2. New Norwegian national guidelines for antibiotic use in primary care Presentation 14.5.09, Nordisk kongress, København Morten Lindbæk professor in general practice, UiO leader Antibiotic Centre for primary care

4. Background  1999: National plan to stop antibiotic resistance  90 % of all antibiotics in Norway is prescribed in primary care and 60 % for resp. tract infections  2 guidelines were proposed  One for primary care  One for hospital care

5. Goals  1999: ”It would be desirable to reduce the antibiotic consumption by 30 % from todays 16 DDD per 1000 inhabitants per day to 10 DDD, corresponding to the level of consumption in Holland”.

6. Important trends in antibiotic use Norway 1999-2006  Total use up from 16.6 DDD to 19,0 DDD (14%)  Penicillin extended spectrum (amoxicillin) up 1,96-2,74 (40%)  Penicillin V down 5,01 – 4,63 (8%)  Kloxa/dikloxa up 0,32-0,66 (100%)  Tetracykliner up 3,19 – 3,24 (2%)  Makrolider up 1,59-2,24 (40%)

7. Relation between antibiotic consumption and proportion resistant pneumococci In some European countries(Goossens et al, Lancet 2005; 365:579-587 )

8. Prevalence of av erythromycin resistance in pneumococci in blood culturs in Norway 2000-2006 NORM 2006

9. Joint edition between the Directorate of health and ASP  On behalf of the government ASP was asked to revise the guidelines in February 2007.  The health directorate and ASP act as joint editors.  The new guidelines get a higher status as ”National professional guidelines”

10. EØS/EU  An increasing number of new antibiotics are introduced in the market.  Due to the EØS-treaty Norwegian authorities can no longer stop marketing of new antibiotics, which was done previously Behovsparagrafen. (Paragraph of need)  The national drug authorities have therefore decided that the following sentence shall be included in all presentations of antibacterials  ”Official national guidelines shall be taken into account in the choice of antibacterials in practice”  Example liberal prescription of ciprofloxacin

11. Plan for the work  Pairs of academic GP and an organ specialist for each chapter, in all 30 persons  Many persons involved in Norsk Elektronisk Legehåndboks (NEL) coworkers were asked

12. Grading of evidence Knowledge based on systematic reviews and metaanalyses of randomised, controlled studies. Level 1 a A Knowledge based on at least one randomised, controlled study. Level 1 b A Knowledge based on at least one well performed controlled study without randomisation. Level 2 a B Knowledge based on at least one other type well performed quasi- experimental study. Level 2 b B Knowledge based on other types of well performed non-experimental studies, such as comparative studies, correlation studies and case studies. Level 3 C Knowledge based on reports or opnions from expert committees, and/or clinical expertise in respected authorities. Level 4 D

13. Implementation  Written guidelines in book  Electronic format on CD and on the web, at  www.antibiotikasentret.no  Short table version in A4-format, with the most common diagnoses and antibiotics  Distribution to all Norwegian GPs, doctors in nursing homes, health stations and emergency rooms  Distribution to all Norwegian medical students and to doctors educated abroad  Guidelines are integrated also in CME for general practice specialisation

14. Implementation  Harmonizing with other guidelines such as those in NEL and other guidelines for other specialisties (pediatrics, skin infections and gynecology, ENT)

15. What’s new? General chapters  Antibiotic resistance  MRSA  Microbiologic diagnostics in GP office  Infections in nursing homes (iv treatment?)  Antibiotics for pregnant and breast-feeding  Delayed prescriptions (half of the patients do not start treatment)  Interactions

16. Some important highlights in respiratory tract infections  Acute otitis media  Acute sinusitis  Acute tonsillitis  Acute bronchitis Pneumonia  Exacerbations of COLD  (Acute conjunctivitis)

17. General considerations  Use of penicillin V as first choice in respiratory tract infections is unchanged  Important to keep the low rate of resistant bacteriae, especially pneumococci and Hæmophilus Influenzae  Macrolides only in patients with penicillin allergy or documented atypicals (LRTI)

18. Dosage of penicillin V  The antibacterial effect of penicillin V is time dependent (minutes over MIC-value). With a short half time, the number of sdosages is crucial.  Norwegian tradition with dosage 1+1+2 (mill.IE) is obsolete. Swedish tradition has been 2x2 mill IE, Denmark? Finland?  Best er 1+1+1+1, alternatively 1+1+1.  Problem: If we recommend this for all conditions, we might reduce the use of penicillin V and get more amoxicillin and macrolide use  In the new guidelines we recommend x 4 for pneumonia, erysipelas (and GAS-tonsilitis).  For other diagnoses we recommend 1 mill IE x 3-4……  The challenge is compliance…

19. Otitis media  Children with fever + deteriorated general condition  Children under 1 year  ”Ear children” (recurrent infections)  perforation > 3 days.  However: Study by Rovers et al: Meta-analysis of individual patient data demonstrated that children with bilateral otitis and children under 2 would benefit more from antibiotics

20. Acute sinusitis  Generalised infection and deteriorated general condition  Symptom duration > 10 days.  Steroid nasal spray? Has only been demonstrated to be beneficial in addition to amoxicillin in US patients with recurrent infections.  Delayed prescription good strategy?  Meta-analysis of individual patient data demonstrated (Young et al) found no subgroups to benefit from antibiotic treatment.

21. Acute tonsillitis  Only treatment of streptococci.  Use of 4 Centor criteria, Strep test only if 2-3 present.  Low dosage, 10 days treatment to avoid recurrency  However: Strep G&C – same clinical course  Children: No benefit from pencillin (Zwart BMJ)  Potential of delayed prescription?

22. Acute bronchitis - pneumonia  No antibiotics for acute bronchitis. Beta 2 - agonist? Stop smoking  Improve diagnostics for pneumonia. Use CRP og SR, may X-ray thorax. Penicillin as first choice.  Atypical LRTI: Await test results? PCR? Erytromycin.

23. COLD-exacerbation change in guideline  Antonisen criteria: Increase in dyspnea, expectoration or purulent secretion. In addition use CRP/ESR.  If all 3 good effect of antibiotics, if 2 doubtful, if 1 no effect  Amoxicillin as first choice. Doxycyclin second choice or by penicillin allergy.

24. Conjunctivitis and kinder garten  Controversies between kinder gartens and parents/doctors whenter children with conjunctivitis should be allowed to og to kinder garten.  Has led to very strict rules in some kinder gartens: Children with some pus in the eye should og to doctor and should start treatment before coming back.  Our response:  The doctor shall decide whether treatment is needed. If moderate symptoms, no treatment or delayed prescription (ref BMJ 2006)  The danger of contagious disease is possibly exaggerated  The kinder garten cannot demand that parents should og to doctor

25. Controversies not covered here  Skin infections  Empiric treatment of urethritis  Bacterial vaginosis in pregnancy  Screening for symptomatic bacteriuria in pregnancy

26. Thanks for your attention