Duration of severe and moderate symptoms in pharyngitis by cause.

OBJECTIVE: This study aimed to assess the cause of acute pharyngitis and determine the duration of severe and moderate symptoms based on the aetiology. DESIGN: Prospective observational study. SITE: One urban health care centre. PARTICIPANTS: Patients aged 15 or older with acute pharyngitis were included. INTERVENTIONS: Bacterial identification was carried out in the microbiology lab using MALDI-TOF in two throat samples. Patients received a symptom diary to return after one week. MAIN MEASUREMENTS: Number of days with severe symptoms, scoring 5 or more in any of the symptoms included in the symptom diary, and moderate symptoms, scoring 3 or more. RESULTS: Among the 149 patients recruited, beta-haemolytic streptococcus group A (GABHS) was the most common aetiology. Symptoms and signs alone as well as the mean Centor score cannot distinguish between GABHS and other bacterial causes in patients with acute pharyngitis. However, there was a trend indicating that infections caused by Streptococcus dysgalactiae and Streptococcus agalactiae presented more severe symptoms, whereas infections attributed to the Streptococcus anginosus group, Fusobacterium spp., and those where oropharyngeal microbiota was isolated tended to have milder symptoms. S. dysgalactiae infections showed a trend towards longer severe and moderate symptom duration. CONCLUSION: GABHS was the most prevalent, but group C streptococcus caused more severe and prolonged symptoms.

Optimising antibiotic exposure by customising the duration of treatment for respiratory tract infections based on patient needs in primary care.

Primary care antimicrobial stewardship programs have limited success in reducing antibiotic use, prompting the search for new strategies. Convincing general practitioners to resist antibiotic prescription amid uncertainty or patient demands usually poses a significant challenge. Despite common practice, standard durations for common infections lack support from clinical studies. Contrary to common belief, extending antibiotic treatment beyond the resolution of symptoms does not seem to prevent or reduce antimicrobial resistance. Shortening the duration of antibiotic therapy has shown to be effective in mitigating the spread of resistance, particularly in cases of pneumonia. Recent hospital randomised trials suggest that ending antibiotic courses by day three for most lower respiratory tract infections is effective and safe. While community studies are scarce, it is likely that these shorter, tailored courses to meet patients' needs would also be effective and safe in primary care. Therefore, primary care studies should investigate the outcomes of advising patients to discontinue antibiotic treatment upon symptom resolution. Implementing patient-centred, customised treatment durations, rather than fixed courses, is crucial for meeting individual patient needs.

Perception and views about individualising antibiotic duration for respiratory tract infections when patients feel better: a qualitative study with primary care professionals.

BACKGROUND: Evidence shows a high rate of unnecessary antibiotic prescriptions for respiratory tract infections (RTIs) in primary care. There is increasing evidence showing that shorter courses for RTIs are safe and help in reducing antimicrobial resistance (AMR). Stopping antibiotics earlier, as soon as patients feel better, rather than completing antibiotic courses, may help reduce unnecessary exposure to antibiotics and AMR. OBJECTIVES: The aim of this study was to explore the perceptions and views of primary care healthcare professionals about customising antibiotic duration for RTIs by asking patients to stop the antibiotic course when they feel better. DESIGN: Qualitative research. SETTING AND PARTICIPANTS: A total of 21 qualitative interviews with primary care professionals (experts and non-experts in AMR) were conducted from June to September 2023. Data were audiorecorded, transcribed and analysed thematically. RESULTS: Overall, experts seemed more amenable to tailoring the antibiotic duration for RTIs when patients feel better. They also found the dogma of 'completing the course' to be obsolete, as evidence is changing and reducing the duration might lead to less AMR, but claimed that evidence that this strategy is as beneficial and safe as fixed courses was unambiguous. Non-experts, however, believed the dogma of completing the course. Clinicians expressed mixed views on what feeling better might mean, supporting a shared decision-making approach when appropriate. Participants claimed good communication to professionals and patients, but were sceptical about the risk of medicalisation when asking patients to contact clinicians again for a check-up visit. CONCLUSIONS: Clinicians reported positive and negative views about individualising antibiotic courses for RTIs, but, in general, experts supported a customised antibiotic duration as soon as patients feel better. The information provided by this qualitative study will allow improving the performance of a large randomised clinical trial aimed at evaluating if this strategy is safe and beneficial.

Effects of C-reactive protein rapid testing and communication skills training on antibiotic prescribing for acute cough. A cluster factorial randomised controlled trial.

This cluster randomised clinical trial carried out in 20 primary care centres in Barcelona was aimed at assessing the effect of a continuous intervention focused on C-reactive protein (CRP) rapid testing and training in enhanced communication skills (ECS) on antibiotic consumption for adults with acute cough due to lower respiratory tract infection (LRTI). The interventions consisted of general practitioners and nurses' use of CRP point-of-care and training in ECS separately and combined, and usual care. The primary outcomes were antibiotic consumption and variation of the quality-adjusted life years during a 6-week follow-up. The difference in the overall antibiotic prescribing between the winter seasons before and after the intervention was calculated. The sample size calculated could not be reached due to the COVID-19 outbreak. A total of 233 patients were recruited. Compared to the usual care group (56.7%) antibiotic consumption among patients assigned to professionals in the ECS group was significantly lower (33.9%, adjusted odds ratio [aOR] 0.38, 95% CI 0.15-0.94, p = 0.037), whereas patients assigned to CRP consumed 43.8% of antibiotics (aOR 0.70, 95% CI 0.29-1.68, p = 0.429) and 38.4% in the combined intervention group (aOR 0.45, 95% CI, 0.17-1.21; p = 0.112). The overall antibiotic prescribing rates in the centres receiving training were lower after the intervention compared to those assigned to usual care, with significant reductions in ß-lactam rates. Patient recovery was similar in all groups. Despite the limited power due to the low number of patients included, we observed that continuous training achieved reductions in antibiotic consumption.

C-reactive protein point-of-care testing in primary care-broader implementation needed to combat antimicrobial resistance.

This study presents the perspective of an international group of experts, providing an overview of existing models and policies and guidance to facilitate a proper and sustainable implementation of C-reactive protein point-of-care testing (CRP POCT) to support antibiotic prescribing decisions for respiratory tract infections (RTIs) with the aim to tackle antimicrobial resistance (AMR). AMR threatens to render life-saving antibiotics ineffective and is already costing millions of lives and billions of Euros worldwide. AMR is strongly correlated with the volume of antibiotics used. Most antibiotics are prescribed in primary care, mostly for RTIs, and are often unnecessary. CRP POCT is an available tool and has been proven to safely and cost-effectively reduce antibiotic prescribing for RTIs in primary care. Though established in a few European countries during several years, it has still not been implemented in many European countries. Due to the complexity of inappropriate antibiotic prescribing behavior, a multifaceted approach is necessary to enable sustainable change. The effect is maximized with clear guidance, advanced communication training for primary care physicians, and delayed antibiotic prescribing strategies. CRP POCT should be included in professional guidelines and implemented together with complementary strategies. Adequate reimbursement needs to be provided, and high-quality, and primary care-friendly POCT organization and performance must be enabled. Data gathering, sharing, and discussion as incentivization for proper behaviors should be enabled. Public awareness should be increased, and healthcare professionals' awareness and understanding should be ensured. Impactful use is achieved when all stakeholders join forces to facilitate proper implementation.

Antimicrobial Agent Use for Urinary Tract Infection in Long-Term Care Facilities in Spain: Results from a Retrospective Analytical Cohort Analysis.

Urinary tract infections (UTIs) are highly prevalent in long-term care facilities, constituting the most common infection in this setting. Our research focuses on analyzing clinical characteristics and antimicrobial prescriptions for UTIs in residents across nursing homes (NH) in Spain. This is a retrospective analytical cohort analysis using a multifaceted approach based on the normalization process theory to improve healthcare quality provided by nursing staff in 34 NHs in Spain. In this study, we present the results of the first audit including 719 UTI cases collected between February and April 2023, with an average age of 85.5 years and 74.5% being women. Cystitis and pyelonephritis presented distinct symptom patterns. Notably, 6% of asymptomatic bacteriuria cases were treated. The prevalence of dipstick usage was 83%, and that of urine culture was only 16%, raising concerns about overreliance, including in the 46 asymptomatic cases, leading to potential overdiagnosis and antibiotic overtreatment. Improved diagnostic criteria and personalized strategies are crucial for UTI management in NHs, emphasizing the need for personalized guidelines on the management of UTIs to mitigate indiscriminate antibiotic use in asymptomatic cases.

Regional and national antimicrobial stewardship activities: a survey from the Joint Programming Initiative on Antimicrobial Resistance-Primary Care Antibiotic Audit and Feedback Network (JPIAMR-PAAN).

Background: Antibiotic overuse and misuse in primary care are common, highlighting the importance of antimicrobial stewardship (AMS) efforts in this setting. Audit and feedback (A&F) interventions can improve professional practice and performance in some settings. Objectives and methods: To leverage the expertise from international members of the Joint Programming Initiative on Antimicrobial Resistance - Primary care Antibiotic Audit and feedback Network (JPIAMR-PAAN). Network members all have experience of designing and delivering A&F interventions to reduce inappropriate antibiotic prescribing in primary care settings. We aim to introduce the network and explore ongoing A&F activities in member regions. An online survey was administered to all network members to collect regional information. Results: Fifteen respondents from 11 countries provided information on A&F activities in their country, and national/regional antibiotic stewardship programmes or policies. Most countries use electronic medical records as the primary data source, antibiotic appropriateness as the main outcome of feedback, and target GPs as the prescribers of interest. Funding sources varied across countries, which could influence the frequency and quality of A&F interventions. Nine out of 11 countries reported having a national antibiotic stewardship programme or policy, which aim to provide systematic support to ongoing AMS efforts and aid sustainability. Conclusions: The survey identified gaps and opportunities for AMS efforts that include A&F across member countries in Europe, Canada and Australia. JPIAMR-PAAN will continue to leverage its members to produce best practice resources and toolkits for antibiotic A&F interventions in primary care settings and identify research priorities.

New paradigms on antibiotic recommendations for community-acquired infections in Spain / Nuevos paradigmas en las recomendaciones antibióticas en las infecciones comunitarias en España

Over the last years, the susceptibility activity of the most common microorganisms causing community-acquired infections has significantly changed in Spain. Based on the susceptibility rates of Streptococcus pyogenes, Streptococcus pneumoniae, Haemophilus influenzae, Escherichia coli, and Klebsiella pneumoniae collected from outpatients aged 15 or older with symptoms of respiratory or urinary tract infections in several Microbiology Departments in Catalonia in 2021, penicillin V should be first choice for most respiratory tract infections, amoxicillin and clavulanate for chronic obstructive pulmonary disease exacerbations and a single dose of fosfomycin or a short-course nitrofurantoin should remain first-line treatments for uncomplicated urinary tract infections. Updated information on antimicrobial resistance for general practitioners is crucial for achieving appropriate empirical management of the most common infections by promoting more rational antibiotic use.(AU)

En los últimos años han cambiado significativamente los porcentajes de sensibilidad de los microorganismos más comunes que causan infecciones adquiridas en la comunidad en España. A partir de los porcentajes de sensibilidad de Streptococcus pyogenes, Streptococcus pneumoniae, Haemophilus influenzae, Escherichia coli y Klebsiella pneumoniae, recogidas de aislados de pacientes ambulatorios de 15 años o más, con síntomas de infecciones respiratorias o urinarias en servicios de microbiología de Cataluña en 2021, fenoximetilpenicilina debería ser la primera opción en la mayoría de los infecciones respiratorias, amoxicilina y ácido clavulánico en las exacerbaciones de la enfermedad pulmonar obstructiva crónica y la monodosis de fosfomicina o la pauta corta de nitrofurantoína como tratamiento de primera línea en las infecciones urinarias no complicadas. Es importante que los médicos de familia dispongan de información actualizada sobre la resistencia a los antimicrobianos para lograr un manejo empírico adecuado de las infecciones más frecuentes al promover un uso más racional de los antibióticos.(AU)

Implementation of the delayed antibiotic prescribing strategy. Prospective observation study in primary care / Implementación de la estrategia de prescripción diferida de antibióticos. Estudio observacional prospectivo en atención primaria

Objectives. We aimed to compare the actual consumption of antibiotics among patients issued delayed antibioticprescribing with the consumption observed in a non-systematic review of studies on delayed prescribing.Methods. Observational study carried out in three primary care centres from September 2018 until March 2020. Wetracked the electronic records of the 82 patients with episodesof acute bronchitis and 44 acute pharyngitis who were givena patient-led delayed prescription to determine whether theprescription was filled and when this medication was obtained.Results. The prescriptions were never filled in 50 cases(39.7%), but five patients took another antibiotic within thefirst two weeks. Out of 76 patients who did take the delayedprescription, only 12 obtained the medication based on the instructions given by the doctors (15.8%).Conclusions. The strategy of delayed antibiotic prescribing resulted in a reduction in antibiotic use, but this reductionwas lower than in randomised clinical trials, being comparable to the results obtained with other observational studies ondelayed antibiotic prescribing. In addition, only a few patientsadhered to the doctors’ instructions (AU)

Objetivos. Evaluar el consumo de antibióticos entre lospacientes a los que se les efectuó una prescripción antibióticadiferida y compararlo con el consumo observado en una revisión no sistemática de estudios de prescripción diferida.Métodos. Estudio observacional en tres centros de saluddesde septiembre 2018 hasta marzo 2020. Se realizó un seguimiento de los registros electrónicos de los 82 pacientes conepisodios de bronquitis aguda y 44 faringitis aguda a los quese les entregó una prescripción diferida para evaluar si fue a lafarmacia a buscarla y cuándo la obtuvo.Resultados. No fueron a buscar la medicación en 50 casos (39,7%), pero cinco pacientes tomaron otro antibiótico enlas dos primeras semanas. De los 76 pacientes que recogieronla prescripción, solo 12 la obtuvieron según las instruccionesde sus médicos (15,8%).Conclusiones. La estrategia de prescripción diferida reduce el consumo de antibióticos, pero esta reducción es menorque la que se observa en ensayos clínicos, siendo comparablecon los resultados observados en otros estudios observacionales sobre prescripción diferida. Además, solo unos pocos pacientes siguieron las instrucciones de sus médicos. (AU)

Improved management of cystitis in primary care following the implementation of a simple multifaceted intervention / Mejora en el manejo de las cistitis en atención primaria después de la implementación de una intervención multimodal simple

Objective: We assessed the impact of the implementation of a simple multifaceted intervention aimed at improving management of cystitis in primary care. Design: Quality control before and after study. Site: Primary care centres in Barcelona city provided by the Catalonian Institute of Health. Participants: The multifaceted intervention consisted of (1) creation of a group with a leader in each of the primary care centres, out of hours services, sexual and reproductive centres, and home visit service, (2) session on management of cystitis in each centre, (3) result feedback for professionals, and (4) provision of infographics for professionals and patients with urinary tract infections. Interventions started in November 2020 and ended in the summer of 2021. Main measurements: Variation in the prescription of first-line antibiotics, usage of antibiotics, and request for urine cultures before and after this intervention. Results: Training sessions took place in 93% of the centres. The use of first-line therapies cystitis increased by 6.4% after the intervention (95% confidence interval [CI], 5.7–7.1%). The use of nitrofurantoin in recurrent cystitis increased, mainly in out of hours service (8.7%; 95% CI, 5.2–12.2%). Urine cultures were more frequently requested after the intervention for recurrent cystitis in both primary care centres and out of hours services, with a 7.2% increase [95% CI, 5.9–8.5%), but also for uncomplicated urinary tract infections (3.1%; 95% CI, 1.8–4.4%). Conclusions: A low-intensity multifaceted intervention on management of cystitis, with strong institutional support, resulted in a better choice of antibiotic in antibiotic prescribing, but the intervention had less impact on the adequacy of urine cultures.(AU)

Objetivo: Evaluamos el impacto de una intervención multimodal en la mejora del manejo de las cistitis en atención primaria. Diseño: Estudio de calidad antes-después. Emplazamiento: Centros de atención primaria de la ciudad de Barcelona proporcionados por el Institut Català de la Salut. Participantes: La intervención multimodal consistió en: (1) creación de un grupo de trabajo con líderes en cada uno de los equipos de atención primaria, servicios de urgencias, centros de atención sexual y reproductiva y servicio de atención domiciliaria, (2) sesión formativa sobre el manejo de las infecciones del tracto urinario en cada centro, (3) retorno de resultados a profesionales, y (4) difusión de infografías a profesionales y pacientes. Las intervenciones comenzaron en noviembre de 2020 y finalizaron en verano de 2021. Mediciones principales: Variación en la prescripción de antibióticos de primera línea, uso de antibióticos y solicitud de urocultivos antes y después de esta intervención. Resultados: Las sesiones de formación se realizaron en el 93% de los centros. La selección de fármacos de primera línea en cistitis aumentó en un 6,4% después de la intervención (intervalo de confianza [IC] 95%: 5,7-7,1%). El uso de nitrofurantoína en cistitis recurrente aumentó, principalmente en servicios de urgencias (8,7%; IC 95%: 5,2-12,2%). Las solicitudes de urocultivos aumentaron después de la intervención en equipos de atención primaria y servicios de urgencias en cistitis recurrentes (7,2%; IC 95%: 5,9-8,5%), pero también en cistitis simples (3,1%; IC 95%: 1,8-4,4%). Conclusiones: Una intervención multimodal de baja intensidad sobre el manejo de las cistitis junto con el apoyo institucional explícito mejoró claramente la selección de antibióticos, pero tuvo menos impacto en la adecuación de los urocultivos.(AU)

Efficacy of high doses of penicillin versus amoxicillin in the treatment of uncomplicated community acquired pneumonia in adults. A non-inferiority controlled clinical trial / Eficacia de dosis altas de penicilina frente a amoxicilina en el tratamiento de la neumonía no complicada adquirida en la comunidad en adultos. Ensayo clínico controlado de no inferioridad

Introduction: Community-acquired pneumonia (CAP) is treated with penicillin in some northern European countries. Objectives: To evaluate whether high-dose penicillin V is as effective as high-dose amoxicillin for the treatment of non-severe CAP. Design: Multicentre, parallel, double-blind, controlled, randomized clinical trial. Setting: 31 primary care centers in Spain. Participants: Patients from 18 to 75 years of age with no significant associated comorbidity and with symptoms of lower respiratory tract infection and radiological confirmation of CAP were randomized to receive either penicillin V 1.6 million units, or amoxicillin 1000mg three times per day for 10 days. Main measurements: The main outcome was clinical cure at 14 days, and the primary hypothesis was that penicillin V would be non-inferior to amoxicillin with regard to this outcome, with a margin of 15% for the difference in proportions. EudraCT register 2012-003511-63. Results: A total of 43 subjects (amoxicillin: 28; penicillin: 15) were randomized. Clinical cure was observed in 10 (90.9%) patients assigned to penicillin and in 25 (100%) patients assigned to amoxicillin with a difference of -9.1% (95% CI, --41.3% to 6.4%; p = .951) for non-inferiority. In the intention-to-treat analysis, amoxicillin was found to be 28.6% superior to penicillin (95% CI, 7.3-58.1%; p = .009 for superiority). The number of adverse events was similar in both groups. Conclusions: There was a trend favoring high-dose amoxicillin versus high-dose penicillin in adults with uncomplicated CAP. The main limitation of this trial was the low statistical power due to the low number of patients included

Introducción: En algunos países la neumonía adquirida en la comunidad (NAC) se trata con penicilina. Objetivo: Evaluar si penicilina V a dosis altas es igual de efectiva que amoxicilina a dosis altas en la NAC no complicada. Diseño. Ensayo clínico paralelo, doble ciego, controlado y multicéntrico. Emplazamiento: Treinta y un centros de salud en España. Participantes: Se reclutaron pacientes de 18 a 75 años de edad sin comorbilidad asociada importante, con síntomas de infección respiratoria inferior y confirmación radiológica de neumonía, que fueron asignados aleatoriamente a 1,6M unidades de penicilina V o amoxicilina 1.000 mg, 3 veces al día, durante 10 días. Mediciones principales: La variable de resultado principal fue curación clínica a los 14 días y se planteó la hipótesis de que penicilina no era inferior a amoxicilina con un margen de 15% para la diferencia de proporciones. Registro EudraCT 2012-003511-63. Resultados: Se aleatorizaron 43 personas (amoxicilina: 28; penicilina: 15). Se observó curación clínica en 10 pacientes asignados a penicilina (90,9%) y en 25 asignados a amoxicilina (100%), observándose una diferencia de -9,1% (IC 95%: -41,3 a 6,4%; p = 0,951) para no inferioridad. En el análisis por intención de tratar amoxicilina fue 28,6% superior a penicilina V (IC 95%: 7,3% a 58,1%; p = 0,009 para superioridad). El número de eventos adversos fue similar en ambos grupos. Conclusiones: Se observó una tendencia de un mayor beneficio de amoxicilina frente a penicilina en adultos con NAC no complicada. La principal limitación fue la baja potencia estadística debido al bajo número de pacientes incluidos