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.

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

OBJETIVO: Evaluar la efectividad de dos tipos de intervención en la prescripción antibiótica en infecciones del tracto respiratorio (ITR). DISEÑO: Estudio antes-después basado en audit. Emplazamiento: Centros de atención primaria de España. Participantes: Médicos de familia registraron durante 15 días en invierno 2008 todas las ITR (preintervención), que se repitió en 2009 (postintervención). Intervenciones: Se realizaron reuniones con presentación y discusión de resultados, sesiones de formación en guías de ITR, folletos informativos para pacientes, talleres en uso de pruebas rápidas (Strep A y proteína C reactiva) y su provisión en las consultas. Los médicos participantes a excepción de Cataluña realizaron la intervención completa (IC), mientras que los médicos de Cataluña realizaron lo mismo menos el taller de pruebas rápidas (intervención parcial [IP]). Se efectuó análisis de regresión logística multinivel considerando como variable dependiente la prescripción antibiótica. RESULTADOS: De los 309 médicos que realizaron el primer registro, 281 completaron la intervención y el segundo registro (90,9%), de los cuales 210 se asignaron a IC y 71 a IP. La odds ratio de prescripción antibiótica después de la intervención fue de 0.99 (IC95%: 0,89-1,10) entre los médicos asignados a IP, mientras que el observado en la IC fue de 0.50 (IC95%: 0,44-0,57, p < 0,001). La mayor reducción de prescripción antibiótica en IC se observó en gripe, catarro común, faringitis aguda, amigdalitis aguda y bronquitis aguda. CONCLUSIONES: La participación activa de los médicos con uso de pruebas rápidas en la consulta se acompaña de una reducción importante de antibióticos en las ITR, sobre todo en las infecciones mayoritariamente virales

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.

[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.

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.

Prescripción de antibióticos en las infecciones del tracto respiratorio y factores predictores de su utilización / Antibiotic prescribing in respiratory tract infections and predictive factors for their use

ObjetivoEl estudio Happy Audit es un proyecto financiado por la Comunidad Europea, y tiene por objetivo mejorar la prescripción antibiótica en las infecciones del tracto respiratorio (ITR). Se realizó el presente estudio para conocer el tratamiento antibiótico administrado en las ITR en España y conocer qué criterios se asocian a su prescripción.DiseñoEstudio transversal realizado en enero y febrero de 2008.EmplazamientoCentros de atención primaria.ParticipantesMédicos de atención primaria de España que registraron durante 3 semanas todas las ITR mediante una plantilla.Mediciones principalesEdad y sexo, días con síntomas, signos presentes (fiebre, tos, otorrea purulenta, odinofagia, exudado amigdalar, adenopatías cervicales, disnea, aumento de esputo, esputo purulento), diagnóstico, tratamiento antibiótico y demanda de antibiótico. Se efectuó regresión logística y se consideró como variable dependiente la prescripción antibiótica.ResultadosDe los 332 médicos a los que se invitó a participar, 309 (93,1%) rellenaron los registros. Se registraron 16.751 ITR; las más frecuentes fueron el resfriado (39,7%), la faringitis (14,4%) y la bronquitis aguda (12,6%). Se prescribieron antibióticos en 4.675 ITR (27,9%), principalmente en neumonía (89,9%), amigdalitis (88,9%) y otitis media (87,3%). El criterio que más se asoció a prescripción antibiótica fue la presencia de exudado amigdalar (odds ratio [OR] de 32,1; intervalo de confianza [IC] del 95%: 24,5 a 42), seguido de otorrea (OR de 25,2; IC del 95%: 18,2 a 35) y esputo purulento (OR de 18,1; IC del 95%: 15,5 a 21,2); en cambio, fue protectora la tos (OR de 0,4; IC del 95%: 0,3 a 0,5).DiscusiónLa prescripción antibiótica en las ITR es muy elevada en España. Este estudio aporta información sobre factores predictores de tratamiento antibiótico fundamental para promover un uso más racional de antibióticos(AU)

ObjectiveHappy Audit project is a European-funded survey aimed at reducing antibiotic prescribing for respiratory tract infections (RTI). The aim of this study is to investigate the antibiotic treatment administered for these RTIs in Spain and to find out which criteria are associated with its use.DesignCross-sectional study carried out in January and February 2008.SettingPrimary health care.ParticipantsGeneral practitioners registered all the RTI during a 3-week period using a template.Principal measurementsAge and gender, days with symptoms, signs presented (fever, cough, purulent ear discharge, sore throat, tonsillar exudate, swollen neck glands, dyspnoea, increase in sputum, purulent sputum), diagnosis, antibiotic therapy and demand of antibiotics. A logistic regression with the prescription of antibiotic as the dependent variable was performed.ResultsOut of the 332 physicians invited to participate, 309 filled in and returned the templates (93.1%), registering 16,751 RTIs, with the common cold (39.7%), pharyngitis (14.4%) and acute bronchitis (12.6%) being the most common. Antibiotic therapy was given to 4,675 RTIs (27.9%), mainly for pneumonia (89.9%), tonsillitis (88.9%), and otitis media (87.3%). The criterion most associated with antibiotic therapy was the presence of tonsillar exudate (OR: 32.1; 95CI%: 24.5–42), followed by ear discharge (25.2; 95%CI: 18.2–35) and purulence of sputum (18.1; 95%CI: 15.5–21.2); conversely, cough (OR: 0.4; 95%CI: 0.3–0.5) was considered as protective factor.DiscussionAntibiotic treatment for RTIs is very high in our country. This study provides information on the criteria that predict this antibiotic therapy and is important to take into account if a more rational use of antibiotics is required(AU)

[Antibiotic prescribing in respiratory tract infections and predictive factors for their use]. / Prescripción de antibióticos en las infecciones del tracto respiratorio y factores predictores de su utilización.

OBJECTIVE: Happy Audit project is a European-funded survey aimed at reducing antibiotic prescribing for respiratory tract infections (RTI). The aim of this study is to investigate the antibiotic treatment administered for these RTIs in Spain and to find out which criteria are associated with its use. DESIGN: Cross-sectional study carried out in January and February 2008. SETTING: Primary health care. PARTICIPANTS: General practitioners registered all the RTI during a 3-week period using a template. PRINCIPAL MEASUREMENTS: Age and gender, days with symptoms, signs presented (fever, cough, purulent ear discharge, sore throat, tonsillar exudate, swollen neck glands, dyspnoea, increase in sputum, purulent sputum), diagnosis, antibiotic therapy and demand of antibiotics. A logistic regression with the prescription of antibiotic as the dependent variable was performed. RESULTS: Out of the 332 physicians invited to participate, 309 filled in and returned the templates (93.1%), registering 16,751 RTIs, with the common cold (39.7%), pharyngitis (14.4%) and acute bronchitis (12.6%) being the most common. Antibiotic therapy was given to 4,675 RTIs (27.9%), mainly for pneumonia (89.9%), tonsillitis (88.9%), and otitis media (87.3%). The criterion most associated with antibiotic therapy was the presence of tonsillar exudate (OR: 32.1; 95CI%: 24.5-42), followed by ear discharge (25.2; 95%CI: 18.2-35) and purulence of sputum (18.1; 95%CI: 15.5-21.2); conversely, cough (OR: 0.4; 95%CI: 0.3-0.5) was considered as protective factor. DISCUSSION: Antibiotic treatment for RTIs is very high in our country. This study provides information on the criteria that predict this antibiotic therapy and is important to take into account if a more rational use of antibiotics is required.