2. 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

3. 2 40-65 % 15-20 % 35-40% 40-45% 0-2 % 20-30 % 0-5 % Prevalence of penicillin resistant pneumococci in Europe

4. 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

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

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

9. 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

10. 102 77 309 39 31 60 -Nordic region -Denmark 102 GPs -Sweden 77 GPs -Balticum region -Lithuania31 GPs -Kaliningrad39 GPs -Region Hispano-America: -Spain 309 GPs -Argentina60GPs -TOTAL 618 GPs

11. 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

12. Kick-off meeting April 2007

15. Project time schedule Total project period: 3 years (April 2007 – March 2010) 2007200820092010 Analysis and conference Second registration of Patients First registration of Patients X Intervention: GPs and patients First invitation of GPs X

16. Project structure

17. Kaliningrad

18. Sweden

19. Lithuania

20. Spain

21. Denmark

22. Argentina

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

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

27. My Practice

31. 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

33. 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

34. Use of Strep A in patients with odinophagia (painful swallowing) PatientsStrepA performed Percentage with Strep A Argentina1500332.2% Denmark106182277.5% Lithuania80300.0% Russia76440.5% Spain7052961.4% Sweden50131963.7% Total11681127410.9%

35. Strep A test in Denmark

36. Strep A test in Sweden

37. 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)

38. 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

39. 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

40. 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

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

42. www.happyaudit.org

43. 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.

44. lbjerrum@health.sdu.dk Thank you

45. 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

46. 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% 132 10 2 38 142 40 134 48 182 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

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

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

51. 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

52. 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

53. 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

54. 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)

55. Number of doctors Number of patients registered Number of patients treated with antibiotics Argentina 6043741780 Denmark 10239041351 Lithauen 3127061152 Russia 3936851215 Spain 309167514675 Sweden 771853764 Total 6183327310937

56. Conclusion  Participating GPs  Estimated: 400  Real number 618  Number of consultations registered  Estimated 20-25.000  Real number: 33.273  Written material completed for all partners  Guidelines, Patient brochures, Reports etc

60. Days with symptoms