External validation of prediction models for pneumonia in primary care patients with lower respiratory tract infection: an individual patient data meta-analysis

Pneumonia remains difficult to diagnose in primary care. Prediction models based on signs and symptoms (S&S) serve to minimize the diagnostic uncertainty. External validation of these models is essential before implementation into routine practice. In this study all published S&S models for prediction of pneumonia in primary care were externally validated in the individual patient data (IPD) of previously performed diagnostic studies

Molecular Diagnostics among Patients with Gastroenteritis in General Practice

Gastroenteritis (GE) is one of the most frequently occurring infectious disease and has a relatively high consultation rate in general practice. In the Netherlands, 5 to 12% of patients with GE consult their general practitioner (GP), amounting to 240 to 600 thousand consultations annually. Although the disease course of GE is in generally favorable and self-limiting, in some patients diagnostics feces testing (DFT) may be indicated to guide further clinical management. DFT and subsequent guided antibiotic treatment may especially be necessary in patients working in healthcare or the food-industry, and in high-risk patients, such as immune-compromised patients, frail elderly, and young children. Traditionally, general practitioners used microbiological culture and microscopy to identify bacteria and parasites causing gastroenteritis. In recent years, molecular-based techniques, such as polymerase chain reaction (PCR), have become available as an alternative to traditional diagnostic modalities. PCR allows for highly sensitive identification of DNA or RNA of multiple enteropathogens in a single stool sample, with shorter turnaround times, improved sampling convenience and diagnostic yield as compared to conventional techniques. While conventional DFT requires up to 4 days before results become available, PCR-based DFT generally takes less than 24 hours. Although these relevant differences between PCR and conventional DFT are likely to influence patient management, healthcare use, and associated costs, an evaluation of the introduction of PCR-based DFT in general practice has not yet been performed. We evaluated the effect of the introduction of PCR-based DFT testing on the management of GE in general practice, as well as on GE-related costs. From our research we can conclude that the current management of patients with GE in general practice – now comprising PCR-based DFT – poorly aligns with guideline indications for empirical antibiotic treatment and DFT. Furthermore, the introduction of PCR is associated with increased use of DFT, healthcare costs per GE episode, and detection and treatment of non-pathogenic protozoa. Additionally, using broad-panel DFT instead of current practice targeted DFT can improve the clinical decision regarding antibiotic treatment in 1 in every 12 patient. These findings need to be interpreted with care, as we were not able to quantify the potential clinical benefits of PCR testing over conventional DFT. However, we conclude that improving adherence to clinical practice guidelines is pivotal to improve current clinical management of GE in general practice. This includes updating of existing guidelines using all available (and new) evidence, increasing awareness among GPs and patients about the proper use of diagnostic and therapeutic resources and stimulating the use of reliable information to patients. When updating the current guideline on gastroenteritis, the position of (broad-panel) PCR-based DFT needs to be more explicitly discussed, describing the different types of indications within the diagnostic workup (e.g. public health or patient’s health perspectives for DFT) and the potential drawbacks and benefits of PCR testing for patients

Fecesonderzoek bij patiënten met diarree

Schierenberg A, Broekhuizen BDL, de Wit NJ. Stool analysis in chronic diarrhoea. Huisarts Wet 2016;59(11):502-6. Diarrhoea is a common problem, with many potential causes. In most cases, it is caused by self-limiting gastroenteritis, for which further diagnostic investigations are not required. Although current guidelines advocate a conservative use of stool analysis, general practitioners (GPs) often request this expensive test. Stool analysis is only of clinical value if symptoms are severe or persistent, or if the patient is immunocompromised. In these cases, stool analysis makes it possible to start appropriate antibiotic treatment or to rule out severe disease. From a public health perspective, stool analysis may be necessary if an epidemic is suspected or if a patient works in the food industry or in healthcare. Overdiagnosis not only leads to high costs but also to unnecessary antibiotic use with adverse consequences to patients, such as the treatment of carriers and non-pathogenic parasites. Better adherence to guidelines can prevent this. Nowadays, most laboratories carry out stool analyses by means of polymerase chain reaction (PCR), which is faster, more convenient, and more accurate than culture and microscopy; however, it can also generate false-positive results with non-viable pathogens. Moreover, PCR tests often include multiple pathogens, so that positive results are sometimes reported for pathogens that were not suspected by the GP or for those of questionable pathogenicity

Efficacy of contingency management for cocaine dependence treatment: a review of the evidence

Cocaine dependence causes serious individual and social harm and a considerable proportion of substance related treatment capacity is devoted to cocaine dependent persons. In the absence of approved pharmacotherapies, other treatments for cocaine dependence should be explored. In this review, the efficacy of Contingency Management (CM), a promising behavior therapy using operant conditioning, is evaluated for the treatment of cocaine dependence. A systematic evaluation of 19 studies with a total of 1,664 patients showed that CM - in combination with standard cognitive behavioral or other psychological interventions - (1) increases cocaine abstinence, (2) improves treatment retention during and after group-based or individual psychological treatment, (3) is of benefit in pharmacotherapy trials, and (4) that CM may act synergistically with pharmacotherapy. This suggests that CM is a promising add-on intervention for cocaine dependence treatment. Therefore, it is advocated to include CM in standard treatment programs for cocaine dependence and future pharmacotherapy research. Future larger studies are deemed necessary to replicate these promising results, now often lacking statistical significanc

Antibiotic treatment of gastroenteritis in primary care

Background: Gastroenteritis (GE) is a frequent reason for consultating a general practitioner. Yet little is known about antibiotic prescribing in primary care patients with GE. In this study, we quantified empirical and targeted antibiotic treatment of GE, compliance with recommendations from primary care clinical practice guidelines (CPGs) and the degree of antimicrobial resistance in patients receiving diagnostic faeces testing (DFT). Methods: We performed a cohort study using routine care data of 160 general practitioners, including electronic patient records from 2013 to 2014. GE episodes were extracted and linked to microbiological laboratory records to retrieve results of DFT. For each episode, data on patient characteristics, DFT results including antimicrobial resistance testing, and antibiotic prescriptions were collected. Results: We identified 13217 GE episodes. Antibiotic treatment was prescribed in 1163 (8.8%) episodes, most frequently with metronidazole (n = 646, 4.9%), azithromycin (n = 254, 1.9%) or ciprofloxacin (n = 184, 1.4%). Treatment was empirical for 641 (5%) GE episodes, of which 30% (n = 191) followed the CPG-recommended antibiotic choice. Targeted treatment following DFT results was prescribed for 537 GE episodes (4%), of which 99% (n = 529) followed CPG recommendations. Non-susceptibility to first- or second-choice antibiotics was demonstrated in three Salmonella isolates (9%-13% of all isolates) and one Campylobacter isolate (1%). Conclusions: Antibiotic treatment of GE in primary care is relatively infrequent, with 1 in 11 episodes treated. Empirical treatment was more frequent compared with targeted treatment and mostly with non-CPG-recommended antibiotics. However, treatment based upon DFT results followed CPG recommendations

Analysis of recruitment in a pragmatic observational study on C-reactive protein point-of-care testing in primary care

NTRODUCTION: Failure to recruit all eligible study patients can lead to biased results. Little is known on selective patient recruitment in studies on implementation of diagnostic devices. OBJECTIVES: The aim of this observational study was to measure recruitment of patients in an implementation study in primary care on use of point-of-care (POC) C-reactive protein (CRP) and to evaluate recruitment bias and its impact on the study endpoint. METHODS: In a cross-sectional observational study on POC CRP implementation and related antibiotics prescribing, we compared included patients with all eligible patients to assess the representativeness of the included subjects. Eligible patients were adults presenting with acute cough in primary care between March and September 2012. The frequency of POC CRP testing and the proportion of prescribed antibiotics were compared between recruited and non-recruited patients. As measure of bias, odds ratios (ORs) with accompanying 95% confidence intervals (CIs) for the association between CRP level (<20 mg/l or not) and antibiotic prescribing were computed. RESULTS: Of all 1473 eligible patients 348 (24%) were recruited. In recruited patients, POC CRP tests were conducted and antibiotics prescribed more frequently as compared to non-recruited patients (81% versus 6% and 44% versus 29%, respectively). The ORs were 18.2 (95%CI: 9.6-34.3), 30.5 (95%CI: 13.2-70.3) and 3.8 (95%CI: 0.9-14.8) respectively in all eligible patients, the recruited and the non-recruited patients. CONCLUSION: Selective recruitment resulted in an overestimation of POC CRP test use and antibiotic prescribing

Guideline adherence for diagnostic faeces testing in primary care patients with gastroenteritis

Background.: Gastroenteritis (GE) is a common reason for primary care consultation. Dutch clinical practice guidelines (CPG) recommend diagnostic faeces testing (DFT) only in primary care patients with severe illness, comprised immunity or increased transmission risk. For its superior accuracy, shorter turnaround time and ease of use, polymerase chain reaction (PCR)-based DFT has largely replaced conventional techniques. It is unknown whether this changed CPG adherence. Objective.: To quantify the effect of PCR introduction on adherence to CPG indications for DFT in primary care patients with GE. Methods.: We performed a cohort study using routine care data of 225 GPs. Episodes of GE where DFT was performed were extracted from electronic patient records. Presenting symptoms were identified and adherence to CPG indications for DFT assessed in two randomly drawn samples of each 500 patients, one from the period before PCR introduction (2010-11) and one after (2013). The association between PCR introduction and adherence was estimated using multivariable regression analysis. Results.: In 88% of all episodes relevant presenting symptoms were reported, most often 'frequent watery stool' (58%) and 'illness duration >10 days' (40%). DFT was performed in 15% of episodes before PCR introduction and in 18% after. Overall, in 17% the DFT request was considered adherent to the CPG, 16% before PCR introduction and 18% after (adjusted OR 1.2, 95% CI 0.9-1.7). Conclusion.: Overall adherence to CPG indications when requesting DFT in primary care patient with GE was 17%. Implementation of PCR-based DFT was not associated with a change in CPG adherence

Guideline adherence for diagnostic faeces testing in primary care patients with gastroenteritis

Background.: Gastroenteritis (GE) is a common reason for primary care consultation. Dutch clinical practice guidelines (CPG) recommend diagnostic faeces testing (DFT) only in primary care patients with severe illness, comprised immunity or increased transmission risk. For its superior accuracy, shorter turnaround time and ease of use, polymerase chain reaction (PCR)-based DFT has largely replaced conventional techniques. It is unknown whether this changed CPG adherence. Objective.: To quantify the effect of PCR introduction on adherence to CPG indications for DFT in primary care patients with GE. Methods.: We performed a cohort study using routine care data of 225 GPs. Episodes of GE where DFT was performed were extracted from electronic patient records. Presenting symptoms were identified and adherence to CPG indications for DFT assessed in two randomly drawn samples of each 500 patients, one from the period before PCR introduction (2010-11) and one after (2013). The association between PCR introduction and adherence was estimated using multivariable regression analysis. Results.: In 88% of all episodes relevant presenting symptoms were reported, most often 'frequent watery stool' (58%) and 'illness duration >10 days' (40%). DFT was performed in 15% of episodes before PCR introduction and in 18% after. Overall, in 17% the DFT request was considered adherent to the CPG, 16% before PCR introduction and 18% after (adjusted OR 1.2, 95% CI 0.9-1.7). Conclusion.: Overall adherence to CPG indications when requesting DFT in primary care patient with GE was 17%. Implementation of PCR-based DFT was not associated with a change in CPG adherence