Barbara Michiels

A systematic review of the evidence on the effectiveness and risks of inactivated influenza vaccines in different target groups

PURPOSE To systematically review the evidence regarding the efficacy, effectiveness and risks of the use of inactivated influenza vaccines in children, healthy adults, elderly individuals and individuals with co-morbidities such as diabetes, chronic lung disease, cardiovascular disease, kidney or liver disease and immune suppression. METHODS The Cochrane database of systematic reviews was searched for relevant reviews and supplemented with searches of the Cochrane Central Register of Controlled Trials database and Medline. Two reviewers independently assessed review and trial quality and extracted data. RESULTS AND CONCLUSIONS The inactivated influenza vaccine has been proven effective in preventing laboratory-confirmed influenza among healthy adults (16-65 years) and children (≥6 years) (GRADE A evidence). However, there is strikingly limited good-quality evidence (all GRADE B, C or not existing) of the effectiveness of influenza vaccination on complications such as pneumonia, hospitalisation and influenza-specific and overall mortality. Inconsistent results are found in studies among children younger than 6 years, individuals with COPD, institutionalised elderly (65 years or older), elderly with co-morbidities and healthcare workers in elderly homes, which can only be explained by bias of unknown origin. The vaccination of pregnant women might be beneficial for their newborns, and vaccination of children might be protective in non-recipients of the vaccine of all ages living in the same community (one RCT, Grade B evidence).

The value of neuraminidase inhibitors for the prevention and treatment of seasonal influenza: a systematic review of systematic reviews.

Controversy has arisen regarding the effectiveness of neuraminidase inhibitors (NIs), especially against influenza-related complications. A literature search was performed to critically assess the evidence collected by the available systematic reviews (SRs) regarding the benefits and disadvantages of NIs (oseltamivir, zanamivir) compared to placebos in healthy and at-risk individuals of all ages for prophylaxis and treatment of seasonal influenza. A SR was done using the Cochrane Database of Systematic Reviews, Health Technology Assessment Database, Database of Abstracts of Reviews of Effects, and Medline (January 2006–July 2012). Two reviewers selected SRs based on randomized clinical trials, which were restricted to intention-to-treat results, and they assessed review (AMSTAR) and study quality indicators (GRADE). The SRs included (N = 9) were of high quality. The efficacy of NIs in prophylaxis ranged from 64% (16–85) to 92% (37–99); the absolute risk reduction ranged from 1.2% to 12.1% (GRADE moderate to low). Clinically relevant treatment benefits of NIs were small in healthy adults and children suffering from influenza-like illness (GRADE high to moderate). Oseltamivir reduced antibiotic usage in healthy adults according to one SR, but this was not confirmed by other reviews (GRADE low). Zanamivir showed a preventive effect on antibiotic usage in children (95% (77–99);GRADE moderate) and on the occurrence of bronchitis in at-risk individuals (59% (30–76);GRADE moderate). No evidence was available on the treatment benefits of NIs in elderly and at-risk groups and their effects on hospitalization and mortality. In oseltamivir trials, nausea, vomiting and diarrhea were significant side-effects. For zanamivir trials, no adverse effects have been reported. The combination of diagnostic uncertainty, the risk for virus strain resistance, possible side effects and financial cost outweigh the small benefits of oseltamivir or zanamivir for the prophylaxis and treatment of healthy individuals. No relevant benefits of these NIs on complications in at-risk individuals have been established.

Efficacy of daily intake of Lactobacillus casei Shirota on respiratory symptoms and influenza vaccination immune response: a randomized, double-blind, placebo-controlled trial in healthy elderly nursing home residents

BACKGROUND Age is associated with immune dysregulation, which results in an increased infection rate and reduced effectiveness of vaccination. OBJECTIVE We assessed whether an intervention with Lactobacillus casei Shirota (LcS) in elderly nursing home residents reduced their susceptibility to respiratory symptoms and improved their immune response to influenza vaccination. DESIGN Between October 2007 and April 2008, a randomized, double-blind, placebo-controlled trial was conducted in 737 healthy people aged ≥ 65 y in 53 nursing homes in Antwerp, Belgium. Volunteers were randomly assigned to receive a probiotic (n = 375; 2 bottles of fermented milk that contained ≥ 6.5 × 10(9) live LcS/bottle) or a placebo (n = 362; similar drink with no bacteria) for 176 d. After 21 d, all subjects received an influenza vaccination. Primary outcome parameters were the number of days with respiratory symptoms, the probability of respiratory symptoms, and antiinfluenza antibody titer by hemagglutination inhibition after vaccination. RESULTS Univariate and multivariate modeling showed no effect of the probiotic on clinical outcome parameters. Generalized linear mixed modeling showed no effect of the probiotic itself on the probability of respiratory symptoms [OR of probiotic: 0.8715; 95% CI: 0.6168, 1.2887). No significant difference regarding the influenza-vaccination immune response was shown. CONCLUSION The results of this study show that daily consumption of a fermented milk drink that contains LcS has no statistically or clinically significant effect on the protection against respiratory symptoms. This trial was registered at clinicaltrials.gov as NCT00849277.

Improving Care And Research Electronic Data Trust Antwerp (iCAREdata): a research database of linked data on out-of-hours primary care

BackgroundPrimary out-of-hours care is developing throughout Europe. High-quality databases with linked data from primary health services can help to improve research and future health services.MethodsIn 2014, a central clinical research database infrastructure was established (iCAREdata: Improving Care And Research Electronic Data Trust Antwerp, www.icaredata.eu) for primary and interdisciplinary health care at the University of Antwerp, linking data from General Practice Cooperatives, Emergency Departments and Pharmacies during out-of-hours care. Medical data are pseudonymised using the services of a Trusted Third Party, which encodes private information about patients and physicians before data is sent to iCAREdata.ResultsiCAREdata provides many new research opportunities in the fields of clinical epidemiology, health care management and quality of care. A key aspect will be to ensure the quality of data registration by all health care providers.ConclusionsThis article describes the establishment of a research database and the possibilities of linking data from different primary out-of-hours care providers, with the potential to help to improve research and the quality of health care services.

Staphylococcus aureus, Including Meticillin-Resistant Staphylococcus aureus, among General Practitioners and Their Patients: A Cross-Sectional Study

Background The role of general practitioners (GPs) as reservoir and potential source for Staphylococcus aureus (SA) transmission is unknown. Our primary objective was to evaluate the prevalence of SA and community-acquired methicillin resistant SA (CA-MRSA) carrier status (including spa typing) among GPs and their patients in Belgium. The secondary objective was to determine the association between SA/CA-MRSA carriage in patients and their characteristics, SA carriage in GPs, GP and practice characteristics. Methods The Belgian GPs, who swabbed their patients in the APRES study (which assessed the prevalence of SA nasal carriage in nine European countries; November 2010 –June 2011), were asked to swab themselves as well (May-June 2011). GPs and their patients had to complete a questionnaire on factors related to SA carriage and transmission. SA isolation including CA-MRSA and spa typing was performed on the swabs. Results In eighteen practices 34 GPs swabbed patients of which 25 GPs provided personal swabs. The analysis was performed on 3008 patient records. Among GPs SA carriage (28%) was more prevalent than among their patients (19.2%), but CA-MRSA carriage was not present. SA was more prevalent among younger patients and those living with cattle. Spa typing SA and MRSA strains did not suggest correlation within practices or between patients and GPs, but chronic skin conditions of GPs and always handshaking patients by SA positive GPs were associated with more SA among patients, and hand washing after every patient contact with less SA among patients in practices with high antibiotic prescribing rates. Conclusion No MRSA was found among GPs, although their SA carriership was higher compared to their patients’. Spa types did not cluster within practices, possibly due to difference in timing of swabbing. To minimise SA transmission to their patients GPs should consider taking appropriate care of their chronic skin diseases, antibiotic prescribing behaviour, handshaking and hand washing habits.

Reducing inappropriate A&E attendances

Ismail et al clearly show that interventions in primary care do not decrease the number of inappropriate attendances at accident and emergency departments (A&E), nor increase patient self-care.1 In Belgium (Flanders), we observed a large increase in attendance of young children at primary care out-of-hours (PCOOH) services after implementation of a general practice cooperative (GPC).2,3 Recently, data from new PCOOH services in colocation …

Implementation of a general practitioner cooperative adjacent to the emergency department of a hospital increases the caseload for the GPC but not for the emergency department.

Background: The implementation of general practitioner cooperatives (GPC) for out-of-hours (OOH) primary care, raises the question if the location of a GPC adjacent to a hospital reduces the OOH caseload of the emergency department (ED). Methods: Two natural experiments were used in this before–after study, the effect of the implementation of two GPCs in two different regions on the out-of-hours caseload of the local EDs was compared. One GPC was located adjacent to the ED of a general hospital, the other was not. GPCs (or rota systems) and EDs in comparable regions were selected as control groups during the same study period. The study was performed in Flanders (Belgium) with no gatekeeping function for general practitioners (GPs). Results: After implementation of the GPC there was a significantly increase in caseload at the GPC in the two regions, mainly due to an increase of consultations with small children. There were no significant changes in caseload at the ED services. Self-referrals’ to the ED did not change significantly. For the GPs the number of home visits decreased during out-of-hours in one region. Conclusion: In a country with no gatekeeping role for GPs, implementing a GPC increased the out-of-hours caseload of the GPCs. The caseload of the EDs stabilised during the study period.

Zanamivir for influenza in adults and children shows limited benefit for treatment of symptomatic influenza and no effect on relevant complications

Commentary on : Heneghan CJ, Onakpoya I, Thompson M, et al. Zanamivir for influenza in adults and children: systematic review of clinical study reports and summary of regulatory comments. BMJ 2014;348:g2547.[OpenUrl][1][Abstract/FREE Full Text][2] The neuraminidase inhibitor zanamivir, administered as an inhaled powder, is approved for the prevention and treatment of influenza in adults and children older than 7 years. Previous systematic reviews (SRs) of zanamivir may have been affected by publication bias and missing data, and clinical recommendations based on such studies should be considered inadequate.1 ,2 To deal with these shortcomings, this SR and meta-analysis (an update of a Cochrane Review)3 reanalysed the prophylactic and treatment effects of zanamivir on those suffering from influenza, based on the full clinical study reports of all relevant trials provided by the manufacturer and on regulatory comments. This review included randomised controlled trials (RCTs) testing zanamivir compared with placebo for … [1]: {openurl}?query=rft.jtitle%253DBMJ%26rft_id%253Dinfo%253Adoi%252F10.1136%252Fbmj.g2547%26rft_id%253Dinfo%253Apmid%252F24811412%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [2]: /lookup/ijlink?linkType=ABST&journalCode=bmj&resid=348/apr09_2/g2547&atom=%2Febmed%2F20%2F1%2F7.atom

Keeping infection at arm's length.

In their Report “Topographical and temporal diversity of the human skin microbiome” (29 May, p. [1190][1]), E. A. Grice et al. found that the richest area (in ecological terms) appeared to be the volar forearm, and the antecubital fossa topped the diversity list. This is the exact site

Therapietrouw bij een antibioticabehandeling: Therapietrouw bij een antibioticabehandeling

SamenvattingIn de huisartsenpraktijk valt het op dat patiënten vaak een voorgestelde antibioticatherapie niet nemen, te laag gedoseerd nemen of vroegtijdig stoppen. Patiënten lijken te weinig kennis te hebben over het belang van de juiste inname van een antibioticum. Meerdere onderzoeken gebeurden al over therapietrouw bij chronisch medicatiegebruik.1,2