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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. Background. 1999: National plan to stop antibiotic resistance
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New Norwegian national guidelines for antibiotic use in primary carePresentation 14.5.09, Nordisk kongress, KøbenhavnMorten Lindbækprofessor in general practice, UiOleader Antibiotic Centre for primary care
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
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”.
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%)
Relation between antibiotic consumption and proportion resistant pneumococci In some European countries(Goossens et al, Lancet 2005; 365:579-587 )
Prevalence of av erythromycin resistance in pneumococci in blood culturs in Norway 2000-2006 NORM 2006
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”
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
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
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
Implementation • Harmonizing with other guidelines such as those in NEL and other guidelines for other specialisties (pediatrics, skin infections and gynecology, ENT)
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
Some important highlights in respiratory tract infections • Acute otitis media • Acute sinusitis • Acute tonsillitis • Acute bronchitis Pneumonia • Exacerbations of COLD • (Acute conjunctivitis)
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)
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…
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
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.
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?
Acute bronchitis - pneumonia • No antibiotics for acute bronchitis. Beta2-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.
COLD-exacerbationchange 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.
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
Controversies not covered here • Skin infections • Empiric treatment of urethritis • Bacterial vaginosis in pregnancy • Screening for symptomatic bacteriuria in pregnancy