Carles Llor

Variabilidad de la prescripción antibiótica en las infecciones respiratorias en dos países de Europa

BACKGROUND Treatment for respiratory tract infections (RTI) in the primary care setting is empirical. Antibiotic prescribing patterns differ among countries and are based on the prevalence of antibiotic resistance in the geographical area. The aim of this study was to compare the antibiotics prescribed by general practitioners (GPs) for RTIs between Spain and Denmark. METHODS Observational multicenter survey carried out in the primary healthcare setting. Two groups of GPs in Spain and Denmark recorded all contacts with RTI patients during a 3-week period between November 2001 and January 2002. RESULTS A total of 2833 RTI cases were registered. Broad-spectrum penicillins and combinations of these drugs plus beta-lactamase inhibitors were the antibiotics most frequently prescribed by Spanish GPs (62.3%), followed by macrolides (22.3%). In contrast, narrow-spectrum penicillins were most commonly prescribed by Danish GPs (58% of all prescriptions), followed by macrolides (29%) (P < .001). Antibiotics most frequently prescribed for ear, tonsillar, sinus and bronchopulmonary infections were broad-spectrum penicillins among Spanish GPs and narrow-spectrum penicillins in Denmark. Spanish GPs prescribed penicillin V only for tonsillitis, accounting for 5.1% of the antibiotics used for this condition, whereas this drug accounted for 91.7% of the prescriptions by their Danish colleagues for the same indication. CONCLUSIONS The substantial differences in RTI management between the participating GPs should make us reflect on the rational use of antibiotics. The discrepancies disclosed may indicate dissimilarities in recommendations, traditions, habits, or antibiotic pressures between the countries studied.

Utilización de Internet en un estudio multicéntrico sobre EPOC en atención primaria. Fase piloto del estudio EFEMAP

Objetivos Conocer la viabilidad de la recogida y transmision de datos clinicos por Internet en un estudio multicen-trico en atencion primaria Pacientes Y Metodos Estudio observacional, multicentrico sobre una poblacion de pacientes con enfermedad pul-monar obstructiva cronica agudizada. Todos los datos se recogieron en un formulario electronico disenado especificamente, que se encontraba incorporado en un ordenador portatil de bolsillo. La transmision de los datos se efectuo on line a una base de datos unificada mediante conexion telefonica por modem Resultados Participaron en esta fase piloto 39 investigadores, que incluyeron a 324 pacientes durante 3 meses. Se generaron 37 consultas telefonicas, la mayoria (54%) referida al funcionamiento del cuestionario electronico, que se soluciono en un promedio de 5,44 min. La metodologia utilizada no presento ningun problema tecnico de importancia ni se detecto ninguna perdida de informacion Conclusiones La utilizacion de Internet en estudios multicentricos en atencion 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 gra-bacion de los mismos tras finalizar el estudio

Etiología bacteriana de la agudización de la bronquitis crónica en atención primaria

Objetivo Pocos estudios se han efectuado en el ambito comunitario para conocer la prevalencia de microorganismos causantes de agudizaciones de la bronquitis cronica. El objetivo del presente estudio ha sido conocer la etiologia bacteriana de la agudizacion de la bronquitis cronica en pacientes que no han requerido hospitalizacion. Pacientes y metodos Se trata de un estudio observacional, transversal y multicentrico, efectuado en atencion primaria de salud durante 2 semanas (noviembre de 2001 y enero de 2002) conun laboratorio central. Participaron 1.947 pacientes afectados de agudizacion leve-moderada incluidos por un total de 650 medicos de atencion primaria. Todas las muestras recibidas se procesaron en un laboratorio central con tincion de Gram, examen microscopico de las muestras y cultivo bacteriano. Resultados Entre los 1.537 cultivos de esputo recogidos, 498 presentaron buena calidad celular microscopica (32,4%). De las 498 muestras de esputo de calidad optima analizadas, fueron positivas 246 (49,4%) y se obtuvieron 468 aislamientos. l germen mas comunmente aislado fue Streptococcus pneumoniae , con 163 casos (34,8%), seguido de Moraxella catarrhalis , con 112 (23,9%), y Haemophilus influenzae , con 59 (12,6%). El 1,2% de los neumococos fueron resistentes a amoxicilina y un 34,3% a los macrolidos. Los antibioticos mayormente prescritos fueron, sin embargo, los macrolidos, en el 38,3% de las ocasiones. Conclusiones S. pneumoniae constituye el microorganismo bacteriano que con mas frecuencia se aisla de los pacientes que sufren agudizaciones de la bronquitis cronica que pueden ser tratados ambulatoriamente.

Factores de riesgo de elevado coste de las agudizaciones de la bronquitis crónica y la EPOC

Objetivo: Identificar las variables de los pacientes, de las agudizaciones y del tratamiento de la bronquitis cronica (BC) y la enfermedad pulmonar obstructiva cronica (EPOC) que se asocian con un mayor coste sanitario directo. Metodo: Estudio observacional y farmacoeconomico en pacientes con BC y EPOC con agudizacion de probable etiologia bacteriana, definida por presentar 2 o mas de los criterios de Anthonisen. Se siguio a los pacientes durante 30 dias y se evaluaron los costes directos derivados de su atencion. El analisis estadistico se efectuo mediante regresion logistica con calculo de las odds ratio (OR) ajustadas, considerando variable dependiente un coste de agudizacion superior a los 150 ?. Resultados: Participaron 252 medicos que recabaron informacion sobre 1.164 pacientes. Se recogieron todos los parametros farmacoeconomicos en 947 pacientes (82,6%). En los primeros 30 dias, 206 acudieron por mala evolucion (21,8%), 69 (7,3%) requirieron atencion 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 hospitalizacion previa (OR = 2,6), mientras que el diagnostico de BC (OR = 0,41) y el tratamiento de la agudizacion con moxifloxacino o amoxicilina-acido clavulanico, comparado con claritromicina (OR = 0,38), se asociaron a un coste bajo. Conclusion: Un 21,8% de los pacientes con agudizacion de la BC y EPOC fracasa, con lo que se genera un coste mayor, fundamentalmente por nuevas visitas medicas y solicitud de pruebas complementarias. Las variables que se asocian a una agudizacion de coste elevado son la oxigenoterapia continua, la hospitalizacion previa y el tratamiento con claritromicina comparada con moxifloxacino o amoxicilina-acido clavulanico.

Bacterial etiology of chronic bronchitis exacerbations treated by primary care physicians

OBJECTIVE Few studies have been carried out to determine the prevalence of microorganisms causing exacerbations of chronic bronchitis in the community setting. The aim of the present study was to determine the bacterial etiology of chronic bronchitis exacerbations in patients not requiring hospitalization. PATIENTS AND METHODS This observational, cross-sectional, multicenter study was carried out at the primary care level during 2 weeks (in November 2001 and January 2002). All laboratory work was carried out at a single center. We studied 1,947 patients with mild-moderate exacerbations treated by 650 primary care physicians. All the sputum samples received for centralized processing were subject to Gram staining, microscopic examination, and bacterial culture. RESULTS Out of 1,537 cultures of sputum samples collected, 498 had good cell quality for microscopic examination (32.4%). Of the 498 good quality samples analyzed, 246 (49.4%) were positive and 468 isolates were obtained. The most commonly isolated germ was Streptococcus pneumoniae (163 cases, 34.8%), followed by Moraxella catarrhalis (112, 23.9%), and Haemophilus influenzae (59, 12.6%). In 1.2% of the S. pneumoniae isolates resistance was found to amoxicillin; resistance to macrolides was found in 34.3%. The antibiotics most commonly prescribed, however, were macrolides (38.3% of the prescriptions). CONCLUSIONS S. pneumoniae was the microorganism most frequently isolated in cases of chronic bronchitis exacerbation treatable in this outpatient setting.

Effectiveness of two types of intervention on antibiotic prescribing in respiratory tract infections in Primary Care in Spain. Happy Audit Study

Objective To evaluate the effectiveness of two types of intervention in reducing antibiotic prescribing in respiratory tract infections (RTI). Design Before–after audit-based study. Setting Primary Care centres in Spain. Participants General practitioners (GPs) registered all patients with RTIs for 15 days in winter 2008 (pre-intervention), and again in winter 2009 (post-intervention). Interventions Intervention activities included meetings, with the presentation and discussion of the results, and several training meetings on RTI guidelines, information brochures for patients, workshops on point-of-care tests – rapid antigen detection tests and C-reactive protein rapid test – and provision of these tests in the clinic. All GPs, with the exception of those in Catalonia, made up the full intervention group (FIG); conversely, Catalan doctors underwent the same intervention, except for the workshop on rapid tests (partial intervention group, PIG). Multilevel logistic regression was performed taking the prescription of antibiotics as the dependent variable. Results Out of a total of 309 GPs involved in the first register, 281 completed the intervention and the second register (90.9%), of which 210 were assigned to the FIG, and 71 to the PIG. The odds ratio of antibiotic prescribing after the intervention was 0.99 (95% CI: 0.89–1.10) among GPs assigned to PIG, and 0.50 (95% CI: 0.44–0.57, p < 0.001) among those who were allocated to FIG. The reduction in antibiotic prescribing in FIG was more marked in flu infection, common cold, acute pharyngitis, acute tonsillitis, and acute bronchitis. Conclusions Active participation of GPs with the performance of point-of-care tests in the clinic is accompanied by a drastic reduction of antibiotic use in RTIs, primarily in infections considered as mainly viral.

The use of amoxicillin and clavulanic acid and quinolones as first choice antibiotics in uncomplicated urinary tract infections in Spain should be reviewed.

Urinary tract infections (UTI) represent a common problem in primary care consultations.1 Uncomplicated communityacquired cystitis is caused by Escherichia coli in approximately 90% of cases.2 The current management of acute uncomplicated cystitis is usually empirical, with neither urine cultures or susceptibility testing being used to guide therapy. Thus, empirical treatment in UTIs should cover E. coli. Resistance of this bacterium to amoxicillin and clavulanic acid and quinolones, albeit variable, is increasing in Spain and may lead to clinical failure.3 The aim of this study was to evaluate the non-susceptibility of Escherichia coli to five commonly prescribed antibiotics in 2006 and 2009. A retrospective analysis of susceptibility towards five antimicrobial agents (amoxicillin and clavulanic acid, cefuroxime, third generation cephalosporins -expressed as percentage of extended-spectrum -lactamases -ciprofloxacin, trimethoprim and sulfamethoxazole, and fosfomycin) among E. coli strains was carried out in urine cultures requested in 2006 and 2009 by primary care physicians, microbiologists and doctors working in the hospital setting. The susceptibility to these antibiotics was determined using automatic microdilution systems -Microscan (Baxter), Wider (Soria-Melguizo), Vitek (Bio-Mérieux) and Phoenix (Bekton-Dickinson) and/or disc-plates. The participating centres were the Hospital of Basurto (Bilbao), Bon Pastor laboratory (Barcelona), Hospital of Donostia (San Sebastián),

Estimated saving of antibiotics in pharyngitis and lower respiratory tract infections if general practitioners used rapid tests and followed guidelines

Introduction General practitioners (GP) in Spain do not have access to rapid tests and adherence to guidelines is usually suboptimal. The aim of the study is to evaluate the estimated number of antibiotics that could have been saved if GPs had appropriately used these tests and had followed the guidelines. Design Observational study. Setting Primary care centres from eight Autonomous Communities in Spain. Participants GPs who had not participated in previous studies on rational use of antibiotics. Intervention GPs registered all the cases of pharyngitis and lower respiratory tract infections (LRTI) during 15 working days in 2015, by means of a 47-item audit. Main measurements Actual GPs’ antibiotic prescription and estimated number of antibiotics that could have been saved according to recent guidelines. Results A total of 126 GPs registered 1012 episodes of pharyngitis and 1928 LRTIs. Antibiotics were given or patients were referred in 497 patients with pharyngitis (49.1%) and 963 patients with LRTI (49.9%). If GPs had appropriately used rapid antigen detection tests and C-reactive protein tests and had strictly followed current guidelines, antibiotics would have been given to 7.6% and 15.1%, respectively, with an estimated saving of 420 antibiotics in patients with sore throat (estimated saving of 84.5%; 95% CI: 81.1–87.4%) and 672 antibiotics in LRTIs (estimated saving of 69.8%,95% CI: 67.1–72.5%). Conclusions GP adherence to guidelines and a correct introduction of rapid tests in clinical practice in Spain could result in a considerable saving of unnecessary prescription of antibiotics in pharyngitis and LRTIs.

Uso prudente de antibióticos y propuestas de mejora desde la atención primaria

Resumen Una tercera parte de las consultas en atencion primaria (AP) obedece a una enfermedad infecciosa y en mas de la mitad de estas se debe a una infeccion del tracto respiratorio. Los datos procedentes de la historia clinica y de la exploracion fisica no ayudan, en la mayoria de las ocasiones, a discernir si la etiologia de la infeccion es bacteriana o no y, en caso de duda, el medico de familia acostumbra a prescribir antibioticos a pesar del efecto marginal de estos medicamentos en la mayoria de las infecciones respiratorias. Ademas, los medicos de AP sobrestimamos la proporcion de pacientes con infecciones que esperan recibir un antibiotico y, a menudo, esta percepcion resulta ser erronea basandose en la literatura cientifica. Ademas, las expectativas de los pacientes suelen basarse en falsas asunciones o experiencias de consultas previas. Distintas estrategias han resultado ser utiles para hacer un uso mas prudente de antibioticos en AP. La prescripcion diferida de antibioticos se recomienda principalmente en infecciones no graves de supuesta etiologia viral en los pacientes que manifiestan su preferencia por recibir antibioticos. La mejora de las habilidades comunicativas tambien ha mostrado ser util para reducir la prescripcion antibiotica asi como la utilizacion de pruebas de diagnostico rapido en la consulta, principalmente tecnicas antigenicas rapidas para el diagnostico de la faringitis estreptococica y la determinacion de la proteina C reactiva. Los resultados del estudio Happy Audit, realizado recientemente en nuestro pais, asi lo confirman.

Selling antimicrobials without prescription – Far beyond an administrative problem

INTRODUCTION Selling antibiotics without prescription is common in many countries; beyond the administrative restrictions, this practice is a risk for patients and society. The aim of the study was to evaluate the information provided by the staff of the pharmacy to a simulated patient requesting an antibiotic. MATERIAL AND METHODS A prospective study was carried out in January 2013 - February 2014 in the Health Region of Tarragona, in which a mystery shopper visited 220 pharmacies requesting an antibiotic to be sold. RESULTS The actress was not asked about allergies in 73.9% of cases and never was asked about possible pregnancy. Recommendation to see a doctor was observed in 36.1% of cases. When antibiotics were not sold, the explanation provided by the staff was reasoned only in 9.9% of the cases. CONCLUSION It is necessary and urgent to improve the training of pharmacists in dispensing antibiotics but also strengthen basic health knowledge among the population.