1 Do you vote for Penicillin? An interactive workshop on treatment of upper respiratory tract infections

2 What did you have for breakfast today?  Danish morgenmad  Continental breakfast  Full hotel breakfast  Nothing

3 What is your occupation?  Family doctor  Trainee  Doctor in other specialty  Other

4 Where do you work?  Denmark  Norway  Sweden  Finland  Iceland  Other country

5 Did you take part in Happy Audit?  Yes  No  What is Happy Audit?

6 Case 1 Sore throat

7 Case 1  28 year old mother with sore throat  2 children, 2 and 6 years. Strep disease in the kindergarden  Fever and pain in throat since 3 days, no other problems from respiratory tract.  Malaise  Temp 38,6 C  Swollen tonsils with exudate  Lymfnodes swollen and painful

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9 Case 1 – What do you do?  CRP  Quicktest for Strep A  1+2  Bacterial culture for Strep A  Treat w Penicillin V without investigations  Treat w Amoxicillin without investigations  No test – no treatment

10 Case 1.1 – her 2 year old child  CRP  Quicktest for Strep A  1+2  Bacterial culture for Strep A  Treat w Penicillin V without investigations  Treat w Amoxicillin without investigations  No test – no treatment

11 Case 1.2  28 year old man with sore throat  Children in the same institution as before  Slight pain in throat since 3 days, no other problems from respiratory tract  Temp 37.1  Slight redness of tonsils.  No exsudate  No swollen and painful lymf glands  Positive quicktest Strep A

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13 Case 1.2 – What do you do?  CRP  Bacterial culture for Strep A  Treat w Penicillin V without investigations  Treat w Amoxicillin without investigations  No treatment

14 Case 1 What did the participants in Happy Audit do?

Use of Strep A in patients with sore throat PatientsStrepA performed Percentage with Strep A Argentina % Denmark % Lithuania % Russia % Spain % Sweden % Total %

Centor criteria*: 1.Fever 2.Tender angular glands 3.Tonsil Coatings 4.Absence of cough *Described by dr. Robert Centor of the University of Alabama

Centor criteria and probability of Streptococci Number of Centor Criteria Probability of Streptococci Recommandation 02%No test – no treatment 13%No test – no treatment 28%Test and treat 319%Test and treat 441%Test and treat Patients with 0-1 Centor criteria should not be tested with Strep A

Strep A test in Denmark

Strep A test in Sweden

23 Case 2 Otitis media

24 Case 2  4 year old child, no previous ear infection  Running nose since 5 days.  Last night severe pain in one ear  Temp 38.1 C  No swollen tonsils  Small lymfnodes slightly swollen and painful

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26 Case 2 – What do you do?  CRP  Nasopharyngeal culture  Treat w Penicillin V without investigations  Treat w Amoxicillin without investigations  Delayed prescription – just in case  No antibiotic, advice  No antibiotic, new appointment in three days

Use of CRP in patients with Otitis PatientsCRP performedPercentage with CRP Argentina % Denmark % Lithuania7922.5% Russia7700.0% Spain % Sweden % Total %

32 Case 3 Cough

33 Case 3  37 year old man  Smokes at parties and business meetings  No previous problems from respiratory tract, but ”always bothered by cough” and ”prolonged colds”  Troublesome coughing, esp at night.  No fever, normal breathing.  Normal lung auscultation

34 Case 3 – What do you do?  CRP  Chest X-ray  1+2  Penicillin V without further investigations  Other antibiotic without further investigations  Delayed prescription – just in case  No antibiotic, advice

Use of CRP in patients with acute Bronchitis PatientsCRP performedPercentage with CRP Argentina % Denmark % Lithuania % Russia % Spain % Sweden % Total %

38 Acute Bronchitis is an acute respiratory tract infection caused by virus, and should, in general, not be treated with antibioticsAcute Bronchitis is an acute respiratory tract infection caused by virus, and should, in general, not be treated with antibiotics CRP may be helpful to distinguish between acute bronchits and pneumoniaCRP may be helpful to distinguish between acute bronchits and pneumonia

39 Case 4 Sinusitis

40 Case 4 - sinusitis  Woman, 28 years old, non-smoker, two small children  Often suffers from sinusitis and always needs antibiotic treatment to recover…  Now nasal congestion > 7 days  Pain under left eye. Worsening when she is leaning forward  Less relief from OTC nasal spray

41 Case 4 – What do you do?  CRP  Sinus X-ray / CT – antibiotics if +ive  Penicillin V without further investigations  Other antibiotic without further investigations  Delayed prescription – just in case  No antibiotic, adv: saline nasal wash, steam etc  Nasal steroid spray

Use of CRP in patients with acute Sinusitis PatientsCRP performedPercentage with CRP Argentina % Denmark % Lithuania7411.4% Russia % Spain % Sweden % Total %

Duration of symptoms at first consultation for patients with sinusitis Median25% percentile75% percentile Argentina425 Denmark7412 Litauen537 Russia325 Spain538,5 Sweden10714 Total5310

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49 Case 5 Exacerbation of COPD

50 Case 5  76 years old, previous smoker  FEV1/FVC = 0.58 at last spirometry  FEV1 45% of expected  Has inhaled anticholinergic, beta2 and steroid treatment.  Gets exacerbation 1-2/year often needs antibiotic treatment to recover…  Now cough and short of breath 4 days  Increased volume of white, foaming sputum  Temp 37.9

51 Case 5  CRP 45  Chest X-ray: No signs of pneumonia  PaO2 92%  Inhalation of bronchodilatator in practice does not relief patients symptoms

52 Case 5 – What do you do?  Penicillin V  Amoxicillin  Amoxi-Clav  Other antibiotic without further investigations  Referral to hospital  No antibiotic treatment

53 Case 5 – Systemic steroids  Acute  Acute and short course  Acute and start continuous treatment  No systemic steroids, increase inhaled steroids instead

Use of CRP in patients with acute exacerbation of COPD PatientsCRP performedPercentage with CRP Argentina % Denmark % Lithuania % Russia % Spain % Sweden % Total %

57 Anthonisen’s criteria*: 1.Increased dyspnoea 2.Increased sputum volume 3.Increase sputum purulence Anthonisen NR, Manfreda J, Warren CPW et al.:Anthonisen NR, Manfreda J, Warren CPW et al.: Antibiotic therapy in exacerbations of chronic obstructive pulmonary disease. Ann Intern Med 1987; 106:

Anthonisen criteria and antibiotic prescribing in patients with exacerbation of COPD

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60 Evaluationof the workshop  Relevance  Use of voting device  Overall quality

This workshop was very relevant for me  Totally disaggree  Partly disagree  Somewhat disagree  Indifferent  Somewhat agree  Partly agree  Totally agree 61

The use of the voting device was good  Totally disaggree  Partly disagree  Somewhat disagree  Indifferent  Somewhat agree  Partly agree  Totally agree 62

The overall quality was satisfying 63  Totally disaggree  Partly disagree  Somewhat disagree  Indifferent  Somewhat agree  Partly agree  Totally agree