What is the role of quality circles in strategies to optimise antibiotic prescribing? A pragmatic cluster-randomised controlled trial in primary care.

OBJECTIVE: To evaluate the effect on antibiotic prescribing of an intervention in existing local quality circles promoting an evidence-based guideline for acute rhinosinusitis. DESIGN: A pragmatic cluster-randomised controlled trial comparing standard dissemination of the guideline by mail with an additional strategy using quality circles. SETTING: General practice in Flanders, Belgium. PARTICIPANTS: General practitioners (GPs) in 18 local quality circles were randomly allocated to two study arms. All GPs received the guideline by mail. GPs in the nine quality circles allocated to the intervention arm received an additional group intervention, which consisted of one self-led meeting using material introduced to the group moderator by a member of the research team. MAIN OUTCOME MEASURES: Adherence to the guideline was measured as differences in the proportion of antibiotic prescriptions, including the choice of antibiotic, between the two study arms after the intervention period. GPs registered their encounters with patients presenting with signs and symptoms of acute rhinosinusitis in a booklet designed for the study. RESULTS: A total of 75 doctors (29% of GPs in the participating quality circles) registered 408 consultations. In the intervention group, 56.9% of patients received an antibiotic compared with 58.3% in the control group. First-choice antibiotics were issued in 34.5% of antibiotic prescriptions in the intervention group compared with 29.4% in the control group. After adjusting for patient and GP characteristics, the ORadj for antibiotics prescribed in the intervention arm compared with the control arm was 0.63 (95% CI 0.29 to 1.37). There was no effect on the choice of antibiotic (ORadj 1.07, 95% CI 0.34 to 3.37). CONCLUSION: A single intervention in quality circles of GPs integrated in the group's normal working procedure did not have a significant effect on the quality of antibiotic prescribing. More attention to the context and structure of primary care practice, and insight into the process of self-reflective learning may provide clues to optimise the effectiveness of quality circles.

Influence of the presence of doctors-in-training on the blood pressure of patients: a randomised controlled trial in 22 teaching practices.

Until now, no information is available about the effect of the presence of a doctor-in-training on a patient's blood pressure. We tested the hypothesis that the presence of a last year medical student might increase the blood pressure of the patient, in addition to the possible pressor response to the doctor-trainer. Normotensive and hypertensive patients with a minimum age of 25 years, visiting for any reason, were recruited at 22 teaching general practices. Patients were randomised into a 'trainee' group (n=133) and a 'no trainee' (n=129) group. The blood pressure was measured at two subsequent contacts. In the 'trainee' group, a student was present at the first visit only. In the 'no trainee' group, both visits were without student. Both groups had similar anthropometric characteristics at entry. At the first visit, systolic pressure was higher in the 'trainee' group than in the control group (139.5 vs 133.1 mmHg, P=0.004), with a similar trend for diastolic pressure (80.2 vs 77.8 mmHg, P=0.07). From the first contact to the follow-up visit, blood pressure decreased in the trainee group by 4.8 mmHg systolic (P<0.001) and 1.7 mmHg diastolic (P=0.03), whereas the corresponding changes in the control group were -0.1 mmHg (P=0.90) and +1.5 mmHg (P=0.03). Thus, the between group differences in these trends averaging 4.7 mmHg (CI 1.5-7.9, P=0.005) systolic and 3.2 mmHg (CI 1.1-5.3, P=0.003) diastolic were statistically significant. We conclude that in teaching-practices, the presence of a doctor-in-training has a significant pressor effect when an experienced general practitioner measures a patient's blood pressure. If confirmed, our findings imply that doctors should be cautious to initiate or adjust antihypertensive treatment when blood pressure readings are obtained in the presence of a student.

Perception of males' aging symptoms, health and well-being in elderly community-dwelling men is not related to circulating androgen levels.

Aging in men is associated with a progressive but variable decline in androgen production. In aging men there is also an increased occurrence of symptoms such as lack of concentration, nervousness, impaired memory, depressive mood, insomnia, lack of energy and general sense of well-being, decreased libido and erectile dysfunction, periodic sweating, bone and joint complaints, reduction of strength and increased adiposity. This ill-defined male climacterium syndrome is often referred to as "andropause", with the underlying implication that it is at least in part related to (relative) androgen deficiency. Recently an "aging males" symptoms' (AMS) rating scale was developed aimed at a more systematic description of severity of symptoms related to a clinically defined "male climacteric". We studied the relationship of male climacteric symptoms as assessed by the AMS with androgen levels and other questionnaires assessing the perception of health and well-being. Serum levels of sex steroids, sex hormone binding globulin and gonadotropins were measured in blood samples of 161 healthy, ambulatory, elderly men, aged 74-89 years who also completed the AMS scale. Mean value of total, free and bioavailable testosterone in this group was 401.6, 6.8 and 151.4 ng/dl, respectively, with 24.7, 32.4 and 52.2% of the values under the normal range for young men. The results of the AMS scores mostly suggested mild psychological and mild to moderate somatovegetative symptoms. However, clear sexual symptoms were reported in 88% of cases. None of the three AMS domain scale scores significantly correlated with testosterone, free testosterone or bioavailable testosterone. Significant correlations were observed between results for the AMS scores and those for other health questionnaires, but none of the subscores for the latter questionnaires correlated with androgen serum levels. In conclusion, the results of this study have shown that, as assessed by the AMS, healthy ambulatory elderly males over 70 had a high perception of sexual symptoms with mild psychological and mild to moderate somatovegetative symptoms. These data failed to support the view that in healthy elderly men, "climacteric symptoms" can predict androgen levels.

Randomised controlled trial of nitrofurantoin versus placebo in the treatment of uncomplicated urinary tract infection in adult women.

BACKGROUND: Urinary tract infections (UTIs) are very common and have been treated with apparent success with antimicrobials for many years. However, there is a paucity of placebo-controlled clinical trials. AIM: To measure the symptomatic and bacteriological short-term effect of nitrofurantoin treatment versus placebo, in the treatment of uncomplicated UTI in adult non-pregnant women. DESIGN OF STUDY: Randomised placebo-controlled trial in general practice. SETTING: Non-pregnant women, aged between 15 and 54 years old, consulting a general practitioner for symtoms suggestive of uncomplicated lower UTI and with pyuria (positive for leucocyte esterase test). METHOD: A dipslide was inoculated in first-void midstream urine and sent for examinion. The patients were randomised to receive nitrofurantoin 100 mg or placebo four times daily for three days. After three, seven, and 14 days a new dipslide was inoculated and symptoms of UTI were checked or improvement of symptoms and bacteriuria. RESULTS: Of 166 women consulting with symptoms suggestive for UTI, 78 had pyuia and agreed to participate in the study (the clinically suspected UTI group); of these, 40 received nitrofurantoin and 38 received placebo. The result for combined symptomatic improvement and cure after three days was 27/35 in the nitrofurantoin group and 19/35 in the placebo group (c2 with Yates' correction P = 0.008; number needed to treat [NNT] = 4.4, 95% confidence interval [CI] = 2.3 to 79). After seven days, combined improvement and cure was observed in 30/34 and 17/33 respectively (P = 0.003, NNT = 2.7, 95% CI = 1.8 to 6.0). At inclusion, 56 women had bacteriuria of > or = 10(5) CFU/ml (the bacteriologically proven UTI group). Of these, 29 received nitrofurantoin and 27 received placebo. After three days the bacteriological cure was 21/26 in the treatment group, compared with 5/25 in the placebo group (P < 0.001; NNT = 1.6, 95% CI= 1.2 to 2.6). After seven days the bacteriological cure rate was 17/23 in the intervention group and 9/22 in the placebo group (P = 0.05, NNT = 3, 95% CI = 1.7 to 17). CONCLUSION: In women with bacteriologically proven UTI, nitrofurantoin was significantly more effective than placebo in achieving bacteriological cure and symptomatic relief in just three days; this was still present after seven days. In patients with clinically suspected UTI the symptomatic effect was statistically significant after

Antibiotic prescribing in acute infections of the nose or sinuses: a matter of personal habit?

BACKGROUND: A proper understanding of how and why GPs prescribe antibiotics in general practice is essential for the design of strategies aimed at making prescribing more rational. OBJECTIVE: The intention of this study is to contribute to such understanding by investigating which elements are important in the GP's decision to prescribe antibiotics for patients with acute infectious complaints of the nose and/or sinuses. METHODS: During their training in general practice, students observed the following elements while attending encounters between their trainer-GP and patients with a runny nose, blocked nose or cough: patient characteristics, contact characteristics, signs and symptoms, diagnosis and prescriptions. Information on practice characteristics and characteristics of the trainer-GP were collected. Data were analysed using multiple logistic regression and multiple linear regression. RESULTS: A total of 722 cases were analysed with the following results: the best independent predictor of an antibiotic prescription is the individual antibiotic prescribing rate (IAPR), which expresses the personal habit of the GP in prescribing antibiotics [adjusted odds ratio (OR) 5.27, 95% confidence interval (CI) 3.22-8.62]. Others are the diagnostic labels "sinusitis" (adjusted OR 2.80, 95% CI 1.2-6.49) and "flu-like syndrome" (adjusted OR 0.08, 95% CI 0.01-0.45), and the sign "sinus tenderness" (adjusted OR 4.37, CI 2.15-8.89). The antibiotic prescribing behaviour intensifies with an increasing tendency to prescribe medication in general (beta = 0.46, P: < 0.00) and with an increasing defensive attitude (beta = 0.22, P: < 0.05). CONCLUSIONS: Whether or not a patient with an acute infection of the nose and/or sinuses will be handed an antibiotic prescription seems to depend more on the attending doctor's prescribing behaviour than on the clinical picture. Further qualitative research into attitudes which may be related to a high tendency to prescribe antibiotics consequently is of the utmost importance.

Which bacteria are found in Belgian women with uncomplicated urinary tract infections in primary health care, and what is their susceptibility pattern anno 95-96?

Dysuria is a frequent reason for encounter in general practice and also gynaecologists and urologists will be frequently confronted with it. In female patients 1/2 to 2/3 of dysuric episodes are due to urinary tract infections. In nearly all cases therapy is started before the results of a culture is available. Therefore it is very important to know which bacteria are most prevalent in the treated population, and what their susceptibility pattern is . Because most available information is based on retrospective data issued from very mixed populations, we performed a prospective study including the most frequently involved population: symptomatic adult women without any symptom of complicated UTI. Among 279 urine specimens collected in general practices, 164 were positive (59%). The most frequent micro-organism found was E. coli (78%), followed by S. saprophyticus (9%) and Proteus spp. (4%). In the 15 remaining specimens, 8 different bacterial species were found. Overall resistance to ampicillin was 30%, to cotrimoxazole 14%, to nitrofurantoin 7%, to fluoroquinolones 1%. The E.coli resistance to ampicillin was 27%, to co-trimoxazole 17%, to nitrofurantoin 1% and to fluoroquinolones 1%. In this population the same bacteria, in the same proportion, are found as in earlier studies in other countries. The susceptibility pattern confirms a substantial resistance level to ampicillin and co-trimoxazole. On the contrary, resistance to nitrofurantoin and fluoroquinolones is negligible. Resistance data from Belgian regional laboratories in their outpatient population were significantly different from ours.

Effect of penicillin on the clinical course of streptococcal pharyngitis in general practice.

The aim of the study was to explore whether penicillin was superior to placebo in altering the clinical course of proven streptococcal pharyngitis. A randomised, parallel, double blind placebo controlled trial of 10 days duration was undertaken in 42 general practices in the Gent region (Flemish part of Belgium). Phenoxymethylpenicillin (adults 250 mg t.i.d. and children 125 mg t.i.d.) or placebo were administrated to 173 patients, aged 5 to 50 y, with acute sore throat and a positive culture for Group A beta-haemolytic streptococci. Penicillin and placebo tablets were identical. Patient compliance was monitored by assay of penicillin in urine (Sarcina lutea method). The primary outcome variable was sore throat as recorded by the physician on Day 3. The experiences of the patients themselves over the 10 day period were also assessed. Secondary outcome variables were other local and general symptoms and signs of streptococcal throat infection. In the penicillin group on Day 3, 23.2% of the patients still complained of sore throat versus 65.9% in the placebo group: difference 42.7% (C.I. 29.4%, 56.1%). This finding was confirmed by survival analysis of the symptom 'sore throat', as recorded by the patients. The physicians recorded on Day 3 a significant positive effect on another symptom (malaise: P < 0.04) and certain clinical signs (abnormal throat: P < 0.07; and redness of throat: P < 0.003). Penicillin had more adverse effects than placebo (P < 0.007). It also inhibited the rise in ASLO (P < 0.001). In this study in general practice, penicillin had a slight but definitive positive effect on the clinical evolution of streptococcal pharyngitis.(ABSTRACT TRUNCATED AT 250 WORDS)

Selective streptococcal agar versus blood agar for detection of group A beta-hemolytic streptococci in patients with acute pharyngitis.

In a study on acute pharyngitis in general practice, we compared a selective group A streptococcal agar (ssA) for the recovery of group A beta-hemolytic streptococci (GABHS) with sheep blood agar. All plates were incubated at 36 degrees C in an atmosphere reinforced with 5% CO2 for 48 h with a first reading after 24 h. A total of 197 GABHS isolates were obtained from 721 throat cultures on both media. The recovery of GABHS was significantly higher after 48 h of incubation for both media. With the ssA plate, we detected significantly more GABHS after 24 h as well as after 48 h of incubation. The ssA plate reduced normal flora qualitatively and quantitatively. In conclusion, ssA is more sensitive and specific for the detection of GABHS than sheep blood agar and moreover easier to read. We recommend incubation for 48 h.