Implementation of the delayed antibiotic prescribing strategy. Prospective observation study in primary care.

OBJECTIVE: We aimed to compare the actual consumption of antibiotics among patients issued delayed antibiotic prescribing with the consumption observed in a non-systematic review of studies on delayed prescribing. METHODS: Observational study carried out in three primary care centres from September 2018 until March 2020. We tracked the electronic records of the 82 patients with episodes of acute bronchitis and 44 acute pharyngitis who were given a patient-led delayed prescription to determine whether the prescription was filled and when this medication was obtained. RESULTS: The prescriptions were never filled in 50 cases (39.7%), but five patients took another antibiotic within the first two weeks. Out of 76 patients who did take the delayed prescription, only 12 obtained the medication based on the instructions given by the doctors (15.8%). CONCLUSIONS: The strategy of delayed antibiotic prescribing resulted in a reduction in antibiotic use, but this reduction was lower than in randomised clinical trials, being comparable to the results obtained with other observational studies on delayed antibiotic prescribing. In addition, only a few patients adhered to the doctors' instructions.

[Utilisation of first-line antibiotics six years after a multifaceted intervention]. / Uso de antibióticos de primera línea 6 años después de una intervención multifacética.

OBJECTIVE: No study has evaluated the impact of a multifaceted intervention on the quality of the antibiotics prescribed more than 5 years later. METHODS: A total of 210 general practitioners (GP) from eight different regions of Spain were asked to participate in two registrations of respiratory tract infections (RTI) in 2008, before, and in 2009, just after a multifaceted intervention including prescriber feedback, clinical guidelines, training sessions focused on appropriate antibiotic prescribing, workshop on rapid tests and provision of these tests in the GP consultation. They were all again invited to participate in a similar registration in 2015. A new group of clinicians from the same areas who had never participated in antimicrobial stewardship courses were also invited to participate and acted as controls. RESULTS: The 121 GPs who continued the study (57.6%) and the 117 control GPs registered 22,407 RTIs. The antibiotic most commonly prescribed was amoxicillin and clavulanic acid, prescribed in 1,801 cases (8.1% of the total), followed by amoxicillin (1,372 prescriptions, 6.2%), being lower among GPs just after the intervention. The third leading antibiotic among GPs just after the intervention was penicillin V (127 cases, 3.3%) whereas macrolides ranked third in the other three groups of GPs. CONCLUSIONS: The use of first-line antibiotic for RTIs wanes over time after an intervention, but their utilisation is still significantly greater among intervened clinicians six years later compared to GPs who have never been exposed to any antimicrobial stewardship programmes.

Misconceptions of Spanish general practitioners' attitudes toward the management of urinary tract infections and asymptomatic bacteriuria: an internet-based questionnaire study.

OBJECTIVE: The diagnosis and management of urinary tract infections (UTI) vary widely across countries and practices. The objective of this study was to gain insight into general practitioners' (GP) perceptions on the current management of UTIs and asymptomatic bacteriuria in Spain. METHODS: Cross-sectional, internet-based questionnaire study answered from July to September 2013. GPs affiliated with the largest Spanish scientific society in primary care (Sociedad Española de Medicina Familiar y Comunitaria) were invited to participate in the study. They were asked about the tests ordered in both uncomplicated and complicated UTIs and about the management in three clinical scenarios, depicting a 50-year woman with: 1. An uncomplicated UTI, 2. A complicated UTI, and 3. An asymptomatic bacteriuria. RESULTS: The questionnaire was completed by 1,239 GPs (6.7%). Urine cultures were reportedly requested by 26.3% of the GPs in uncomplicated UTIs and by 71.8% of the cases corresponding to the complicated UTIs whereas it was declared that dipsticks were the preferred tests in only uncomplicated UTIs (38.2%). A total of 22% and 13.2% of the GPs stated that they would withhold antibiotic therapy in patients with low-count and high-count asymptomatic bacteriuria, respectively. CONCLUSIONS: GPs have important misconceptions as to the indications for ordering urine cultures and in interpreting the definitions of common UTIs and treating UTIs and asymptomatic bacteriuria. The unnecessary use of antibiotics in patients with asymptomatic bacteriuria is considerable in Spain.

Repetition of the rapid antigen test in initially negative supposed streptococcal pharyngitis is not necessary in adults.

AIMS: To determine whether the repetition of the rapid antigen detection test (RADT) in patients, with a high suspicion of presenting pharyngitis by group A beta-haemolytic streptococci (GABHS), with a previously negative test improves the validity of the test. METHODS: Two hundred and twenty-two patients aged 14 years or more with acute pharyngitis and two or more Centor criteria--tonsillar exudates, fever, tenderness in the lymph glands and/or absence of cough--were consecutively recruited. In all patients, a pharyngotonsillar sample was obtained with two swabs, one for the RADT (OSOM Strep A Genzyme test, Genzyme Diagnostics, Cambridge, MA, USA) and the other was sent to the Department of Microbiology for culture. In patients with a negative RADT, the determination was repeated. The sensitivity, specificity and predictive values were determined. RESULTS: Cultures were positive for GABHS in 55 patients (24.8%). Three false-negatives and 14 false-positives were observed by comparing the rapid test with throat culture, achieving a sensitivity of 94.5% and a specificity of 91.6%. Positive and negative predictive values were 78.8% and 98.1% respectively. Taking the second determination in the negative cases into account, the results were 96.4%, 91.6%, 79.1% and 98.7% respectively. CONCLUSIONS: The negative predictive value achieved with the RADT determination was very high. Repetition of the test only slightly improved this percentage, making repetition of this test unnecessary.

Antibiotic prescribing over the last 16 years: fewer antibiotics but the spectrum is broadening.

The purpose of this study was to quantify the antibiotics prescribed in the outpatient setting of all primary health care professionals in Catalonia during 1992-2007. We calculated prescribed defined daily doses per 1,000 inhabitants and day (DID) from data provided by the Catalonian Health Service. The antibiotics analysed belonged to the J01 group (ATC/DDD classification). The overall prescribing of antibacterials has decreased by 11.9% during this period (1992: 16.75 DID, 2007: 14.75 DID). During this 16-year period, an increase was observed for penicillins (from 46.1% in 1992 to 59.6% in 2007) and for quinolones (from 13.3% to 15.7%). The prescription of cephalosporins remained steady and, conversely, a decrease in macrolides was found (from 14.8% to 12.2%). The leading antibiotic prescribed in 2007 was amoxicillin plus clavulanic acid (5.15 DID), followed by amoxicillin (2.95 DID). The former has increased by 84.4% since 2002. Penicillin V prescribing reached a peak in 2007 with 0.034 DID. There has been a slight reduction in antibiotic prescription in this 16-year study, with an increase of penicillins, mainly at the expense of those of broader antibacterial spectrum. Awareness of the rational use of antibiotics is mandatory, basically aimed at reducing the overall prescribing of antibiotics and encouraging those with a narrower spectrum.

Diagnóstico clínico y tratamiento de la faringoamigdalitis estreptocócica / Clinical diagnosis of streptococcal pharyngoamygdalitis

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Exacerbations worsen the quality of life of chronic obstructive pulmonary disease patients in primary healthcare.

AIMS: To investigate the evolution of the quality of life of patients with chronic obstructive pulmonary disease (COPD) and quantify the impact of exacerbations on the deterioration of quality of life over 2 years. METHODS: Multicentre, observational, prospective 2-year study carried out in primary care. Patients with COPD were seen every 6 months. All the exacerbations developing during the study period were recorded and the quality of life of these patients was measured with the St. George's Respiratory Questionnaire (SGRQ). RESULTS: Twenty-seven physicians participated and collected information on 136 patients with a mean age of 70 years (SD: 9.7) and a mean forced expiratory volume in 1 s (FEV(1)) of 48.7% predicted (SD: 14.5%). The mean global score of the SGRQ was 39.6 at the beginning of the study and 37.9 at the end. Patients without exacerbations improved an average of -5.32 units compared with a worsening of +0.2 among patients with exacerbations (p = 0.023). Among the latter, patients with only one exacerbation improved -3.8 units (p = 0.012) compared with a worsening of +2.4 in those with two or more exacerbations (p = 0.134). The impact of exacerbations was greater in patients with more preserved pulmonary function, with a change in the SGRQ among patients with or without exacerbations of +0.23 and -6.17 (p = 0.017), respectively in patients with a FEV(1) > 50%, vs. +0.18 and -4.39 (p = 0.32) in patients with a FEV(1)

[Risk factors for increased cost of exacerbations of chronic bronchitis and chronic obstructive pulmonary disease]. / Factores de riesgo de elevado coste de las agudizaciones de la bronquitis crónica y la EPOC.

OBJECTIVE: To identify what variables characterizing the patients, exacerbations, and treatment of chronic bronchitis and chronic obstructive pulmonary disease (COPD) are associated with a higher direct health cost. METHOD: Observational pharmacoeconomic study of exacerbations of chronic bronchitis and COPD (of probable bacterial etiology, defined as Anthonisen types I or II). Direct health costs were assessed during 30 days of follow-up. Logistic regression was employed for statistical analysis, with calculation of the adjusted odds ratios (OR). An exacerbation cost greater than 150 euros was defined as the dependent variable. RESULTS: Data on 1164 patients were collected by 252 physicians. Pharmacoeconomic data were complete in 947 patients (82.6%). In the first 30 days, 206 sought medical attention because of unsatisfactory response to treatment (21.8%), 69 (7.3%) attended the emergency room, and 22 (2.3%) were admitted to hospital. Overall, 101 exacerbations (10.7%) were classified as high cost (> 150 euros). Continuous oxygen therapy (OR = 7.58) and previous hospitalization (OR = 2.6) were associated with high-cost exacerbations, whereas diagnosis of chronic bronchitis (OR = 0.41) and treatment of the exacerbation with moxifloxacin or amoxicillin-clavulanic acid as opposed to clarithromycin (OR = 0.38) were associated with low-cost exacerbations. CONCLUSION: Treatment failure was reported for 21.8% of the patients with exacerbations of chronic bronchitis and COPD. Repeated medical visits and requests for complementary tests were the main factors responsible for increased cost. Variables associated with high-cost exacerbations were continuous oxygen therapy, previous hospitalization, and treatment with clarithromycin as opposed to moxifloxacin or amoxicillin-clavulanic acid.

Factores de riesgo de elevado coste de las agudizaciones de la bronquitis crónica y la EPOC / Risk factors for increased cost of exacerbations of chronic bronchitis and Chronic Obstructive Pulmonary Disease

Objetivo: Identificar las variables de los pacientes, de las agudizaciones y del tratamiento de la bronquitis crónica (BC) y la enfermedad pulmonar obstructiva crónica (EPOC) que se asocian con un mayor coste sanitario directo. Método: Estudio observacional y farmacoeconómico en pacientes con BC y EPOC con agudización de probable etiología bacteriana, definida por presentar 2 o más de los criterios de Anthonisen. Se siguió a los pacientes durante 30 días y se evaluaron los costes directos derivados de su atención. El análisis estadístico se efectuó mediante regresión logística con cálculo de las odds ratio (OR) ajustadas, considerando variable dependiente un coste de agudización superior a los 150 €. Resultados: Participaron 252 médicos que recabaron información sobre 1.164 pacientes. Se recogieron todos los parámetros farmacoeconómicos en 947 pacientes (82,6%). En los primeros 30 días, 206 acudieron por mala evolución (21,8%), 69 (7,3%) requirieron atención en urgencias y 22 (2,3%) precisaron ingreso. Se clasificaron como de coste elevado (> 150 €) 101 agudizaciones (10,7%). Las variables que se asociaron a un coste elevado fueron la oxigenoterapia continua (OR = 7,58) y la hospitalización previa (OR = 2,6), mientras que el diagnóstico de BC (OR = 0,41) y el tratamiento de la agudización con moxifloxacino o amoxicilina-ácido clavulánico, comparado con claritromicina (OR = 0,38), se asociaron a un coste bajo. Conclusión: Un 21,8% de los pacientes con agudización de la BC y EPOC fracasa, con lo que se genera un coste mayor, fundamentalmente por nuevas visitas médicas y solicitud de pruebas complementarias. Las variables que se asocian a una agudización de coste elevado son la oxigenoterapia continua, la hospitalización previa y el tratamiento con claritromicina comparada con moxifloxacino o amoxicilina-ácido clavulánico

Objective: To identify what variables characterizing the patients, exacerbations, and treatment of chronic bronchitis and chronic obstructive pulmonary disease (COPD) are associated with a higher direct health cost. Method: Observational pharmacoeconomic study of exacerbations of chronic bronchitis and COPD (of probable bacterial etiology, defined as Anthonisen types I or II). Direct health costs were assessed during 30 days of follow-up. Logistic regression was employed for statistical analysis, with calculation of the adjusted odds ratios (OR). An exacerbation cost greater than €150 was defined as the dependent variable. Results: Data on 1164 patients were collected by 252 physicians. Pharmacoeconomic data were complete in 947 patients (82.6%). In the first 30 days, 206 sought medical attention because of unsatisfactory response to treatment (21.8%), 69 (7.3%) attended the emergency room, and 22 (2.3%) were admitted to hospital. Overall, 101 exacerbations (10.7%) were classified as high cost (> €150). Continuous oxygen therapy (OR=7.58) and previous hospitalization (OR=2.6) were associated with high-cost exacerbations, whereas diagnosis of chronic bronchitis (OR=0.41) and treatment of the exacerbation with moxifloxacin or amoxicillin­clavulanic acid as opposed to clarithromycin (OR=0.38) were associated with low-cost exacerbations. Conclusion: Treatment failure was reported for 21.8% of the patients with exacerbations of chronic bronchitis and COPD. Repeated medical visits and requests for complementary tests were the main factors responsible for increased cost. Variables associated with high-cost exacerbations were continuous oxygen therapy, previous hospitalization, and treatment with clarithromycin as opposed to moxifloxacin or amoxicillin- clavulanic acid

Economic evaluation of the antibiotic treatment of exacerbations of chronic bronchitis and COPD in primary care.

This was an observational and economic survey performed in primary care practices throughout Spain to assess the effectiveness and direct medical costs derived from antibiotic treatment of exacerbations of chronic bronchitis (CB) and chronic obstructive pulmonary disease (COPD) in primary care. A total of 252 physicians included 1456 valid patients, 80% were male and the mean age was 68.2 years (SD = 9.8). The antibiotic treatment administered was moxifloxacin in 575 (39.5%), amoxicillin/clavulanate in 460 (31.6%) and clarithromycin in 421 (28.9%). No significant differences were found in clinical and demographic characteristics between treatment arms. The 30-days follow-up visit was completed by 1097 (75%) patients, who were therefore valid for economic evaluation. During follow-up, 440 new medical visits were generated, 69 patients required attendance in emergency wards (6.3%) and 22 were hospitalised (2%). The overall mean cost of exacerbation was Euro 118.58 [95% confidence interval (CI) = Euro 92.2-144.9] and Euro 52.44 (44.2%) were due to therapeutical failure. The mean cost of exacerbation was Euro 111.46 (95% CI = Euro 73.4-149.5) for patients treated with moxifloxacin, Euro 109.45 (95% CI = Euro 68.2-150.7) for those treated with amoxicillin/clavulanic acid and Euro 138.95 (95% CI = Euro 89.4-188.5) for patients receiving clarithromycin. In conclusion, a significant number of patients require new medical interventions after ambulatory treatment of exacerbations of CB or COPD. The mean cost of an exacerbation was Euro 118.58 and failure was responsible for 44.2% of the total cost of exacerbation.

[Pharmacoeconomic analysis of patients with acute exacerbation of chronic bronchitis treated with telithromycin or cefuroxime-axetil]. / Análisis farmacoeconómico del tratamiento de pacientes con exacerbación aguda de la bronquitis crónica con telitromicina o cefuroxima-axetilo.

INTRODUCTION: A pharmacoeconomic analysis was done to compare the efficiency of two treatments in the acute exacerbation of chronic bronchitis: telithromycin and cefuroxime-axetil. METHODS: Restrospective analysis, modeled through a decision tree. The effectiveness of the treatments was estimated through a randomized and double-blind clinical trial in which 800 mg/day (5 days) of telithromycin were compared with 1,000 mg/day (10 days) of cefuroxime-axetil in patients with acute exacerbation of chronic bronchitis (140 and 142 patients, respectively). Resources use was estimated from clinical trial and from Spanish data, and the unit costs through a health costs dabatase. The model was validated by a panel of Spanish clinical experts. RESULTS: Since the clinical trial was designed to demonstrate equivalence, there were no significant differences of effectiveness among both treatments (with a rate of clinical cure of 86.4% and 83.1%, respectively) which means that an analysis of costs minimization was done. In the average case, the average cost of the disease by patient was 174.83 Euros with telithromycin and 194.68 Euros with cefuroxime-axetil (a difference of 19.85 Euros). The results were maintained in the analysis of sensitivity, with favorable differences for telithromycin that ranged between 18.04 Euros and 22.25 Euros. CONCLUSIONS: With telithromycin up to 22 Euros by patient with acute exacerbation of chronic bronchitis could be saved, in comparison with cefuroxime-axetil.

Análisis farmacoeconómico del tratamiento de la neumonía adquirida en la comunidad con telitromicina o claritromicina / Pharmacoeconomic analysis of community-acquired pneumonia treatment with telithromycin or clarithromycin

Se realizó un análisis farmacoeconómico para comparar la eficiencia de dos tratamientos en la neumonía adquirida en la comunidad: telitromicina y claritromicina. El estudio fue retrospectivo, modelizado mediante un árbol de decisiones. La eficacia de los tratamientos se estimó a partir de un ensayo clínico, aleatorizado y doble ciego, en el que se compararon 800 mg/día de telitromicina oral (10 días) con 1000 mg/día de claritromicina oral (10 días) en pacientes con neumonía adquirida en la comunidad (162 y 156, respectivamente). La utilización de recursos se estimó a partir del ensayo clínico y de fuentes españolas, y los costes unitarios mediante una base de datos de costes sanitarios. El modelo fue validado por un panel de expertos españoles. Como el ensayo clínico se diseñó para demostrar equivalencia, no hubo diferencias significativas de eficacia entre los tratamientos (con una tasa de curación clínica del 88,3 por ciento y el 88,5 por ciento, respectivamente), por lo que se hizo un análisis de minimización de costes. En el caso base, el coste medio de la enfermedad por paciente fue de 308,29 euros con telitromicina y de 331,5 euros con claritromicina (diferencia de 23,21 euros). Los resultados fueron estables en el análisis de sensibilidad, con diferencias favorables a telitromicina que oscilaron entre 5,50 y 45,45 euros. Un mayor coste de adquisición no implica necesariamente un mayor coste de la enfermedad. Con telitromicina se podría ahorrar hasta 45,45 euros por paciente con neumonía de adquisición en la comunidad, en comparación con claritromicina (AU)

[Pharmacoeconomic analysis of community-acquired pneumonia treatment with telithromycin or clarithromycin]. / Analisis farmacoeconomico del tratamiento de la neumonia adquirida en la comunidad con telitromicina o claritromicina.

A pharmacoeconomic analysis was carried out comparing the efficacy of two treatment options for community-acquired pneumonia (CAP): telithromycin and clarithromycin. It was a retrospective analysis using a decision tree model. The efficacy of the two treatment options was estimated from a randomized, double-blind clinical trial, in which 800 mg/day oral telithromycin for 10 days was compared to 1000 mg/day oral clarithromycin for 10 days in patients with CAP (162 and 156 respectively). The use of resources was estimated based on the clinical trial and Spanish sources, and the unit costs from a Spanish health costs database. Costs were evaluated for the acquisition of antibiotic treatments, change of antibiotic due to therapeutic failure, hospital admissions, adverse reactions to treatment, primary care visits, tests and indirect costs (working days lost). The model was validated by a panel of Spanish clinical experts. As the clinical trial was designed to show equivalence, there were no significant differences in efficacy between the treatment options (clinical cure rate 88.3% and 88.5%, respectively), and a cost minimization analysis was performed. In the base case, the average cost of the disease per patient was 308.29 euros with telithromycin and 331.5 euros with clarithromycin (a difference of 23.21 euros). The results were stable in the susceptibility analysis, with differences favorable to telithromycin ranging between 5.50 and 45.45 euros. Telithromycin results in a cost savings of up to 45.45 euros per CAP patient compared to clarithromycin.

[Use of the Internet in a multicenter study of chronic obstructive pulmonary disease in primary care. Pilot phase of the EFEMAP study]. / Utilización de Internet en un estudio multicéntrico sobre EPOC en atención primaria. Fase piloto del estudio EFEMAP.

OBJECTIVE: To determine the reliability of clinical data collection and transmission by Internet in a multicenter primary care study. PATIENTS AND METHODS: Multicenter, observational study of a population of patients with exacerbated chronic obstructive pulmonary disease (COPD). All data were gathered in a specifically designed digital program on a palm-held pocket computer. Information was transmitted on-line by modem to a central database. RESULTS: Thirty-nine researchers participated in this pilot phase. Over three months 324 patients were treated. Thirty-seven telephone consultations were generated, most (54%) in reference to how the digitized questionnaire worked. Questions were solved in a mean 5.44 minutes. No important technical problems occurred and no information was lost. CONCLUSIONS: The use of the Internet to transfer data for multicentric studies in primary care is possible. This system should be more widely used in the future, as it allows faster data collection and eliminates the need to input data at the end of the study.

Utilización de Internet en un estudio multicéntrico sobre EPOC en atención primaria. Fase piloto del estudio EFEMAP / Use of the Internet in a multicenter study of chronic obstructive pulmonary disease in primary care. Pilot phase of the EFEMAP study

OBJETIVOS: Conocer la viabilidad de la recogida y transmisión de datos clínicos por Internet en un estudio multicéntrico en atención primaria. PACIENTES Y MÉTODOS: Estudio observacional, multicéntrico sobre una población de pacientes con enfermedad pulmonar obstructiva crónica agudizada. Todos los datos se recogieron en un formulario electrónico diseñado específicamente, que se encontraba incorporado en un ordenador portátil de bolsillo. La transmisión de los datos se efectuó on line a una base de datos unificada mediante conexión telefónica por módem. RESULTADOS: Participaron en esta fase piloto 39 investigadores, que incluyeron a 324 pacientes durante 3 meses. Se generaron 37 consultas telefónicas, la mayoría (54 per cent) referida al funcionamiento del cuestionario electrónico, que se solucionó en un promedio de 5,44 min. La metodología utilizada no presentó ningún problema técnico de importancia ni se detectó ninguna pérdida de información. CONCLUSIONES: La utilización de Internet en estudios multicéntricos en atención primaria es posible. Este sistema debe extenderse en un futuro, pues permite una rapidez superior en la entrada de datos y elimina la necesidad de grabación de los mismos tras finalizar el estudio (AU)

[A tumor registry at a primary care center]. / Registro de tumores en un centro de asistencia primaria.

AIM: We analysed the data obtained from a tumor register kept in a Primary Care Centre (PCC) to find out the variables which contribute to the diagnostic and therapeutic evolution of our patients. DESIGN: Retrospective study on every Neoplasia registered in the Centre. PATIENTS: 293 malignant Neoplasias were recorded in the period between June 1984 and June 1990 (184 in males--62.8%; and 109 in women--37.2%). MEASUREMENTS AND MAIN RESULTS: The intervals between symptom and consultation (ISC), between consultation and referral (ICR), between referral and diagnosis (IRD) and between diagnosis and treatment (IDT) were evaluated. The average age at the moment of diagnosis was 59 (SD:13). There were 3.9% double neoplasias. The most frequent type was lung cancer with 41 cases (14%). This also occupied first place among men, whereas breast cancer did so among women. 10 tumours were diagnosed by screening: 4 breast, 5 cervix and 1 endometrium, which represent 16%, 50% and 14.3% respectively of these cancers. For all neoplasias taken together, the average time of ISC was 44.09 days (SD 73.48) and of IDT 25.75 days (SD:61.55). Given the wide variations, we assessed the most common types of tumour. CONCLUSIONS: The usefulness of keeping a tumour register in a Primary Care Centre, which could identify the factors which affect diagnostic delays and find possible corrective measures to reduce the delays, was appraised.