher C Butler
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
| | - Sue Pavitt
- Dental Translational and Clinical Research Unit, Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - Jonathan Sandoe
- Healthcare Associated Infection Group, University of Leeds and Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Sarah Tonkin-Crine
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
- National Institute for Health Research (NIHR) Health Protection Research Unit (HPRU) in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford, UK
| |
Collapse
|
30
|
Ouchi D, García-Sangenís A, Moragas A, van der Velden AW, Verheij TJ, Butler CC, Bongard E, Coenen S, Cook J, Francis NA, Godycki-Cwirko M, Lundgren PT, Lionis C, Radzeviciene Jurgute R, Chlabicz S, De Sutter A, Bucher HC, Seifert B, Kovács B, de Paor M, Sundvall PD, Aabenhus R, Harbin NJ, Ieven G, Goossens H, Lindbæk M, Bjerrum L, Llor C. Clinical prediction of laboratory-confirmed influenza in adults with influenza-like illness in primary care. A randomized controlled trial secondary analysis in 15 European countries. Fam Pract 2022; 39:398-405. [PMID: 34611715 DOI: 10.1093/fampra/cmab122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Clinical findings do not accurately predict laboratory diagnosis of influenza. Early identification of influenza is considered useful for proper management decisions in primary care. OBJECTIVE We evaluated the diagnostic value of the presence and the severity of symptoms for the diagnosis of laboratory-confirmed influenza infection among adults presenting with influenza-like illness (ILI) in primary care. METHODS Secondary analysis of patients with ILI who participated in a clinical trial from 2015 to 2018 in 15 European countries. Patients rated signs and symptoms as absent, minor, moderate, or major problem. A nasopharyngeal swab was taken for microbiological identification of influenza and other microorganisms. Models were generated considering (i) the presence of individual symptoms and (ii) the severity rating of symptoms. RESULTS A total of 2,639 patients aged 18 or older were included in the analysis. The mean age was 41.8 ± 14.7 years, and 1,099 were men (42.1%). Influenza was microbiologically confirmed in 1,337 patients (51.1%). The area under the curve (AUC) of the model for the presence of any of seven symptoms for detecting influenza was 0.66 (95% confidence interval [CI]: 0.65-0.68), whereas the AUC of the symptom severity model, which included eight variables-cough, fever, muscle aches, sweating and/or chills, moderate to severe overall disease, age, abdominal pain, and sore throat-was 0.70 (95% CI: 0.69-0.72). CONCLUSION Clinical prediction of microbiologically confirmed influenza in adults with ILI is slightly more accurate when based on patient reported symptom severity than when based on the presence or absence of symptoms.
Collapse
Affiliation(s)
- Dan Ouchi
- University Institute in Primary Care Research Jordi Gol i Gurina, Barcelona, Spain.,Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Spain
| | - Ana García-Sangenís
- University Institute in Primary Care Research Jordi Gol i Gurina, Barcelona, Spain
| | - Ana Moragas
- University Institute in Primary Care Research Jordi Gol i Gurina, Barcelona, Spain
| | - Alike W van der Velden
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands
| | - Theo J Verheij
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands
| | - Christopher C Butler
- Nuffield Department of Primary Health Care Sciences, University of Oxford, Oxford, United Kingdom
| | - Emily Bongard
- Nuffield Department of Primary Health Care Sciences, University of Oxford, Oxford, United Kingdom
| | - Samuel Coenen
- Centre for General Practice, Department of Family Medicine & Population Health, University of Antwerp, Antwerp, Belgium
| | - Johanna Cook
- Nuffield Department of Primary Health Care Sciences, University of Oxford, Oxford, United Kingdom
| | - Nick A Francis
- Primary Care Research Centre, University of Southampton, Southampton,United Kingdom
| | - Maciek Godycki-Cwirko
- Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Lodz, Lodz, Poland
| | - Pia Touboul Lundgren
- Département de Santé Publique, Université Côte d'Azur, Centre Hospitalier Universitaire de Nice, Nice, France
| | - Christos Lionis
- Clinic of Social and Family Medicine, Faculty of Medicine, University of Crete, Crete, Greece
| | | | - Sławomir Chlabicz
- Department of Family Medicine, Medical University of Bialystok, Bialystok, Poland
| | - An De Sutter
- Centre for Family Medicine UGent, Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Heiner C Bucher
- Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Bohumil Seifert
- Department of General Practice, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | | | - Muireann de Paor
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland (RCSI), Health Research Board Primary Care Clinical Trial Network Ireland, National University of Ireland Galway, Galway, Ireland
| | - Pär-Daniel Sundvall
- Research, Education, Development & Innovation Primary Health Care, Region Västra Götaland and Institute of Medicine, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
| | - Rune Aabenhus
- Section and Research Unit of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Nicolay Jonassen Harbin
- Antibiotic Centre for Primary Care, Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Greet Ieven
- Laboratory of Clinical Microbiology, Antwerp, University Hospital, Edegem, Belgium
| | - Herman Goossens
- Laboratory of Clinical Microbiology, Antwerp, University Hospital, Edegem, Belgium
| | - Morten Lindbæk
- Antibiotic Centre for Primary Care, Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Lars Bjerrum
- Section and Research Unit of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Carl Llor
- University Institute in Primary Care Research Jordi Gol i Gurina, Barcelona, Spain.,Department of Public Health, General Practice, University of Southern Denmark, Odense, Denmark
| |
Collapse
|
31
|
Blyth MH, Cannings-John R, Hay AD, Butler CC, Hughes K. Is the NICE traffic light system fit-for-purpose for children presenting with undifferentiated acute illness in primary care? Arch Dis Child 2022; 107:444-449. [PMID: 34548278 DOI: 10.1136/archdischild-2021-322768] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 09/09/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND The National Institute of Clinical Excellence (NICE) traffic light system uses children's symptoms and signs to categorise acute infections into red, amber and green. To our knowledge, no study has described the proportion of children with acute undifferentiated illness who fall into these categories in primary care, which is important since red and amber children are considered at higher risk of serious illness requiring urgent secondary care assessment. AIM To estimate the proportion of acutely unwell children presenting to primary care classified by the NICE traffic light system as red, amber or green, and to describe their initial management. DESIGN AND SETTING Secondary analysis of the Diagnosis of Urinary Tract infection in Young children prospective cohort study. METHOD 6797 children under 5 years presenting to 225 general practices with acute undifferentiated illness were retrospectively mapped to the NICE traffic light system by a panel of general practitioners. RESULTS 6406 (94%) children were classified as NICE red (32%) or amber (62%) with 1.6% red and 0.3%, respectively, referred the same day for hospital assessment; and 46% and 31%, respectively, treated with antibiotics. The remaining 385 (6%) were classified green, with none referred and 27% treated with antibiotics. Results were robust to sensitivity analyses. CONCLUSION The majority of children presenting to UK primary care with acute undifferentiated illness meet red or amber NICE traffic light criteria,with only 6% classified as low risk, making it unfit for use in general practice. Research is urgently needed to establish as triage system suitable for general practice.
Collapse
Affiliation(s)
- Megan Hedd Blyth
- Division of Population Medicine, Cardiff University, Cardiff, UK
| | | | - Alastair D Hay
- Division of Primary Health Care, University of Bristol, Bristol, UK
| | - Christopher C Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Kathryn Hughes
- Division of Population Medicine, Cardiff University, Cardiff, UK
| |
Collapse
|
32
|
Borek AJ, Pilbeam C, Mableson H, Wanat M, Atkinson P, Sheard S, Martindale AM, Solomon T, Butler CC, Gobat N, Tonkin-Crine S. Experiences and concerns of health workers throughout the first year of the COVID-19 pandemic in the UK: A longitudinal qualitative interview study. PLoS One 2022; 17:e0264906. [PMID: 35294450 PMCID: PMC8926177 DOI: 10.1371/journal.pone.0264906] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 02/21/2022] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE To identify the experiences and concerns of health workers (HWs), and how they changed, throughout the first year of the COVID-19 pandemic in the UK. METHODS Longitudinal, qualitative study with HWs involved in patient management or delivery of care related to COVID-19 in general practice, emergency departments and hospitals. Participants were identified through snowballing. Semi-structured telephone or video interviews were conducted between February 2020 and February 2021, audio-recorded, summarised, and transcribed. Data were analysed longitudinally using framework and thematic analysis. RESULTS We conducted 105 interviews with 14 participants and identified three phases corresponding with shifts in HWs' experiences and concerns. (1) Emergency and mobilisation phase (late winter-spring 2020), with significant rapid shifts in responsibilities, required skills, and training, and challenges in patient care. (2) Consolidation and preparation phase (summer-autumn 2020), involving gradual return to usual care and responsibilities, sense of professional development and improvement in care, and focus on learning and preparing for future. (3) Exhaustion and survival phase (autumn 2020-winter 2021), entailing return of changes in responsibilities, focus on balancing COVID-19 and non-COVID care (until becoming overwhelmed with COVID-19 cases), and concerns about longer-term impacts of unceasing pressure on health services. Participants' perceptions of COVID-19 risk and patient/public attitudes changed throughout the year, and tiredness and weariness turned into exhaustion. CONCLUSIONS Results showed a long-term impact of the COVID-19 pandemic on UK HWs' experiences and concerns related to changes in their roles, provision of care, and personal wellbeing. Despite mobilisation in the emergency phase, and trying to learn from this, HWs' experiences seemed to be similar or worse in the second wave partly due to many COVID-19 cases. The findings highlight the importance of supporting HWs and strengthening system-level resilience (e.g., with resources, processes) to enable them to respond to current and future demands and emergencies.
Collapse
Affiliation(s)
- Aleksandra J. Borek
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Caitlin Pilbeam
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Hayley Mableson
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, United Kingdom
| | - Marta Wanat
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Paul Atkinson
- Institute of Population Health, University of Liverpool, Liverpool, United Kingdom
| | - Sally Sheard
- Institute of Population Health, University of Liverpool, Liverpool, United Kingdom
| | - Anne-Marie Martindale
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, United Kingdom
| | - Tom Solomon
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, United Kingdom
- National Institute for Health Research Health Protection Research Unit in Emerging and Zoonotic Infections, University of Liverpool, Liverpool, United Kingdom
- Department of Neurology, Walton Centre NHS Foundation Trust, Liverpool, United Kingdom
| | - Christopher C. Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Nina Gobat
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Sarah Tonkin-Crine
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Oxford, United Kingdom
| |
Collapse
|
33
|
Bruyndonckx R, Bilcke J, van der Velden AW, Li X, Hens N, Coenen S, Butler CC, Beutels P. Impact of Adding Oseltamivir to Usual Care on Quality-Adjusted Life-Years During Influenza-Like Illness. Value Health 2022; 25:178-184. [PMID: 35094790 DOI: 10.1016/j.jval.2021.08.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 07/06/2021] [Accepted: 08/09/2021] [Indexed: 06/14/2023]
Abstract
OBJECTIVES The ALIC4E trial has shown that oseltamivir reduces recovery time while increasing the risk of nausea. This secondary analysis of the ALIC4E trial aimed to determine the gain in quality-adjusted life-years (QALYs) associated with adding oseltamivir to usual primary care in patients presenting with influenza-like illness (ILI). METHODS Patients with ILI were recruited during the influenza season (2015-2018) in 15 European countries. Patients were assigned to usual care with or without oseltamivir through stratified randomization (age, severity, comorbidities, and symptom onset). Patients' health status was valued with the EQ-5D and visual analog scale (VAS) for up to 28 days. Average EQ-5D and VAS scores over time were estimated for both treatment groups using one-inflated beta regression in children (<13 years old) and adults (≥13 years old). QALY gain was calculated as the difference between the groups. Sensitivity analysis considered the value set to convert EQ-5D answers to summary scores and the follow-up period. RESULTS In adults, oseltamivir gained 0.0006 (95% confidence interval 0.0002-0.0010) QALYs, whereas no statistically significant gain was found in children (14-day follow-up, EQ-5D). QALY gains were statistically significant in patients aged ≥65 years, patients without relevant comorbidities, or patients experiencing symptoms for ≤48 hours. Using VAS and accounting for 28-day follow-up resulted in higher QALY gain. CONCLUSIONS QALY gain owing to oseltamivir is limited compared with other diseases, and its clinical meaningfulness remains to be determined. Further analysis is needed to evaluate whether QALY gain and its impact on ILI treatment cost render oseltamivir cost-effective.
Collapse
Affiliation(s)
- Robin Bruyndonckx
- Interuniversity Institute for Biostatistics and Statistical Bioinformatics, Data Science Institute, Hasselt University, Hasselt, Belgium; Laboratory of Medical Microbiology, Vaccine and Infectious Disease Institute, University of Antwerp, Antwerp, Belgium
| | - Joke Bilcke
- Centre for Health Economic Research and Modelling Infectious Diseases, Vaccine and Infectious Disease Institute, University of Antwerp, Antwerp, Belgium.
| | - Alike W van der Velden
- Julius Centre for Health, Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Xiao Li
- Centre for Health Economic Research and Modelling Infectious Diseases, Vaccine and Infectious Disease Institute, University of Antwerp, Antwerp, Belgium
| | - Niel Hens
- Interuniversity Institute for Biostatistics and Statistical Bioinformatics, Data Science Institute, Hasselt University, Hasselt, Belgium; Centre for Health Economic Research and Modelling Infectious Diseases, Vaccine and Infectious Disease Institute, University of Antwerp, Antwerp, Belgium
| | - Samuel Coenen
- Laboratory of Medical Microbiology, Vaccine and Infectious Disease Institute, University of Antwerp, Antwerp, Belgium; Department of Family Medicine and Population Health, Centre for General Practice, University of Antwerp, Antwerp, Belgium
| | - Christopher C Butler
- Institute for Primary Care and Public Health, Cardiff University, Cardiff, England, UK
| | - Philippe Beutels
- Centre for Health Economic Research and Modelling Infectious Diseases, Vaccine and Infectious Disease Institute, University of Antwerp, Antwerp, Belgium
| |
Collapse
|
34
|
Wanat M, Santillo M, Borek AJ, Butler CC, Anthierens S, Tonkin-Crine S. OUP accepted manuscript. JAC Antimicrob Resist 2022; 4:dlac026. [PMID: 35321397 PMCID: PMC8935206 DOI: 10.1093/jacamr/dlac026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
In order to design appropriate antimicrobial stewardship (AMS) programmes, it is crucial to understand challenges to tackling antibiotic resistance (AMR) specific to each healthcare setting. Antibiotic prescribing in primary care accounts for most prescriptions with a significant proportion considered clinically inappropriate. Qualitative research has a long history in social sciences, but its value and contribution are still contested in medical journals including in the AMR/AMS field. However, through its focus on understanding, meaning making and explaining, qualitative research can offer insights in how to improve AMS efforts in primary care. This paper provides an overview of unique considerations, contributions and challenges related to using qualitative research in AMS to help the AMS community new to qualitative research to utilize its potential most fully. First, we discuss specific considerations for AMS in relation to the stages of conducting a qualitative study, including identifying a research question and choosing a suitable methodology; sampling appropriate participants; planning a recruitment strategy; choosing a method of data collection; and conducting data analysis. These are illustrated with examples of qualitative AMS studies in primary care. Second, we highlight the importance of patient and public involvement throughout all stages of the project and ensuring quality in qualitative AMS research. Finally, drawing on these considerations, we make a further case for the value and contribution of qualitative methodologies in AMS/AMR research while outlining future directions for both AMS and qualitative research, including the need for studies with diverse actors; interdisciplinary collaborations; and complex decisions on methodologies and timelines.
Collapse
Affiliation(s)
- Marta Wanat
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- Corresponding author. E-mail: ; @SKGTonkinCrine, @BorekAleksandra, @MartaSantillo, @marta_wanat, @sibylanthierens, @ChrisColButler
| | - Marta Santillo
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Aleksandra J. Borek
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Christopher C. Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Sibyl Anthierens
- Department of Family Medicine and Population Health, University of Antwerp, Antwerp, Belgium
| | - Sarah Tonkin-Crine
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Oxford, UK
| |
Collapse
|
35
|
Abstract
Antibiotic use (and misuse) accelerates antimicrobial resistance (AMR), and addressing this complex problem necessitates behaviour change related to infection prevention and management and to antibiotic prescribing and use. As most antibiotic courses are prescribed in primary care, a key focus of antimicrobial stewardship (AMS) is on changing behaviours outside of hospital. Behavioural science draws on behaviour change theories, techniques and methods developed in health psychology, and can be used to help understand and change behaviours related to AMR/AMS. Qualitative methodologies can be used together with a behavioural science approach to explore influences on behaviour and develop and evaluate behavioural interventions. This paper provides an overview of how the behavioural science approach, together with qualitative methods, can contribute and add value to AMS projects. First, it introduces and explains the relevance of the behavioural science approach to AMR/AMS. Second, it provides an overview of behaviour change ‘tools’: behaviour change theories/models, behavioural determinants and behaviour change techniques. Third, it explains how behavioural methods can be used to: (i) define a clinical problem in behavioural terms and identify behavioural influences; (ii) develop and implement behavioural AMS interventions; and (iii) evaluate them. These are illustrated with examples of using qualitative methods in AMS studies in primary care. Finally, the paper concludes by summarizing the main contributions of taking the behavioural science approach to qualitative AMS research in primary care and discussing the key implications and future directions for research and practice.
Collapse
Affiliation(s)
- Aleksandra J. Borek
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- Corresponding author. E-mail:
| | - Marta Santillo
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Marta Wanat
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Christopher C. Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- National Institute for Health Research (NIHR) Health Protection Research Unit (HPRU) in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford, UK
| | - Sarah Tonkin-Crine
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- National Institute for Health Research (NIHR) Health Protection Research Unit (HPRU) in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford, UK
| |
Collapse
|
36
|
Borek AJ, Maitland K, McLeod M, Campbell A, Hayhoe B, Butler CC, Morrell L, Roope LSJ, Holmes A, Walker AS, Tonkin-Crine S. Impact of the COVID-19 Pandemic on Community Antibiotic Prescribing and Stewardship: A Qualitative Interview Study with General Practitioners in England. Antibiotics (Basel) 2021; 10:antibiotics10121531. [PMID: 34943743 PMCID: PMC8698307 DOI: 10.3390/antibiotics10121531] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 12/03/2021] [Accepted: 12/10/2021] [Indexed: 01/21/2023] Open
Abstract
The COVID-19 pandemic has had a profound impact on the delivery of primary care services. We aimed to identify general practitioners’ (GPs’) perceptions and experiences of how the COVID-19 pandemic influenced antibiotic prescribing and antimicrobial stewardship (AMS) in general practice in England. Twenty-four semi-structured interviews were conducted with 18 GPs at two time-points: autumn 2020 (14 interviews) and spring 2021 (10 interviews). Interviews were audio-recorded, transcribed and analysed thematically, taking a longitudinal approach. Participants reported a lower threshold for antibiotic prescribing (and fewer consultations) for respiratory infections and COVID-19 symptoms early in the pandemic, then returning to more usual (pre-pandemic) prescribing. They perceived the pandemic as having had less impact on antibiotic prescribing for urinary and skin infections. Participants perceived the changing ways of working and consulting (e.g., proportions of remote and in-person consultations) in addition to changing patient presentations and GP workloads as influencing the fluctuations in antibiotic prescribing. This was compounded by decreased engagement with, and priority of, AMS due to COVID-19-related urgent priorities. Re-engagement with AMS is needed, e.g., through reviving antibiotic prescribing feedback and targets/incentives. The pandemic disrupted, and required adaptations in, the usual ways of working and AMS. It is now important to identify opportunities, e.g., for re-organising ways of managing infections and AMS in the future.
Collapse
Affiliation(s)
- Aleksandra J. Borek
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK; (K.M.); (C.C.B.); (S.T.-C.)
- Correspondence:
| | - Katherine Maitland
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK; (K.M.); (C.C.B.); (S.T.-C.)
| | - Monsey McLeod
- National Institute for Health Research (NIHR) Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London W12 0NN, UK; (M.M.); (A.C.); (A.H.)
- Centre for Medication Safety and Service Quality, Pharmacy Department, Imperial College Healthcare NHS Trust, London W6 8RF, UK
- NIHR Imperial Patient Safety Translational Research Centre, Imperial College London, London W6 8RF, UK
| | - Anne Campbell
- National Institute for Health Research (NIHR) Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London W12 0NN, UK; (M.M.); (A.C.); (A.H.)
| | - Benedict Hayhoe
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, London W6 8RP, UK;
- NIHR Applied Research Collaboration Northwest London, London W6 8RP, UK
| | - Christopher C. Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK; (K.M.); (C.C.B.); (S.T.-C.)
| | - Liz Morrell
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford OX3 7LF, UK; (L.M.); (L.S.J.R.)
| | - Laurence S. J. Roope
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford OX3 7LF, UK; (L.M.); (L.S.J.R.)
- NIHR Oxford Biomedical Research Centre, Oxford OX3 9DU, UK;
| | - Alison Holmes
- National Institute for Health Research (NIHR) Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London W12 0NN, UK; (M.M.); (A.C.); (A.H.)
| | - Ann Sarah Walker
- NIHR Oxford Biomedical Research Centre, Oxford OX3 9DU, UK;
- NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford OX3 9DU, UK
- Nuffield Department of Medicine, University of Oxford, Oxford OX3 9DU, UK
| | - Sarah Tonkin-Crine
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK; (K.M.); (C.C.B.); (S.T.-C.)
- NIHR Oxford Biomedical Research Centre, Oxford OX3 9DU, UK;
| | | |
Collapse
|
37
|
Hobbs FDR, Yu LM, Saville BR, Bafadhel M, Butler CC. High-dose budesonide for early COVID-19 - Authors' reply. Lancet 2021; 398:2147-2148. [PMID: 34895528 PMCID: PMC8660058 DOI: 10.1016/s0140-6736(21)02449-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 10/28/2021] [Indexed: 11/28/2022]
Affiliation(s)
- F D Richard Hobbs
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK.
| | - Ly-Mee Yu
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK
| | | | - Mona Bafadhel
- Nuffield Department of Clinical Medicine, University of Oxford, Oxford OX2 6GG, UK
| | - Christopher C Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK
| |
Collapse
|
38
|
Smith MC, Ashdown HF, Sheppard JP, Butler CC, Bankhead C. Statin prescription in patients with chronic obstructive pulmonary disease and risk of exacerbations: a retrospective cohort study in the Clinical Practice Research Datalink. BMJ Open 2021; 11:e050757. [PMID: 34876426 PMCID: PMC8655534 DOI: 10.1136/bmjopen-2021-050757] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 11/08/2021] [Indexed: 01/25/2023] Open
Abstract
OBJECTIVE Observational studies have suggested a beneficial effect of taking statins on frequency of chronic obstructive pulmonary disease (COPD) exacerbations. However, clinical trials of statins in people with COPD did not confirm those results. This study aimed to investigate this association using a methodological approach, which reduces the biases associated with some previous observational study designs. DESIGN Retrospective cohort study comparing new-users of statins with non-users. SETTING General practices in England contributing to the Clinical Practice Research Datalink in 2007-2017, with linkage to data on Hospital Episode Statistics inpatient episodes. PARTICIPANTS 48 124 people with COPD, aged over 40 years, who had not been prescribed statin in the previous year. EXPOSURE Participants became new-users of statins at their first prescription for a statin during follow-up. They were then assumed to remain statin users. Statin users were compared with non-users. OUTCOMES Primary outcomes were COPD exacerbation, or severe exacerbation requiring hospitalisation. Secondary outcomes were death from any cause (for comparison with other studies) and urinary tract infection (negative-control). Maximum follow-up was 3 years. Adjusted HR were calculated using time-dependent Cox regression. The Andersen-Gill model was used for recurrent exacerbations. Covariates included demographic variables, variables related to COPD severity, cardiovascular comorbidities as time-dependent variables, and other comorbidities at baseline. RESULTS 7266 participants became new-users of statins over an average 2.5 years of follow-up. In total, 30 961 people developed an exacerbation, 8110 severe exacerbation, 3650 urinary tract infection and 5355 died. Adjusted HR (95% CI) in statin users compared with non-users were first exacerbation 1.01 (0.96-1.06), severe exacerbation 0.92 (0.84-0.99), number of exacerbations 1.00 (0.97-1.04), urinary tract infection 1.10 (0.98-1.23) and death 0.63 (0.57-0.70). CONCLUSIONS In this study of health records from a Primary Care database, statin use in people with COPD was not associated with a lower risk of COPD exacerbation.
Collapse
Affiliation(s)
- Margaret C Smith
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Helen Frances Ashdown
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - James Peter Sheppard
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Christopher C Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Clare Bankhead
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| |
Collapse
|
39
|
Harbin NJ, Rystedt K, Lindbaek M, Radzeviciene R, Westin J, Gunnarsson R, Butler CC, van der Velden AW, Verheij TJ, Sundvall PD. Does C-reactive protein predict time to recovery and benefit from oseltamivir treatment in primary care patients with influenza-like illness? A randomized controlled trial secondary analysis. Scand J Prim Health Care 2021; 39:527-532. [PMID: 34850657 PMCID: PMC8725887 DOI: 10.1080/02813432.2021.2006482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
OBJECTIVE Recovery time and treatment effect of oseltamivir in influenza-like illness (ILI) differs between patient groups. A point-of-care test to better predict ILI duration and identify patients who are most likely to benefit from oseltamivir treatment would aid prescribing decisions in primary care. This study aimed to investigate whether a C-reactive protein (CRP) concentration of ≥30 mg/L can predict (1) ILI disease duration, and (2) which patients are most likely to benefit from oseltamivir treatment. DESIGN Secondary analysis of randomized controlled trial data. SETTING Primary care in Lithuania, Sweden and Norway during three consecutive influenza seasons 2016-2018. SUBJECTS A total of 277 ILI patients aged one year or older and symptom duration of ≤72 h. MAIN OUTCOME MEASURES Capillary blood CRP concentration at baseline, and ILI recovery time defined as having 'returned to usual daily activity' with residual symptoms minimally interfering. RESULTS At baseline, 20% (55/277) had CRP concentrations ≥30mg/L (range 0-210). CRP concentration ≥30 mg/L was not associated with recovery time (adjusted hazards ratio (HR) 0.80: 95% CI 0.50-1.3; p = 0.33). Interaction analysis of CRP concentration ≥30 mg/L and oseltamivir treatment did not identify which patients benefit more from oseltamivir treatment (adjusted HR 0.69: 95% CI 0.37-1.3; p = 0.23). CONCLUSION There was no association between CRP concentration of ≥30 mg/L and recovery time from ILI. Furthermore, CRP could not predict which ILI patients benefit more from oseltamivir treatment. Hence, we do not recommend CRP testing for predicting ILI recovery time or identifying patients who will receive particular benefit from oseltamivir treatment.Key PointsPredicting disease course of influenza-like illness (ILI), and identifying which patients benefit from oseltamivir treatment is a challenge for physicians.• There was no association between CRP concentration at baseline and recovery time in patients consulting with ILI in primary care.• There was no association between CRP concentration at baseline and benefit from oseltamivir treatment.• We, therefore, do not recommend CRP testing for predicting recovery time or in decision-making concerning oseltamivir prescribing in ILI patients.
Collapse
Affiliation(s)
- Nicolay Jonassen Harbin
- Antibiotic Center for Primary Care, Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
- CONTACT Nicolay Jonassen Harbin Antibiotikasenteret for primaermedisin, Postboks 1130 Blindern, Oslo, 0317, Norway
| | - Karin Rystedt
- Research, Education, Development and Innovation, Primary Health Care, Region Västra Götaland, Sweden
- General Practice/Family Medicine, School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Centre for Antibiotic Resistance Research (CARe) at University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Närhälsan Stenstorp vårdcentral, Stenstorp, Sweden
| | - Morten Lindbaek
- Antibiotic Center for Primary Care, Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
| | | | - Johan Westin
- Department of Infectious Diseases, Institute of Biomedicine, University of Gothenburg, Gothenburg, Sweden
| | - Ronny Gunnarsson
- Research, Education, Development and Innovation, Primary Health Care, Region Västra Götaland, Sweden
- General Practice/Family Medicine, School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Centre for Antibiotic Resistance Research (CARe) at University of Gothenburg, Gothenburg, Sweden
| | - Christopher C. Butler
- Department of Primary Care Health Services, University of Oxford, Radcliffe Observatory Quarter, Oxford, UK
| | - Alike W. van der Velden
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Theo J. Verheij
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Pär-Daniel Sundvall
- Research, Education, Development and Innovation, Primary Health Care, Region Västra Götaland, Sweden
- General Practice/Family Medicine, School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Centre for Antibiotic Resistance Research (CARe) at University of Gothenburg, Gothenburg, Sweden
| |
Collapse
|
40
|
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] [What about the content of this article? (0)] [Affiliation(s)] [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.
Collapse
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
| |
Collapse
|
41
|
Borek AJ, Campbell A, Dent E, Moore M, Butler CC, Holmes A, Walker AS, McLeod M, Tonkin-Crine S. Development of an intervention to support the implementation of evidence-based strategies for optimising antibiotic prescribing in general practice. Implement Sci Commun 2021; 2:104. [PMID: 34526140 PMCID: PMC8441243 DOI: 10.1186/s43058-021-00209-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 08/30/2021] [Indexed: 11/21/2022] Open
Abstract
Background Trials show that antimicrobial stewardship (AMS) strategies, including communication skills training, point-of-care C-reactive protein testing (POC-CRPT) and delayed prescriptions, help optimise antibiotic prescribing and use in primary care. However, the use of these strategies in general practice is limited and inconsistent. We aimed to develop an intervention to enhance uptake and implementation of these strategies in primary care. Methods We drew on the Person-Based Approach to develop an implementation intervention in two stages. (1) Planning and design: We defined the problem in behavioural terms drawing on existing literature and conducting primary qualitative research (nine focus groups) in high-prescribing general practices. We identified ‘guiding principles’ with intervention objectives and key features and developed logic models representing intended mechanisms of action. (2) Developing the intervention: We created prototype intervention materials and discussed and refined these with input from 13 health professionals and 14 citizens in two sets of design workshops. We further refined the intervention materials following think-aloud interviews with 22 health professionals. Results Focus groups highlighted uncertainties about how strategies could be used. Health professionals in the workshops suggested having practice champions, brief summaries of each AMS strategy and evidence supporting the AMS strategies, and they and citizens gave examples of helpful communication strategies/phrases. Think-aloud interviews helped clarify and shorten the text and user journey of the intervention materials. The intervention comprised components to support practice-level implementation: antibiotic champions, practice meetings with slides provided, and an ‘implementation support’ website section, and components to support individual-level uptake: website sections on each AMS strategy (with evidence, instructions, links to electronic resources) and material resources (patient leaflets, POC-CRPT equipment, clinician handouts). Conclusions We used a systematic, user-focussed process of developing a behavioural intervention, illustrating how it can be used in an implementation context. This resulted in a multicomponent intervention to facilitate practice-wide implementation of evidence-based strategies which now requires implementing and evaluating. Focusing on supporting the uptake and implementation of evidence-based strategies to optimise antibiotic use in general practice is critical to further support appropriate antibiotic use and mitigate antimicrobial resistance. Supplementary Information The online version contains supplementary material available at 10.1186/s43058-021-00209-7.
Collapse
Affiliation(s)
- Aleksandra J Borek
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK.
| | - Anne Campbell
- National Institute for Health Research (NIHR) Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK
| | - Elle Dent
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
| | - Michael Moore
- Primary Care Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Christopher C Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
| | - Alison Holmes
- National Institute for Health Research (NIHR) Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK
| | - A Sarah Walker
- NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford, UK.,NIHR Oxford Biomedical Research Centre, Oxford, UK.,Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Monsey McLeod
- National Institute for Health Research (NIHR) Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK.,Centre for Medication Safety and Service Quality, Pharmacy Department, Imperial College Healthcare NHS Trust, London, UK.,NIHR Imperial Patient Safety Translational Research Centre, Imperial College London, London, UK
| | - Sarah Tonkin-Crine
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
| | | |
Collapse
|
42
|
Wanat M, Hoste M, Gobat N, Anastasaki M, Böhmer F, Chlabicz S, Colliers A, Farrell K, Karkana MN, Kinsman J, Lionis C, Marcinowicz L, Reinhardt K, Skoglund I, Sundvall PD, Vellinga A, Goossens H, Butler CC, van der Velden A, Anthierens S, Tonkin-Crine S. Supporting Primary Care Professionals to Stay in Work During the COVID-19 Pandemic: Views on Personal Risk and Access to Testing During the First Wave of Pandemic in Europe. Front Med (Lausanne) 2021; 8:726319. [PMID: 34568383 PMCID: PMC8461232 DOI: 10.3389/fmed.2021.726319] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 08/12/2021] [Indexed: 12/23/2022] Open
Abstract
Background: Minimising primary care professionals' (PCPs) risk of SARS-CoV-2 infection is crucial to ensure their safety as well as functioning health care system. PCPs' perspectives on the support they needed in the early stages of a public health crisis can inform future preparedness. Aim: To understand PCPs' experiences of providing care during the COVID-19 pandemic, with focus on personal risk from COVID-19 and testing. Design and Setting: Qualitative study using semi-structured interviews with PCPs in England, Belgium, the Netherlands, Ireland, Germany, Poland, Greece and Sweden, between April and July 2020. Method: Interviews were analysed using a combination of inductive and deductive thematic analysis techniques. Results: Eighty interviews were conducted, showing that PCPs tried to make sense of their risk of both contracting and severity of COVID-19 by assessing individual risk factors and perceived effectiveness of Personal Protective Equipment (PPE). They had limited access to PPE yet continued providing care as their "duty." Some PCPs felt that they were put in high-risk situations when patients or colleagues were not flagging symptoms of COVID-19. Not having access to testing in the initial stages of the pandemic was somewhat accepted but when available, was valued. Conclusion: Access to adequate PPE and testing, as well as training for staff and education for patients about the importance of ensuring staff safety is crucial. Given PCPs' varied response in how they appraised personal risk and their tolerance for working, PCPs may benefit from the autonomy in deciding how they want to work during health emergencies.
Collapse
Affiliation(s)
- Marta Wanat
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Melanie Hoste
- 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
| | - Nina Gobat
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Marilena Anastasaki
- Clinic of Social and Family Medicine, Faculty of Medicine, University of Crete, Crete, Greece
| | - Femke Böhmer
- Institute of General Practice, Rostock University Medical Centre, Rostock, Germany
| | - Slawomir Chlabicz
- Department of Family Medicine, Medical University of Bialystok, Bialystok, Poland
| | - Annelies Colliers
- Department of Family Medicine and Population Health, University of Antwerp, Antwerp, Belgium
| | - Karen Farrell
- School of Medicine, National University of Ireland, Galway, Ireland
| | - Maria-Nefeli Karkana
- Clinic of Social and Family Medicine, Faculty of Medicine, University of Crete, Crete, Greece
| | - John Kinsman
- European Centre for Disease Prevention and Control (ECDC), Solna, Sweden
| | - Christos Lionis
- Clinic of Social and Family Medicine, Faculty of Medicine, University of Crete, Crete, Greece
| | - Ludmila Marcinowicz
- Department of Obstetrics, Gynaecology and Maternity Care, Medical University of Bialystok, Bialystok, Poland
| | - Katrin Reinhardt
- Institute of General Practice, Rostock University Medical Centre, Rostock, Germany
| | - Ingmarie Skoglund
- General Practice/Family Medicine, School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Research, Education, Development & Innovation, Primary Health Care, Gothenburg, Sweden
| | - Pär-Daniel Sundvall
- General Practice/Family Medicine, School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Research, Education, Development & Innovation, Primary Health Care, Gothenburg, Sweden
| | - Akke Vellinga
- School of Medicine, National University of Ireland, Galway, Ireland
- Health Research Board (HRB) Primary Care Clinical Trials Network, Galway, Ireland
| | - Herman Goossens
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute, University of Antwerp, Antwerp, Belgium
- Laboratory of Clinical Microbiology, Antwerp University Hospital, Edegem, Belgium
| | - Christopher C. Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
- National Institute for Health Research (NIHR) Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford in Partnership With Public Health England, Oxford, United Kingdom
| | - Alike van der Velden
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands
| | - Sibyl Anthierens
- Department of Family Medicine and Population Health, University of Antwerp, Antwerp, Belgium
| | - Sarah Tonkin-Crine
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
- National Institute for Health Research (NIHR) Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford in Partnership With Public Health England, Oxford, United Kingdom
| |
Collapse
|
43
|
Yu LM, Bafadhel M, Dorward J, Hayward G, Saville BR, Gbinigie O, Van Hecke O, Ogburn E, Evans PH, Thomas NPB, Patel MG, Richards D, Berry N, Detry MA, Saunders C, Fitzgerald M, Harris V, Shanyinde M, de Lusignan S, Andersson MI, Barnes PJ, Russell REK, Nicolau DV, Ramakrishnan S, Hobbs FDR, Butler CC. Inhaled budesonide for COVID-19 in people at high risk of complications in the community in the UK (PRINCIPLE): a randomised, controlled, open-label, adaptive platform trial. Lancet 2021; 398:843-855. [PMID: 34388395 PMCID: PMC8354567 DOI: 10.1016/s0140-6736(21)01744-x] [Citation(s) in RCA: 165] [Impact Index Per Article: 55.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 07/13/2021] [Accepted: 07/20/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND A previous efficacy trial found benefit from inhaled budesonide for COVID-19 in patients not admitted to hospital, but effectiveness in high-risk individuals is unknown. We aimed to establish whether inhaled budesonide reduces time to recovery and COVID-19-related hospital admissions or deaths among people at high risk of complications in the community. METHODS PRINCIPLE is a multicentre, open-label, multi-arm, randomised, controlled, adaptive platform trial done remotely from a central trial site and at primary care centres in the UK. Eligible participants were aged 65 years or older or 50 years or older with comorbidities, and unwell for up to 14 days with suspected COVID-19 but not admitted to hospital. Participants were randomly assigned to usual care, usual care plus inhaled budesonide (800 μg twice daily for 14 days), or usual care plus other interventions, and followed up for 28 days. Participants were aware of group assignment. The coprimary endpoints are time to first self-reported recovery and hospital admission or death related to COVID-19, within 28 days, analysed using Bayesian models. The primary analysis population included all eligible SARS-CoV-2-positive participants randomly assigned to budesonide, usual care, and other interventions, from the start of the platform trial until the budesonide group was closed. This trial is registered at the ISRCTN registry (ISRCTN86534580) and is ongoing. FINDINGS The trial began enrolment on April 2, 2020, with randomisation to budesonide from Nov 27, 2020, until March 31, 2021, when the prespecified time to recovery superiority criterion was met. 4700 participants were randomly assigned to budesonide (n=1073), usual care alone (n=1988), or other treatments (n=1639). The primary analysis model includes 2530 SARS-CoV-2-positive participants, with 787 in the budesonide group, 1069 in the usual care group, and 974 receiving other treatments. There was a benefit in time to first self-reported recovery of an estimated 2·94 days (95% Bayesian credible interval [BCI] 1·19 to 5·12) in the budesonide group versus the usual care group (11·8 days [95% BCI 10·0 to 14·1] vs 14·7 days [12·3 to 18·0]; hazard ratio 1·21 [95% BCI 1·08 to 1·36]), with a probability of superiority greater than 0·999, meeting the prespecified superiority threshold of 0·99. For the hospital admission or death outcome, the estimated rate was 6·8% (95% BCI 4·1 to 10·2) in the budesonide group versus 8·8% (5·5 to 12·7) in the usual care group (estimated absolute difference 2·0% [95% BCI -0·2 to 4·5]; odds ratio 0·75 [95% BCI 0·55 to 1·03]), with a probability of superiority 0·963, below the prespecified superiority threshold of 0·975. Two participants in the budesonide group and four in the usual care group had serious adverse events (hospital admissions unrelated to COVID-19). INTERPRETATION Inhaled budesonide improves time to recovery, with a chance of also reducing hospital admissions or deaths (although our results did not meet the superiority threshold), in people with COVID-19 in the community who are at higher risk of complications. FUNDING National Institute of Health Research and United Kingdom Research Innovation.
Collapse
Affiliation(s)
- Ly-Mee Yu
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Mona Bafadhel
- Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Jienchi Dorward
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK; Centre for the AIDS Programme of Research in South Africa, University of KwaZulu-Natal, Durban, South Africa
| | - Gail Hayward
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Benjamin R Saville
- Berry Consultants, Austin, TX, USA; Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Oghenekome Gbinigie
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Oliver Van Hecke
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Emma Ogburn
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Philip H Evans
- College of Medicine and Health, University of Exeter, Exeter, UK; National Institute for Health Research Clinical Research Network, National Institute for Health Research, London, UK
| | - Nicholas P B Thomas
- National Institute for Health Research Clinical Research Network, National Institute for Health Research, London, UK; Royal College of General Practitioners, London, UK
| | - Mahendra G Patel
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Duncan Richards
- Oxford Clinical Trials Research Unit, Botnar Research Centre, University of Oxford, Oxford, UK
| | | | | | | | | | - Victoria Harris
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Milensu Shanyinde
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Simon de Lusignan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | - Peter J Barnes
- National Heart and Lung Institute, Imperial College, London, UK
| | | | - Dan V Nicolau
- Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK; UQ Centre for Clinical Research, University of Queensland, Brisbane, QLD, Australia
| | - Sanjay Ramakrishnan
- National Institute for Health Research Oxford Biomedical Research Centre, Oxford, UK
| | - F D Richard Hobbs
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK.
| | - Christopher C Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK.
| |
Collapse
|
44
|
Morrell L, Buchanan J, Roope LSJ, Pouwels KB, Butler CC, Hayhoe B, Tonkin-Crine S, McLeod M, Robotham JV, Holmes A, Walker AS, Wordsworth S. Public preferences for delayed or immediate antibiotic prescriptions in UK primary care: A choice experiment. PLoS Med 2021; 18:e1003737. [PMID: 34460825 PMCID: PMC8439451 DOI: 10.1371/journal.pmed.1003737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Revised: 09/14/2021] [Accepted: 07/15/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Delayed (or "backup") antibiotic prescription, where the patient is given a prescription but advised to delay initiating antibiotics, has been shown to be effective in reducing antibiotic use in primary care. However, this strategy is not widely used in the United Kingdom. This study aimed to identify factors influencing preferences among the UK public for delayed prescription, and understand their relative importance, to help increase appropriate use of this prescribing option. METHODS AND FINDINGS We conducted an online choice experiment in 2 UK general population samples: adults and parents of children under 18 years. Respondents were presented with 12 scenarios in which they, or their child, might need antibiotics for a respiratory tract infection (RTI) and asked to choose either an immediate or a delayed prescription. Scenarios were described by 7 attributes. Data were collected between November 2018 and February 2019. Respondent preferences were modelled using mixed-effects logistic regression. The survey was completed by 802 adults and 801 parents (75% of those who opened the survey). The samples reflected the UK population in age, sex, ethnicity, and country of residence. The most important determinant of respondent choice was symptom severity, especially for cough-related symptoms. In the adult sample, the probability of choosing delayed prescription was 0.53 (95% confidence interval (CI) 0.50 to 0.56, p < 0.001) for a chesty cough and runny nose compared to 0.30 (0.28 to 0.33, p < 0.001) for a chesty cough with fever, 0.47 (0.44 to 0.50, p < 0.001) for sore throat with swollen glands, and 0.37 (0.34 to 0.39, p < 0.001) for sore throat, swollen glands, and fever. Respondents were less likely to choose delayed prescription with increasing duration of illness (odds ratio (OR) 0.94 (0.92 to 0.96, p < 0.001)). Probabilities of choosing delayed prescription were similar for parents considering treatment for a child (44% of choices versus 42% for adults, p = 0.04). However, parents differed from the adult sample in showing a more marked reduction in choice of the delayed prescription with increasing duration of illness (OR 0.83 (0.80 to 0.87) versus 0.94 (0.92 to 0.96) for adults, p for heterogeneity p < 0.001) and a smaller effect of disruption of usual activities (OR 0.96 (0.95 to 0.97) versus 0.93 (0.92 to 0.94) for adults, p for heterogeneity p < 0.001). Females were more likely to choose a delayed prescription than males for minor symptoms, particularly minor cough (probability 0.62 (0.58 to 0.66, p < 0.001) for females and 0.45 (0.41 to 0.48, p < 0.001) for males). Older people, those with a good understanding of antibiotics, and those who had not used antibiotics recently showed similar patterns of preferences. Study limitations include its hypothetical nature, which may not reflect real-life behaviour; the absence of a "no prescription" option; and the possibility that study respondents may not represent the views of population groups who are typically underrepresented in online surveys. CONCLUSIONS This study found that delayed prescription appears to be an acceptable approach to reducing antibiotic consumption. Certain groups appear to be more amenable to delayed prescription, suggesting particular opportunities for increased use of this strategy. Prescribing choices for sore throat may need additional explanation to ensure patient acceptance, and parents in particular may benefit from reassurance about the usual duration of these illnesses.
Collapse
Affiliation(s)
- Liz Morrell
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
- * E-mail:
| | - James Buchanan
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
- NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford, United Kingdom
- NIHR Biomedical Research Centre Oxford, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom
| | - Laurence S. J. Roope
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
- NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford, United Kingdom
- NIHR Biomedical Research Centre Oxford, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom
| | - Koen B. Pouwels
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
- NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford, United Kingdom
| | - Christopher C. Butler
- NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford, United Kingdom
- Nuffield Department of Primary Care Sciences, University of Oxford, Oxford, United Kingdom
| | - Benedict Hayhoe
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, United Kingdom
| | - Sarah Tonkin-Crine
- NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford, United Kingdom
- Nuffield Department of Primary Care Sciences, University of Oxford, Oxford, United Kingdom
| | - Monsey McLeod
- NIHR Health Protection Research Unit in Healthcare-Associated Infections and Antimicrobial Resistance, Imperial College London, London, United Kingdom
- Centre for Medication Safety and Service Quality, Pharmacy Department, Imperial College Healthcare NHS Trust, London, United Kingdom
- NIHR Imperial Patient Safety Translational Research Centre, Imperial College London, London, United Kingdom
| | - Julie V. Robotham
- Modelling and Economics Unit, National Infection Service, Public Health England, London, United Kingdom
| | - Alison Holmes
- NIHR Health Protection Research Unit in Healthcare-Associated Infections and Antimicrobial Resistance, Imperial College London, London, United Kingdom
| | - A. Sarah Walker
- NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford, United Kingdom
- NIHR Biomedical Research Centre Oxford, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom
- Nuffield Department of Medicine, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom
| | - Sarah Wordsworth
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
- NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford, United Kingdom
- NIHR Biomedical Research Centre Oxford, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom
| | | |
Collapse
|
45
|
van der Velden AW, Bax EA, Bongard E, Munck Aabenhus R, Anastasaki M, Anthierens S, Balan A, Böhmer F, Bruno P, Chlabicz S, Coenen S, Colliers A, Emmerich S, Garcia-Sangenis A, Ghazaryan H, van der Linde SR, Malania L, Pauer J, Tomacinschii A, Tonkin-Crine S, Vellinga A, Zastavnyy I, Verheij T, Goossens H, Butler CC. Primary care for patients with respiratory tract infection before and early on in the COVID-19 pandemic: an observational study in 16 European countries. BMJ Open 2021; 11:e049257. [PMID: 34326052 PMCID: PMC8326026 DOI: 10.1136/bmjopen-2021-049257] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 07/07/2021] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE To describe primary health care (consultation characteristics and management) for patients contacting their general practitioner (GP) with a respiratory tract infection (RTI) early on in the COVID-19 pandemic in contrasting European countries, with comparison to prepandemic findings. SETTING Primary care in 16 countries (79 practices), when no routine SARS-CoV-2 testing was generally available. DESIGN AND PARTICIPANTS Before (n=4376) and early in the pandemic (n=3301), patients with RTI symptoms were registered in this prospective audit study. OUTCOME MEASURES Consultation characteristics (type of contact and use of PPE) and management characteristics (clinical assessments, diagnostic testing, prescribing, advice and referral) were registered. Differences in these characteristics between countries and between pandemic and prepandemic care are described. RESULTS Care for patients with RTIs rapidly switched to telephone/video consultations (10% in Armenia, 91% in Denmark), and when consultations were face-to-face, GPs used PPE during 97% (95% CI 96% to 98%) of contacts. Laboratory testing for SARS-CoV-2 in primary care patients with RTIs was rapidly implemented in Denmark (59%) and Germany (31%), while overall testing for C reactive protein decreased. The proportion of patients prescribed antibiotics varied considerably between countries (3% in Belgium, 48% in UK) and was lower during the pandemic compared with the months before, except for Greece, Poland and UK. GPs provided frequent and varied COVID-related advice and more frequently scheduled a follow-up contact (50%, 95% CI 48% to 52%). GPs reported a slightly higher degree of confidence in the likely effectiveness of their management in face-to-face (73% (very) confident, 95% CI 71% to 76%) than in virtual consultations (69%, 95% CI 67% to 71%). CONCLUSIONS Despite between-country variation in consultation characteristics, access to SARS-CoV-2 laboratory testing and medication prescribing, GPs reported a high degree of confidence in managing their patients with RTIs in the emerging pandemic. Insight in the highly variable pandemic responses, as measured in this multicountry audit, can aid in fine-tuning national action and in coordinating a pan-European response during future pandemic threats.
Collapse
Affiliation(s)
- Alike W van der Velden
- Julius Center for Health Sciences and Primary Care, UMC Utrecht, Utrecht, The Netherlands
| | - Eva A Bax
- Julius Center for Health Sciences and Primary Care, UMC Utrecht, Utrecht, The Netherlands
| | - Emily Bongard
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | - Marilena Anastasaki
- Clinic of Social and Family Medicine, University of Crete, Heraklion, Greece
| | - Sibyl Anthierens
- Family Medicine and Population Health, Universiteit Antwerpen, Antwerpen, Belgium
| | | | - Femke Böhmer
- Institute of General Practice, Rostock University Medical Center, Rostock, Germany
| | - Pascale Bruno
- Département de Santé Publique, Centre Hospitalier Universitaire de Nice, Nice, France
| | - Slawomir Chlabicz
- Department of Family Medicine Medical, University of Bialystok, Bialystok, Poland
| | - Samuel Coenen
- Family Medicine and Population Health, Universiteit Antwerpen, Antwerpen, Belgium
| | - Annelies Colliers
- Family Medicine and Population Health, Universiteit Antwerpen, Antwerpen, Belgium
| | | | - Ana Garcia-Sangenis
- Medicines Research Unit, Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain
| | - Hrachuhi Ghazaryan
- General Pediatrics, Wigmore Clinic Medical Center Yerevan, Yerevan, Armenia
| | - Sanne R van der Linde
- Julius Center for Health Sciences and Primary Care, UMC Utrecht, Utrecht, The Netherlands
| | - Lile Malania
- National Center for Disease Control and Public Health, Tbilisi, Georgia
| | | | - Angela Tomacinschii
- University Clinic of Primary Medical Assistance, State University of Medicine 'N. Testemițanu', Chişinǎu, the Republic of Moldova
| | - Sarah Tonkin-Crine
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | - Ihor Zastavnyy
- NGO Academy of Family Medicine of Ukraine, Lviv, Ukraine
| | - Theo Verheij
- Julius Center for Health Sciences and Primary Care, UMC Utrecht, Utrecht, The Netherlands
| | - Herman Goossens
- Medical Microbiology, Vaccine and Infectious Diseases Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium
| | - Christopher C Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| |
Collapse
|
46
|
Bruyndonckx R, Stuart B, Little P, Hens N, Ieven M, Butler CC, Verheij TJM, Goossens H, Coenen S. The Effect of Amoxicillin in Adult Patients Presenting to Primary Care with Acute Cough Predicted to Have Pneumonia or a Combined Viral-Bacterial Infection. Antibiotics (Basel) 2021; 10:antibiotics10070817. [PMID: 34356738 PMCID: PMC8300796 DOI: 10.3390/antibiotics10070817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 06/18/2021] [Accepted: 07/02/2021] [Indexed: 11/16/2022] Open
Abstract
While most cases of acute cough are self-limiting, antibiotics are prescribed to over 50%. This proportion is inappropriately high given that benefit from treatment with amoxicillin could only be demonstrated in adults with pneumonia (based on chest radiograph) or combined viral-bacterial infection (based on modern microbiological methodology). As routine use of chest radiographs and microbiological testing is costly, clinical prediction rules could be used to identify these patient subsets. In this secondary analysis of data from a multicentre randomised controlled trial in adults presenting to primary care with acute cough, we used prediction rules for pneumonia or combined infection and assessed the effect of amoxicillin in patients predicted to have pneumonia or combined infection on symptom duration, symptom severity and illness deterioration. In total, 2056 patients that fulfilled all inclusion criteria were randomised, 1035 to amoxicillin, 1021 to placebo. Neither patients with a predicted pneumonia nor patients with a predicted combined infection were significantly more likely to benefit from amoxicillin. While the studied clinical prediction rules may help primary care clinicians to reduce antibiotic prescribing for low-risk patients, they did not identify adult acute cough patients that would benefit from amoxicillin treatment.
Collapse
Affiliation(s)
- Robin Bruyndonckx
- Interuniversity Institute for Biostatistics and Statistical Bioinformatics (I-BIOSTAT), Data Science Institute (DSI), Hasselt University, 3500 Hasselt, Belgium;
- Laboratory of Medical Microbiology, Vaccine & Infectious Diseases Institute (VAXINFECTIO), University of Antwerp, 2610 Antwerp, Belgium; (M.I.); (H.G.); (S.C.)
- Correspondence: ; Tel.: +32-11-268-631
| | - Beth Stuart
- Aldermoor Health Centre, University of Southampton, Southampton SO16 5ST, UK; (B.S.); (P.L.)
| | - Paul Little
- Aldermoor Health Centre, University of Southampton, Southampton SO16 5ST, UK; (B.S.); (P.L.)
| | - Niel Hens
- Interuniversity Institute for Biostatistics and Statistical Bioinformatics (I-BIOSTAT), Data Science Institute (DSI), Hasselt University, 3500 Hasselt, Belgium;
- Centre for Health Economic Research and Modelling Infectious Diseases (CHERMID), Vaccine & Infectious Disease Institute, University of Antwerp, 2610 Antwerp, Belgium
| | - Margareta Ieven
- Laboratory of Medical Microbiology, Vaccine & Infectious Diseases Institute (VAXINFECTIO), University of Antwerp, 2610 Antwerp, Belgium; (M.I.); (H.G.); (S.C.)
| | - Christopher C. Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK;
| | - Theo J. M. Verheij
- Julius Centre for Health, Sciences and Primary Care, University Medical Centre Utrecht, 3508 GA Utrecht, The Netherlands;
| | - Herman Goossens
- Laboratory of Medical Microbiology, Vaccine & Infectious Diseases Institute (VAXINFECTIO), University of Antwerp, 2610 Antwerp, Belgium; (M.I.); (H.G.); (S.C.)
| | - Samuel Coenen
- Laboratory of Medical Microbiology, Vaccine & Infectious Diseases Institute (VAXINFECTIO), University of Antwerp, 2610 Antwerp, Belgium; (M.I.); (H.G.); (S.C.)
- Centre for General Practice, Department of Family Medicine & Population Health (FAMPOP), University of Antwerp, 2610 Antwerp, Belgium
| | | |
Collapse
|
47
|
Buchanan J, Roope LSJ, Morrell L, Pouwels KB, Robotham JV, Abel L, Crook DW, Peto T, Butler CC, Walker AS, Wordsworth S. Preferences for Medical Consultations from Online Providers: Evidence from a Discrete Choice Experiment in the United Kingdom. Appl Health Econ Health Policy 2021; 19:521-535. [PMID: 33682065 PMCID: PMC7937442 DOI: 10.1007/s40258-021-00642-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 01/23/2021] [Indexed: 06/12/2023]
Abstract
BACKGROUND In the UK, consultations for prescription medicines are available via private providers such as online pharmacies. However, these providers may have lower thresholds for prescribing certain drugs. This is a particular concern for antibiotics, given the increasing burden of antimicrobial resistance. Public preferences for consultations with online providers are unknown, hence the impact of increased availability of online consultations on antibiotic use and population health is unclear. OBJECTIVE To conduct a discrete choice experiment survey to understand UK public preferences for seeking online consultations, and the factors that influence these preferences, in the context of having symptoms for which antibiotics may be appropriate. METHODS In a survey conducted between July and August 2018, general population respondents completed 16 questions in which they chose a primary care consultation via either their local medical centre or an online provider. Consultations were described in terms of five attributes, including cost and similarity to traditional 'face-to-face' appointments. Choices were modelled using regression analysis. RESULTS Respondents (n = 734) placed a high value on having a consultation via their local medical centre rather than an online provider, and a low value on consultations by phone or video. However, respondents characterised as 'busy young professionals' showed a lower strength of preference for traditional consultations, with a higher concern for convenience. CONCLUSION Before COVID-19, the UK public had limited appetite for consultations with online providers, or for consultations that were not face-to-face. Nevertheless, prescriptions from online providers should be monitored going forward, particularly for antibiotics, and in key patient groups.
Collapse
Affiliation(s)
- James Buchanan
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Headington, Oxford, OX3 9NS, UK.
- National Institute for Health Research Health Research Protection Unit in Healthcare Associated Infections and Antimicrobial Resistance, Oxford, OX3 9DU, UK.
| | - Laurence S J Roope
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Headington, Oxford, OX3 9NS, UK
- National Institute for Health Research Health Research Protection Unit in Healthcare Associated Infections and Antimicrobial Resistance, Oxford, OX3 9DU, UK
- National Institute for Health Research Biomedical Research Centre, John Radcliffe Hospital, Headley Way, Headington, Oxford, OX3 9DU, UK
| | - Liz Morrell
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Headington, Oxford, OX3 9NS, UK
| | - Koen B Pouwels
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Headington, Oxford, OX3 9NS, UK
- National Institute for Health Research Health Research Protection Unit in Healthcare Associated Infections and Antimicrobial Resistance, Oxford, OX3 9DU, UK
- Modelling and Economics Unit, National Infection Service, Public Health England, Wellington House, 133-155 Waterloo Road, London, SE1 8UG, UK
| | - Julie V Robotham
- National Institute for Health Research Health Research Protection Unit in Healthcare Associated Infections and Antimicrobial Resistance, Oxford, OX3 9DU, UK
- Modelling and Economics Unit, National Infection Service, Public Health England, Wellington House, 133-155 Waterloo Road, London, SE1 8UG, UK
| | - Lucy Abel
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
| | - Derrick W Crook
- National Institute for Health Research Health Research Protection Unit in Healthcare Associated Infections and Antimicrobial Resistance, Oxford, OX3 9DU, UK
- National Institute for Health Research Biomedical Research Centre, John Radcliffe Hospital, Headley Way, Headington, Oxford, OX3 9DU, UK
- Nuffield Department of Medicine, University of Oxford, Old Road Campus, Headington, Oxford, OX3 7BN, UK
| | - Tim Peto
- National Institute for Health Research Health Research Protection Unit in Healthcare Associated Infections and Antimicrobial Resistance, Oxford, OX3 9DU, UK
- National Institute for Health Research Biomedical Research Centre, John Radcliffe Hospital, Headley Way, Headington, Oxford, OX3 9DU, UK
- Nuffield Department of Medicine, University of Oxford, Old Road Campus, Headington, Oxford, OX3 7BN, UK
| | - Christopher C Butler
- National Institute for Health Research Health Research Protection Unit in Healthcare Associated Infections and Antimicrobial Resistance, Oxford, OX3 9DU, UK
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
| | - A Sarah Walker
- National Institute for Health Research Health Research Protection Unit in Healthcare Associated Infections and Antimicrobial Resistance, Oxford, OX3 9DU, UK
- National Institute for Health Research Biomedical Research Centre, John Radcliffe Hospital, Headley Way, Headington, Oxford, OX3 9DU, UK
- Nuffield Department of Medicine, University of Oxford, Old Road Campus, Headington, Oxford, OX3 7BN, UK
| | - Sarah Wordsworth
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Headington, Oxford, OX3 9NS, UK
- National Institute for Health Research Health Research Protection Unit in Healthcare Associated Infections and Antimicrobial Resistance, Oxford, OX3 9DU, UK
- National Institute for Health Research Biomedical Research Centre, John Radcliffe Hospital, Headley Way, Headington, Oxford, OX3 9DU, UK
| |
Collapse
|
48
|
Borek AJ, Anthierens S, Allison R, McNulty CAM, Lecky DM, Costelloe C, Holmes A, Butler CC, Walker AS, Tonkin-Crine S. How did a Quality Premium financial incentive influence antibiotic prescribing in primary care? Views of Clinical Commissioning Group and general practice professionals. J Antimicrob Chemother 2021; 75:2681-2688. [PMID: 32573692 DOI: 10.1093/jac/dkaa224] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 04/24/2020] [Accepted: 04/27/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The Quality Premium (QP) was introduced for Clinical Commissioning Groups (CCGs) in England to optimize antibiotic prescribing, but it remains unclear how it was implemented. OBJECTIVES To understand responses to the QP and how it was perceived to influence antibiotic prescribing. METHODS Semi-structured telephone interviews were conducted with 22 CCG and 19 general practice professionals. Interviews were analysed thematically. RESULTS The findings were organized into four categories. (i) Communication: this was perceived as unstructured and infrequent, and CCG professionals were unsure whether they received QP funding. (ii) Implementation: this was influenced by available local resources and competing priorities, with multifaceted and tailored strategies seen as most helpful for engaging general practices. Many antimicrobial stewardship (AMS) strategies were implemented independently from the QP, motivated by quality improvement. (iii) Mechanisms: the QP raised the priority of AMS nationally and locally, and provided prescribing targets to aim for and benchmark against, but money was not seen as reinvested into AMS. (iv) Impact and sustainability: the QP was perceived as successful, but targets were considered challenging for a minority of CCGs and practices due to contextual factors (e.g. deprivation, understaffing). CCG professionals were concerned with potential discontinuation of the QP and prescribing rates levelling off. CONCLUSIONS CCG and practice professionals expressed positive views of the QP and associated prescribing targets and feedback. The QP helped influence change mainly by raising the priority of AMS and defining change targets rather than providing additional funding. To maximize impact, behavioural mechanisms of financial incentives should be considered pre-implementation.
Collapse
Affiliation(s)
- Aleksandra J Borek
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | - Rosalie Allison
- Primary Care and Interventions Unit, Public Health England, Gloucester, UK
| | | | - Donna M Lecky
- Primary Care and Interventions Unit, Public Health England, Gloucester, UK
| | - Ceire Costelloe
- Faculty of Medicine, School of Public Health, Imperial College London, London, UK
| | - Alison Holmes
- Department of Infectious Diseases, Imperial College London, London, UK.,National Institute for Health Research (NIHR) Health Protection Research Unit (HPRU) in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK
| | - Christopher C Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - A Sarah Walker
- National Institute for Health Research (NIHR) Health Protection Research Unit (HPRU) in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford, UK.,Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Sarah Tonkin-Crine
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK.,National Institute for Health Research (NIHR) Health Protection Research Unit (HPRU) in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford, UK
| |
Collapse
|
49
|
Hayward G, Butler CC, Yu LM, Saville BR, Berry N, Dorward J, Gbinigie O, van Hecke O, Ogburn E, Swayze H, Bongard E, Allen J, Tonner S, Rutter H, Tonkin-Crine S, Borek A, Judge D, Grabey J, de Lusignan S, Thomas NPB, Evans PH, Andersson MI, Llewelyn M, Patel M, Hopkins S, Hobbs FDR. Platform Randomised trial of INterventions against COVID-19 In older peoPLE (PRINCIPLE): protocol for a randomised, controlled, open-label, adaptive platform, trial of community treatment of COVID-19 syndromic illness in people at higher risk. BMJ Open 2021; 11:e046799. [PMID: 34145016 PMCID: PMC8214989 DOI: 10.1136/bmjopen-2020-046799] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 05/14/2021] [Indexed: 01/10/2023] Open
Abstract
INTRODUCTION There is an urgent need to idenfy treatments for COVID-19 that reduce illness duration and hospital admission in those at higher risk of a longer illness course and complications. METHODS AND ANALYSIS The Platform Randomised trial of INterventions against COVID-19 In older peoPLE trial is an open-label, multiarm, prospective, adaptive platform, randomised clinical trial to evaluate potential treatments for COVID-19 in the community. A master protocol governs the addition of new interventions as they become available, as well as the inclusion and cessation of existing intervention arms via frequent interim analyses. The first three interventions are hydroxychloroquine, azithromycin and doxycycline. Eligible participants must be symptomatic in the community with possible or confirmed COVID-19 that started in the preceding 14 days and either (1) aged 65 years and over or (2) aged 50-64 years with comorbidities. Recruitment is through general practice, health service helplines, COVID-19 'hot hubs' and directly through the trial website. Participants are randomised to receive either usual care or a study drug plus usual care, and outcomes are collected via daily online symptom diary for 28 days from randomisation. The research team contacts participants and/or their study partner following days 7, 14 and 28 if the online diary is not completed. The trial has two coprimary endpoints: time to first self-report of feeling recovered from possible COVID-19 and hospital admission or death from possible COVID-19 infection, both within 28 days from randomisation. Prespecified interim analyses assess efficacy or futility of interventions and to modify randomisation probabilities that allocate more participants to interventions with better outcomes. ETHICS AND DISSEMINATION Ethical approval Ref: 20/SC/0158 South Central - Berkshire Research Ethics Committee; IRAS Project ID: 281958; EudraCT Number: 2020-001209-22. Results will be presented to policymakers and at conferences and published in peer-reviewed journals. TRIAL REGISTRATION NUMBER ISRCTN86534580.
Collapse
Affiliation(s)
- Gail Hayward
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Christopher C Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Ly-Mee Yu
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Benjamin R Saville
- Berry Consultants, Austin, Texas, USA
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | | | - Jienchi Dorward
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- Centre for the Aids Programme of Research in South Africa, Durban, South Africa
| | - Oghenekome Gbinigie
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Oliver van Hecke
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Emma Ogburn
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Hannah Swayze
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Emily Bongard
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Julie Allen
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Sharon Tonner
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Heather Rutter
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Sarah Tonkin-Crine
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Aleksandra Borek
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - David Judge
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Jenna Grabey
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Simon de Lusignan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- Department of Clinical and Experimental Medicine, University of Surrey, Guildford, UK
| | - Nicholas P B Thomas
- Windrush Medical Practice, Witney, UK
- Royal College of General Practitioners, London, UK
| | - Philip H Evans
- St Leonard's Research Practice, Exeter, UK
- University of Exeter Medical School, Exeter, UK
| | | | - Martin Llewelyn
- Department of Microbiology and Infection, University Hospitals Sussex NHS Foundation Trust, Brighton, UK
- Department of Global Health and Infection, Brighton and Sussex Medical School, Brighton, UK
| | - Mahendra Patel
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | - F D Richard Hobbs
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| |
Collapse
|
50
|
Moragas A, Garcia-Sangenís A, Prats Escudero A, Bayona Faro C, Hernández Ibáñez R, Brotons C, Vilella T, Puig M, Freixedas Casaponsa R, Cobo Guerrero S, Pera H, van der Velden AW, Butler CC, Llor C. [Prevalence of microbiologically-confirmed influenza in patients with influenza-like illness in primary care and clinical and epidemiological characteristics]. Rev Esp Quimioter 2021; 34:468-475. [PMID: 34118801 PMCID: PMC8638842 DOI: 10.37201/req/032.2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
OBJECTIVE We evaluated the prevalence of microbiologically-confirmed influenza infection among patients with influenza-like symptoms and compared the clinical and epidemiological characteristics of patients with and without influenza infection. METHODS Retrospective study of a cohort of patients with influenza-like symptoms from 2016 to 2018 who participated in a clinical trial in thirteen urban primary centres in Catalonia. Different epidemiological data were collected. Patients rated the different symptoms and signs on a Likert scale (absent, little problem, moderate problem and severe problem) and self-reported the measure of health status with the EuroQol visual analogue scale. A nasopharyngeal swab was taken for microbiological isolation of influenza and other microorganisms. RESULTS A total of 427 patients were included. Microbiologically confirmed influenza was found in 240 patients (56.2%). The percentage of patients with moderate-to-severe cough, muscle aches, tiredness and dizziness was greater among patients with microbiologically confirmed influenza. The self-reported health status was significantly lower among patients with true flu infection (mean of 36.3 ± 18.2 vs 41.7 ± 17.8 in patients without influenza; p<0.001). CONCLUSIONS Clinical findings are not particularly useful for confirming or excluding the diagnosis of influenza when intensity is not considered. However, the presence of moderate-to-severe cough, myalgias, tiredness and dizziness along with a poor health status is more common in patients with confirmed flu infection.
Collapse
Affiliation(s)
- A Moragas
- Ana Moragas. Centro de Salud Jaume I, Tarragona. C. Felip Pedrell, 45-47. 43005 Tarragona, Spain.
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|