Predicting the use of antibiotics after initial symptomatic treatment of an uncomplicated urinary tract infection:analyses performed after a randomised controlled trial

Objective To predict antibiotic use after initial treatment with ibuprofen using data from a randomised controlled trial comparing ibuprofen to pivmecillinam in the treatment of women with symptoms of an uncomplicated urinary tract infection (UTI). Setting 16 sites in a primary care setting in Norway, Sweden and Denmark. Participants Data from 181 non-pregnant women aged 18–60 presenting with symptoms of uncomplicated UTI, initially treated with ibuprofen. Methods Using the least absolute shrinkage and selection operator logistic regression model, we conducted analyses to see if baseline information could help us predict which women could be treated with ibuprofen without risking treatment failure and which women should be recommended antibiotics. Results Of the 143 women included in the final analysis, 77 (53.8%) recovered without antibiotics and 66 (46.2 %) were subsequently prescribed antibiotics. In the unadjusted binary logistic regression, the number of days with symptoms before inclusion (<3 days) and feeling moderately unwell or worse (≥4 on a scale of 0–6) were significant predictors for subsequent antibiotic use. In the adjusted model, no predictors were significantly associated with subsequent antibiotic use. The area under the curve of the final model was 0.66 (95% CI: 0.57 to 0.74). Conclusion We did not find any baseline information that significantly predicted the use of antibiotic treatment. Identifying women who need antibiotic treatment to manage their uncomplicated UTI is still challenging. Larger data sets are needed to develop models that are more accurat

Strategies to reduce antibiotic use in women with uncomplicated urinary tract infection in primary care: protocol of a systematic review and meta-analysis including individual patient data.

INTRODUCTION Uncomplicated urinary tract infection (UTI) in women is a common reason to present in general practice and is usually treated with antibiotics to reduce symptom severity and duration. Results of recent clinical trials indicate that non-antibiotic treatment approaches can also be effective. However, it remains unclear which patients would benefit from antibiotic treatment and which can effectively and safely be treated without antibiotics. This systematic review and meta-analysis aims to estimate the effect of treatment strategies to reduce antibiotic use in comparison with immediate antibiotic treatment and to identify prognostic factors and moderators of treatment effects. A further aim is to identify subgroups of patients benefiting from a specific therapy. METHODS AND ANALYSIS A systematic literature search will be performed to identify randomised controlled trials which investigated the effect of treatment strategies to reduce antibiotic use in female adults with uncomplicated UTI compared with immediate antibiotic treatment. Therefore, the primary outcome of the meta-analysis is incomplete recovery. Anonymised individual patient data (IPD) will be collected. Aggregate data will be used for pairwise comparisons of treatment strategies using meta-analysis models with random effects accounting for potential between-study heterogeneity. Potential effect moderators will be explored in meta-regressions. For IPD, generalised linear mixed models will be used, which may be adjusted for baseline characteristics. Interactions of baseline variables with treatment effects will be explored. These models will be used to assess direct comparisons of treatment, but might be extended to networks. ETHICS AND DISSEMINATION The local institutional review and ethics board judged the project a secondary analysis of existing anonymous data which meet the criteria for waiver of ethics review. Dissemination of the results will be via published scientific papers and presentations. Key messages will be promoted for example, via social media or press releases. PROSPERO REGISTRATION NUMBER CRD42019125804

Can antibiotic prescriptions in respiratory tract infections be improved? A cluster-randomized educational intervention in general practice – The Prescription Peer Academic Detailing (Rx-PAD) Study [NCT00272155]

BACKGROUND: More than half of all antibiotic prescriptions in general practice are issued for respiratory tract infections (RTIs), despite convincing evidence that many of these infections are caused by viruses. Frequent misuse of antimicrobial agents is of great global health concern, as we face an emerging worldwide threat of bacterial antibiotic resistance. There is an increasing need to identify determinants and patterns of antibiotic prescribing, in order to identify where clinical practice can be improved. METHODS/DESIGN: Approximately 80 peer continuing medical education (CME) groups in southern Norway will be recruited to a cluster randomized trial. Participating groups will be randomized either to an intervention- or a control group. A multifaceted intervention has been tailored, where key components are educational outreach visits to the CME-groups, work-shops, audit and feedback. Prescription Peer Academic Detailers (Rx-PADs), who are trained GPs, will conduct the educational outreach visits. During these visits, evidence-based recommendations of antibiotic prescriptions for RTIs will be presented and software will be handed out for installation in participants PCs, enabling collection of prescription data. These data will subsequently be linked to corresponding data from the Norwegian Prescription Database (NorPD). Individual feedback reports will be sent all participating GPs during and one year after the intervention. Main outcomes are baseline proportion of inappropriate antibiotic prescriptions for RTIs and change in prescription patterns compared to baseline one year after the initiation of the tailored pedagogic intervention. DISCUSSION: Improvement of prescription patterns in medical practice is a challenging task. A thorough evaluation of guidelines for antibiotic treatment in RTIs may impose important benefits, whereas inappropriate prescribing entails substantial costs, as well as undesirable consequences like development of antibiotic resistance. Our hypothesis is that an educational intervention program will be effective in improving prescription patterns by reducing the total number of antibiotic prescriptions, as well as reducing the amount of broad-spectrum antibiotics, with special emphasis on macrolides

Antivirals for influenza-Like Illness? A randomised Controlled trial of Clinical and Cost effectiveness in primary CarE (ALIC4 E): the ALIC4 E protocol

INTRODUCTION: Effective management of seasonal and pandemic influenza is a high priority internationally. Guidelines in many countries recommend antiviral treatment for older people and individuals with comorbidity at increased risk of complications. However, antivirals are not often prescribed in primary care in Europe, partly because its clinical and cost effectiveness has been insufficiently demonstrated by non-industry funded and pragmatic studies. METHODS AND ANALYSIS: Antivirals for influenza-Like Illness? An rCt of Clinical and Cost effectiveness in primary CarE is a European multinational, multicentre, open-labelled, non-industry funded, pragmatic, adaptive-platform, randomised controlled trial. Initial trial arms will be best usual primary care and best usual primary care plus treatment with oseltamivir for 5 days. We aim to recruit at least 2500 participants ≥1 year presenting with influenza-like illness (ILI), with symptom duration ≤72 hours in primary care over three consecutive periods of confirmed high influenza incidence. Participant outcomes will be followed up to 28 days by diary and telephone. The primary objective is to determine whether adding antiviral treatment to best usual primary care is effective in reducing time to return to usual daily activity with fever, headache and muscle ache reduced to minor severity or less. Secondary objectives include estimating cost-effectiveness, benefits in subgroups according to age (64 years), severity of symptoms at presentation (low, medium and high), comorbidity (yes/no), duration of symptoms (≤48 hours/>48-72 hours), complications (hospital admission and pneumonia), use of additional prescribed medication including antibiotics, use of over-the-counter medicines and self-management of ILI symptoms. ETHICS AND DISSEMINATION: Research ethics committee (REC) approval was granted by the NRES Committee South Central (Oxford B) and Clinical Trial Authority (CTA) approval by The Medicines and Healthcare products Regulatory Agency. All participating countries gained national REC and CTA approval as required. Dissemination of results will be through peer-reviewed scientific journals and conference presentations

Experiences with a structured conversation tool: a qualitative study on feasibility in general practice in Norway

AbstractObjective To study the feasibility of a structured conversation tool (ICIT) in Norwegian general practice.Design and participants A structured conversation tool with elements from Cognitive Behavioral Therapy (CBT) was developed for use at the encounter in general practice to increase patient’s self-coping ability and the GPs management and sick leave assessment in patients with MUPS. Eight GPs received training and used the ICIT on 49 patients with MUPS. The physicians were gathered into two focus groups. The interviews were recorded on tape, transcribed, and analyzed with systematic text condensation.Main outcome measures The aim of our study was to examine any benefit and the feasibility of the ICIT in general practice.Results The physicians found the ICIT helpful to sort out, clarify and concretize the patients' issues. They felt less fatigued as patients took on a greater responsibility for their own recovery and reported a greater satisfaction and better management with the patients. A salutogenic approach gave the physicians greater insight into their patients’ lives and their issues, opening for new treatment options and aiding in recovery. By focusing on the patient’s potential capabilities despite their medical condition, some physicians experienced that patients on sick leave returned to work quicker.Conclusions The GPs in this study reported that the ICIT was helpful in consultations with patients due to unspecific medical conditions and facilitated a sense of competence for the physician. KEY POINTSGPs need communication skill training for integrated treatment and sick leave assessment for patients with Medically Unexplained Physical Symptoms (MUPS).•The GPs experienced that the structured conversation tool was beneficial in structuring, clarifying, and substantiating the patient's problems.•The GPs experienced a greater insight into their patients and their issues, opening new treatment options and aiding in recovery.•The GPs experienced patients’ quicker recovery and returns to work by starting immediate treatment using the conversation tool

Accuracy of signs, symptoms and blood tests for diagnosing acute bacterial rhinosinusitis and CT-confirmed acute rhinosinusitis in adults: protocol of an individual patient data meta-analysis

Introduction This protocol outlines a diagnostic individual patient data (IPD) meta-analysis aimed at developing simple prediction models based on readily available signs, symptoms and blood tests to accurately predict acute bacterial rhinosinusitis and CT-confirmed (fluid level or total opacification in any sinus) acute rhinosinusitis (ARS) in adults presenting to primary care with clinically diagnosed ARS, target conditions associated with antibiotic benefit.Methods and analysis The systematic searches of PubMed and Embase of a review on the accuracy of signs and symptoms for diagnosing ARS in ambulatory care will be updated to April 2020 to identify relevant studies. Authors of eligible studies will be contacted and invited to provide IPD. Methodological quality of the studies will be assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. Candidate predictor selection will be based on knowledge from existing literature, clinical reasoning and availability. Multivariable logistic regression analyses will be used to develop prediction models aimed at calculating absolute risk estimates. Large unexplained between-study heterogeneity in predictive accuracy of the models will be explored and may lead to either model adjustment or derivation of separate context-specific models. Calibration and discrimination will be evaluated to assess the models’ performance. Bootstrap resampling techniques will be used to assess internal validation and to inform on possible adjustment for overfitting. In addition, we aim to perform internal–external cross-validation procedures.Ethics and dissemination In this IPD meta-analysis, no identifiable patient data will be used. As such, the Medical Research Involving Humans Subject Act does not apply, and official ethical approval is not required. Findings will be published in international peer-reviewed journals and presented at scientific conferences.PROSPERO registration number PROSPERO CRD42020175659