H ealth A lliance for P rudent P rescribing, Y ield

1. Health Alliance for Prudent Prescribing, Yield AndUse of anti-microbial Drugs In the Treatment of Respiratory Tract Infections Proposal for EU DG Research, March 2006 Coordinator: Research Unit of General Practice, Odense, Denmark

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

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

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

5. Resistant StrainsRare Antimicrobial Exposure Resistant Strains Dominant x x x x x x x x x x x x Selection for Antibiotic Resistance

8. HAPPY AUDITObjective • 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

9. 60 77 31 102 39 • Nordic region • Denmark 102 GPs • Sweden 77 GPs • Balticum region • Lithuania 31 GPs • Kaliningrad 39 GPs • Region Hispano-America: • Spain 309 GPs • Argentina 60GPs • TOTAL 618 GPs 309

10. Kick-off meeting April 2007

12. X X Analysis and conference Second registration of Patients Intervention: GPs and patients First registration of Patients First invitation of GPs Project time schedule 2007 2008 2009 2010 Total project period: 3 years (April 2007 – March 2010)

13. Kaliningrad

14. Sweden

15. Lithuania

16. Spain

17. Denmark

18. Argentina

21. Intervention material for professionals Reportwithaggregated and individualresults Happy Audit Guidelines Laboratory test instructions

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

23. My Practice

24. My Practice My Practice

27. Centor criteria*: Fever Tender angular glands Tonsil Coatings Absence of cough *Described by dr. Robert Centor of the University of Alabama

29. Centorcriteria and probability of Streptococci Patients with 0-1 Centor criteria should not be tested with Strep A

30. Use of Strep A in patients withodinophagia (painfulswallowing)

31. Strep A test in Denmark

32. Strep A test in Sweden

33. 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

34. Overuse of Strep A maylead to inappropriateantibiotictreatments Generally, Strep A should not beperformed in: Asymptomaticcarriers of Streptococci Patients withsorethroat and lessthan 2 Centorcriteria

35. Conclusion • Denmark, Sweden: • Overuse of Strepmaylead to inappropriateantibiotictreatment and initiativesshouldbetaken to reduceoveruse of Strep A testing in general practice • Spain, Argentina, Lithuania, Russia: • Introduction of Strep A mayleed to a lowerprescribing in patients withsorethorat and initiativesshouldbetaken to introduceStrep A in general practice

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

37. www.happyaudit.org

38. 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.

39. Thank you lbjerrum@health.sdu.dk

40. Validationstudy of Strep A in general practice in Barcelona • Inclusded 182 patients withsorethroat and ≥ 2 Centorcriteria • Tests: • ThroatCulture • Strep A

41. AmigdalitisLa validez de la prueba de Strep A pare diagnosticar Estrep betahem gr A Pos predictive value PPV = 38/48 = 79% 38 48 10 Neg predictive value NPV = 132/134 = 98% 2 132 134 40 142 182 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

43. Nycocard CRP single test • Axis-Shield, Norway • Trainingthroughlocaldistributors • Instrument freeduring test period

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

46. 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

47. 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

48. 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

49. The final set of indicators • 6 acute sinusitis • 9 acuteotitis 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)