Rationale, design and organization of the delayed antibiotic prescription (DAP) trial: a randomized controlled trial of the efficacy and safety of delayed antibiotic prescribing strategies in the non-complicated acute respiratory tract infections in general practice.

BACKGROUND: Respiratory tract infections are an important burden in primary care and it's known that they are usually self-limited and that antibiotics only alter its course slightly. This together with the alarming increase of bacterial resistance due to increased use of antimicrobials calls for a need to consider strategies to reduce their use. One of these strategies is the delayed prescription of antibiotics. METHODS: Multicentric, parallel, randomised controlled trial comparing four antibiotic prescribing strategies in acute non-complicated respiratory tract infections. We will include acute pharyngitis, rhinosinusitis, acute bronchitis and acute exacerbation of chronic bronchitis or chronic obstructive pulmonary disease (mild to moderate). The therapeutic strategies compared are: immediate antibiotic treatment, no antibiotic treatment, and two delayed antibiotic prescribing (DAP) strategies with structured advice to use a course of antibiotics in case of worsening of symptoms or not improving (prescription given to patient or prescription left at the reception of the primary care centre 3 days after the first medical visit). DISCUSSION: Delayed antibiotic prescription has been widely used in Anglo-Saxon countries, however, in Southern Europe there has been little research about this topic. The DAP trial wil evaluate two different delayed strategies in Spain for the main respiratory infections in primary care. TRIAL REGISTRATION: This trial is registered with ClinicalTrials.gov, number http://NCT01363531.

Prescription Strategies in Acute Uncomplicated Respiratory Infections: A Randomized Clinical Trial.

IMPORTANCE: Delayed antibiotic prescription helps to reduce antibiotic use with reasonable symptom control. There are different strategies of delayed prescription, but it is not yet clear which one is the most effective. OBJECTIVE: To determine the efficacy and safety of 2 delayed strategies in acute, uncomplicated respiratory infections. DESIGN, SETTING, AND PARTICIPANTS: We recruited 405 adults with acute, uncomplicated respiratory infections from 23 primary care centers in Spain to participate in a pragmatic, open-label, randomized clinical trial. INTERVENTIONS: Patients were randomized to 1 of 4 potential prescription strategies: (1) a delayed patient-led prescription strategy; (2) a delayed prescription collection strategy requiring patients to collect their prescription from the primary care center; (3) an immediate prescription strategy; or (4) a no antibiotic strategy. Delayed prescription strategies consist of prescribing an antibiotic to take only if the symptoms worsen or if there is no improvement several days after the medical visit. MAIN OUTCOMES AND MEASURES: The primary outcomes were the duration of symptoms and severity of symptoms. Each symptom was scored using a 6-point Likert scale (scores of 3 or 4 were considered moderate; 5 or 6, severe). Secondary outcomes included antibiotic use, patient satisfaction, and patients' beliefs in the effectiveness of antibiotics. RESULTS: A total of 405 patients were recruited, 398 of whom were included in the analysis; 136 patients (34.2%) were men; mean (SD) age, 45 (17) years. The mean severity of symptoms ranged from 1.8 to 3.5 points on the Likert scale, and mean (SD) duration of symptoms described on first visit was 6 (6) days. The mean (SD) general health status on first visit was 54 (20) based on a scale with 0 indicating worst health status; 100, best status. Overall, 314 patients (80.1%) were nonsmokers, and 372 patients (93.5%) did not have a respiratory comorbidity. The presence of symptoms on first visit was similar among the 4 groups. The mean (SD) duration of severe symptoms was 3.6 (3.3) days for the immediate prescription group and 4.7 (3.6) days for the no prescription group. The median (interquartile range [IQR]) of severe symptoms was 3 (1-4) days for the prescription collection group and 3 (2-6) days for the patient-led prescription group. The median (IQR) of the maximum severity for any symptom was 5 (3-5) for the immediate prescription group and the prescription collection group; 5 (4-5) for the patient-led prescription group; and 5 (4-6) for the no prescription group. Patients randomized to the no prescription strategy or to either of the delayed strategies used fewer antibiotics and less frequently believed in antibiotic effectiveness. Satisfaction was similar across groups. CONCLUSIONS AND RELEVANCE: Delayed strategies were associated with slightly greater but clinically similar symptom burden and duration and also with substantially reduced antibiotic use when compared with an immediate strategy. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01363531.

Validación del Analyz-Strep A Rapid Test en el diagnóstico de la faringitis aguda / Validation Analyz-Strep A Rapid Test in the diagnosis of acute pharyngitis

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[Validation of a rapid antigenic test in the diagnosis of pharyngitis caused by group a beta-haemolytic Streptococcus]. / Validación de una técnica antigénica rápida en el diagnóstico de la faringitis por estreptococo betahemolítico del grupo A.

OBJECTIVE: To determine the validity of the rapid antigen test (RAT) OSOM StrepA Genzyme for the diagnosis of acute pharyngitis caused by group A beta-haemolytic strep (GABHS). DESIGN: Diagnostic techniques survey. SETTING: Urban primary care centre, Spain. PARTICIPANTS: All patients over 14 years old seen in 6 surgeries with sore throat and 2 or more Centor criteria: pharyngotonsillar exudate, tender laterocervical nodes, absence of coughing, and/or history or presence of fever. PRINCIPAL MEASUREMENTS: Pharyngeal swabs were taken from all the patients, one for RAT and another to send for culture in the microbiology department. RESULTS: A total of 182 patients were evaluable, with a mean age of 30.6 (12.1) years of which 116 were women (63.7%); 63 patients had 2 Centor criteria; 83 had 3 and 36, the 4 criteria. The culture was positive in 102 patients (56%), with GABHS showing infection in forty (22%; 95% confidence interval [CI], 21.2-22.8). Group C Streptococcus was isolated in 26 patients (14.3%). GABHS was higher among patients with four Centor criteria (38.9% vs 25.3% observed among those with 3 criteria and 7.9% with 2 criteria; P<.001). Sensitivity of RAT was 95%, with a specificity of 93%, a positive predictive value of 79.2% and a negative predictive value of 98.5%. CONCLUSIONS: These results show the usefulness of RAT for diagnosing streptococcal pharyngitis. Its use should be spread to all primary care practices.

Estilos de vida de los sujetos que toman fármacos para dos o más factores de riesgo cardiovascular. Estudio TAR-RISC / Lifestyles of subjects who take drugs for two or more cardiovascular risk factors. TAR-RISC Study

Objetivo: Describir las características basales y los estilos de vida de la población de una regiónsanitaria con medicación para 2 o más factores de riesgo cardiovascular.Diseño: Estudio descriptivo transversal.Emplazamiento: Atención primaria de Tarragona.Participantes: Los sujetos, menores de 65 años, se identificaron a partir de los datos dedispensación de especialidades farmacéuticas antihipertensivas, hipoglucemiantes e hipocolesterolemiantes.Mediciones y resultados principales: Se diseñaron cuestionarios estructurados específicos paracada agrupación de fármacos y la información se recogió telefónicamente. Se analizaron edad,sexo, sedentarismo, hábito enólico, tabáquico, dietético e índice de masa corporal.Se entrevistó a 1.201 personas, con una edad media de 58,9±7,6 a˜nos. El 54,2% eranhombres. Tomaban fármacos antihipertensivos e hipocolesterolemiantes 636 sujetos (53,0%),antihipertensivos e hipoglucemiantes 212 (17,7%), hipocolesterolemiantes e hipoglucemiantes128 (10,8%) y fármacos de los 3 grupos 225 sujetos (18,7%). El 19,2% declararon ser fumadoresactivos y el 5,7% manifestaron un consumo excesivo de alcohol. Doscientos sesenta y seis sujetos(22,2%) aseguraron no seguir ninguna dieta. El 15% declararon ser sedentarios o hacer una mínima actividad física. El índice de masa corporal medio fue de 29,9±4,9 kg/m2, siendo más alto entre los sujetos que tomaban antihipertensivos e hipoglucemiantes (p<0,001). Un 44,2% presentaba obesidad. Conclusiones: Aproximadamente 1/5 de los sujetos que toman al menos 2 grupos farmacológicosson fumadores activos, 1/4 del total no hace dieta, 1/2 son obesos y 2/3 partes realizan poca onula actividad física. Estos resultados muestran el bajo cumplimiento de las medidas higiénicodietéticas por parte de los pacientes con riesgo cardiovascular elevado(AU)

Objective: To describe the basic characteristics and lifestyles of the population of a HealthRegion, on medication for two or more cardiovascular risk factors.Design: Cross-sectional descriptive study.Setting: Tarragona Primary Care.Participants: The subjects, less than 65 years-old, were identified by the dispensing data ofhypertensive, glucose-lowering and lipid-lowering pharmaceutical drugs.Main measurements and results: Specific structured questionnaires were designed for eachdrugs group, and the information was gathered by telephone. Age, sex, sedentarism, alcoholand tobacco habits, diet and body mass index were analysed.A total of 1201 patients, with a mean age of 58.9±7.6 years, were interviewed. There were54.2% males. A total of 636 (53.0%) subjects took anti-hypertensive and cholesterol loweringdrugs, 212 (17.7%) anti-hypertensive and glucose lowering drugs, and 128 (10.8%) cholesterollowering and glucose lowering drugs, and 225 (18.7%) patients took drugs from the three groups.There were 19.2% active smokers, 5.7% stated excessive alcohol consumption, 266 (22.2%) statedthat they did not follow any diet, and 15% were sedentary or did a minimum of physicalactivity. The mean body mass index was 29.9±4.9 kg/m2, being highest among the subjects whotook anti-hypertensive and glucose lowering drugs (P<0.001), and 44.2% were obese.Conclusions: Approximately one fifth of the subjects who took at least 2 pharmacological groupswas an active smoker, one quarter of the total did not follow a diet, half were obese and twothirdsdid little or no physical activity. These results show low compliance to hygienic-dieteticmeasures by patients with an increased cardiovascular risk(AU)

Validación de una técnica antigénica rápida en el diagnóstico de la faringitis por estreptococo betahemolítico del grupo A / Validation of a rapid antigen test in the diagnosis of pharyngitis caused by group A beta-haemolytic streptococcus

Objetivo. Determinamos la validez de latécnica antigénica rápida (TAR) OSOMStrepA Genzyme en el diagnóstico de lafaringitis aguda causada por estreptococobetahemolítico del grupo A (EBHGA).Diseño. Estudio de pruebas diagnósticas.Emplazamiento. Equipo urbano de atenciónprimaria.Participantes. Todos los pacientes mayoresde 14 años atendidos en 6 consultas consíntomas de odinofagia y 2 o más de loscriterios de Centor (exudado faringoamigdalar,adenopatías laterocervicales dolorosas,ausencia de tos y/o historia o presenciade fiebre).Mediciones principales. A todos los pacientesse les tomó una muestra faringoamigdalarcon 2 hisopos, uno para TAR y otro que fueremitido al servicio de microbiología pararealizar cultivo.Resultados. Fueron evaluables 182 sujetos,con una edad media de 30,6 ± 12,1 años,116 mujeres (63,7%). Presentaron 2, 3y 4 criterios de Centor 63, 83 y 36 sujetos,respectivamente. El cultivo fue positivo en102 casos (56%), observándose infección porEBHGA en 40 pacientes (22%; intervalode confianza [IC] del 95%, 21,2-22,8); en26 casos se aisló estreptococo del grupo C(14,3%). La infección por EBHGA presentóuna mayor prevalencia entre los pacientescon 4 criterios (un 38,9% frente a un 25,3%observado con 3 criterios y frente al 7,9%con 2 criterios; p < 0,001). La TAR tuvo unasensibilidad del 95%, una especificidad del93%, un valor predictivo positivo del 79,2%y un valor predictivo negativo del 98,5%.Conclusiones. Estos resultados demuestranla utilidad de la TAR para el diagnósticode la faringitis estreptocócica. Su uso deberíaextenderse a todas las consultas de atenciónprimaria

Objective. To determine the validity of therapid antigen test (RAT) OSOM StrepAGenzyme for the diagnosis of acutepharyngitis caused by group Abeta-haemolytic strep (GABHS).Design. Diagnostic techniques survey.Setting. Urban primary care centre, Spain.Participants. All patients over 14 years oldseen in 6 surgeries with sore throat and 2or more Centor criteria: pharyngotonsillarexudate, tender laterocervical nodes, absenceof coughing, and/or history or presence offever.Principal measurements. Pharyngeal swabswere taken from all the patients, one forRAT and another to send for culture inthe microbiology department.Results. A total of 182 patients wereevaluable, with a mean age of 30.6 (12.1)years of which 116 were women (63.7%); 63patients had 2 Centor criteria; 83 had 3 and36, the 4 criteria. The culture was positive in102 patients (56%), with GABHS showinginfection in forty (22%; 95% confidenceinterval [CI], 21.2-22.8). Group CStreptococcus was isolated in 26 patients(14.3%). GABHS was higher amongpatients with four Centor criteria (38.9% vs25.3% observed among those with 3 criteriaand 7.9% with 2 criteria; P<.001). Sensitivityof RAT was 95%, with a specificity of 93%,a positive predictive value of 79.2%and a negative predictive value of 98.5%.Conclusions. These results show theusefulness of RAT for diagnosingstreptococcal pharyngitis. Its use shouldbe spread to all primary care practices

Prescripción diferida de antibióticos en España / Delayed prescription of antibiotics in Spain

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