1. G aps, challenges and opportunities Theo Verheij University Medical Center Utrecht Lower Respiratory Tract Infections in Primary Care

2. Acute (tracheo)bronchitis (Community-acquired) pneumonia

3. Incidence of acute LRTI syndromes in primary care Acute cough: 100 per 1000 persons per year Acute bronchitis: 50 per 1000 persons per year Pneumonia: 5 per 1000 persons per year

4. Antibiotic use in lower respiratory tract infections 65 – 95% of all patients 18,000,000 treatments per year in EU

5. Over- and underpresciptions of antibiotics in RTIs AB indicated and prescribed AB not indicated but prescribed AB not indicated, not rescribed AB indicated but not prescribed

6. Number of ab prescriptions per 1000 patiënts in 2001

7. ESAC data on outpatient antibiotic use in Europe. Goossens et al.

8. Resistance of S. pneumoniae against penicilline G EARSS annual report 2002. www.earss.rivm.nl

9. Health care Public health The public science Bad guidelines Lack of evidence overprescription Demanding antibiotics

10. Gaps in knowledge on lower respiratory tract infections 1.Behaviour and expectations of doctors and patients? 2.Aetiology? 3.Diagnostic strategies? 4.Treatment? 5.Prediction of poor outcome? 6.Cost-effectiveness? 7.Potential of genetics to enhance clinical care?

11. Behaviour and expectations of doctors?

12. Macfarlane J. Semin Respir Infect 1999;14:151–162 POPULATION WITH ACUTE LOWER RESPIRATORY TRACT ILLNESS IN THE COMMUNITY (1000) PATIENTS CONSULTING WITH SYMPTOMS OF LOWER RESPIRATORY TRACT ILLNESS (100) COMMUNITY LRTI TREATED WITH ANTIBIOTICS (50) PNEUMONIA DIAGNOSED IN COMMUNITY (10) PNEUMONIA ADMITTED TO HOSPITAL (2) HOSPITAL COMMUNITY DIE (0-1) ITU (0-1) Behaviour and expectations of patients?

13. Aetiology of lower respiratory tract infections in the community (% of cases)

14. Questions on aetiology Are all lower respiratory syndromes infectious? Similar in all European regions? Carriership? How are the bacterial resistance rates in primary care in the different countries?

15. Questions on diagnosis I How to detect pneumonia? 10-15% of patients with acute cough have pneumonia Diagnostic value of signs and symptoms ??? Additional value of tests? (C-reactive protein)

16. Questions on diagnosis II How to detect/rule out bacterial LRTI? Two small studies in primary care with conflicting results

17. Questions on diagnosis III How to detect underlying chronic diseases? 45% of patients with cough > 2 weeks have unknown astma/COPD!

18. Questions on antimicrobial therapy Not effective in healthy adults with acute bronchitis (9 RCTs) One trial showed relevant effect in patients with more severe symptoms and in elderly What are the effects in elderly and in patients with chronic conditions?

19. Questions on prognosis Prediction rules developed in hospital How to predict poor outcome in primary care?

20. Questions on cost-effectiveness Costs and benefits of diagnostic strategies? Costs and benefits of antimicrobial treatment? Costs and benefits of prediction models?

21. Questions on genomics What are the genetic risk factors for severe LRTI? What are the genetic risk factors for poor outcome? Which genetic factors in bacteria contribute to disease severity? Which genetic factors in bacteria contribute to development and spread of resistance?

22. Challenges Opportunity collaboration