Recommended and prescribed symptomatic treatment for acute maxillary sinusitis in Finnish primary care.

We studied the use of symptomatic medication in the treatment of acute maxillary sinusitis (AMS) in primary care and whether this use is in accordance with national guidelines. The data was collected annually in the Antimicrobial Treatment Strategies (MIKSTRA) Program in 30 primary health care centres throughout Finland during one week in November in the years from 1998 to 2002. Physicians and nurses collected the data about the diagnoses, prescription-only medicines and over the counter medicines prescribed or recommended for all patients with an infection during the study weeks. The MIKSTRA data comprised of 23.002 first consultations for an infection: 2.448 patients were diagnosed as having AMS. Altogether, 41% of them received some symptomatic medicine. Antihistamines with or without sympathomimetics were the most commonly prescribed or recommended symptomatic medicines (23% of the patients). For comparison, systemic antibacterial agents were prescribed for 93% of the AMS patients. We conclude that Finnish physicians recommend or prescribe more symptomatic medication without proven efficacy for AMS than recommended by the national guidelines. Especially, the use of antihistamines with or without sympathomimetics, mostly the combination of acrivastine and pseudoephedrine, was common although antihistamines were recommended only for patients with allergy or nasal polyps.

Cost-effectiveness of implementing national guidelines in the treatment of acute otitis media in children.

OBJECTIVES: Acute otitis media (AOM) is one of the most common diseases of childhood, representing a major disease burden on the society. New evidence-based guidelines for AOM, focusing on children under 7 years of age, were introduced in Finland in 1999. The aim of this study was to evaluate the cost-effectiveness of implementing those guidelines in Finland. METHODS: A 5-year prospective trial was conducted in thirty community primary healthcare centers in Finland. All AOM patients between 0 and 6 years of age visiting the study health centers for the first time, for this episode of illness, during 1 week in November 1998 (n = 579) and November 2002 (n = 369) were included in this study. The outcome measure was the percentage of symptom-free patients. RESULTS: The mean direct cost of an AOM episode per patient stayed almost the same after implementing the guidelines, euro152 in 1998 and euro150 in 2002. After implementing the guidelines, the percentage of symptom-free patients was 10 percentage points higher than before the guidelines. The treatment after the implementation of the guidelines, thus, was a dominant strategy. CONCLUSIONS: Implementing the guidelines to the treatment of AOM in children was associated with extra health benefits at slightly lower direct costs and, thus, is a dominant strategy. The focus of this study was on the short-term effects of the treatment; including long-term effects in the analysis might affect the results.

Macrolide and azithromycin use are linked to increased macrolide resistance in Streptococcus pneumoniae.

The connection between regional rates of antimicrobial resistance in Streptococcus pneumoniae and regional antimicrobial use in Finland was investigated. During the 6-year study period of 1997 to 2002, a total of 31,609 S. pneumoniae isolates were tested for penicillin resistance and a total of 23,769 isolates were tested for macrolide resistance in 18 central hospital districts in Finland. The regional macrolide resistance rates were compared with the local use of (i) all macrolides pooled and (ii) azithromycin. The penicillin resistance levels were compared with the consumption data for (i) penicillins, (ii) cephalosporins, (iii) all beta-lactams pooled, and (iv) all macrolides pooled. A statistically significant association between macrolide resistance and total use of macrolides and the use of azithromycin was found. Moreover, total use of beta-lactams and total use of cephalosporins were significantly connected to low-level penicillin resistance. A statistically significant association between penicillin-nonsusceptible isolates and penicillin or total macrolide consumption was not found. In conclusion, total macrolide use and azithromycin use are associated with increased macrolide resistance, and beta-lactam use and cephalosporin use are connected to increased low-level penicillin resistance in S. pneumoniae. Unnecessary prescribing of macrolides and cephalosporins should be avoided.

Management of pain in acute otitis media in Finnish primary care.

Most treatment recommendations for acute otitis media favour active use of pain relief medication. These data comprised 3059 Finnish primary care acute otitis media patients. We found that 10.4% of the patients were prescribed or recommended analgesics, which is in contrast to treatment recommendations.

The Antimicrobial Treatment Strategies (MIKSTRA) program: a 5-year follow-up of infection-specific antibiotic use in primary health care and the effect of implementation of treatment guidelines.

BACKGROUND: A national 5-year follow-up study of infection-specific antibiotic use in primary care was conducted to see if prescribing practices change after implementing new treatment guidelines. METHODS: The data were collected during 1 week of November each year from 1998 to 2002 from 30 health care centers that covered a total population of 819,777 persons and in 2002 from 20 control health care centers that covered a population of 545,098 persons. National guidelines for 6 major infections (otitis media, sinusitis, throat infection, acute bronchitis, urinary tract infection, and bacterial skin infection) were published in 1999-2000. Multifaceted interventions were performed by local trainers teaching his or her coworkers, supported by feedback and patient and public information. RESULTS: The 6 infections targeted for intervention, together with unspecified upper respiratory tract infection constituted 80%-85% of all infections. The proportion of patients who received prescriptions for antibiotics did not change significantly. However, use of first-line antibiotics increased for all infections, and the change was significant for sinusitis (P<.001), acute bronchitis (P=.015), and urinary tract infections (P=.009). Also, the percentage of antibiotic treatments prescribed for the recommended duration increased significantly. Correct prescribing for respiratory tract infections improved by 6.4 percentage units (P<.001). However, there was no statistically significant difference in performance between study and control health care centers at follow-up. CONCLUSIONS: Moderate qualitative improvements in antibiotic use were observed after multifaceted intervention, but prescribing for unjustified indications, mainly acute bronchitis, did not decrease. Obtained infection-specific information on management of patients with infections in primary health care is an important basis for planning targeted interventions in the future.

Reduction in fluoroquinolone susceptibility among non-typhoidal strains of Salmonella enterica isolated from Finnish patients.

OBJECTIVES: The proportion of Salmonella isolates with reduced susceptibility to fluoroquinolones has increased during recent years in many countries, especially in South-east Asia. The present study was performed to evaluate the incidence of and changes in quinolone resistance in Salmonella isolates of either foreign or domestic origin in Finland. METHODS: A total of 1004 Salmonella isolates collected from Finnish patients between 2000 and 2004 were analysed for ciprofloxacin susceptibility. Of these isolates, 504 were of domestic origin and 500 were of foreign origin, collected from travellers to 43 different countries. The Salmonella collection consisted of 89 different serotypes. All isolates belonged to non-typhoidal Salmonella enterica. RESULTS: Of all isolates, 3 (0.3%) were ciprofloxacin-resistant (MIC > or = 4 mg/L) and 214 (21.3%) exhibited reduced susceptibility to ciprofloxacin (MIC > or = 0.125-2 mg/L). The annual proportion of reduced susceptibility varied between 3 and 15% among the domestic Salmonella isolates (P = 0.123). Between 2000 and 2004, the annual proportion of reduced susceptibility increased significantly (from 23 to 39%; P = 0.001) among all foreign isolates as well as among those from Spain alone (from 4 to 73%; P < 0.001). Among the isolates from Thailand, reduced ciprofloxacin susceptibility remained at a constantly high level (52-66%) throughout the study. CONCLUSIONS: Our results show that reduced fluoroquinolone susceptibility in S. enterica is not restricted to South-east Asia alone but continues to grow rapidly in many parts of the world including countries of the European Union.

Prescription rates and diagnostic patterns are stable: a comparison of high-, medium- and low-prescribing primary care physicians treating community-acquired respiratory tract infections.

The objective was to study prescription practices of primary care physicians in prescribing antibiotics for community-acquired respiratory tract infections. Design was time series analysis and cross-sectional survey. The setting was 30 community primary health care centres. A case report form was completed for 3478 patient consultations treated by 198 office-based primary care physicians. Main outcome measures were: classification of diagnoses of respiratory tract infections made by each physician; number of antibiotic prescriptions related to these diagnoses; each physician's mean weekly number of antibiotic prescriptions during 6 months before and after the survey. Patients' risk (odds ratio: OR) to receive an antibiotic prescription from the high and medium prescribers was 5.81 (95% confidence interval [CI] 4.85-6.96) and 2.41 (95% CI 2.04-2.86), compared to low prescribers. High and medium prescribers made more diagnoses of otitis media (OR 2.07, 95% CI 1.70-2.53 and 1.85, 95% CI 1.51-2.26, respectively) and fewer diagnoses of unspecified upper respiratory tract infection (OR 0.32, 95% CI 0.26-0.38 and 0.57, 95% CI 0.48-0.68, respectively) than low prescribers. The rank of the prescription rate of high, medium and low prescriber groups remained the same for all diagnoses except pneumonia. In addition, the annual rank between high, medium and low prescriber groups remained stable; high group prescribed more antibiotics during the year than medium group, which prescribed more than low prescriber group.

Management of acute maxillary sinusitis in Finnish primary care. Results from the nationwide MIKSTRA study.

OBJECTIVES: To study the management of acute maxillary sinusitis (AMS) in Finnish primary care and to compare it both to recommendations in national guidelines and to the management of other upper respiratory tract infections (URTI). DESIGN: A cross-sectional multi-centre epidemiological survey. SETTING: Thirty primary care health centres in Finland. SUBJECTS: 7284 patients with symptoms of possible acute rhinosinusitis during one week in both November 1998 and November 1999. MAIN OUTCOME MEASURE: Symptoms and their duration, use of diagnostic tools, choice of antibiotics, patient outcomes. RESULTS: A total of 1601 patients were diagnosed as having AMS (12% of all patients with infectious disease). In 45% of cases the differentiation between AMS and URTI was based on clinical examination alone. Sinus ultrasound was the most common diagnostic tool used (38%). Sinus radiography or blood tests (CRP or leukocytes) were both studied in 8% of cases. AMS was diagnosed and treated with antibiotics also in the early stages of URTI when viruses are the most likely explanation. In total, 83% of patients with AMS received a prescription for antibiotics; the most common choice was amoxycillin (37%), doxycycline was used in 29% of cases, and macrolides in 15%. CONCLUSIONS: Antibiotics are prescribed for AMS 2 to 5 times more often than true disease incidence would suggest in Finland. The choice of antibiotics follows the guideline recommendations; however, use of macrolides is higher than recommended. Physicians feel strong pressure from patients to prescribe antibiotics for AMS. Primary care physicians need better support in the accurate diagnosis of AMS.

Effect of macrolide consumption on erythromycin resistance in Streptococcus pyogenes in Finland in 1997-2001.

The aim of this study was to investigate the association between regional macrolide resistance in Streptococcus pyogenes and macrolide use in Finland. During 1997-2001, a total of 50,875 S. pyogenes isolates were tested for erythromycin susceptibility in clinical microbiology laboratories throughout Finland. The local erythromycin resistance levels were compared with the regional consumption data of all macrolides pooled and, separately, with the use of azithromycin. The regional resistance rates of 1 year were compared with the regional consumption of the previous year and with the average rates of use for the 2 previous years. A linear mixed model for repeated measures was used in modeling the association. A statistically significant association existed between regional erythromycin resistance in S. pyogenes and consumption of macrolides; association with azithromycin use alone was not found.

Increased risk of asthma among Finnish construction workers.

AIM: To determine the risk of asthma among 7891 Finnish construction workers in the Pirkanmaa Region of southern Finland. METHOD: Retrospective cohort study of hospital records of the Tampere University Hospital. A population of Pirkanmaa paper mill workers (n=2686) and the Pirkanmaa working age population (n=252,500) served as reference populations. RESULTS: There were 147 new cases of asthma among the construction workers in 1991-1995. The annual rate was 37 per 10,000 workers and the odds ratio was 2.1 [95% confidence interval (CI)=1.2-3.6] for the women and 1.8 (95% CI=1.5-2.2) for the men when compared with the general working age population. In general, the risk of asthma among the paper mill workers did not differ from the risk of asthma among the general working age population. The construction workers had an increased risk for asthma, although the number of reported cases of occupational asthma was lower for the construction workers than for the paper mill workers or for the working population. CONCLUSION: Construction work, especially dusty tasks, was associated with an elevated risk of asthma. Thus the effect of exposure to irritant agents may have a role in the development of asthma among construction workers. For the most part, these cases of asthma do not meet the criteria for occupational asthma because the specified causal agent can not be defined. The aetiologic agents and mechanisms of asthma in construction work should be clarified for preventive measures.

Evaluation of a new cellulose sponge-tipped swab for microbiological sampling: a laboratory and clinical investigation.

A new type of swab (Cellswab; Cellomeda, Turku, Finland), utilizing a highly absorbent cellulose viscose sponge material, was compared to some traditional swabs. The survival of 14 aerobic and 10 anaerobic and microaerophilic bacterial species in the Cellswab, two commercial swab transport systems (Copan, Brescia, Italy, and Orion Diagnostica, Espoo, Finland), and one Dacron swab (Technical Service Consultants Ltd. [TSC], Heywood, United Kingdom) was evaluated. Bacteria were suspended in broth, into which the swabs were dipped. The Cellswab absorbed 1.3 times more fluid and released 3.5 times more fluid upon plating than the other swabs. Aerobic bacteria were stored in dry tubes, the others in transport medium, at 4 degrees C and room temperature (RT), for up to 14 days. Swab samples were transferred to plates at 0, 1, 2, 4, 7, and 14 days. For 10 strains the Cellswab yielded > or =10% of the original CFU for longer than all the other swabs. In the clinical study, the ability of the Cellswab to detect beta-hemolytic streptococci from throat samples (n = 995) was compared to that of the TSC Dacron swab. The swabs performed equally, both when their samples were transferred to plates immediately and after storage for 1 day at 4 degrees C or RT. The changes in normal microbiota after storage were also similar. The Cellswab was found to perform at least as well as ordinary swabs. It was better at storing fastidious strains, and at keeping bacteria viable for long storage times; it might well be a useful replacement or complement to ordinary swabs.