Effectiveness of two types of intervention on antibiotic prescribing in respiratory tract infections in Primary Care in Spain. Happy Audit Study.

OBJECTIVE: To evaluate the effectiveness of two types of intervention in reducing antibiotic prescribing in respiratory tract infections (RTI). DESIGN: Before-after audit-based study. SETTING: Primary Care centres in Spain. PARTICIPANTS: General practitioners (GPs) registered all patients with RTIs for 15 days in winter 2008 (pre-intervention), and again in winter 2009 (post-intervention). INTERVENTIONS: Intervention activities included meetings, with the presentation and discussion of the results, and several training meetings on RTI guidelines, information brochures for patients, workshops on point-of-care tests - rapid antigen detection tests and C-reactive protein rapid test - and provision of these tests in the clinic. All GPs, with the exception of those in Catalonia, made up the full intervention group (FIG); conversely, Catalan doctors underwent the same intervention, except for the workshop on rapid tests (partial intervention group, PIG). Multilevel logistic regression was performed taking the prescription of antibiotics as the dependent variable. RESULTS: Out of a total of 309 GPs involved in the first register, 281 completed the intervention and the second register (90.9%), of which 210 were assigned to the FIG, and 71 to the PIG. The odds ratio of antibiotic prescribing after the intervention was 0.99 (95% CI: 0.89-1.10) among GPs assigned to PIG, and 0.50 (95% CI: 0.44-0.57, p<0.001) among those who were allocated to FIG. The reduction in antibiotic prescribing in FIG was more marked in flu infection, common cold, acute pharyngitis, acute tonsillitis, and acute bronchitis. CONCLUSIONS: Active participation of GPs with the performance of point-of-care tests in the clinic is accompanied by a drastic reduction of antibiotic use in RTIs, primarily in infections considered as mainly viral.

C-reactive protein testing in patients with acute rhinosinusitis leads to a reduction in antibiotic use.

OBJECTIVE: To evaluate the effect of C-reactive protein (CRP) testing on the antibiotic prescribing in patients with acute rhinosinusitis. METHODS: Audit-based study carried out in primary care centres in Spain. GPs registered episodes of rhinosinusitis during 3-week period before and after an intervention. Two types of intervention were considered: full intervention group (FIG) consisting in individual feedback based on results from the first registry, courses in rational antibiotic prescribing, guidelines, patient information leaflets, workshops on rapid tests and use of the CRP test. GPs in the partial intervention group (PIG) underwent all the above intervention except for the workshop and they did not have access to CRP. Multilevel logistic regression analysis was performed considering the prescription of antibiotics as the dependent variable. RESULTS: Two hundred and ten physicians were assigned to FIG and 71 to PIG. In 2009, 59 new physicians were included as a control group. Two hundred and sixty-seven GPs visited contacts with rhinosinusitis (78.5%) registering a total of 836 cases. In the group of GPs with access to CRP rapid test, 207 patients with rhinosinusitis (75.3%) were tested and antibiotics were prescribed in 156 patients (56.7%). Antibiotics were prescribed in 87 patients (82.9%) in the group of GPs exposed to PIG and in 52 patients (86.7%) in the control group (P < 0.001). Antibiotic prescription was significantly reduced after the intervention among physicians assigned to FIG, with an odds ratio of antibiotic prescribing of 0.12 (95% confidence interval: 0.01-0.32). CONCLUSION: Physicians with access to CRP tests significantly reduced antibiotic prescription in patients with rhinosinusitis.

Effect of two interventions on reducing antibiotic prescription in pharyngitis in primary care.

OBJECTIVES: to evaluate the effect of two interventions on reducing antibiotic prescription in pharyngitis. METHODS: a prospective, non-randomized, before-after controlled study was carried out in primary care centres throughout Spain. General practitioners (GPs) registered all cases of pharyngitis during a 3 week period before and after two types of intervention in 2008 and 2009, respectively. Full intervention consisted of discussion sessions of the results of the first registry, courses for GPs, guidelines, patient information leaflets, workshops on rapid tests and the use of rapid antigen detection tests (RADTs) in their consulting offices. The physicians in the partial intervention group underwent all the above intervention except for the workshop, and RADTs were not provided. A control group was also included in 2009. Multilevel logistic regression was performed considering the prescription of antibiotics as the dependent variable. RESULTS: a total of 280 GPs registered cases with pharyngitis (70 partial intervention and 210 full intervention). Fifty-nine new physicians were included as a control group. A total of 6849 episodes of pharyngitis were registered. Antibiotic prescription was significantly lower after intervention for the full intervention group, but not for the partial intervention group. According to the multivariate model, in comparison with the control group, the odds ratio of antibiotic prescription after the intervention was 0.52 [95% confidence interval (95% CI) 0.23-1.18] in the partial intervention group and 0.23 (95% CI 0.11-0.47) in the full intervention group. CONCLUSIONS: intervention was beneficial for reducing the prescription of antibiotics, but was only statistically significant when the GPs were provided with RADTs.

The adherence of GPs to guidelines for the diagnosis and treatment of lower urinary tract infections in women is poor.

OBJECTIVES: To assess the adherence of GPs to evidence-based guidelines for the diagnosis and management of lower urinary tract infection (UTI) in women. METHODS: A cross-sectional study was performed from March to July 2009 in primary care offices. Physicians consecutively registered the first six UTI attended during an 8-week period. Age, days with symptoms, episode of infection, associated morbidity, signs and symptoms, diagnostic procedures performed, antibiotic prescription, allergies and referral or not were registered. The type of antibiotic course (short or long) and first-choice treatments were also taken into account. RESULTS: Of 176 physicians invited to participate, 110 (62.5%) included 658 women with lower UTI. Urine dipstick was performed in 550 cases (83.6%) and urine culture was requested in 235 women (35.7%), with criteria for culture in 49.6% and without criteria in 32.8%. Antibiotic treatment was administered in 634 cases (96.4%). Short courses were given to 385 women (60.7%) and 75 of those with complicated UTI were treated with long courses (66.4%). First-choice antibiotics were administered as empiric treatment in only 92 women with uncomplicated UTI (17.7%). CONCLUSIONS: These results highlight the poor adherence of GPs to the current recommendations of clinical practice guidelines with a high number of inappropriate urine cultures requested and a low utilization of first-choice antibiotics.

Health Alliance for prudent antibiotic prescribing in patients with respiratory tract infections (HAPPY AUDIT) -impact of a non-randomised multifaceted intervention programme.

BACKGROUND: Excessive use of antibiotics is worldwide the most important reason for development of antimicrobial resistance. As antibiotic resistance may spread across borders, high prevalence countries may serve as a source of bacterial resistance for countries with a low prevalence. Therefore, bacterial resistance is an important issue with a potential serious impact on all countries. Initiatives have been taken to improve the quality of antibiotic prescribing in primary care, but only few studies have been designed to determine the effectiveness of multifaceted strategies across countries with different practice setting. The aim of this study was to evaluate the impact of a multifaceted intervention targeting general practitioners (GPs) and patients in six countries with different health organization and different prevalence of antibiotic resistance. METHODS: GPs from two Nordic countries, two Baltic Countries and two Hispano-American countries registered patients with respiratory tract infections (RTIs) in 2008 and 2009. After first registration they received individual prescriber feedback and they were offered an intervention programme that included training courses, clinical guidelines, posters for waiting rooms, patient brochures and access to point of care tests (Strep A and C-Reactive Protein). Antibiotic prescribing rates were compared before and after the intervention. RESULTS: A total of 440 GPs registered 47011 consultations; 24436 before the intervention (2008) and 22575 after the intervention (2009). After the intervention, the GPs significantly reduced the percentage of consultations resulting in an antibiotic prescription. In patients with lower RTI the GPs in Lithuania reduced the prescribing rate by 42%, in Russia by 25%, in Spain by 25%, and in Argentina by 9%. In patients with upper RTIs, the corresponding reductions in the antibiotic prescribing rates were in Lithania 20%, in Russia 15%, in Spain 9%, and in Argentina 5%. CONCLUSION: A multifaceted intervention programme targeting GPs and patients and focusing on improving diagnostic procedures in patients with RTIs may lead to a marked reduction in antibiotic prescribing. The pragmatic before-after design used may suffer from some limitations and the reduction in antibiotic prescribing could be influenced by factors not related to the intervention.

[Incidence of SARS-CoV-2 infection in close contacs. Telephone follow-up in Primary Care]. / Incidencia de infección por SARS-CoV-2 en contactos estrechos. Seguimiento telefónico en Atención Primaria.

OBJECTIVE: To study the incidence of infection in close contacts with patiens with SARS-CoV-2 infection using a telephone monitoring protocol after the recommendation of isolation and quarantine at home. PATIENTS AND METHODS: Cohort study, with 124 patients older than 15 years, included consecutively, asymptomatic at the time of the consultation, who had had close contact (<2 meters) with confirmed or possible cases of SARS-CoV-2 infection. The intervention consisted of 2 weeks of home isolation and quarantine, contacting by phone on days, 2, 4, 7 and 14 after the contact. The event of interest was the appereance of symptoms compatible with SARS-CoV-2 infection. RESULTS: The average age was 45.1 years (55.6% women); 328 phone calls were made (average 2.6 calls for patient). After 2 weeks of follow-up, 6 patients developed symptoms, confirming serologically or by PCR in 3 of them (2.4%, CI 95%: 0.8-6.9). CONCLUSIONS: The incidence of SARS-CoV-2 infection in close contacts is low 2 weeks after home isolation and quarantine at home.

Incidence of SARS-CoV-2 infection in close contacs. Telephone follow-up in Primary Care.

OBJECTIVE: To study the incidence of infection in close contacts with patiens with SARS-CoV-2 infection using a telephone monitoring protocol after the recommendation of isolation and quarantine at home. PATIENTS AND METHODS: Cohort study, with 124 patients older than 15 years, included consecutively, asymptomatic at the time of the consultation, who had had close contact (<2 m) with confirmed or possible cases of SARS-CoV-2 infection. The intervention consisted of 2 weeks of home isolation and quarantine, contacting by phone on days, 2, 4, 7 and 14 after the contact. The event of interest was the appereance of symptoms compatible with SARS-CoV-2 infection. RESULTS: The average age was 45.1 years (55.6% women); 328 phone calls were made (average 2.6 calls for patient). After 2 weeks of follow-up, 6 patients developed symptoms, confirming serologically or by PCR in 3 of them (2.4%, CI 95%: 0.8-6.9). CONCLUSIONS: The incidence of SARS-CoV-2 infection in close contacts is low 2 weeks after home isolation and quarantine at home.

OBJETIVO: Estudiar mediante un protocolo de seguimiento telefónico la incidencia de infección en los contactos estrechos de pacientes con infección por SARS-CoV-2 tras la recomendación de aislamiento y cuarentena en el domicilio. PACIENTES Y MÉTODOS: Estudio de cohortes, con 124 pacientes mayores de 15 años, incluidos consecutivamente, asintomáticos en el momento de la visita, con contacto estrecho (<2 metros) con casos confirmados o posibles de infección por SARS-CoV-2. La intervención consistió en aislamiento y cuarentena en domicilio durante 2 semanas, contactando telefónicamente los días 2, 4, 7 y 14 tras el contacto. El evento de interés fue la aparición de clínica compatible con infección por SARS-CoV-2. RESULTADOS: La edad media fue de 45,1 años (55,6% mujeres). Se realizaron 328 llamadas telefónicas (media de 2,6 llamadas por paciente). Tras 2 semanas de seguimiento desarrollaron síntomas 6 pacientes, confirmados serológicamente o por PCR en 3 de ellos (2,4%; IC 95%: 0,8­6,9). CONCLUSIONES: La incidencia de infección por SARS-CoV-2 en los contactos estrechos es baja a las 2 semanas tras el aislamiento y cuarentena domiciliarios.

A Co-Design Process to Elaborate Educational Materials to Promote Appropriate Use of Antibiotics for Acute Lower Respiratory Tract Infections in Primary Healthcare in Catalonia (Spain).

PURPOSE: Co-design processes with patients allow developing health education materials, that are adapted to the population's knowledge and use of language, to reduce inappropriate antibiotic use. PATIENTS AND METHODS: This study presents a co-design process of educational material with patients (over 18 years old) with a previous diagnosis of acute lower respiratory tract infection. The co-design was framed within a qualitative study (Phase I, interviews; Phase II, focus group) conducted in Barcelona between April and September 2019. RESULTS: Twenty-nine semi-structured interviews were conducted. Six people participated in the focus group. Based on participants' narratives, educational materials can be useful to support healthcare consultations. Materials should be designed to be accessible in terms of the content and language used. CONCLUSION: The co-design of educational materials is essential for health promotion. This study presents an example of how materials can be co-developed with patients. The material elaborated in this study is being used for the ISAAC-CAT project and may be useful for future research, practice in health services and health policy.

Health Alliance for Prudent Prescribing, Yield and Use of Antimicrobial Drugs in the Treatment of Respiratory Tract Infections (HAPPY AUDIT).

BACKGROUND: Excessive and inappropriate use of antibiotics is considered to be the most important reason for development of bacterial resistance to antibiotics. As antibiotic resistance may spread across borders, high prevalence countries may serve as a source of bacterial resistance for countries with a low prevalence. Therefore, bacterial resistance is an important issue with a potential serious impact on all countries. The majority of respiratory tract infections (RTIs) are treated in general practice. Most infections are caused by virus and antibiotics are therefore unlikely to have any clinical benefit. Several intervention initiatives have been taken to reduce the inappropriate use of antibiotics in primary health care, but the effectiveness of these interventions is only modest. Only few studies have been designed to determine the effectiveness of multifaceted strategies in countries with different practice setting. The aim of this study is to evaluate the impact of a multifaceted intervention targeting general practitioners (GPs) and patients in six countries with different prevalence of antibiotic resistance: Two Nordic countries (Denmark and Sweden), two Baltic Countries (Lithuania and Kaliningrad-Russia) and two Hispano-American countries (Spain and Argentina). METHODS/DESIGN: HAPPY AUDIT was initiated in 2008 and the project is still ongoing. The project includes 15 partners from 9 countries. GPs participating in HAPPY AUDIT will be audited by the Audit Project Odense (APO) method. The APO method will be used at a multinational level involving GPs from six countries with different cultural background and different organisation of primary health care. Research on the effect of the intervention will be performed by analysing audit registrations carried out before and after the intervention. The intervention includes training courses on management of RTIs, dissemination of clinical guidelines with recommendations for diagnosis and treatment, posters for the waiting room, brochures to patients and implementation of point of care tests (Strep A and CRP) to be used in the GPs'surgeries. To ensure public awareness of the risk of resistant bacteria, media campaigns targeting both professionals and the public will be developed and the results will be published and widely disseminated at a Working Conference hosted by the World Association of Family Doctors (WONCA-Europe) at the end of the project period. DISCUSSION: HAPPY AUDIT is an EU-financed project with the aim of contributing to the battle against antibiotic resistance through quality improvement of GPs' diagnosis and treatment of RTIs through development of intervention programmes targeting GPs, parents of young children and healthy adults. It is hypothesized that the use of multifaceted strategies combining active intervention by GPs will be effective in reducing prescribing of unnecessary antibiotics for RTIs and improving the use of appropriate antibiotics in suspected bacterial infections.

Autonomy, power dynamics and antibiotic use in primary healthcare: A qualitative study.

Antibiotic resistance is a global health concern. Although numerous strategies have tried to reduce inadequate antibiotic prescribing, antibiotics are still prescribed in 60% of acute lower respiratory tract infections (ALRTIs) cases in Catalonia (Spain). This study aims to explore service users' experiences of ALRTIs, the quality and access to healthcare services, and health education. Selective purposive sampling was carried out, based on a prior definition of participant characteristics. These were sex, age, ethnicity, date of the last ALRTI, number of ALRTIs in the last year, and treatments received. Participants with a previous diagnosis of ALRTIs were recruited from three primary health care centres in Barcelona and one in Tarragona. Twenty-nine interviews were conducted between April and June 2019. A content thematic analysis was performed. Three themes were identified: 1) risk perceptions and help-seeking; 2) treatment preferences and antibiotic use; and 3) relationship dynamics and communication with healthcare professionals. Accounts of service users' sense of autonomy towards their health and power dynamics within the healthcare system were apparent. Supporting service users to become reliable, subjective and agentic experts of their health and bodies could help them to voice their healthcare agendas. Power structures embedded within healthcare, political and economic institutions should be challenged so that healthcare services can be co-developed (with service users) and based on service users' autonomy and horizontal relationships. Special consideration should be paid to the intersection of social vulnerabilities. A concordance approach to prescribing could be key to improve the responsible use of antibiotics and to contribute to the prevention of AMR in primary healthcare. The marketisation of health, and the increased demands of private healthcare in Spain due to the financial pressures on public healthcare as a consequence of the financial crisis of 2008 and the COVID-19 pandemic, are a risk for promoting adequate antibiotic prescribing and use. Trial registration The ISAAC-CAT study has been registered in the NCT registry, ID: NCT03931577.

The sale of antibiotics without prescription in pharmacies in Catalonia, Spain.

BACKGROUND: Current regulations in Spain state that antibiotics cannot be sold without a medical prescription. The objective of this study was to quantify the percentage of pharmacies selling antibiotics without an official medical prescription in Catalonia, Spain, by the simulation of 3 different clinical cases presented by actors. METHODS: A prospective study was performed from January through May 2008. Three different cases were presented at pharmacies: sore throat, acute bronchitis, and a urinary tract infection. Three levels of demand were used to convince the pharmacists to sell an antibiotic. RESULTS: A total of 197 pharmacies were visited. Antibiotics were obtained from 55 (79.7%) of 69 pharmacies when a urinary tract infection was simulated, 24 (34.8%) of 69 pharmacies when a sore throat was simulated, and 10 (16.9%) of 59 pharmacies when acute bronchitis was simulated (P < .001). Among the pharmacies that sold antibiotics, the pharmacists provided an explanation as to the number of times per day the drug should be taken in 84.3%, explained the duration of treatment in 68.7%, and inquired about allergies prior to the sale of the antibiotic in only 16.9%. Of the 108 pharmacies that did not sell the antibiotics, only 57 (52.8%) explained that they could not be given over the counter for health care reasons or to avoid antibiotic resistance. CONCLUSIONS: These results demonstrate that, although illegal, the sale of antibiotics without a prescription continues in Spain. This should be taken into account by countries that are currently considering the possibility of making some antibiotics available over the counter.

[Bacterial etiology of chronic bronchitis exacerbations treated by primary care physicians]. / Etiología bacteriana de la agudización de la bronquitis crónica en atención primaria.

OBJECTIVE: Few studies have been carried out to determine the prevalence of microorganisms causing exacerbations of chronic bronchitis in the community setting. The aim of the present study was to determine the bacterial etiology of chronic bronchitis exacerbations in patients not requiring hospitalization. PATIENTS AND METHODS: This observational, cross-sectional, multicenter study was carried out at the primary care level during 2 weeks (in November 2001 and January 2002). All laboratory work was carried out at a single center. We studied 1,947 patients with mild-moderate exacerbations treated by 650 primary care physicians. All the sputum samples received for centralized processing were subject to Gram staining, microscopic examination, and bacterial culture. RESULTS: Out of 1,537 cultures of sputum samples collected, 498 had good cell quality for microscopic examination (32.4%). Of the 498 good quality samples analyzed, 246 (49.4%) were positive and 468 isolates were obtained. The most commonly isolated germ was Streptococcus pneumoniae (163 cases, 34.8%), followed by Moraxella catarrhalis (112, 23.9%), and Haemophilus influenzae (59, 12.6%). In 1.2% of the S. pneumoniae isolates resistance was found to amoxicillin; resistance to macrolides was found in 34.3%. The antibiotics most commonly prescribed, however, were macrolides (38.3% of the prescriptions). CONCLUSIONS: S. pneumoniae was the microorganism most frequently isolated in cases of chronic bronchitis exacerbation treatable in this outpatient setting.

Incidencia de infección por SARS-CoV-2 en contactos estrechos. Seguimiento telefónico en Atención Primaria / Incidence of SARS-CoV-2 infection in close contacs. Telephone follow-up in Primary Care

Objetivo: Estudiar mediante un protocolo de seguimiento telefónico la incidencia de infección en los contactos estrechos de pacientes con infección por SARS-CoV-2 tras la recomendación de aislamiento y cuarentena en el domicilio.Pacientes y métodosEstudio de cohortes, con 124 pacientes mayores de 15 años, incluidos consecutivamente, asintomáticos en el momento de la visita, con contacto estrecho (<2 metros) con casos confirmados o posibles de infección por SARS-CoV-2. La intervención consistió en aislamiento y cuarentena en domicilio durante 2 semanas, contactando telefónicamente los días 2, 4, 7 y 14 tras el contacto. El evento de interés fue la aparición de clínica compatible con infección por SARS-CoV-2.ResultadosLa edad media fue de 45,1 años (55,6% mujeres). Se realizaron 328 llamadas telefónicas (media de 2,6 llamadas por paciente). Tras 2 semanas de seguimiento desarrollaron síntomas 6 pacientes, confirmados serológicamente o por PCR en 3 de ellos (2,4%; IC 95%: 0,8-6,9).ConclusionesLa incidencia de infección por SARS-CoV-2 en los contactos estrechos es baja a las 2 semanas tras el aislamiento y cuarentena domiciliarios. (AU)

Objective: To study the incidence of infection in close contacts with patiens with SARS-CoV-2 infection using a telephone monitoring protocol after the recommendation of isolation and quarantine at home.Patients and methodsCohort study, with 124 patients older than 15 years, included consecutively, asymptomatic at the time of the consultation, who had had close contact (<2 meters) with confirmed or possible cases of SARS-CoV-2 infection. The intervention consisted of 2 weeks of home isolation and quarantine, contacting by phone on days, 2, 4, 7 and 14 after the contact. The event of interest was the appereance of symptoms compatible with SARS-CoV-2 infection.ResultsThe average age was 45.1 years (55.6% women); 328 phone calls were made (average 2.6 calls for patient). After 2 weeks of follow-up, 6 patients developed symptoms, confirming serologically or by PCR in 3 of them (2.4%, CI 95%: 0.8-6.9).ConclusionsThe incidence of SARS-CoV-2 infection in close contacts is low 2 weeks after home isolation and quarantine at home. (AU)

Variables associated with recovery from acute exacerbations of chronic bronchitis and chronic obstructive pulmonary disease.

OBJECTIVE: To identify risk factors for late recovery and failure after ambulatory treatment of exacerbations of chronic bronchitis (CB) and chronic obstructive pulmonary disease (COPD). METHODS: Observational, non-randomised study of risk factors carried out in 2001 and 2002 in Primary Care practices. Patients aged 40 or older diagnosed with an exacerbation of CB or COPD of probable bacterial etiology were included in the study and followed up for 10 days. Patients were treated with amoxicillin plus clavulanic acid (co-amoxiclav) 500-125 mg tds for 10 days, clarithromycin 500 mg bd for 10 days or moxifloxacin 400 mg od for 5 days. RESULTS: Two hundred and fifty-two general practitioners participated, registering 1147 valid patients. The rate of failure at day 10 was 15.1% without significant differences among the antibiotic treatments. Median time to recovery was 5 days. Factors significantly associated with late recovery (>5 days) on multivariate analysis were: use of long-term oxygen (OR=1.96; 95%CI=1.35-2.85); use of short-acting beta-2 agonists (OR=1.51; 1.17-1.92). The use of moxifloxacin had a "protective" effect against late recovery compared to co-amoxiclav (OR=0.34; 0.26-0.45) and clarithromycin (OR=0.41; 0.31-2.85). Factors associated with therapeutic failure were: previous hospitalisation (OR=1.61; 1.08-2.42); and 2 or more exacerbations the previous year (OR=1.51; 1.04-2.17); criteria of CB had a protective effect against failure (OR=0.53; 0.35-0.79). CONCLUSIONS: There are readily identifiable risk factors for ambulatory treatment failure of exacerbations of CB and COPD. In addition, long-term oxygen therapy and short-acting beta-2 agonists are associated with late recovery, and the use of moxifloxacin compared with co-amoxiclav and clarithromycin is associated with faster recovery of symptoms.

Interventions to improve adherence to first-line antibiotics in respiratory tract infections. The impact depends on the intensity of the intervention.

BACKGROUND: Many interventions aimed at improving the quality of antibiotic prescribing have been investigated, but more knowledge is needed regarding the impact of different intensity interventions. OBJECTIVES: To compare the effect of two interventions, a basic intervention (BI) and intensive intervention (II), aimed to improve the adherence to recommendations on first-line antibiotics in patients with respiratory tract infections (RTIs). METHODS: General practitioners (GPs) from different regions of Spain were offered two different interventions on antibiotic prescribing. They registered all patients with RTIs during 15 days before (2008) and after (2009) the intervention. GPs in Catalonia were exposed to BI including prescriber feedback, clinical guidelines and training sessions focused on appropriate antibiotic prescribing. The other group of GPs was exposed to an II, which besides BI, also included training and access to point-of-care tests in practice. RESULTS: The GPs registered 15 073 RTIs before the intervention and 12 760 RTIs after. The antibiotic prescribing rate reduced from 27.7% to 19.8%. Prescribing of first-choice antibiotics increased after the intervention in both groups. In the group of GPs following the BI, first-line antibiotics accounted for 23.8% of antibiotics before the intervention and 29.4% after (increase 5.6%, 95% confidence interval (CI): 1.2-10%), while in the group of GPs following the II these figures were 26.2% and 48.6% (increase 22.4%, 95% CI: 18.8-26%), respectively. CONCLUSION: Multifaceted interventions targeting GPs can improve adherence to recommendations for first-line antibiotic prescribing in patients with RTI, with intensive interventions that include point-of-care testing being more effective.

[Physicians with access to point-of-care tests significantly reduce the antibiotic prescription for common cold]. / Los médicos que disponen de pruebas rápidas disminuyen significativamente la prescripción de antibióticos en el resfriado común.

OBJECTIVE: This study was aimed at evaluating the effect of two levels of intervention on the antibiotic prescribing in patients with common cold. METHODS: Before and after audit-based study carried out in primary healthcare centres in Spain. General practitioners registered all the episodes of common cold during 15 working days in January and February in 2008 (preintervention). Two types of intervention were considered: full intervention, consisting in individual feedback based on results from the first registry, courses in rational antibiotic prescribing, guidelines, patient information leaflets, workshops on rapid tests -rapid antigen detection and C-reactive protein tests- and provision of these tests in the surgeries; and partial intervention, consisting of all the above intervention except for the workshop and they did not have access to rapid tests. The same registry was repeated in 2009 (postintervention). In addition, new physicians filled out only the registry in 2009 (control group). RESULTS: 210 physicians underwent the full intervention, 71 the partial intervention and 59 were assigned to the control group. The 340 doctors prescribed antibiotics in 274 episodes of a total of 12,373 cases registered (2.2%).The greatest percentage of antibiotic prescription was found in the control group (4.6%). The partial intervention increased the antibiotic prescription percentage from 1.1% to 2.7% while only doctors who underwent the complete intervention lead to a significant reduction of antibiotics prescribed, from 2.9% before to 0.7% after the intervention (p<0.001). CONCLUSION: Only physicians with access to rapid tests significantly reduced antibiotic prescription in patients with common cold.

[Do general practitioners follow the therapeutical recommendations of cystitis in women? INURA study]. / ¿Siguen los médicos de Atención Primaria las recomendaciones terapéuticas de las cistitis en la mujer? Estudio INURA.

OBJECTIVE: The management of lower urinary tract infections varies from physician to physician. The aim of this study was to assess whether general practitioners follow the evidence-based guidelines for the management of cystitis in women. METHODS: Cross-sectional study carried out from March to July 2009 in which physicians consecutively registered in a template during a 8-week period the first six episodes of cystitis by means attended at the medical consultation. Age, episode of infection, associated morbidity, antibiotic prescription, and type of antibiotic course (short or long regimen) were determined. RESULTS: Out of 176 physicians invited to participate, 110 included 658 women with lower urinary tract infections with antibiotic treatment being administered in 634 cases. Short courses were given to 385 women (60.7%) and 249 women were given long schedules (39.3%). A total of 343 out of all noncomplicated cystitis were treated with short courses (62.9%) and 75 out of complicated cystitis were treated with long courses (66.4%). First-choice antibiotics were administered as empiric treatment in only 111 women (17.5%). CONCLUSIONS: These results highlight a poor adherence of general practitioners to current recommendations of clinical practice guidelines in cystitis with a low utilization of first-choice antibiotics.

Impact on antibiotic prescription of rapid antigen detection testing in acute pharyngitis in adults: a randomised clinical trial.

BACKGROUND: Acute pharyngitis is one of the most frequent reasons for a GP consultation, and in most cases an antibiotic is prescribed. AIM: To determine the impact of rapid antigen detection testing (RADT) to identify group A beta haemolytic streptococcus in acute pharyngitis on the utilisation of antibiotics and appropriateness of their use. DESIGN AND SETTING: Cluster randomised controlled trial in primary care centres in Catalonia, Spain. METHOD: Patients with acute pharyngitis aged 14 years or older with at least one Centor criterion (fever, tonsillar exudate, tender enlarged anterior cervical lymph nodes, or absence of cough) were recruited. Participant physicians were randomly assigned to one of two study arms: an intervention group (assigned to RADT) and a control group (following usual care, without RADT). RESULTS: Of the 557 adults enrolled, 543 could be evaluated for analysis (281 [51.7%] in the intervention group and 262 [48.3%] in the control group). GPs without access to RADT were more likely to prescribe antibiotics compared with those who performed rapid tests (64.1% versus 43.8%, P<0.001). The more Centor criteria the patients presented, the greater the number of antibiotics prescribed, regardless of whether RADT was available (P<0.001). Antibiotics were prescribed in 30.7% of the cases with negative RADT results. Inappropriate antibiotic prescription was observed in 226 cases (43%), and was significantly greater in the control than in the intervention group (60% versus 26.9%; P<0.001). CONCLUSION: Even though more than 30% of negative RADT results resulted in antibiotic prescribing, the study findings support the use of RADT in the consultation. This strategy has an important impact on reducing antibiotic prescription among adults with acute pharyngitis.