[Show abstract][Hide abstract] ABSTRACT: Background
Urinary tract infections (UTI) are the most frequent bacterial infection affecting women and account for about 15% of antibiotics prescribed in primary care. However, some women with a UTI are not prescribed antibiotics or are prescribed the wrong antibiotics, while many women who do not have a microbiologically confirmed UTI are prescribed antibiotics. Inappropriate antibiotic prescribing unnecessarily increases the risk of side effects and the development of antibiotic resistance, and wastes resources.POETIC is a randomised controlled trial of a Point Of Care Test (POCT) (Flexicult¿) guided UTI management strategy for use in primary care, which may help General Practitioners more effectively decide both whether or not to prescribe antibiotics, and if so, to select the most appropriate antibiotic.Methods/design614 adult female patients will be recruited from four primary care research networks (Wales, England, Spain, the Netherlands) and individually randomised to either POCT guided care or the guideline-informed `standard care¿ arm. Urine and stool samples (where possible) will be obtained at presentation (day 1) and two weeks later for microbiological analysis. All participants will be followed up on the course of their illness and their quality of life, using a 2 week self-completed symptom diary. At 3 months, a primary care notes review will be conducted for evidence of further evidence of treatment failures, recurrence, complications, hospitalisations and health service costs.The primary objective is to compare appropriate antibiotic use on day 3 between the POCT and standard care arms using multi-level logistic regression to produce an odds ratio and associated 95% confidence interval. Costs of the two management approaches will be assessed in terms of the primary outcome.DiscussionAlthough the Flexicult¿ POCT is used in some countries in routine primary care, it¿s clinical and cost effectiveness has never been evaluated in a randomised clinical trial. If shown to be effective, the use of this POCT could benefit individual sufferers and provide evidence for health care authorities to develop evidence based policies to combat the spread and impact of the unprecedented rise of infections caused by antibiotic resistant bacteria in Europe.Trial registration number ISRCTN65200697 (Registered 10 September 2013).
BMC Family Practice 11/2014; 15(1):187. · 1.74 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Evidence shows a high rate of unnecessary antibiotic prescriptions in primary care in Europe and the United States. Given the costs of widespread use and associated antibiotic resistance, reducing inappropriate use is a public health priority.
Journal of General Internal Medicine 11/2014; · 3.42 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Antimicrobial use in farm animals might contribute to the development of antimicrobial resistance in humans and animals, and there is an urgent need to reduce antimicrobial use in farm animals. Veterinarians are typically responsible for prescribing and overseeing antimicrobial use in animals. A thorough understanding of veterinarians' current prescribing practices and their reasons to prescribe antimicrobials might offer leads for interventions to reduce antimicrobial use in farm animals. This paper presents the results of a qualitative study of factors that influence prescribing behaviour of farm animal veterinarians. Semi-structured interviews with eleven farm animal veterinarians were conducted, which were taped, transcribed and iteratively analysed. This preliminary analysis was further discussed and refined in an expert meeting. A final conceptual model was derived from the analysis and sent to all the respondents for validation. Many conflicting interests are identifiable when it comes to antimicrobial prescribing by farm animal veterinarians. Belief in the professional obligation to alleviate animal suffering, financial dependency on clients, risk avoidance, shortcomings in advisory skills, financial barriers for structural veterinary herd health advisory services, lack of farmers' compliance to veterinary recommendations, public health interests, personal beliefs regarding the veterinary contribution to antimicrobial resistance and major economic powers are all influential determinants in antimicrobial prescribing behaviour of farm animal veterinarians. Interventions to change prescribing behaviour of farm animal veterinarians could address attitudes and advisory skills of veterinarians, as well as provide tools to deal with (perceived) pressure from farmers and advisors to prescribe antimicrobials. Additional (policy) measures could probably support farm animal veterinarians in acting as a more independent animal health consultant.
Zoonoses and Public Health 11/2014; · 2.09 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: General public views and expectations around the use of antibiotics can influence general practitioners' antibiotic prescribing decisions. We set out to describe the knowledge, attitudes and beliefs about the use of antibiotics for respiratory tract infections in adults in Poland, and explore differences according to where people live in an urban-rural continuum.
PLoS ONE 10/2014; 9(10):e109248. · 3.53 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background:In acute cough patients, impaired lung function as present in chronic lung conditions like asthma and chronic obstructive pulmonary disease (COPD) are often thought to negatively influence course of disease, but clear evidence is lacking.Aims:To investigate the influence of lung function abnormalities on course of disease and response to antibiotic therapy in primary care patients with acute cough.Methods:A total of 3,104 patients with acute cough (⩽28 days) were included in a prospective observational study with a within-nested trial, of which 2,427 underwent spirometry 28-35 days after inclusion. Influence of the lung function abnormalities fixed obstruction (forced expiratory volume in 1 s (FEV1)/forced vital capacity (FVC) ratio <0.7) and bronchodilator responsiveness (FEV1 increase of ⩾12% or 200 ml after 400 μg salbutamol) on symptom severity, duration and worsening were evaluated using uni- and multivariable regression models. Antibiotic use was defined as the reported use of antibiotics ⩾5 days in the first week. Interaction terms were calculated to investigate modifying effects of lung function on antibiotic effect.Results:The only significant association was the effect of severe airway obstruction on symptom severity on days 2-4 (difference=0.31, 95% confidence interval (CI)=0.03-0.60, P=0.03). No evidence of a differential effect of lung function on the effect of antibiotics was found. Prior use of inhaled steroids was associated with a 30% slower resolution of symptoms rated 'moderately bad' or worse (hazard ratio=0.75, 95% CI=0.63-0.90, P=0.00).Conclusions:In adult patients with acute cough, lung function abnormalities were neither significantly associated with course of disease nor did they modify the effect of antibiotics.
NPJ primary care respiratory medicine. 09/2014; 24:14067.
[Show abstract][Hide abstract] ABSTRACT: Rhinovirus infections occur frequently throughout life and have been reported in about one-third of asymptomatic cases. The clinical significance of sequential rhinovirus infections remains unclear. To determine the incidence and clinical relevance of sequential rhinovirus detections, nasopharyngeal samples from 2485 adults with acute cough/lower respiratory illness were analysed. Patients were enrolled prospectively by general practitioners from 12 European Union countries during three consecutive years (2007-2010). Nasopharyngeal samples were collected at the initial general practitioner consultation and 28 days thereafter and symptom scores were recorded by patients over that period. Rhinovirus RNA was detected in 444 (18%) out of 2485 visit one samples and in 110 (4.4%) out of 2485 visit two respiratory samples. 21 (5%) of the 444 patients had both samples positive for rhinovirus. Genotyping of both virus detections was successful for 17 (81%) out of 21 of these patients. Prolonged rhinovirus shedding occurred in six (35%) out of 21 and re-infection with a different rhinovirus in 11 (65%) out of 21. Rhinovirus re-infections were significantly associated with chronic obstructive pulmonary disease (p=0.04) and asthma (p=0.02) and appeared to be more severe than prolonged infections. Our findings indicate that in immunocompetent adults rhinovirus re-infections are more common than prolonged infections, and chronic airway comorbidities might predispose to more frequent rhinovirus re-infections.
European Respiratory Journal 07/2014; 44(1):169-77. · 7.13 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Canuti and Martin Deijs have contributed equally to this work. Previously unknown or unexpected pathogens may be responsible for that proportion of respiratory diseases in which a causative agent cannot be identified. The application of broad-spectrum, sequence independent virus discovery techniques may be useful to reduce this proportion and widen our knowledge about respiratory pathogens. Thanks to the availability of high-throughput sequencing (HTS) technology, it became today possible to detect viruses which are present at a very low load, but the clinical relevance of those viruses must be investigated. In this study we used VIDISCA-454, a restriction enzyme based virus discovery method that utilizes Roche 454 HTS system, on a nasal swab collected from a subject with respiratory complaints. A γ-papillomavirus was detected (complete genome: 7142 bp) and its role in disease was investigated. Respiratory samples collected both during the acute phase of the illness and 2 weeks after full recovery contained the virus. The patient presented antibodies directed against the virus but there was no difference between IgG levels in blood samples collected during the acute phase and 2 weeks after full recovery. We therefore concluded that the detected γ-papillomavirus is unlikely to be the causative agent of the respiratory complaints and its presence in the nose of the patient is not related to the disease. Although HTS based virus discovery techniques proved their great potential as a tool to clarify the etiology of some infectious diseases, the obtained information must be subjected to cautious interpretations. This study underlines the crucial importance of performing careful investigations on viruses identified when applying sensitive virus discovery techniques, since the mere identification of a virus and its presence in a clinical sample are not satisfactory proofs to establish a causative link with a disease.
Frontiers in Microbiology 07/2014; 5:374. · 3.94 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: A positive patient safety culture is considered a main condition for patient safety. Several initiatives have been taken with the intention to improve this culture in healthcare. Because these were mainly implemented in hospitalized care settings not much is known about ameliorating patient safety culture in general practice. Therefore, we aimed at examining the effect of two patient safety culture interventions in general practice.
We conducted a cluster randomized three armed trial, one control group and two intervention groups, in thirty general practices in the Netherlands. The interventions consisted of a Dutch patient safety culture questionnaire solely, or this questionnaire combined with a workshop on practice location. The workshop was based on MaPSaF and processed the practice results of theculture questionnaire. It comprised theory and discussion with the objective to draw a practice specific action plan. After randomisation 10 practices served as controls, 10 practices received the safety culture questionnaire as intervention, and 10 had the combination of the questionnaire and the workshop. All practices were asked to fill out a practice information form before the intervention and one year hereafter. In this form general safety and quality issues were addressed such as whether the practice had a formal incident reporting procedure, the number of incident reports and whether they were analysed; whether there was a complaint procedure and number of registered complaints; whether there were staff meetings and if patient safety (culture) were part of these; whether training was followed in the field of patient safety and whether a safety management system or policy was present. Improvement in patient safety culture was operationalized as an increase in reported number of incident as a primary outcome measure. At follow-up, we also asked all staff of all practices, including the controls, to complete the safety culture questionnaire. In addition, to be able to evaluate the process of patient safety improvements we performed semi-structured interviews.
Thirty practices completed the pre practice information form. During the intervention period two practices in the 'combination' group dropped out. For this, we randomly moved one of the control practices to this intervention group. Up until now, 27 practices filled out this questionnaire post intervention. The SCOPE questionnaire is completed by 171 respondents distributed over the 28 practices with a range of 1 to 13. We conducted 48 interviews with respectively 24 physicians, 21 medical assistants and 3 practice nurses. Data cleaning and analysis about to start and will be finished by the end of 2013.
this study is one of the first attempting to at shed light on the effectiveness of patient safety culture improvement interventions in general practice. With collecting both quantitative and qualitative data, not only the effect of the intervention is examined but also potential underlying grounds for the results in the practices can be clarified. These findings will contribute to our knowledge about patient safety improvements in general practice and may enhance future interventions.
[Show abstract][Hide abstract] ABSTRACT: Patient safety culture, described as shared values, attitudes and behavior of staff in a health-care organization, gained attention as a subject of study as it is believed to be related to the impact of patient safety improvements. However, in primary care, it is yet unknown, which effect interventions have on the safety culture.
To review literature on the use of interventions that effect patient safety culture in primary care.
Searches were performed in PubMed, EMBASE, CINAHL, and PsychINFO on March 4, 2013. Terms defining safety culture were combined with terms identifying intervention and terms indicating primary care. Inclusion followed if the intervention effected patient safety culture, and effect measures were reported.
The search yielded 214 articles from which two were eligible for inclusion. Both studies were heterogeneous in their interventions and outcome; we present a qualitative summary. One study described the implementation of an electronic medical record system in general practices as part of patient safety improvements. The other study facilitated 2 workshops for general practices, one on risk management and another on significant event audit. Results showed signs of improvement, but the level of evidence was low because of the design and methodological problems.
These studies in general practice provide a first understanding of improvement strategies and their effect in primary care. As the level of evidence was low, no clear preference can be determined. Further research is needed to help practices make an informed choice for an intervention.
Journal of Patient Safety 03/2014; · 0.88 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Countries generally present their overall use of antibiotics as an indicator of antibiotic prescribing quality. Additional insight is urgently needed for targeted improvement recommendations: first, data on specific clinical indications for which antibiotics are used, and second, on distinguishing whether changes in patient consultation or changes in physician prescribing drive changing antibiotic use for particular indications. The aim of this study was to describe the antibiotic management of infectious diseases in the clinical context, by analysing prescribing by physicians and patient consultation incidences per indication over time.
A database with all contact data for infectious diseases from 45 primary care practices in the Netherlands (2007-10) was used. Consultation incidences, prescribing rates and choice of antibiotic were analysed per International Classification of Primary Care (ICPC) chapter and relevant ICPC codes.
Antibiotics were prescribed in ∼25% of infectious disease episodes, mainly respiratory infections, urinary infections and ear and skin infections. Overall, this resulted in 300 prescribed courses of antibiotics per 1000 patient-years. Given a stable prescription rate, a 19% increase in the number of consultations explained the increased antibiotic prescribing for urinary tract infections. Given a stable consultation incidence, an 8% reduction in prescribing rate explained the decreased antibiotic prescribing for respiratory tract infections. Macrolides were predominantly prescribed for respiratory disease (∼66%), amoxicillin/clavulanate for respiratory disease (∼42%) and urinary illness (∼25%), and fluoroquinolones for urinary and genital indications.
Insight into the reasons for the decreased prescribing for respiratory tract infections and the increased prescribing for urinary tract infections was provided by a detailed analysis of incidences and prescribing rates. For respiratory disease, the second- and third-choice antibiotics were overused. Complete data on infectious disease management, with respect to patient and physician behaviour, are crucial for understanding changes in antibiotic use, and in defining strategies to reduce inappropriate antibiotic use.
Journal of Antimicrobial Chemotherapy 02/2014; · 5.34 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: For a better understanding of the maintenance of immune mechanisms to Bordetella pertussis (Bp) in relation to age, we investigated the dynamic range of specific B cell responses in various age-groups at different time points after a laboratory confirmed pertussis infection. Blood samples were obtained in a Dutch cross sectional observational study from symptomatic pertussis cases. Lymphocyte subpopulations were phenotyped by flowcytometry before and after culture. Memory B (Bmem) cells were differentiated into IgG antibody secreting cells (ASC) by polyclonal stimulation and detected by an ELISPOT assay specific for pertussis antigens pertussis toxin (Ptx), filamentous haemagglutinin (FHA) and pertactin (Prn). Bp antigen specific IgG concentrations in plasma were determined using multiplex technology. The majority of subjects having experienced a clinical pertussis episode demonstrated high levels of both Bp specific IgG and Bmem cell levels within the first 6 weeks after diagnosis. Significantly lower levels were observed thereafter. Waning of cellular and humoral immunity to maintenance levels occurred within 9 months after antigen encounter. Age was found to determine the maximum but not base-line frequencies of Bmem cell populations; higher levels of Bmem cells specific for Ptx and FHA were reached in adults and (pre-) elderly compared to under-fours and schoolchildren in the first 6 weeks after Bp exposure, whereas not in later phases. This age effect was less obvious for specific IgG levels. Nonetheless, subjects' levels of specific Bmem cells and specific IgG were weakly correlated. This is the first study to show that both age and closeness to last Bp encounter impacts the size of Bp specific Bmem cell and plasma IgG levels.
PLoS ONE 01/2014; 9(1):e85227. · 3.53 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Despite stable overall antibiotic use between 2007 and 2011 in The Netherlands, use of nitrofurantoin and trimethoprim increased by 32%. The background of this increased antibiotic use against uropathogens is unknown.
To determine whether increased use of urinary tract infection antibiotics is caused by changes in patients' consultation or physicians' prescribing behaviour and to investigate attitudes and opinions of women with respect to cystitis management and antibiotics.
Consultation and prescribing for International Classification of Primary Care (ICPC) codes U01 (dysuria), U02 (frequency), U05 (other urination problems), U70 (pyelonephritis) and U71 (cystitis) were determined from 2007 to 2010, using routinely collected primary health care data. Separately, behaviour of women with respect to managing cystitis, consultation and opinions towards (delayed) antibiotic treatment were studied using questionnaires in 2012.
Consultation for U02 and U71 significantly increased from 93 to 114/1000 patient-years from 2007 to 2010; proportion of episodes in which an antibiotic was prescribed remained constant. Questionnaires revealed that urination problems and pain were dominant complaints of cystitis; pain medication, however, was not adequately used. One-third of women directly consult upon first symptoms, whereas the majority awaits an average of 4 days. Sixty-six per cent of women report to be willing to postpone antibiotic use.
Increased use of urinary tract infection antibiotics may be caused by increased consultation for cystitis in primary care. Future research should focus on the outcomes of adequate pain medication, enhanced diagnostic procedures and of delaying antibiotic use in cystitis management.
[Show abstract][Hide abstract] ABSTRACT: Clinician-parent interaction and health system influences on parental acceptance of prescribing decisions for children with respiratory tract infections (RTIs) may be important determinants of antibiotic use.
To achieve a deeper understanding of parents' acceptance, or otherwise, of clinicians' antibiotic prescribing decisions for children with RTIs.
Qualitative interviews with parents of child patients who had recently consulted in primary care with a RTI in four European countries, with a five-stage analytic framework approach (familiarization, developing a thematic framework from interview questions and emerging themes, indexing, charting and interpretation).
Fifty of 63 parents accepted clinicians' management decisions, irrespective of antibiotic prescription. There were no notable differences between networks. Parents ascribed their acceptance to a trusting and open clinician-patient relationship, enhanced through continuity of care, in which parents felt able to express their views. There was a lack of congruence about antibiotics between parents and clinicians in 13 instances, mostly when parents disagreed about clinicians' decision to prescribe (10 accounts) rather than objecting to withholding antibiotics (three accounts). All but one parent adhered to the prescribing decision, although some modified how the antibiotic was administered.
Parents from contrasting countries indicated that continuity of care, open communication in consultations and clinician-patient trust was important in acceptance of management of RTI in their children and in motivating adherence. Interventions to promote appropriate antibiotic use in children should consider a focus on eliciting parents' perspectives and promoting and building on continuity of care within a trusting clinician-patient relationship.
[Show abstract][Hide abstract] ABSTRACT: Background: Outpatients with acute cough who expect, hope for or ask for antibiotics may be more unwell, benefit more from antibiotic treatment, and be more satisfied with care when they are prescribed antibiotics. Clinicians may not accurately identify those patients. Objective: To explore whether patient views (expecting, hoping for or asking for antibiotics) are associated with illness presentation and resolution, whether patient views are accurately perceived by clinicians, and the association of all these factors with antibiotic prescribing and patient satisfaction with care. Methods: Prospective observational study of 3402 adult patients with acute cough presenting in 14 primary care networks. Correlations and associations tested with multilevel logistic regression and McNemar s tests, and Cohens Kappa, positive agreement (PA) and negative agreement (NA) calculated as appropriate. Results: 1,213 (45.1%) patients expected, 1,093 (40.6%) hoped for, and 275 (10.2%) asked for antibiotics. Clinicians perceived 840 (31.3%) as wanting to be prescribed antibiotics (McNemars test, p,0.05). Their perception agreed modestly with the three patient views (Kappas = 0.29, 0.32 and 0.21, PAs = 0.56, 0.56 and 0.33, NAs = 0.72, 0.75 and 0.82, respectively). 1,464 (54.4%) patients were prescribed antibiotics. Illness presentation and resolution were similar for patients regardless their views. These associations were not modified by antibiotic treatment. Patient expectation and hope (OR:2.08, 95% CI:[1.48,2.93] and 2.48 [1.73,3.55], respectively), and clinician perception (12.18 [8.31,17.84]) were associated with antibiotic prescribing. 2,354 (92.6%) patients were satisfied. Only those hoping for antibiotics were less satisfied when antibiotics were not prescribed (0.39 [0.17,0.90]). Conclusion: Patient views about antibiotic treatment were not useful for identifying those who will benefit from antibiotics. Clinician perceptions did not match with patient views, but particularly influenced antibiotic prescribing. Patients were generally satisfied with care, but those hoping for but not prescribed antibiotics were less satisfied. Clinicians need to more effectively elicit and address patient views about antibiotics.
[Show abstract][Hide abstract] ABSTRACT: Background. Point-of-care (POC) C-reactive protein (CRP) testing is increasingly used in primary care to assist general practitioners (GPs) in the diagnostic workup for various complaints. The present study compares analytical performance, agreement and user-friendliness of five of these POC CRP tests. Methods. The following five POC CRP tests were evaluated: Afinion and NycoCard Reader II (both Alere), Eurolyser Smart 700/340 (Eurolyser), QuikRead go and QuikRead 101 (both Orion Diagnostica). Results were compared with those of a standard immunoturbidimetric method performed on a routine analyzer (Olympus AU 2700, Beckman Coulter). Analytical performance and agreement with the laboratory standard for the five different POC tests were analyzed. Subsequently, user-friendliness of the POC tests was assessed. Results. Within-day CVs varied from 2.6% (QuikRead go) to 19.4% (Eurolyser Smart 700/340) for low CRP values (< 20 mg/L), and 1.1% (QuikRead go) to 17.5% (Eurolyser Smart 700/340) for high values (> 100 mg/L). Between-day CVs varied from 4.6% (Afinion) to 30.5% (Eurolyser Smart 700/340) for low values and 4.0% (QuikRead go) to 18.0% (Eurolyser Smart 700/340) for high values. With high CRP values (> 100 mg/L) agreement with the laboratory standard systematically decreased for all POC tests. Regarding user-friendliness Afinion and Eurolyser Smart 700/340 were judged easiest to operate. Conclusions. Analytical performance, agreement, and user-friendliness of the POC CRP tests varied considerably, yet overall four devices showed adequate analytical performance and agreement.
Scandinavian journal of clinical and laboratory investigation 10/2013; · 1.38 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background
High-volume prescribing of antibiotics in primary care is a major driver of antibiotic resistance. Education of physicians and patients can lower prescribing levels, but it frequently relies on highly trained staff. We assessed whether internet-based training methods could alter prescribing practices in multiple health-care systems.
After a baseline audit in October to December, 2010, primary-care practices in six European countries were cluster randomised to usual care, training in the use of a C-reactive protein (CRP) test at point of care, in enhanced communication skills, or in both CRP and enhanced communication. Patients were recruited from February to May, 2011. This trial is registered, number ISRCTN99871214.
The baseline audit, done in 259 practices, provided data for 6771 patients with lower-respiratory-tract infections (3742 [55·3%]) and upper-respiratory-tract infections (1416 [20·9%]), of whom 5355 (79·1%) were prescribed antibiotics. After randomisation, 246 practices were included and 4264 patients were recruited. The antibiotic prescribing rate was lower with CRP training than without (33% vs 48%, adjusted risk ratio 0·54, 95% CI 0·42—0·69) and with enhanced-communication training than without (36% vs 45%, 0·69, 0·54—0·87). The combined intervention was associated with the greatest reduction in prescribing rate (CRP risk ratio 0·53, 95% CI 0·36—0·74, p<0·0001; enhanced communication 0·68, 0·50—0·89, p=0·003; combined 0·38, 0·25—0·55, p<0·0001).
Internet training achieved important reductions in antibiotic prescribing for respiratory-tract infections across language and cultural boundaries.
European Commission Framework Programme 6, National Institute for Health Research, Research Foundation Flanders.
The Lancet 10/2013; 382(9899):1175-82. · 39.21 Impact Factor