Morten Lindbæk

Randomised, double blind, placebo controlled trial of penicillin V and amoxycillin in treatment of acute sinus infections in adults.

Abstract Objective: To compare the effectiveness of penicillin V and amoxycillin with placebo in treatment of adult patients with acute sinusitis. Design: Randomised, double blind, placebo controlled trial. Setting: Norwegian general practice. Subjects: 130 adult patients with a clinical diagnosis of acute sinusitis confirmed by computed tomography. Main outcome measures: Subjective status after three and 10 days of treatment, difference in clinical severity score between day 0 and day 10 as evaluated by the general practitioner, difference in score from computed tomography on day 0 and day 10, and duration of sinusitis. Results: Amoxycillin and penicillin V led to significantly faster and better recovery than placebo. By day 10, 71 patients receiving antibiotic treatment (86%) considered themselves to be recovered or much better compared with 25 (57%) receiving placebo. The mean (95% confidence interval) reductions in clinical severity scores by day 10 were 5.4 (5.0 to 5.8) for penicillin V, 5.5 (4.9 to 6.0) for amoxycillin, and 3.4 (2.8 to 4.0) for placebo. For the antibiotic groups combined the number of patients with the greatest degree of improvement on computed tomography (scale 0-16)—that is, score 5-16 on day 10—was 31/83 (37%) compared with 10/44 (23%) receiving placebo. The median duration of the sinusitis was nine days in the amoxycillin group, 11 days in the penicillin V group, and 17 days in the placebo group. Conclusion: Penicillin V and amoxycillin are significantly more effective than placebo in the treatment of acute sinusitis. Key messages The median duration of sinusitis with different treatment was nine days for amoxycillin, 11 days for penicillin V, and 17 days for placebo More than half of the patients receiving antibiotic treatment reported side effects but few gave severe discomfort Half of the patients receiving placebo tablets felt restored or much better after 10 days

Improving antibiotic prescribing in acute respiratory tract infections: cluster randomised trial from Norwegian general practice (prescription peer academic detailing (Rx-PAD) study)

Objective To assess the effects of a multifaceted educational intervention in Norwegian general practice aiming to reduce antibiotic prescription rates for acute respiratory tract infections and to reduce the use of broad spectrum antibiotics. Design Cluster randomised controlled study. Setting Existing continuing medical education groups were recruited and randomised to intervention or control. Participants 79 groups, comprising 382 general practitioners, completed the interventions and data extractions. Interventions The intervention groups had two visits by peer academic detailers, the first presenting the national clinical guidelines for antibiotic use and recent research evidence on acute respiratory tract infections, the second based on feedback reports on each general practitioner’s antibiotic prescribing profile from the preceding year. Regional one day seminars were arranged as a supplement. The control arm received a different intervention targeting prescribing practice for older patients. Main outcome measures Prescription rates and proportion of non-penicillin V antibiotics prescribed at the group level before and after the intervention, compared with corresponding data from the controls. Results In an adjusted, multilevel model, the effect of the intervention on the 39 intervention groups (183 general practitioners) was a reduction (odds ratio 0.72, 95% confidence interval 0.61 to 0.84) in prescribing of antibiotics for acute respiratory tract infections compared with the controls (40 continuing medical education groups with 199 general practitioners). A corresponding reduction was seen in the odds (0.64, 0.49 to 0.82) for prescribing a non-penicillin V antibiotic when an antibiotic was issued. Prescriptions per 1000 listed patients increased from 80.3 to 84.6 in the intervention arm and from 80.9 to 89.0 in the control arm, but this reflects a greater incidence of infections (particularly pneumonia) that needed treating in the intervention arm. Conclusions The intervention led to improved antibiotic prescribing for respiratory tract infections in a representative sample of Norwegian general practitioners, and the courses were feasible to the general practitioners. Trial registration Clinical trials NCT00272155.

Cochlear implants and quality of life: A prospective study

Objective: To evaluate changes in quality of life, anxiety, and depression after cochlear implantation in adults. Design: Twenty-seven postlingually deafened adults who had received a MED-EL Combi 40+ implant were investigated. One generic Health-Related Quality of Life measure, the SF-36, two disease-specific measures, the Patient Quality of Life Form (PQLF) and the Index Relative Questionnaire Form (IRQF) completed by a near relative to the patient, in addition to a domain specific measure, the Hopkins Symptom Check List 25 items (HSCL-25), were used in a prospective study. The subjects were investigated before surgery and 12 to 15 months after surgery. Results: The scores were significantly better after surgery in four of six categories of the PQLF. In the IRQF, where a family member of the cochlear implant recipient was studied, the scores were significantly better in four of five categories. There was a significant improvement in the HSCL-25 scores after surgery. In the SF-36, only one of eight scales showed significant improvement. Conclusions: Cochlear implants were associated with statistically significant improvement in quality of life in postlingually deafened adults. The improvements were largest in the categories concerning communication, feelings of being a burden, isolation, and relations to friends and family. The implants also improved the relatives’ daily lives. There was a statistically significant reduction in degree of depression and anxiety. Reduction in anxiety and depression was associated with gain in quality of life.

GPs’ antibiotic prescription patterns for respiratory tract infections – still room for improvement

Abstract Objective. Inappropriate use of antibiotics is associated with increased antibiotic resistance in the community. About 90% of all antibiotic prescriptions in Norway are issued by general practitioners and in 60% issued for respiratory tract infections. The article describes and analyses antibiotic prescription patterns by general practitioners in Vestfold, Norway. Design. Prospective cohort study. Subjects. A total of 145 list-holding general practitioners in Vestfold, Norway in February to March 2003. Methods. Merging of two electronic administrative data sets: antibiotic prescriptions dispensed in pharmacies and general practitioners’ electronic bills from the National Insurance Agency. Main outcome measures. Proportion and type of antibiotic prescribed for different respiratory tract infectious diagnoses. Results. We found large variations among general practitioners’ antibiotic prescription habits. In 27% of consultations with RTI diagnoses, an antibiotic was prescribed; 37% were for Penicillin V and 28% for a macrolide. Quinolones and cephalosporins were only rarely prescribed. In a logistic regression analysis the following factors were independently associated with antibiotic prescription rate: type of infection, type of contact, being a general practitioner specialist, and years since medical exam. In another logistic regression analysis the following factors were independently associated with broad-spectrum antibiotic prescription: type of infection, age of patient, type of contact, being a specialist, length of list, and being a high prescriber of antibiotics. Conclusion. The variation in proportion of total antibiotic prescribing and broad-spectrum prescription for respiratory tract infections is high, and reveals potentials to change general practitioners’ prescription behaviour, in order to maintain the positive situation in Norway as to antibiotic resistance.

Are children carrying the burden of broad-spectrum antibiotics in general practice? Prescription pattern for paediatric outpatients with respiratory tract infections in Norway

Objectives To investigate the antibiotic prescription pattern and factors that influence the physicians’ choice of antibiotic. Design Observational study. Setting Primary healthcare in Norway, December 2004 through November 2005. Participants 426 general practitioners, GPs, in Norway, giving 24 888 respiratory tract infection episodes with 19 938 children aged 0–6 years. Outcome measures Assess antibiotic prescription details and patient and GP characteristics associated with broad-spectrum and narrow-spectrum antibiotic use. Results Of the 24 888 episodes in the study, 26.2% (95% CI 25.7% to 26.8%) included an antibiotic prescription. Penicillin V accounted for 42% and macrolide antibiotics for 30%. The prescription rate varied among the physicians, with a mean of 25.5% (95% CI 24.2% to 26.7%). Acute tonsillitis gave the highest odds for a prescription, OR 33.6 (95% CI 25.7% to 43.9%), compared to ‘acute respiratory tract infections and symptoms’ as a reference group. GPs with a prescription rate of 33.3% or higher had the larger probability for broad-spectrum antibiotic prescriptions, OR 3.33 (95% CI 2.01% to 5.54%). Antibiotic prescriptions increased with increasing patient age. Conclusions We found a low antibiotic prescription rate for childhood respiratory tract infections. However, our figures indicate an overuse of macrolide antibiotics and penicillins with extended spectrum, more so than in the corresponding study including the adult population. Palatability of antibiotic suspensions and other administrative challenges affect medication compliance in children. To help combat antibiotic resistance, guidelines need to be followed, in particular for our youngest patients. Trial registration number (clinicaltrials.org) NCT00272155.

Can antibiotic prescriptions in respiratory tract infections be improved? A cluster-randomized educational intervention in general practice - The Prescription Peer Academic Detailing (Rx-PAD) Study [NCT00272155]

BackgroundMore than half of all antibiotic prescriptions in general practice are issued for respiratory tract infections (RTIs), despite convincing evidence that many of these infections are caused by viruses. Frequent misuse of antimicrobial agents is of great global health concern, as we face an emerging worldwide threat of bacterial antibiotic resistance. There is an increasing need to identify determinants and patterns of antibiotic prescribing, in order to identify where clinical practice can be improved.Methods/DesignApproximately 80 peer continuing medical education (CME) groups in southern Norway will be recruited to a cluster randomized trial. Participating groups will be randomized either to an intervention- or a control group. A multifaceted intervention has been tailored, where key components are educational outreach visits to the CME-groups, work-shops, audit and feedback. Prescription Peer Academic Detailers (Rx-PADs), who are trained GPs, will conduct the educational outreach visits. During these visits, evidence-based recommendations of antibiotic prescriptions for RTIs will be presented and software will be handed out for installation in participants PCs, enabling collection of prescription data. These data will subsequently be linked to corresponding data from the Norwegian Prescription Database (NorPD). Individual feedback reports will be sent all participating GPs during and one year after the intervention. Main outcomes are baseline proportion of inappropriate antibiotic prescriptions for RTIs and change in prescription patterns compared to baseline one year after the initiation of the tailored pedagogic intervention.DiscussionImprovement of prescription patterns in medical practice is a challenging task. A thorough evaluation of guidelines for antibiotic treatment in RTIs may impose important benefits, whereas inappropriate prescribing entails substantial costs, as well as undesirable consequences like development of antibiotic resistance. Our hypothesis is that an educational intervention program will be effective in improving prescription patterns by reducing the total number of antibiotic prescriptions, as well as reducing the amount of broad-spectrum antibiotics, with special emphasis on macrolides.

Which is the best method to trace group A streptococci in sore throat patients: culture or GAS antigen test?

Objective – To compare an antigen detection test (GAS antigen test) with the results from combinations of two various bacteriological test media in general practice patients with sore throat. Furthermore to assess the diagnostic properties of the chosen GAS antigen test and to compare semi-quantitative results of this test with the bacterial load found in the throat culture. Setting – Two Norwegian general practices in Stokke and Kongsberg communities. Subjects – 306 patients with sore throat lasting less than 7 days; 244 were adults, 62 were children under 10 years old, mean age 23.9 years (SD 15.0), 40% were men. Main outcome measures – Results from GAS antigen test, and distribution of bacteriological findings in throat cultures, compared with the results of our GAS antigen test; semi-quantitative results of the GAS antigen test compared with the bacterial load by culture. Results – In the primary culture 110 patients harboured group A streptococci (GAS) infection, while the second culture identified another 17, giving a total of 127 patients. Some 33 patients harboured large-colony groups C and G. The GAS antigen test used had a sensitivity of 97% and specificity of 95% regarding GAS when compared with the two cultures. We found a significant correlation between the bacterial loads by culture and the semi-quantitative results of the GAS antigen test. Conclusions – By using a second, different set of bacteriological media, we identified an additional 17 patients with GAS infections. This raises the question of validity of frequently used reference standards in studies related to streptococcal infections. Compared with the combined results of the two throat cultures, the GAS antigen test used showed high sensitivity and specificity. Semi-quantitative evaluations of the rapid immunological test may also be of clinical value.

Pregnancy outcome after gestational exposure to erythromycin – a population‐based register study from Norway

AIMS Erythromycin is a macrolide antibiotic indicated for respiratory tract infections, genital chlamydia and skin infections. It has recently been suggested that erythromycin use in the first trimester of pregnancy can increase the risk of congenital cardiovascular malformations. This study aimed to determine whether erythromycin exposure in the first trimester is associated with cardiovascular or other malformations. METHODS We studied 180 120 women in Norway who were pregnant during 2004-2007. Data on all live births stillbirths and induced abortions after 12 gestational weeks from The Medical Birth Registry of Norway (MBRN) were linked to information from the Norwegian prescription database (NorPD). We compared the pregnancy outcomes of women who had taken erythromycin (n= 1786, 1.0%), penicillin V (n= 4921, 2.7%) or amoxicillin (n= 1599, 0.9%) in their first trimester with outcomes of women who had not taken any systemic antibiotics (n= 163 653, 90.9%) during this period. RESULTS The risk of cardiovascular malformations was not significantly different with or without exposure to erythromycin in the first trimester (adjusted OR = 1.2 [95% CI 0.8, 1.8]) or in the most vulnerable period of heart formation (adjusted OR = 1.6 [95% CI 0.9-3.0]). Sub-analyses showed that the risk for any specific malformations was not increased with erythromycin, macrolides, penicillin V or amoxicillin compared with no antibiotic use in first trimester. CONCLUSIONS This large, population-based register study did not find that exposure to erythromycin or macrolides in the first trimester of pregnancy was associated with fetal cardiovascular or other malformations. These results suggest that the risk of erythromycin use during early pregnancy, if any, is low.

Clinical course of suspected viral sore throat in young adults: Cohort study

Objective. To evaluate the natural clinical course of suspected viral sore throat. Design. Prospective cohort study. Setting. Five military camps in Norway. Methods. In a randomized placebo-controlled trial comparing the effect of bovine colostrum tablets or placebo on non-streptococcal sore throat in young adults no statistically significant difference in illness duration was found. The participants were thus regarded as one cohort. The authors analysed 10.0 cm visual analogue scales (VAS) scores for ‘sickness’ and sore throat, using 1.0 cm as a cut-off for recovery. They furthermore explored whether the VAS for sore throat was a good test to discriminate between recovered/not recovered by use of a receiver operating characteristic (ROC) curve. Results. For sore throat, it was found that 51% had recovered by day 6 and 91% had recovered by day 8. Similarly for sickness, 65% had recovered by day 6 and 94% by day 8. The daily VAS scores for ‘sickness’ and sore throat were highly correlated (p = 0.001). The mean day of recovery from ‘sickness’ and sore throats (based on VAS scores) was 5.5 and 4.7 respectively and 5.3 based on the dichotomous outcome for throat pain. The ROC curve revealed that a VAS score < 1.0 was the best cut-off point for recovery, with a sensitivity of 0.74 and a specificity of 0.90. Conclusion. Almost all the patients had recovered by day 8. A high correlation was found between sickness and sore throat. These data will assist clinicians and others promoting self-care to set realistic expectations regarding recovery from URTI in young adults.

Syndromic management of sexually transmitted diseases in Botswana's primary health care: quality of care aspects.

Objectives To evaluate the quality of care of the syndromic management of sexually transmitted diseases (STDs) in Botswanas primary health care.