Katarina Hedin

Asymptomatic bacteriuria in a population of elderly in municipal institutional care

Objective - To study the prevalence of asymptomatic bacteriuria (ABU) among patients in municipal institutional care for the elderly. Design - A cross-sectional study. Setting - Three different municipalities in southern Sweden. Subjects - 237 elderly people in municipal institutional care. Main outcome measures - Positive urine cultures. Results - In the first culture, the prevalence of bacteriuria was 42%; 47% for women and 30% for men. ABU occurred in 23% of the patients; in 26% of women and in 16% of men. Urinary incontinence was more common among patients with ABU. Conclusion - Bacteriuria is common among elderly people living in institutions. This should be borne in mind when patients in institutional care for the elderly have fever. Other differential diagnoses than urinary tract infection should be considered before antibiotic treatment is given.

Alcohol‐based hand‐disinfection reduced children's absence from Swedish day care centers

Aim: To determine if the use of alcohol‐based hand‐disinfection as a complement to regular hand washing at daycare centers (DCCs) can reduce the childhood rate of absenteeism.

Infection prevention at day-care centres: Feasibility and possible effects of intervention

Objective. To study the effect of an educationally oriented intervention programme, with the recommendations from the National Board of Health and Welfare as a base. Design. A prospective intervention study. Setting. Six day-care centres in Växjö, Sweden. Three centres comprised the intervention group and three constituted the control group. Subjects and main outcome measures. The parents and personnel completed a questionnaire on their views concerning information about infectious diseases. During a nine-month period, parents of all children reported every episode of absence, the number of days absent, the cause of absence, and any contact with doctors or prescription of antibiotics. Results. The guidelines were implementable in routine child day-care. Parents found regular information valuable and felt better informed about infectious diseases. Multilevel analyses showed no statistically significant results of the intervention. “Infection-prone” children had more sickness absence, doctors consultations, and antibiotic prescriptions than those not “infection-prone”. Conclusion. It is possible to implement an educationally oriented intervention programme directed against infectious diseases in child day-care. No significant effect of the intervention was found, which is why a larger intervention study is needed.

Management of patients with sore throats in relation to guidelines: An interview study in Sweden

Abstract Objective. To explore how a group of Swedish general practitioners (GPs) manage patients with a sore throat in relation to current guidelines as expressed in interviews. Design. Qualitative content analysis was used to analyse semi-structured interviews. Setting. Swedish primary care. Subjects. A strategic sample of 25 GPs. Main outcome measures. Perceived management of sore throat patients. Results. It was found that nine of the interviewed GPs were adherent to current guidelines for sore throat and 16 were non-adherent. The two groups differed in terms of guideline knowledge, which was shared within the team for adherent GPs while idiosyncratic knowledge dominated for the non-adherent GPs. Adherent GPs had no or low concerns for bacterial infections and differential diagnosis whilst non-adherent GPs believed that in patients with a sore throat any bacterial infection should be identified and treated with antibiotics. Patient history and examination was mainly targeted by adherent GPs whilst for non-adherent GPs it was often redundant. Non-adherent GPs reported problems getting patients to abstain from antibiotics, whilst no such problems were reported in adherent GPs. Conclusion. This interview study of sore throat management in a strategically sampled group of Swedish GPs showed that while two-thirds were non-adherent and had a liberal attitude to antibiotics one-third were guideline adherent with a restricted view on antibiotics. Non-adherent GPs revealed significant knowledge gaps. Adherent GPs had discussed guidelines within the primary care team while non-adherent GPs had not. Guideline implementation thus seemed to be promoted by knowledge shared in team discussions.

I'm Dr Jekyll and Mr Hyde: are GPs' antibiotic prescribing patterns contextually dependent? A qualitative focus group study.

Abstract Objective. To explore factors and circumstances contributing to prudent antibiotic prescribing for respiratory tract infections in primary care. Design. Two focus groups representing rural and urban areas. A semi-structured interview guide with open-ended questions and an editing analysis style was used. They were examined to identify meaning units that were sorted into categories in an iterative process throughout the analysis. Setting. Primary health care in two counties in southern Sweden. Subjects. Two groups including seven and six general practitioners (GPs) respectively, men and women of different ages with different professional experiences. Main outcome measures. Exploration of categories, determination of themes, construction of models. Results. The decision to prescribe antibiotics takes place in the encounter between GP and patient, initially characterized by harmony or fight and the subsequent process by collaboration or negotiation, resulting in agreement, compromise, or disagreement. Several factors influence the meeting and contribute to enhancing the conditions for rational prescribing. These conditions are connected to the GP, the relationship, and the setting; organization as well as professional culture. The findings indicate synergies between the factors, and that one factor can sometimes compensate for lack of another. Continuity and mutual trust can make a brief consultation successful, but lack of continuity can eliminate the effects of knowledge and professional skills. Conclusions. The findings emphasize the importance of the encounter between the GP and the patient for prudent antibiotic prescribing. Furthermore, the importance of an appropriate organization of primary care, which promotes continuity and encourages professional autonomy, is demonstrated.

Infections in families with small children: Use of social insurance and healthcare

Objective. To examine infectious symptoms on a daily basis in families with small children and how often these infections cause people to stay at home or seek healthcare. Design. A population-based prospective study. Setting. Child health clinics in seven municipalities in Sweden. Subjects and main outcome measures. All family members of 835 families who came with an 18-month-old child to a child health clinic were asked to register all infectious symptoms in a diary for a month. They were also asked to indicate whether they had stayed at home from day-care or school, whether social insurance had been used, and whether they had contacted healthcare facilities or seen a physician. Results. In total, 7% of the 18-month-old children and 34% of the parents had no symptoms during the winter month. The most common symptom was a runny nose. The 18-month-old children had 1.6 symptom episodes with an average duration of 5.6 days. Of the symptom episodes 13% led to contact with healthcare facilities and 6% to an antibiotic prescription. Of the symptom days 27% required staying at home and in 10% social insurance was claimed. Conclusion. Symptoms of infection among families with small children were common, with a runny nose being the most common. Physician consultations and antibiotic prescriptions were used in a small proportion of the symptom episodes. Social insurance was claimed in about one-third of the days with absence from day-care.

Reduction in antibiotic prescribing for respiratory tract infections in Swedish primary care- a retrospective study of electronic patient records.

BackgroundSwedish studies on antibiotic use in primary care have been based on one-week registrations of infections. In order to study adherence to guidelines, analyses based on large databases that provide information on diagnosis linked prescriptions, are needed. This study describes trends in management of infections in Swedish primary care particularly with regards to antibiotic prescribing and adherence to national guidelines.MethodsA descriptive study of Sweden’s largest database regarding diagnosis linked antibiotic prescription data, the Primary care Record of Infections in Sweden (PRIS), for the years 2008, 2010 and 2013.ResultsAlthough the consultation rate for all infections remained around 30% each year, antibiotic prescribing rates decreased significantly over the years from 53.7% in 2008, to 45.5% in 2010, to 38.6% in 2013 (p = .032). The antibiotic prescribing rate for respiratory tract infections (RTIs) decreased from 40.5% in 2008 to 24.9% in 2013 while those for urinary tract infections and skin and soft tissue infections were unchanged. For most RTI diagnoses there was a decrease in prescription rate from 2008 to 2013, particularly for the age group 0–6 years. Phenoxymethylpenicillin (PcV) was the antibiotic most often prescribed, followed by tetracycline. Tonsillitis and acute otitis media were the two RTI diagnoses with the highest number of prescriptions per 1000 patient years (PY). For these diagnoses an increase in adherence to national guidelines was seen, with regards to treatment frequency, choice of antibiotics and use of rapid antigen detection test. The frequency in antibiotic prescribing varied greatly between different Primary Healthcare Centres (PHCCs).ConclusionFalling numbers of consultations and decreased antibiotic prescription rates for RTIs have reduced the antibiotic use in Swedish primary care substantially. Overprescribing of antibiotics could still be suspected due to large variability in prescribing frequency, especially for acute bronchitis and sinusitis. Continuous evaluation of diagnosis linked prescribing data and feedback to doctors is essential in order to achieve a more prudent antibiotic use.

Physician consultation and antibiotic prescription in Swedish infants: population-based comparison of group daycare and home care.

Background: Daycare infants have more infectious episodes, see a physician more often, and are prescribed antibiotics more often than home care infants.

Uncertainty in clinical practice - an interview study with Swedish GPs on patients with sore throat.

BackgroundUncertainty is inevitable in clinical practice in primary care and tolerance for uncertainty and concern for bad outcomes has been shown to vary between physicians. Uncertainty is a factor for inappropriate antibiotic prescribing. Evidence-based guidelines as well as near-patient tests are suggested tools to decrease uncertainty in the management of patients with respiratory tract infections. The aim of this paper was to describe strategies for coping with uncertainty in patients with pharyngotonsillitis in relation to guidelines.MethodsAn interview study was conducted among a strategic sample of 25 general practitioners (GPs).ResultsAll GPs mentioned potential dangerous differential diagnoses and complications. Four strategies for coping with uncertainty were identified, one of which was compliant with guidelines, “Adherence to guidelines”, and three were idiosyncratic: “Clinical picture and C-reactive protein (CRP)”, “Expanded control”, and “Unstructured”. The residual uncertainty differed for the different strategies: in the strategy “Adherence to guidelines” and “Clinical picture and CRP” uncertainty was avoided, based either on adherence to guidelines or on the clinical picture and near-patient CRP; in the strategy “Expanded control” uncertainty was balanced based on expanded control; and in the strategy “Unstructured” uncertainty prevailed in spite of redundant examination and anamnesis.ConclusionThe majority of the GPs avoided uncertainty and deemed they had no problems. Their strategies either adhered to guidelines or comprised excessive use of tests. Thus use of guidelines as well as use of more near-patient tests seemed associated to reduced uncertainty, although the later strategy at the expense of compliance to guidelines. A few GPs did not manage to cope with uncertainty or had to put in excessive work to control uncertainty.

Near-patient tests and the clinical gaze in decision-making of Swedish GPs not following current guidelines for sore throat - a qualitative interview study

BackgroundExcessive antibiotics use increases the risk of resistance. Previous studies have shown that the Centor score combined with Rapid Antigen Detection Test (RADT) for Group A Streptococci can reduce unnecessary antibiotic prescribing in patients with sore throat. According to the former Swedish guidelines RADT was recommended with 2–4 Centor criteria present and antibiotics were recommended if the test was positive. C- reactive protein (CRP) was not recommended for sore throats. Inappropriate use of RADT and CRP has been reported in several studies.MethodsFrom a larger project 16 general practitioners (GPs) who stated management of sore throats not according to the guidelines were identified. Half-hour long semi-structured interviews were conducted. The topics were the management of sore throats and the use of near-patient tests. Qualitative content analysis was used.ResultsThe use of the near-patient test interplayed with the clinical assessment and the perception that all infections caused by bacteria should be treated with antibiotics. The GPs expressed a belief that the clinical picture was sufficient for diagnosis in typical cases. RADT was not believed to be relevant since it detects only one bacterium, while CRP was considered as a reliable numerical measure of bacterial infection.ConclusionsInappropriate use of near-patient test can partly be understood as remnants of outdated knowledge. When new guidelines are introduced the differences between them and the former need to be discussed more explicitly.