Procalcitonin guided antibiotic therapy and hospitalization in patients with lower respiratory tract infections: a prospective, multicenter, randomized controlled trial

<p>Abstract</p> <p>Background:</p> <p>Lower respiratory tract infections like acute bronchitis, exacerbated chronic obstructive pulmonary disease and community-acquired pneumonia are often unnecessarily treated with antibiotics, mainly because of physicians' difficulties to distinguish viral from bacterial cause and to estimate disease-severity. The goal of this trial is to compare medical outcomes, use of antibiotics and hospital resources in a strategy based on enforced evidence-based guidelines versus procalcitonin guided antibiotic therapy in patients with lower respiratory tract infections.</p> <p>Methods and design:</p> <p>We describe a prospective randomized controlled non-inferiority trial with an open intervention. We aim to randomize over a fixed recruitment period of 18 months a minimal number of 1002 patients from 6 hospitals in Switzerland. Patients must be >18 years of age with a lower respiratory tract infections <28 days of duration. Patients with no informed consent, not fluent in German, a previous hospital stay within 14 days, severe immunosuppression or chronic infection, intravenous drug use or a terminal condition are excluded. Randomization to either guidelines-enforced management or procalcitonin-guided antibiotic therapy is stratified by centre and type of lower respiratory tract infections. During hospitalization, all patients are reassessed at days 3, 5, 7 and at the day of discharge. After 30 and 180 days, structured phone interviews by blinded medical students are conducted. Depending on the randomization allocation, initiation and discontinuation of antibiotics is encouraged or discouraged based on evidence-based guidelines or procalcitonin cut off ranges, respectively. The primary endpoint is the risk of combined disease-specific failure after 30 days. Secondary outcomes are antibiotic exposure, side effects from antibiotics, rate and duration of hospitalization, time to clinical stability, disease activity scores and cost effectiveness. The study hypothesis is that procalcitonin-guidance is non-inferior (i.e., at worst a 7.5% higher combined failure rate) to the management with enforced guidelines, but is associated with a reduced total antibiotic use and length of hospital stay.</p> <p>Discussion:</p> <p>Use of and prolonged exposure to antibiotics in lower respiratory tract infections is high. The proposed trial investigates whether procalcitonin-guidance may safely reduce antibiotic consumption along with reductions in hospitalization costs and antibiotic resistance. It will additionally generate insights for improved prognostic assessment of patients with lower respiratory tract infections.</p> <p>Trial registration:</p> <p>ISRCTN95122877</p

Reconstructing the 2003/2004 H3N2 influenza epidemic in Switzerland with a spatially explicit, individual-based model

ABSTRACT: BACKGROUND: Simulation models of influenza spread play an important role for pandemic preparedness. However, as the world has not faced a severe pandemic for decades, except the rather mild H1N1 one in 2009, pandemic influenza models are inherently hypothetical and validation is, thus, difficult. We aim at reconstructing a recent seasonal influenza epidemic that occurred in Switzerland and deem this to be a promising validation strategy for models of influenza spread. METHODS: We present a spatially explicit, individual-based simulation model of influenza spread. The simulation model bases upon (i) simulated human travel data, (ii) data on human contact patterns and (iii) empirical knowledge on the epidemiology of influenza. For model validation we compare the simulation outcomes with empirical knowledge regarding (i) the shape of the epidemic curve, overall infection rate and reproduction number, (ii) age-dependent infection rates and time of infection, (iii) spatial patterns. RESULTS: The simulation model is capable of reproducing the shape of the 2003/2004 H3N2 epidemic curve of Switzerland and generates an overall infection rate (14.9 percent) and reproduction numbers (between 1.2 and 1.3), which are realistic for seasonal influenza epidemics. Age and spatial patterns observed in empirical data are also reflected by the model: Highest infection rates are in children between 5 and 14 and the disease spreads along the main transport axes from west to east. CONCLUSIONS: We show that finding evidence for the validity of simulation models of influenza spread by challenging them with seasonal influenza outbreak data is possible and promising. Simulation models for pandemic spread gain more credibility if they are able to reproduce seasonal influenza outbreaks. For more robust modelling of seasonal influenza, serological data complementing sentinel information would be beneficia

Switzerland’s COVID-19 Policy Response: Consociational Crisis Management and Neo-corporatist Reopening

Switzerland responded to the first COVID-19 wave fairly successfully by employing both public health and economic measures. During the state of emergency, the federal government made a firm decision to flatten the infection curve and to protect especially at-risk populations. During the lockdown period, the focus of the political debate shifted from health to the economy as the Federal Council (i.e., the national executive) started to prepare for the country's reopening. While government still had full power due to the emergency situation defined under national epidemic law, the shift in the debate also meant a shift in the way that the government made decisions. Switzerland is a power-sharing consociational democracy with strong neo-corporatist features. While the executive untypically relied heavily on health experts within and outside the administration during the lockdown, the reopening strategy shows clear features of Swiss neo-corporatism, including the resurgence and influence of the traditional big economic vested interests over the government's approach to decision making

The Emotional Foundations of Political Support: How Fear and Anger Affect Trust in the Government in Times of the Covid‐19 Pandemic

Crises like the current coronavirus pandemic evoke negative emotions in the general public. To date, however, little research has been conducted on the influence of these mental states on trust in the government – the uncontested key player in times of crises. Drawing on the appraisal and affective intelligence theories of emotions, we argue that fear and anger as the two crucial negative emotions in times of crises have divergent effects on trust in the government: Whereas fear leads to a rally‐‘round‐the‐flag effect increasing trust in the government, anger attributes blame for the adverse circumstances to the government. We present empirical evidence for our arguments with an original three‐wave online panel survey of 1’600 Swiss residents during the unprecedented times of the coronavirus pandemic. Our analysis provides empirical support for our arguments and further shows that the relationship is strongest for right‐wing respondents

Where does learning take place? The role of intergovernmental cooperation in policy diffusion

Although it is widely accepted that a decentralised system can enhance policy learning and the spread of best practices, an under-researched question is where that learning process takes place. Using data on the diffusion of health care policies in Switzerland, this article analyses the role of institutionalised intergovernmental cooperation and its impact on the spread of successful policies.The results show that joint membership of policy makers in health policy specific intergovernmental bodies is related to the diffusion of best practices