HHealth ealth AAlliance for lliance for PPrudent rudent PPrescribing, rescribing, YYield ield

AAndnd UUsese of anti-microbial of anti-microbial DDrugs rugs IIn the n the TTreatment reatment of Respiratory Tract Infectionsof Respiratory Tract Infections

Proposal for EU DG Research, March 2006

Coordinator: Research Unit of General Practice, Odense, Denmark

22

40-65 %

15-20 %

35-40%

40-45%

0-2 %

20-30 % 0-5 %

0-5 %

0-5 %

Prevalence of penicillin resistant pneumococci in Europe

Use of antibiotics in Europa 2002Use of antibiotics in Europa 2002DDD/1000 persons/dayDDD/1000 persons/day

Gossens et al: Outpatient antibiotic use in Europe and association with resistance: a cross-national database study. The Lancet 2005

From: Emerging Infectious Diseases 2004;19(3):514

Penicillin-resistance in pneumococci

Linear correlation between use of antibiotics and

resistance

Resistant StrainsRare

xx

Resistant Strains Dominant

Antimicrobial Exposure

xxxx

xx

xx

xx

Selection for Antibiotic ResistanceSelection for Antibiotic Resistance

HAPPY AUDITHAPPY AUDITObjectiveObjective

to reduce the occurrence of to reduce the occurrence of bacterial resistancebacterial resistance by reducing prescribing by reducing prescribing

of unnecessary of unnecessary antibiotics for respiratory antibiotics for respiratory tract infections tract infections

by improving the use of by improving the use of appropriate antibiotics in appropriate antibiotics in suspected bacterial suspected bacterial infectionsinfections

by improving the quality by improving the quality of diagnostic procedures of diagnostic procedures for RTIs in general for RTIs in general practicepractice

102

77

309

39

31

60

- Nordic region- Denmark 102 GPs- Sweden 77 GPs

- Balticum region- Lithuania 31 GPs- Kaliningrad 39 GPs

- Region Hispano-America: - Spain 309 GPs- Argentina 60GPs

- TOTAL 618 GPs

Kick-off meeting April 2007Kick-off meeting April 2007

Project time scheduleProject time schedule

Total project period: 3 years (April 2007 – March 2010)

2007 2008 2009 2010

Analysis and conference

Second registration of Patients

First registration of Patients

X

Intervention: GPs and patients

First invitation of GPs

X

Kaliningrad

Sweden

Lithuania

Spain

Denmark

Argentina

Intervention material for Intervention material for professionalsprofessionals

Report with aggregated and individual Report with aggregated and individual resultsresults

Happy Audit GuidelinesHappy Audit Guidelines Laboratory test instructionsLaboratory test instructions

Respiratory infections in

general practice

Results from 6 countries

Reports in national language including individual results were sent to all paticipating GPs

My Practice

My Practice My Practice

Centor criteria*:Centor criteria*:

1.1. FeverFever2.2. Tender angular glands Tender angular glands 3.3. Tonsil Coatings Tonsil Coatings 4.4. Absence of cough Absence of cough

*Described by dr. Robert Centor *Described by dr. Robert Centor of the University of Alabamaof the University of Alabama

Centor criteria and probability of Centor criteria and probability of StreptococciStreptococci

Number of Centor Criteria

Probability of Streptococci

Recommandation

0 2% No test – no treatment

1 3% No test – no treatment

2 8% Test and treat

3 19% Test and treat

4 41% Test and treat

Patients with 0-1 Centor criteria should not be tested with Strep A

Use of Strep A in patients with Use of Strep A in patients with odinophagia (painful swallowing)odinophagia (painful swallowing)

Patients StrepA performed

Percentage with Strep A

Argentina 1500 33 2.2%

Denmark 1061 822 77.5%

Lithuania 803 0 0.0%

Russia 764 4 0.5%

Spain 7052 96 1.4%

Sweden 501 319 63.7%

Total 11681 1274 10.9%

Strep A test in DenmarkStrep A test in Denmark

Strep A test in SwedenStrep A test in Sweden

Carriers of StreptococciCarriers of Streptococci 5-10% of individuals are asymptomatic 5-10% of individuals are asymptomatic

carriers of streptococcicarriers of streptococci A Strep A test will show that carriers have A Strep A test will show that carriers have

streptococci streptococci even though they are not even though they are not causing symptomscausing symptoms. .

Generally, carriers should not be treated Generally, carriers should not be treated with antibioticswith antibiotics

Overuse of Strep A may lead to Overuse of Strep A may lead to inappropriate antibiotic inappropriate antibiotic

treatmentstreatments

Generally, Strep A should not be Generally, Strep A should not be performed in:performed in:

Asymptomatic carriers of StreptococciAsymptomatic carriers of Streptococci Patients with sore throat and less than 2 Patients with sore throat and less than 2

Centor criteriaCentor criteria

ConclusionConclusion

Denmark, Sweden:Denmark, Sweden: Overuse of Strep may lead to inappropriate Overuse of Strep may lead to inappropriate

antibiotic treatment and initiatives should be antibiotic treatment and initiatives should be taken to reduce overuse of Strep A testing in taken to reduce overuse of Strep A testing in general practicegeneral practice

Spain, Argentina, Lithuania, Russia:Spain, Argentina, Lithuania, Russia: Introduction of Strep A may leed to a lower Introduction of Strep A may leed to a lower

prescribing in patients with sore thorat and prescribing in patients with sore thorat and initiatives should be taken to introduce Strep A in initiatives should be taken to introduce Strep A in general practice general practice

0

20

40

60

80

100

1 2 3 4 5

EAPs/Facultatiu Objectiu >70%

”The more you use it,- the faster you lose it”

Burke JP, Lancet 1995;345:977

www.happyaudit.org

Collaboration in Europe about Collaboration in Europe about rational prescribing of antibioticsrational prescribing of antibiotics

CHAMPChanging behaviour of Health care

professionals And the general public towards a More Prudent use of anti-

microbial agents.

lbjerrum@health.sdu.dk

Thank you

Validation study of Validation study of Strep A in general Strep A in general practice in Barcelonapractice in Barcelona

Inclusded 182 Inclusded 182 patients with sore patients with sore throat and ≥ 2 Centor throat and ≥ 2 Centor criteriacriteria

Tests: Tests: Throat CultureThroat Culture Strep AStrep A

4444

AmigdalitisAmigdalitisLa validez de la prueba de Strep A La validez de la prueba de Strep A pare diagnosticar Estrep betahem gr Apare diagnosticar Estrep betahem gr A

Cult + Cult - Total

Strep A pos.

Strep A neg.

Pos predictive valuePPV = 38/48 = 79%

Neg predictive valueNPV = 132/134 = 98%

Specificity: 132/142 = 93%

132

10

2

38

142 40

134

48

182

Sensitivity:38/40 = 95%

Llor et al. Validación de una técnica antigénica rápida en el diagnóstico de la faringitis por esptreptococo beta-hemolitico del grupo A, Aten Primaria 2008

Nycocard CRP single testNycocard CRP single test

Axis-Shield, Axis-Shield, NorwayNorway Training through Training through

local distributorslocal distributors Instrument free Instrument free

during test periodduring test period

Development of Development of

quality indicators quality indicators for diagnosis and treatment offor diagnosis and treatment of

respiratory tract infections respiratory tract infections

in general practice in general practice

Tonsillitis/pharyngitisTonsillitis/pharyngitisNumber of patients with a positive StrepA testNumber of patients with a positive StrepA test

----------------------------------------------------------------------------------------------------------------------------------------------------Number of patients with acute tonsillitis/pharyngitis Number of patients with acute tonsillitis/pharyngitis

treated with antibiotics treated with antibiotics

Number of patients treated with narrow-spectrum penicillin Number of patients treated with narrow-spectrum penicillin (J01CE)(J01CE)

---------------------------------------------------------------------------------------Number of patients ---------------------------------------------------------------------------------------Number of patients with acute tonsillitis/pharyngitis with acute tonsillitis/pharyngitis

treated with antibioticstreated with antibiotics

Experts – to doExperts – to do

Rate to what extent they agree with the Rate to what extent they agree with the relevancerelevance of the 59 quality indicators – of the 59 quality indicators – according to: according to:

A. Reducing antimicrobial resistanceA. Reducing antimicrobial resistance

B. Clinical relevance for the patient*B. Clinical relevance for the patient*

* Reducing symptoms and/or shortening duration of the actual course * Reducing symptoms and/or shortening duration of the actual course of the diseaseof the disease

ConsensusConsensus

The item should be retained: The item should be retained:

≥ ≥ 75 % of participants scored the item ≥ 575 % of participants scored the item ≥ 5

The item should be excluded: The item should be excluded:

≥ ≥ 75 % of participants scored the item ≤ 375 % of participants scored the item ≤ 3

No consensus: No consensus: items which failed to meet either of the above criteriaitems which failed to meet either of the above criteria

The final set of indicatorsThe final set of indicators

6 6 acute sinusitisacute sinusitis 9 acute9 acute otitis mediaotitis media 6 acute tonsillitis/pharyngitis6 acute tonsillitis/pharyngitis 7 acute lower respiratory tract infection (LRTI)7 acute lower respiratory tract infection (LRTI) 1 acute respiratory tract infection (RTI)1 acute respiratory tract infection (RTI) 1 penicillin allergy1 penicillin allergy 1 acute bronchitis1 acute bronchitis 5 pneumonia 5 pneumonia 5 exacerbation of chronic obstructive pulmonary disease 5 exacerbation of chronic obstructive pulmonary disease

(COPD)(COPD)

Number of doctors

Number of patientsregistered

Number of patients treated with antibiotics

Argentina 60 4374 1780

Denmark 102 3904 1351

Lithauen 31 2706 1152

Russia 39 3685 1215

Spain 309 16751 4675

Sweden 77 1853 764

Total 618 33273 10937

ConclusionConclusion Participating GPsParticipating GPs

Estimated: 400Estimated: 400 Real number 618Real number 618

Number of consultations registeredNumber of consultations registered Estimated 20-25.000Estimated 20-25.000 Real number: 33.273Real number: 33.273

Written material completed for all partnersWritten material completed for all partners Guidelines, Patient brochures, Reports etcGuidelines, Patient brochures, Reports etc

Days with symptomsDays with symptoms