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.

Previous antibiotic exposure and antibiotic resistance of commensal Staphylococcus aureus in Spanish primary care.

INTRODUCTION: Commensal flora of healthy people is becoming an important reservoir of resistant bacteria. OBJECTIVES: To evaluate the relationship of previous antibiotic-dispensed and resistance pattern of strains of Staphylococcus aureus in primary care patients. METHODS: A cross-sectional study was carried out in seven primary care centres in Catalonia, Spain, from October 2010 to May 2011, as part of the APRES (The appropriateness of prescribing antibiotics in primary care in Europe concerning antibiotic resistance) study. Outpatients aged 4 or more who did not present an infectious disease and had not taken antibiotic or had not been hospitalised in the previous 3 months were invited to participate. Nasal swabs were collected for S. aureus culture, and antimicrobial susceptibility testing was carried out. Antibiotics dispensed boxes in the previous 4 years were extracted from Information System for Research in Primary Care. RESULTS: A total of 4,001 nasal swabs were collected, and 3,969 were tested for identification, 765 S. aureus were tested for resistance. Resistance rates to penicillin, azithromycin and methicillin were 87.1%, 11.6% and 1.3%, respectively, and a total of 10 MRSA strains were isolated (1.3%). Penicillin-resistant staphylococci were statistically significantly associated with the previous number of packages of penicillin dispensed (OR, 1.18; 95% CI, 1.04-1.35). CONCLUSION: Although no causal inference is possible, an association was observed between previous antibiotic dispensation and isolation of resistant organisms in community-dwelling individuals, mainly between packages of penicillin and penicillin-resistant staphylococci.

Sensibilidad antibiótica de Staphylococcus aureus y Streptococcus pneumoniae en personas portadoras nasales sanas en atención primaria en el área de Barcelona / Antibiotic susceptibility of Staphylococcus aureus and Streptococcus pneumoniae in healthy carrier individuals in primary care in Barcelona area

Introducción: La información existente sobre la resistencia a los antibióticos se basa habitualmente en muestras de personas hospitalizadas. El objetivo fue evaluar la prevalencia de resistencia antibiótica de cepas de Staphylococcus aureus y Streptococcus pneumoniae de personas portadores nasales atendidas en las consultas de atención primaria según edad y sexo. Diseño: Estudio transversal. Emplazamiento. Siete centros de salud del área de Barcelona. Participantes. Personas portadoras nasales a partir de 4 años de edad, sin signos de enfermedad infecciosa y que no habían tomado antibióticos ni habían estado hospitalizados en los 3 meses anteriores. Mediciones principales: Se recogieron 3.969 frotis nasales válidos para identificación entre 2010 y 2011 y fueron enviados a un laboratorio central de microbiología para el aislamiento de ambos gérmenes. La resistencia a los antibióticos se estableció según los puntos de corte actuales de la guía del European Committee on Antimicrobial Susceptibility Testing. Resultados: La prevalencia de S. aureus resistente a meticilina fue del 1,3% (IC 95%: 0,5-2,1%), con porcentajes de resistencia frente a fenoximetilpenicilina del 87,1% y a azitromicina del 11,6%, sin observar diferencias significativas según edad y sexo. Un 2,4% (IC 95%: 0,1-4,7%) de las cepas de neumococo fueron altamente resistentes a fenoximetilpenicilina y macrólidos, mientras que las mayores resistencias se observaron frente a cefaclor (53,3%), tetraciclina (20%) y cefuroxima (12,1%). Conclusiones: Estos patógenos tienen resistencias más bajas en la comunidad que las que se observan en el medio hospitalario. Es importante que se conozca la resistencia antibiótica actual para poder hacer un uso más prudente de los antibióticos (AU)

Introduction: The information available on antibiotic resistance patterns are generally based on specimens from hospitalised individuals. This study was aimed at evaluating the antibiotic resistance rate of nasal carriage strains of Staphylococcus aureus and Streptococcus pneumoniae in healthy individuals, in accordance with age and gender, attended in Primary Care Centres (PCC). Design: Cross-sectional study. Setting: Seven PCC in the Barcelona area. Participants: Healthy nasal carriers aged 4 years or more who did not present with any sign of infectious disease, and had not taken any antibiotic or had been hospitalised in the previous 3 months. Main measurements: A total of 3,969 nasal swabs valid for identification were collected between 2010 and 2011 and were sent to one central microbiological laboratory for isolation of both pathogens. Resistance to common antibiotics was determined on the basis of the current European Committee on Antimicrobial Susceptibility Testing guidelines on cut-off points. Results: The prevalence of methicillin-resistant S.aureus was 1.3% (95% CI: 0.5-2.1%), with resistance rates of 87.1% to phenoxymethylpenicillin and 11.6% to azithromycin, with no significant differences with age and gender. A total of 2.4% (95 CI%: 0.1-4.7%) of the pneumococcal strains were highly resistant to both phenoxymethylpenicillin and macrolides, whereas the highest resistance rates were to cefaclor (53.3%), followed by tetracycline (20%) and cefuroxime (12.1%). Conclusions: These pathogens have lower resistance rates in the community than in the hospital setting. Primary Care physicians must be more aware of the current antimicrobial resistance, in order to ensure prudent use of antibiotics (AU)

[Antibiotic susceptibility of Staphylococcus aureus and Streptococcus pneumoniae in healthy carrier individuals in primary care in Barcelona area]. / Sensibilidad antibiótica de Staphylococcus aureus y Streptococcus pneumoniae en personas portadoras nasales sanas en atención primaria en el área de Barcelona.

INTRODUCTION: The information available on antibiotic resistance patterns are generally based on specimens from hospitalised individuals. This study was aimed at evaluating the antibiotic resistance rate of nasal carriage strains of Staphylococcus aureus and Streptococcus pneumoniae in healthy individuals, in accordance with age and gender, attended in Primary Care Centres (PCC). DESIGN: Cross-sectional study. SETTING: Seven PCC in the Barcelona area. PARTICIPANTS: Healthy nasal carriers aged 4years or more who did not present with any sign of infectious disease, and had not taken any antibiotic or had been hospitalised in the previous 3months. MAIN MEASUREMENTS: A total of 3,969 nasal swabs valid for identification were collected between 2010 and 2011 and were sent to one central microbiological laboratory for isolation of both pathogens. Resistance to common antibiotics was determined on the basis of the current European Committee on Antimicrobial Susceptibility Testing guidelines on cut-off points. RESULTS: The prevalence of methicillin-resistant S.aureus was 1.3% (95%CI: 0.5-2.1%), with resistance rates of 87.1% to phenoxymethylpenicillin and 11.6% to azithromycin, with no significant differences with age and gender. A total of 2.4% (95CI%: 0.1-4.7%) of the pneumococcal strains were highly resistant to both phenoxymethylpenicillin and macrolides, whereas the highest resistance rates were to cefaclor (53.3%), followed by tetracycline (20%) and cefuroxime (12.1%). CONCLUSIONS: These pathogens have lower resistance rates in the community than in the hospital setting. Primary Care physicians must be more aware of the current antimicrobial resistance, in order to ensure prudent use of antibiotics.

Prevalencia de portadores nasales de Staphylococcus aureus y Streptococcus pneumoniae en atención primaria y factores asociados a la colonización / Prevalence of nasal carriage of Staphylococcus aureus and Streptococcus pneumoniae in Primary Care and factors associated with colonization

OBJETIVO: Determinar la prevalencia de portadores nasales de Staphylococcus aureus (S. aureus) y Streptococcus pneumoniae (S. pneumoniae) en personas atendidas en las consultas de Atención Primaria del área de Barcelona, así como los factores que se asocian a la condición de portador sano. MÉTODOS: Estudio transversal multicéntrico realizado entre 2010-2011, en el que participaron 27 profesionales de Atención Primaria. Se obtuvieron 3969 frotis nasales de población mayor de 4 años y sin signos de enfermedad infecciosa. Variables dependientes: ser portador de S.aureus y/o de S. pneumoniae. Variables independientes: características socio demográficas, estado de salud, estado vacunal, ocupación laboral y convivencia con niños. Se realizó el análisis descriptivo, cálculo de la prevalencia de portadores sanos de S.aureus y/o de S. pneumoniae y se ajustaron modelos de regresión logística según edad. RESULTADOS: En niños de 4 a 14 años, la prevalencia de portadores de S.aureus fue 35,7%, de S. pneumoniae del 27,1% y co-colonizados del 5,8%. En adultos mayores de 14 años fue del 17,8, del 3,5 y del 0,5% respectivamente. En niños, ser portador de S.aureus se asoció con no presentar S. pneumoniae, y ser portador de S. pneumoniae con no presentar S.aureus y menor edad. En adultos, ser portador de S.aureus se asoció con ser hombre, menor e dad y trabajar en sanidad, y ser portador de S. pneumoniae con convivir con menores de 6 años. La proporción de portadores co-colonizados es baja (1,0%). CONCLUSIONES: La prevalencia de portadores en niños es mayor que en los adultos. Salvo la edad, no se observan otros factores comunes que se asocien a la condición de portador sano de estas 2 bacterias por separado

OBJECTIVE: To determine (I) the prevalence of Staphylococcus aureus (S.aureus) and Streptococcus pneumoniae (S. pneumoniae) nasal carriage in Primary Health Care patients in area of Barcelona, and (II) the factors associated with S.aureus and S. pneumoniae colonization. METHODS: Multi-center cross-sectional study conducted in 2010-2011 with the participation of 27 Primary Health Care professionals. Nasopharyngeal swabs were obtained from 3,969 patients over 4 years of age who did not present with any sign of infection. Dependent variables: S.aureus and/or S. pneumoniae carrier state. Independent variables: socio-demographic characteristics, health status, vaccination status, occupation, and living with children. A descriptive analysis was performed. The prevalence of carriers of S.aureus and/or S. pneumoniae was calculated and logistic regression models were adjusted by age. RESULTS: In children from 4 to 14 years old, the prevalence of S.aureus carriers was 35.7%, of S.pneumoniae 27.1%, and 5.8% were co-colonized. In adults older than 14 years old, the prevalence was 17.8%, 3.5%, and 0.5%, respectively. In children, S.aureus carrier state was inversely associated with S. pneumoniae carrier state; S. pneumoniae was associated with younger age, and inversely associated with S.aureus carrier state. In adults, being a carrier of S.aureus was associated with male gender, younger age, and a health-related occupation, whereas S. pneumoniae carrier state was associated with living with children under 6 years of age. The proportion of co-colonized carriers was low (1.0%). CONCLUSIONS: The proportion of S.aureus and S. pneumoniae carriers was higher in children than in adults. Age was the only factor associated with healthy carrier status for S. aureus and for S. pneumoniae

[Prevalence of nasal carriage of Staphylococcus aureus and Streptococcus pneumoniae in Primary Care and factors associated with colonization]. / Prevalencia de portadores nasales de Staphylococcus aureus y Streptococcus pneumoniae en atención primaria y factores asociados a la colonización.

OBJECTIVE: To determine (i) the prevalence of Staphylococcus aureus (S.aureus) and Streptococcus pneumoniae (S.pneumoniae) nasal carriage in Primary Health Care patients in area of Barcelona, and (ii) the factors associated with S.aureus and S.pneumoniae colonization. METHODS: Multi-center cross-sectional study conducted in 2010-2011 with the participation of 27 Primary Health Care professionals. Nasopharyngeal swabs were obtained from 3,969 patients over 4 years of age who did not present with any sign of infection. DEPENDENT VARIABLES: S.aureus and/or S.pneumoniae carrier state. INDEPENDENT VARIABLES: socio-demographic characteristics, health status, vaccination status, occupation, and living with children. A descriptive analysis was performed. The prevalence of carriers of S.aureus and/or S.pneumoniae was calculated and logistic regression models were adjusted by age. RESULTS: In children from 4 to 14 years old, the prevalence of S.aureus carriers was 35.7%, of S.pneumoniae 27.1%, and 5.8% were co-colonized. In adults older than 14 years old, the prevalence was 17.8%, 3.5%, and 0.5%, respectively. In children, S.aureus carrier state was inversely associated with S.pneumoniae carrier state; S.pneumoniae was associated with younger age, and inversely associated with S.aureus carrier state. In adults, being a carrier of S.aureus was associated with male gender, younger age, and a health-related occupation, whereas S.pneumoniae carrier state was associated with living with children under 6 years of age. The proportion of co-colonized carriers was low (1.0%). CONCLUSIONS: The proportion of S.aureus and S.pneumoniae carriers was higher in children than in adults. Age was the only factor associated with healthy carrier status for S.aureus and for S.pneumoniae.

Effectiveness of anti-inflammatory treatment versus antibiotic therapy and placebo for patients with non-complicated acute bronchitis with purulent sputum. The BAAP Study protocol.

BACKGROUND: Acute bronchitis is one of the most prevalent respiratory infections in primary care, and in more than 90% of the cases antibiotics are prescribed, mainly when purulent expectoration is present. However, this process is usually viral in origin and the benefits of antibiotic treatment are marginal. On the other hand, in recent years bronchitis has been considered more as an inflammatory than an infectious process. Thus, the aim of this study is to evaluate the clinical effectiveness of a schedule of an oral anti-inflammatory compared with an antibiotic regimen and another group assigned to receive a placebo. METHODS AND DESIGN: A total of 420 patients from 15 to 70 years of age with no associated comorbidity, presenting respiratory tract infection of at least one week of evolution, with cough as the predominant symptom, the presence of purulent expectoration and at least one other symptom of the respiratory tract (dyspnoea, wheezing, chest discomfort or pain), with no alternative explanation such as pneumonia, will be included in a prospective, randomised and controlled, clinical trial with placebo. The patients will be randomised to receive one of three treatments: ibuprofen, amoxycillin and clavulanic acid or placebo for 10 days. The main outcome measure is the number of days with frequent cough defined by the symptom diary with a score of 1 or more. DISCUSSION: This trial is designed to evaluate the number of days with frequent cough with anti-inflammatory treatment compared with antimicrobial treatment and placebo in previously healthy patients with a clinical picture of acute bronchitis and purulent expectoration. It is hypothesized that anti-inflammatory treatment is more effective than antibiotic treatment to reduce cough, which is the most disturbing symptom for patients with this infection. TRIAL REGISTRATION: ISRCTN07852892.

Knowledge and attitudes of primary health care physicians and nurses with regard to population screening for colorectal cancer in Balearic Islands and Barcelona.

BACKGROUND: Primary health care (PHC) professionals play a key role in population screening of colorectal cancer. The purposes of the study are: to assess knowledge and attitudes among PHC professionals with regard to colorectal cancer screening, as well as the factors that determine their support for such screening. METHODS: Questionnaire-based survey of PHC physicians and nurses in the Balearic Islands and in a part of the metropolitan area of Barcelona. RESULTS: We collected 1,219 questionnaires. About 84% of all professionals believe that screening for colorectal cancer by fecal occult blood test (FOBT) is effective. Around 68% would recommend to their clients a colorectal cancer screening program based on FOBT and colonoscopy. About 31% are reluctant or do not know. Professionals perceive the fear of undergoing a colonoscopy as the main obstacle in getting patients to participate, and the invasive nature of this test is the main reason behind their resistance to this program. The main barriers to support the screening program among PHC professionals are lack of knowledge (nurses) and lack of time (physicians). On multivariate analysis, the factors associated with reluctance to recommend colorectal cancer screening were: believing that FOBT has poor sensitivity and is complicated; that colonoscopy is an invasive procedure; that a lack of perceived benefit could discourage client participation; that only a minority of clients would participate; thinking that clients are fed up with screening tests and being unaware if they should be offered something to ensure their participation in the programme. CONCLUSIONS: Two in every three PHC professionals would support a population screening program for colorectal cancer screening. Factors associated with reluctance to recommend it were related with screening tests characteristics as sensitivity and complexity of FOBT, and also invasive feature of colonoscopy. Other factors were related with patients' believes.

Reducción en la prescripción de antibióticos en la sinusitis mediante la realización de una auditoría / Reduction in the prescription of antibiotics in pharyngoamygdalitis and sinusitis by means of an audit

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Indicadores cualitativos en la prescripción de antibióticos: ¿son los más adecuados? / Qualitative indicators in antibiotic prescription: are they the most appropriate ones?

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[Variability of antibiotic prescribing for respiratory tract infections in two European countries]. / Variabilidad de la prescripción antibiótica en las infecciones respiratorias en dos países de Europa.

BACKGROUND: Treatment for respiratory tract infections (RTI) in the primary care setting is empirical. Antibiotic prescribing patterns differ among countries and are based on the prevalence of antibiotic resistance in the geographical area. The aim of this study was to compare the antibiotics prescribed by general practitioners (GPs) for RTIs between Spain and Denmark. METHODS: Observational multicenter survey carried out in the primary healthcare setting. Two groups of GPs in Spain and Denmark recorded all contacts with RTI patients during a 3-week period between November 2001 and January 2002. RESULTS: A total of 2833 RTI cases were registered. Broad-spectrum penicillins and combinations of these drugs plus beta-lactamase inhibitors were the antibiotics most frequently prescribed by Spanish GPs (62.3%), followed by macrolides (22.3%). In contrast, narrow-spectrum penicillins were most commonly prescribed by Danish GPs (58% of all prescriptions), followed by macrolides (29%) (P < .001). Antibiotics most frequently prescribed for ear, tonsillar, sinus and bronchopulmonary infections were broad-spectrum penicillins among Spanish GPs and narrow-spectrum penicillins in Denmark. Spanish GPs prescribed penicillin V only for tonsillitis, accounting for 5.1% of the antibiotics used for this condition, whereas this drug accounted for 91.7% of the prescriptions by their Danish colleagues for the same indication. CONCLUSIONS: The substantial differences in RTI management between the participating GPs should make us reflect on the rational use of antibiotics. The discrepancies disclosed may indicate dissimilarities in recommendations, traditions, habits, or antibiotic pressures between the countries studied.

Variabilidad de la prescripción antibiótica en las infecciones respiratorias en dos países de Europa / Variability of antibiotic prescribing for respiratory tract infections in two European countries

Antecedentes. En atención primaria, el tratamiento de las infecciones del tracto respiratorio (ITR) es empírico. Los patrones de prescripción de antibióticos son distintos entre países y vienen dados por la prevalencia de resistencias antimicrobianas existentes. El objetivo de este estudio fue comparar qué antibióticos prescriben los médicos de atención primaria en las ITR en España y Dinamarca. Métodos. Estudio observacional multicéntico efectuado en atención primaria de salud. Dos grupos de médicos de atención primaria de España y de Dinamarca registraron todas las visitas con ITR durante un período de 3 semanas entre noviembre de 2001 y enero de 2002. Resultados. Se registraron un total de 2.833 casos de ITR. Los antibióticos más prescritos por los médicos españoles fueron las penicilinas de amplio espectro, asociadas o no a inhibidores de betalactamasas (62,3%), seguido de los macrólidos (22,3%), mientras que en el caso de los daneses fueron las penicilinas de espectro reducido (58% de todos los antibióticos prescritos), seguido de los macrólidos (29%; p < 0,001). En las infecciones óticas, amigdalares, sinusales y broncopulmonares, los antibióticos más prescritos por los médicos españoles fueron las penicilinas de amplio espectro y en Dinamarca las penicilinas de espectro reducido. Los médicos españoles sólo prescribieron fenoximetil penicilina para las amigdalitis, suponiendo en esta infección el 5,1% del total, mientras que los colegas daneses la prescribieron en el 91,7% para esta indicación. Conclusiones. Las importantes diferencias existentes en el tratamiento antibiótico de las ITR entre los médicos participantes debe hacernos reflexionar sobre la utilización racional de los antibióticos. Esto podría ser producto de tradiciones, hábitos, recomendaciones y presiones distintas entre ambos países (AU)

Background. Treatment for respiratory tract infections (RTI) in the primary care setting is empirical. Antibiotic prescribing patterns differ among countries and are based on the prevalence of antibiotic resistance in the geographical area. The aim of this study was to compare the antibiotics prescribed by general practitioners (GPs) for RTIs between Spain and Denmark. Methods. Observational multicenter survey carried out in the primary healthcare setting. Two groups of GPs in Spain and Denmark recorded all contacts with RTI patients during a 3-week period between November 2001 and January 2002. Results. A total of 2833 RTI cases were registered. Broad-spectrum penicillins and combinations of these drugs plus beta-lactamase inhibitors were the antibiotics most frequently prescribed by Spanish GPs (62.3%), followed by macrolides (22.3%). In contrast, narrow-spectrum penicillins were most commonly prescribed by Danish GPs (58% of all prescriptions), followed by macrolides (29%) (P < .001). Antibiotics most frequently prescribed for ear, tonsillar, sinus and bronchopulmonary infections were broad-spectrum penicillins among Spanish GPs and narrow-spectrum penicillins in Denmark. Spanish GPs prescribed penicillin V only for tonsillitis, accounting for 5.1% of the antibiotics used for this condition, whereas this drug accounted for 91.7% of the prescriptions by their Danish colleagues for the same indication. Conclusions. The substantial differences in RTI management between the participating GPs should make us reflect on the rational use of antibiotics. The discrepancies disclosed may indicate dissimilarities in recommendations, traditions, habits, or antibiotic pressures between the countries studied (AU)

Respiratory tract infections in general practice: considerable differences in prescribing habits between general practitioners in Denmark and Spain.

OBJECTIVE: The prevalence of antibiotic resistance in a country reflects the local consumption of antibiotics. The majority of antibiotics are prescribed in general practice and most prescriptions are attributable to treatment of respiratory tract infections (RTIs). The aim of this study was to compare general practitioners' (GPs') prescribing of antibiotics for respiratory tract infections in a country with a high prevalence of antibiotic resistance (Spain) with a country with a low prevalence of antibiotic resistance (Denmark). METHODS: A group of GPs in Copenhagen and Barcelona registered all contacts ( n=2833) with patients with RTIs during a 3-week period between 1 November 2001 and 31 January 2002. RESULTS: Overall, Spanish GPs treated a higher proportion of patients than Danish GPs. After adjusting for unequal distribution of age and sex, we found that Spanish GPs prescribed significantly more antibiotics to patients with focus of infection in tonsils and bronchi/lungs. Narrow-spectrum penicillin was the most used antibiotic in Denmark, representing 58% of all prescriptions issued, followed by macrolide and broad-spectrum penicillin. In Spain, prescriptions were distributed among a great number of compounds, with broad-spectrum penicillins and combinations of amoxicillin plus beta-lactamase inhibitors most frequently used. CONCLUSION: The substantial difference in the way GPs manage respiratory tract infections in Denmark and Spain cannot be explained by different patterns of RTIs in general practice. The discrepancies indicate variations in national recommendations, different treatment traditions or different impact of pharmaceutical marketing.