A systematic review and meta-analysis of the effects of antibiotic consumption on antibiotic resistance.

BACKGROUND: Greater use of antibiotics during the past 50 years has exerted selective pressure on susceptible bacteria and may have favoured the survival of resistant strains. Existing information on antibiotic resistance patterns from pathogens circulating among community-based patients is substantially less than from hospitalized patients on whom guidelines are often based. We therefore chose to assess the relationship between the antibiotic resistance pattern of bacteria circulating in the community and the consumption of antibiotics in the community. METHODS: Both gray literature and published scientific literature in English and other European languages was examined. Multiple regression analysis was used to analyse whether studies found a positive relationship between antibiotic consumption and resistance. A subsequent meta-analysis and meta-regression was conducted for studies for which a common effect size measure (odds ratio) could be calculated. RESULTS: Electronic searches identified 974 studies but only 243 studies were considered eligible for inclusion by the two independent reviewers who extracted the data. A binomial test revealed a positive relationship between antibiotic consumption and resistance (p < .001) but multiple regression modelling did not produce any significant predictors of study outcome. The meta-analysis generated a significant pooled odds ratio of 2.3 (95% confidence interval 2.2 to 2.5) with a meta-regression producing several significant predictors (F(10,77) = 5.82, p < .01). Countries in southern Europe produced a stronger link between consumption and resistance than other regions. CONCLUSIONS: Using a large set of studies we found that antibiotic consumption is associated with the development of antibiotic resistance. A subsequent meta-analysis, with a subsample of the studies, generated several significant predictors. Countries in southern Europe produced a stronger link between consumption and resistance than other regions so efforts at reducing antibiotic consumption may need to be strengthened in this area. Increased consumption of antibiotics may not only produce greater resistance at the individual patient level but may also produce greater resistance at the community, country, and regional levels, which can harm individual patients.

The appropriateness of prescribing antibiotics in the community in Europe: study design.

BACKGROUND: Over 90% of all antibiotics in Europe are prescribed in primary care. It is important that antibiotics are prescribed that are likely to be effective; however, information about antibiotic resistance in the community is incomplete. The aim of our study is to investigate the appropriateness of antibiotic prescribing in primary care in Europe by collecting and combining patterns of antibiotic resistance patterns and antibiotic prescription patterns in primary care. We will also evaluate the appropriateness of national antibiotic prescription guidelines in relation to resistance patterns. METHODS/DESIGN: Antibiotic resistance will be studied in an opportunistic sample from the community in nine European countries. Resistance data will be collected by taking a nose swab of persons (N = 4,000 per country) visiting a primary care practice for a non-infectious disease. Staphylococcus aureus and Streptococcus pneumoniae will be isolated and tested for resistance to a range of antibiotics in one central laboratory. Data on antibiotic prescriptions over the past 5 years will be extracted from the electronic medical records of General Practitioners (GPs). The results of the study will include the prevalence and resistance data of the two species and 5 years of antibiotic prescription data in nine European countries. The odds of receiving an effective antibiotic in each country will be calculated as a measure for the appropriateness of prescribing. Multilevel analysis will be used to assess the appropriateness of prescribing. Relevant treatment guidelines of the nine participating countries will be evaluated using a standardized instrument and related to the resistance patterns in that country. DISCUSSION: This study will provide valuable and unique data concerning resistance patterns and prescription behaviour in primary care in nine European countries. It will provide evidence-based recommendations for antibiotic treatment guidelines that take resistance patterns into account which will be useful for both clinicians and policy makers. By improving antibiotic use we can move towards controlling the resistance problem globally.

Survey of prophylactic antibiotic use amongst UK cochlear implant surgeons.

Cochlear implant patients are at an increased risk of pneumococcal meningitis. Recent government guidelines require all implant patients to undergo pneumococcal vaccination. The guidelines also suggest antibiotic prophylaxis but no clear guidelines regarding which antibiotic to use or for how long were issued.We asked each implant centre within the UK to describe their antibiotic protocol for cochlear implantation.Our results have showed that 100% of UK implant surgeons use antibiotic prophylaxis. The type of antibiotic and duration vary significantly between centres. Interestingly, however, the regimes followed by most practices do not adhere to surgical principles of antibiotic prophylaxis.

Corticosteroid sparing effects of vitamin C and magnesium in asthma: a randomised trial.

AIM: The study aims to assess the a priori hypothesis that regular supplementation with vitamin C or magnesium will permit a reduction in the corticosteroid dose required to maintain asthma control in adults. METHODS: We invited all participants recruited from primary care centres who completed a parallel-group, randomised, placebo-controlled, 16-week supplementation trial of 1g/day vitamin C or 450 mg/day magnesium to continue and participate in a structured corticosteroid reduction protocol over 10 weeks. RESULTS: A total of 92 participants (29 vitamin C, 31 magnesium and 32 placebo) entered the study. Assuming no reduction in corticosteroid dose in the 10 who subsequently withdrew, the geometric mean reductions in inhaled corticosteroid dose achieved with vitamin C, magnesium and placebo were 49, 13 and 11 microg, respectively. Relative to placebo, the unadjusted effect of vitamin C was significant, and remained at borderline significance after adjustment for baseline corticosteroid dose (relative reduction ratio=4.03, 95% CI 0.95 to 17.1, P=0.06). CONCLUSIONS: We conclude that while vitamin C supplements may have modest corticosteroid sparing effects and hence the potential to reduce exposure to their side effects, magnesium supplements have no effect on the inhaled corticosteroid dose required to maintain asthma control.

Sex inequalities in access to care for patients with diabetes in primary care: questionnaire survey.

BACKGROUND: Health experiences differ between men and women. The health services have focused their attention on gynaecological health problems in women, however women with non-gynaecological health problems could be unintentionally neglected. Given the increased prevalence of diabetes, the healthcare needs and experiences of women with diabetes are increasing. AIM: To determine the extent of sex inequalities in access to care for diabetes in primary care. DESIGN OF STUDY: Cross-sectional population-based questionnaire study. SETTING: Twenty-three general practices spread through 23 different primary care trusts in the former Trent Region, UK. METHOD: The study consisted of a random sample of 1,673 patients with diabetes. Outcomes measured were odds ratios adjusted for age for measures of physical access to the GP's surgery; ease of obtaining appointments; access to primary care professionals; levels of routine diabetes care received; barriers to physical activity, problems eating and psychological distress as measured by the 18 score Diabetes Health Profile. RESULTS: Women were less likely than men to report that they had talked to their GP or practice nurse about their diabetes in the previous 12 months and were less likely to report that they were able to book routine appointments at convenient times. Almost 40% of all patients with diabetes reported difficulty in visiting the GP's surgery for their diabetes care, and women were more likely to report difficulties in visiting the surgery than men. Women were more likely than men to be afraid to go out alone (7.9% versus 3.6%) and more likely to be housebound (6.8% versus 2.4%). Women had significantly higher scores for eating problems and barriers to physical activity than men. CONCLUSIONS: Women report more problems with access to diabetes care than men. If the ambitions of the National Service Framework are to be met, then positive action needs to be taken to improve access to care for women with diabetes.

General practice characteristics associated with rates of testing and detection of hepatitis C: cross-sectional study in Nottingham and Derbyshire.

The aim of this study was to determine general practice characteristics associated with testing rates for hepatitis C virus (HCV) and the proportion of tests with a positive result. The study included all patients tested for HCV from all general practices in the primary care trusts in Nottingham and Southern Derbyshire, UK over 2 years. There was a large variation between practices in HCV testing rates and the proportion of positive tests. Single-handed practices had higher testing rates and rates of positive results. Practices where at least half of the GPs were female had higher testing rates but lower positivity rates. The variation observed was not explained by deprivation or rurality of the practice.

Prevalence and antibiotic resistance of commensal Streptococcus pneumoniae in nine European countries.

The human microbiota represents an important reservoir of antibiotic resistance. Moreover, the majority of antibiotics are prescribed in primary care. For this reason, we assessed the prevalence and antibiotic resistance of nasal carriage strains of Streptococcus pneumoniae, the most prevalent bacterial causative agent of community-acquired respiratory tract infections, in outpatients in nine European countries. Nasal swabs were collected between October 2010 and May 2011, from 32,770 patients, recruited by general practices in nine European countries. Overall prevalence of S. pneumoniae nasal carriage in the nine countries was 2.9%. The carriage was higher in men (3.7%) than in women (2.7%). Children (4-9 years) had a higher carriage prevalence (27.2%) compared with those older than 10 years (1.9%). The highest resistance observed was to cefaclor. The highest prevalence of multidrug resistance was found in Spain and the lowest prevalence was observed in Sweden.

A comparison of research general practices and their patients with other practices--a cross-sectional survey in Trent.

BACKGROUND: When interpreting results of studies undertaken by research networks we need to know how representative volunteer practices and their registered patients are of the total population of practices and patients in their locality. AIM: To compare the following in research and non-research general practices in one region: practice and population demography, morbidity and mortality, selected performance indicators, and health outcomes. DESIGN OF STUDY: Cross-sectional survey. SETTING: Sixty-six Trent Focus Collaborative Research Network general practices and 749 other general practices in Trent, United Kingdom. METHOD: Practice characteristics and GP contract data were obtained from the NHS Executive, Quarry House, Leeds. The Trent Regional NHS Hospital Admission Database was searched to identify all relevant admissions to hospital from all practices between 1 April 1993 and 31 March 1997. Ward-linked data on cancer were obtained from the Trent Cancer Registry. RESULTS: Of the 815 general practices in Trent Region in the study period, 66 (8%) were in the Trent Focus network. They were more likely to be involved in training GPs and to have a female partner. They tended to be larger, with fewer single-handed doctors and younger GPs. Network practices prescribed a higher proportion of generics (median % prescribed/practice = 70%, versus 51%, Mann-Whitney U = 1615, P<0.0001). There were no clinically important differences between hospital admission rates between the two groups or waiting times for surgical procedures. There was no difference in the incidence of cancer and standardised mortality ratios related to the electoral wards of the GP surgery. CONCLUSION: Although there were differences in practice structure and some aspects of performance, we found no important differences in the demography of registered patients, nor in morbidity, mortality, or access to or use of secondary care.

A case-control study on the effect of hormone replacement therapy on ischaemic heart disease.

BACKGROUND: Many clinicians believe that hormone replacement therapy (HRT) protects against coronary heart disease (CHD) in women. However, recent reports have cast some doubt on this because of lack of dose-response or duration-response effects. Since CHD is common in women--about half of all postmenopausal women will get it and about a third of these will die from it--the effect of HRT on CHD is of great public health importance. AIM: To determine the degree of cardioprotection conferred by HRT, including the effect of duration, time since last issue, the addition of progestogens, route of administration, and dose. DESIGN: Population-based case-control study. SETTING: Nine general practices recruited from the Trent Focus Collaborative Research Network. METHOD: A total of 417 female cases with CHD matched by age and practice to 2435 controls with a case-control ratio of 1:5.8 were studied. The main outcome measure was the odds ratio for CHD calculated by conditional logistic regression adjusted for diabetes, hypertension, body mass index, and smoking. RESULTS: No evidence was found, either from univariate analysis or multivariate analysis, that use of HRT was associated with reduced risk of CHD (odds ratio = 1.32; 95% confidence interval = 0.93 to 1.87). Indeed, the trend was in the opposite direction. There was no association for different types of HRT (opposed or unopposed) or routes of administration. Similarly, there was no association for current or past use and no effect for dose or duration. CONCLUSION: This study adds to growing evidence that HRT does not confer cardioprotection. Until there is robust evidence to the contrary, general physicians need to assess risks and benefits of HRT independently of any possible reduction in risk of CHD.

Quality of care indicators for population-based primary care in New Zealand.

AIM: To develop a set of non-invasive, evidence-based, population-based quality of care indicators for primary care in New Zealand and to test their feasibility. METHODS: New Zealand, British and Australian publications were reviewed and a set of quality of care indicators was constructed. These were trialed on data collected from seventeen fully computerised practices from the FirstHealth network of general practices. RESULTS: 28 indicators are proposed in five categories: smoking cessation, preventive health activities, prescribing quality, chronic disease management and data quality. We were able to calculate ten indicators from data already collected routinely, a further twelve could be calculated now with more sophisticated data queries and six would require the trial practices to collect further data. CONCLUSIONS: While any set of indicators is arbitrary there are sufficient research data to support a set of evidence-based, population-focused, quality of care indicators in New Zealand primary health care. In computerised practices these indicators can be calculated from routinely collected data.

Assisted delivery in the teenage population: the effect of inter-hospital variation, deprivation, and age.

UNLABELLED: The objective was to determine the relationship between the risk of assisted delivery in women aged under 20 years and place of treatment, deprivation and age. DESIGN: Cross sectional survey utilising routinely collected hospitals admissions data. POPULATION: Teenagers (women aged under 20 years) whose delivery resulted in a hospital admission in the period April 1st 1994 to March 31st 1997 in the Trent Health Region of England. METHODS: The cases were identified using Office of Population Census and Surveys procedural codes, and International Classification of Diseases diagnostic codes associated with delivery. Variables collected included type of delivery, age at delivery and place of treatment. The data were analysed using the chi-square test for categorical data and the independent samples t-test for continuous data. Logistic regression analysis was used to calculate adjusted odds ratios for the variables of type of assisted delivery and place of treatment. MAIN OUTCOME MEASURES: Factors associated with increased risk of assisted delivery. RESULTS: There was variation in rates of instrumental delivery between hospitals, with two having a significantly increased risk of assisted delivery, suggesting that place of treatment may be a factor in the risk of teenage patients experiencing an assisted delivery. There was also a large amount of variation in terms of the risk of experiencing a forceps or vacuum extraction compared to caesarean section. Age (under 16 years and 16-19 years of age) had no effect on the risk of a teenage patient experiencing an assisted delivery (X2 = 2.59 df = 1 P = 0.11 OR 1.27 (95% CI 0.94 to 1.72)). Similarly, teenagers who experience an assisted delivery were not more likely to come from a more deprived area than teenagers who did not have an assisted delivery (P = 0.189). CONCLUSIONS: The risk of assisted delivery varied between hospitals, suggesting that this factor is important in terms of a young women's risk of an assisted delivery. The young women in this study who had experienced an assisted delivery were not significantly different to young women who had a normal delivery. They were not more likely to be aged under 16 years of age, and were not more likely to be from a more deprived area.

Teenagers at risk of unintended pregnancy: identification of practical risk markers for use in general practice from a retrospective analysis of case records in the United Kingdom.

The United Kingdom has one of the highest teenage pregnancy rates in Western Europe with a high proportion of unintended pregnancies resulting in termination. General practice is one source of contraceptive and sexual advice for teenagers but it is difficult to target young women most at risk. This study was performed to determine whether it was possible to identify any markers that could alert general practitioners to the need to give appropriate opportunistic preventive advice. This was a retrospective case-control study in which the general practice medical records of young women with a recorded history of termination of pregnancy resulting from conception between the ages of 13-19 years inclusive were examined for details of consultations and contraceptive provision prior to conception. Where appropriate, comparison was made with an age and practice-matched control group. A total of 53 cases were identified and compared with 159 controls. In the 12 months prior to conception approximately half of the cases had discussed contraception and two-fifths had been prescribed oral contraception. A significantly higher proportion of cases than controls had consulted for emergency contraception and also for urinary tract symptoms. Weaker associations were also found with younger age of starting contraception, and also recorded side-effects or dissatisfaction with contraception. Lapsed contraception and previous pregnancy were noted as other potential markers of risk. The findings from this study may assist primary care professionals in focussing opportunistic sexual health interventions at some teenagers who are at higher risk of unintended pregnancy.

Prevalence and resistance of commensal Staphylococcus aureus, including meticillin-resistant S aureus, in nine European countries: a cross-sectional study.

BACKGROUND: Information about the prevalence of Staphylococcus aureus resistance to antimicrobial drugs has mainly been obtained from invasive strains, although the commensal microbiota is thought to be an important reservoir of resistance. We aimed to compare the prevalence of nasal S aureus carriage and antibiotic resistance, including meticillin-resistant S aureus (MRSA), in healthy patients across nine European countries. METHODS: In this cross-sectional study, nasal swabs were obtained from 32,206 patients recruited by family doctors participating in existing nationwide family doctor networks in Austria, Belgium, Croatia, France, Hungary, Spain, Sweden, the Netherlands, and the UK. Eligible patients were aged 4 years or older (≥ 18 years in the UK) and presented with a non-infectious disorder. Swabs were sent to national microbiological laboratories for identification and isolation of S aureus. Antibiotic resistance testing was done at one central microbiological laboratory. We established the genotypic structure of the isolated MRSA strains with the spa typing method. FINDINGS: S aureus was isolated from 6956 (21 · 6%) of 32,206 patients swabbed. The adjusted S aureus prevalence for patients older than 18 years ranged from 12 · 1% (Hungary) to 29 · 4% (Sweden). Except for penicillin, the highest recorded resistance rate was to azithromycin (from 1 · 6% in Sweden to 16 · 9% in France). In total, 91 MRSA strains were isolated, and the highest MRSA prevalence was reported in Belgium (2 · 1%). 53 different spa types were detected-the most prevalent were t002 (n = 9) and t008 (n = 8). INTERPRETATION: The prevalence of S aureus nasal carriage differed across the nine European countries assessed, even after correction for age, sex, and family doctor. Generally, the prevalence of resistance, including that of MRSA, was low. The MRSA strains recorded showed genotypic heterogeneity, both within and between countries. FUNDING: European Commission, 7th Framework Programme(grant agreement 223083).

Research using electronic patient records in general practice. The EGPRN meeting in Bertinoro, Italy, May 2009.

The European General Practice Research Network organized an international workshop on research using electronic patient records in Bertinoro, Italy, in May 2009. The authors were keynote speakers at the workshop, tasked with summarizing the theme research presentations on each of the two days of the meeting. The conference discussed the utility of capturing data in a way that can be appropriately analysed. In this application, the use of ICPC was repeatedly mentioned. Such research requires disciplined data entry and retrieval, and many times consistency in coding is a challenge, which may be met by definitions for coded classes. Quality of data is a concern in such research, and there were suggestions to involve the patients in improving the quality of their record. Clinicians are qualified to code data into electronic patient records accurately, capturing the fine nuances of the consultation. Income incentives, such as the Quality Outcomes Framework, run the risk of data distortion to improve financial gain. The role of all family doctors in research was emphasized, and the full potential of collecting data from family practice is practically achievable only through large databases collecting clinical records from every practice. EGPRN has dealt with this emerging theme in primary care research over the years. Interested family doctors are invited to attend future conferences to develop collaborative research projects using electronic patient records.

International consensus on Vibrant Soundbridge® implantation in children and adolescents.

OBJECTIVE: Active middle ear implants augment hearing in patients with sensorineural, conductive, and mixed hearing losses with great success. However, the application of active middle ear implants has been restricted to compromised ears in adults only. Recently, active middle ear implants have been successfully implanted in patients younger than 18 years of age with all types of hearing losses. The Vibrant Soundbridge (VSB) active middle ear implant has been implanted in more than 60 children and adolescents worldwide by the end of 2008. In October 2008, experts from the field with experience in this population met to discuss VSB implantation in patients below the age of 18. METHODS: A consensus meeting was organized including a presentation session of cases from worldwide centers and a discussion session in which implantation, precautions, and alternative means of hearing augmentation were discussed. At the end of the meeting, a consensus statement was written by the participating experts. The present consensus paper describes the outcomes and medical/surgical complications: the outcomes are favourable in terms of hearing thresholds, speech intelligibility in quiet and in noise, with a low incidence of intra- and postoperative complications. CONCLUSIONS: Taken together, the VSB offers another viable treatment for children and adolescents with compromised hearing. However, other treatment options should also be taken into consideration. The advantages and disadvantages of all possible treatment options should be weighed against each other in the light of each individual case to provide the best solution; counseling should include a.o. surgical issues and MRI compatibility.