H ealth A lliance for P rudent P rescribing, Y ield And Use of anti-microbial D rugs I n the T reatment of Respiratory Tract Infections Proposal for EU DG Research, March 2006 Coordinator: Research Unit of General Practice, Odense, Denmark

% % 35-40% 40-45% 0-2 % % 0-5 % Prevalence of penicillin resistant pneumococci in Europe

Use of antibiotics in Europa 2002 DDD/1000 persons/day Gossens et al: Outpatient antibiotic use in Europe and association with resistance: a cross-national database study. The Lancet 2005

From: Emerging Infectious Diseases 2004;19(3):514 Penicillin-resistance in pneumococci Linear correlation between use of antibiotics and resistance

Resistant Strains Rare x x Resistant Strains Dominant Antimicrobial Exposure x x x x x x x x x x Selection for Antibiotic Resistance

HAPPY AUDIT Objective  to reduce the occurrence of bacterial resistance  by reducing prescribing of unnecessary antibiotics for respiratory tract infections  by improving the use of appropriate antibiotics in suspected bacterial infections  by improving the quality of diagnostic procedures for RTIs in general practice

Nordic region -Denmark 102 GPs -Sweden 77 GPs -Balticum region -Lithuania31 GPs -Kaliningrad39 GPs -Region Hispano-America: -Spain 309 GPs -Argentina60GPs -TOTAL 618 GPs

HAPPY AUDIT 618 GPs from 6 countries: - Nordic region -Denmark 102 GPs -Sweden 77 GPs - Balticum region -Lithuania31 GPs -Kaliningrad39 GPs - Region Hispano-America: -Spain 309 GPs -Argentina60 GPs

Kick-off meeting April 2007

Project time schedule Total project period: 3 years (April 2007 – March 2010) Analysis and conference Second registration of Patients First registration of Patients X Intervention: GPs and patients First invitation of GPs X

Project structure

Kaliningrad

Sweden

Lithuania

Spain

Denmark

Argentina

Intervention material for professionals  Report with aggregated and individual results  Happy Audit Guidelines  Laboratory test instructions

Respiratory infections in general practice Results from 6 countries Reports in national language including individual results were sent to all paticipating GPs

My Practice

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

Use of Strep A in patients with odinophagia (painful swallowing) PatientsStrepA performed Percentage with Strep A Argentina % Denmark % Lithuania % Russia % Spain % Sweden % Total %

Strep A test in Denmark

Strep A test in Sweden

Reasons for antibiotic treatment of streptococ tonsillitis  Reduce symptoms  0-1 Centor criteria: No effect  2-3 Centor criteria: Moderate effect (1-2 days)  4 Crentor criteria: Substantial effect (2-3 days)  Prevent spread of streptococci  Prevent complications  Peritonsillar abscess (doubtfull : NNT >4000)  Glomerulonephritis (no evidence for effect of antibiotics)  Rheumatic fever (very seldom: NNT >4000)

Carriers of Streptococci  5-10% of individuals are asymptomatic carriers of streptococci  A Strep A test will show that carriers have streptococci even though they are not causing symptoms.  Generally, carriers should not be treated with antibiotics

Overuse of Strep A may lead to inappropriate antibiotic treatments  Generally, Strep A should not be performed in:  Asymptomatic carriers of Streptococci  Patients with sore throat and less than 2 Centor criteria

Conclusion  Denmark, Sweden:  Overuse of Strep may lead to inappropriate antibiotic treatment and initiatives should be taken to reduce overuse of Strep A testing in general practice  Spain, Argentina, Lithuania, Russia:  Introduction of Strep A may leed to a lower prescribing in patients with sore thorat and initiatives should be taken to introduce Strep A in general practice

”The more you use it, - the faster you lose it” Burke JP, Lancet 1995;345:977

Collaboration in Europe about rational prescribing of antibiotics CHAMP Changing behaviour of Health care professionals And the general public towards a More Prudent use of anti- microbial agents.

Thank you

Validation study of Strep A in general practice in Barcelona  Inclusded 182 patients with sore throat and ≥ 2 Centor criteria  Tests:  Throat Culture  Strep A 44

Amigdalitis La validez de la prueba de Strep A pare diagnosticar Estrep betahem gr A Pos predictive value PPV = 38/48 = 79% Neg predictive value NPV = 132/134 = 98% Specificity: 132/142 = 93% Sensitivity: 38/40 = 95% Llor et al. Validación de una técnica antigénica rápida en el diagnóstico de la faringitis por esptreptococo beta- hemolitico del grupo A, Aten Primaria 2008

Nycocard CRP single test  Axis-Shield, Norway  Training through local distributors  Instrument free during test period

Development of quality indicators for diagnosis and treatment of respiratory tract infections in general practice

Tonsillitis/pharyngitis Number of patients with a positive StrepA test Number of patients with acute tonsillitis/pharyngitis treated with antibiotics Number of patients treated with narrow-spectrum penicillin (J01CE) Number of patients with acute tonsillitis/pharyngitis treated with antibiotics

Experts – to do  Rate to what extent they agree with the relevance of the 59 quality indicators – according to: A. Reducing antimicrobial resistance B. Clinical relevance for the patient* * Reducing symptoms and/or shortening duration of the actual course of the disease

Consensus The item should be retained: ≥ 75 % of participants scored the item ≥ 5 The item should be excluded: ≥ 75 % of participants scored the item ≤ 3 No consensus: items which failed to meet either of the above criteria

The final set of indicators  6 acute sinusitis  9 acute otitis media  6 acute tonsillitis/pharyngitis  7 acute lower respiratory tract infection (LRTI)  1 acute respiratory tract infection (RTI)  1 penicillin allergy  1 acute bronchitis  5 pneumonia  5 exacerbation of chronic obstructive pulmonary disease (COPD)

Number of doctors Number of patients registered Number of patients treated with antibiotics Argentina Denmark Lithauen Russia Spain Sweden Total

Conclusion  Participating GPs  Estimated: 400  Real number 618  Number of consultations registered  Estimated  Real number:  Written material completed for all partners  Guidelines, Patient brochures, Reports etc

Days with symptoms