The Opportunity of Point-of-Care Diagnostics in General Practice:Modelling the Effects on Antimicrobial Resistance

OBJECTIVES: Antimicrobial resistance (AMR) is a public health threat associated with antibiotic consumption. Community-acquired acute respiratory tract infections (CA-ARTIs) are a major driver of antibiotic consumption in primary care. We aimed to quantify the investments required for a large-scale rollout of point-of care (POC) diagnostic testing in Dutch primary care, and the impact on AMR due to reduced use of antibiotics. METHODS: We developed an individual-based model that simulates consultations for CA-ARTI at GP practices in the Netherlands and compared a scenario where GPs test all CA-ARTI patients with a hypothetical diagnostic strategy to continuing the current standard-of-care for the years 2020-2030. We estimated differences in costs and future AMR rates caused by testing all patients consulting for CA-ARTI with a hypothetical diagnostic strategy, compared to the current standard-of-care in GP practices. RESULTS: Compared to the current standard-of-care, the diagnostic algorithm increases the total costs of GP consultations for CA-ARTI by 9% and 19%, when priced at €5 and €10, respectively. The forecast increase in Streptococcus pneumoniae resistance against penicillins can be partly restrained by the hypothetical diagnostic strategy from 3.8 to 3.5% in 2030, albeit with considerable uncertainty. CONCLUSIONS: Our results show that implementing a hypothetical diagnostic strategy for all CA-ARTI patients in primary care raises the costs of consultations, while lowering antibiotic consumption and AMR. Novel health-economic methods to assess and communicate the potential benefits related to AMR may be required for interventions with limited gains for individual patients, but considerable potential related to antibiotic consumption and AMR

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

Using microbiological data to improve the use of antibiotics for respiratory tract infections: A protocol for an individual patient data meta-analysis

Background Resistance to antibiotics is rising and threatens future antibiotic effectiveness. ‘Antibiotic targeting’ ensures patients who may benefit from antibiotics receive them, while being safely withheld from those who may not. Point-of-care tests may assist with antibiotic targeting by allowing primary care clinicians to establish if symptomatic patients have a viral, bacterial, combined, or no infection. However, because organisms can be harmlessly carried, it is important to know if the presence of the virus/bacteria is related to the illness for which the patient is being assessed. One way to do this is to look for associations with more severe/prolonged symptoms and test results. Previous research to answer this question for acute respiratory tract infections has given conflicting results with studies has not having enough participants to provide statistical confidence. Aim To undertake a synthesis of IPD from both randomised controlled trials (RCTs) and observational cohort studies of respiratory tract infections (RTI) in order to investigate the prognostic value of microbiological data in addition to, or instead of, clinical symptoms and signs. Methods A systematic search of Cochrane Central Register of Controlled Trials, Ovid Medline and Ovid Embase will be carried out for studies of acute respiratory infection in primary care settings. The outcomes of interest are duration of disease, severity of disease, repeated consultation with new/worsening illness and complications requiring hospitalisation. Authors of eligible studies will be contacted to provide anonymised individual participant data. The data will be harmonised and aggregated. Multilevel regression analysis will be conducted to determine key outcome measures for different potential pathogens and whether these offer any additional information on prognosis beyond clinical symptoms and signs. Trial registration PROSPERO Registration number: CRD42023376769

Using microbiological data to improve the use of antibiotics for respiratory tract infections: A protocol for an individual patient data meta-analysis

Background: Resistance to antibiotics is rising and threatens future antibiotic effectiveness. ‘Antibiotic targeting’ ensures patients who may benefit from antibiotics receive them, while being safely withheld from those who may not. Point-of-care tests may assist with antibiotic targeting by allowing primary care clinicians to establish if symptomatic patients have a viral, bacterial, combined, or no infection. However, because organisms can be harmlessly carried, it is important to know if the presence of the virus/bacteria is related to the illness for which the patient is being assessed. One way to do this is to look for associations with more severe/prolonged symptoms and test results. Previous research to answer this question for acute respiratory tract infections has given conflicting results with studies has not having enough participants to provide statistical confidence. Aim: To undertake a synthesis of IPD from both randomised controlled trials (RCTs) and observational cohort studies of respiratory tract infections (RTI) in order to investigate the prognostic value of microbiological data in addition to, or instead of, clinical symptoms and signs. Methods: A systematic search of Cochrane Central Register of Controlled Trials, Ovid Medline and Ovid Embase will be carried out for studies of acute respiratory infection in primary care settings. The outcomes of interest are duration of disease, severity of disease, repeated consultation with new/worsening illness and complications requiring hospitalisation. Authors of eligible studies will be contacted to provide anonymised individual participant data. The data will be harmonised and aggregated. Multilevel regression analysis will be conducted to determine key outcome measures for different potential pathogens and whether these offer any additional information on prognosis beyond clinical symptoms and signs. Trial registration: PROSPERO Registration number: CRD42023376769

Evaluation of a web-based intervention to reduce antibiotic prescribing for LRTI in six European countries: quantitative process analysis of the GRACE/INTRO randomised controlled trial.

To reduce the spread of antibiotic resistance, there is a pressing need for worldwide implementation of effective interventions to promote more prudent prescribing of antibiotics for acute LRTI. This study is a process analysis of the GRACE/INTRO trial of a multifactorial intervention that reduced antibiotic prescribing for acute LRTI in six European countries. The aim was to understand how the interventions were implemented and to examine effects of the interventions on general practitioners' (GPs') and patients' attitudes

Impetigo incidence and treatment : a retrospective study of Dutch routine primary care data

BACKGROUND: There is a lack of recently published data on impetigo presentation incidence and treatment practices in the routine Western European primary care setting. OBJECTIVES: To investigate impetigo incidence, treatments and recurrence in primary care in the Netherlands. METHODS: A retrospective, observational study. Electronic records of patients treated for impetigo in 2015 at 29 general practices in Utrecht and surrounds were reviewed. An episode of impetigo was defined as one or more patient-doctor contacts within 8 weeks of the index consultation. Within an episode, patient demographics and prescribing patterns were analysed including number of treatments, and the category and sequence of individual medicines. RESULTS: A total of 1761 impetigo episodes were managed, with an incidence rate of 13.6 per 1000 person years. Impetigo peaked in summer. Most patients, the majority children, experienced a single episode (93%), and 25% had eczema as comorbidity. Topical antibiotics (primarily fusidic acid) were the most prescribed initial treatments (85%), followed by oral antibiotics (14%). Topical antibiotics were progressively used less over subsequent treatments, while there was an inverse increase in oral antibiotic use. Topical fusidic acid as the most common first line treatment seemed satisfactory as only 12% of initial treatments with this drug received further therapy. Repeat treatments generally occurred within 7 days. CONCLUSION: This study of impetigo prescribing patterns in primary care highlighted that Dutch general practitioners were generally adherent to national treatment guidelines. Topical treatment, and if needed systemic small-spectrum antibiotic treatment, appeared satisfactory; these findings aid in antimicrobial stewardship

Improving antibiotic prescribing quality by an intervention embedded in the primary care practice accreditation : the ARTI4 randomized trial

OBJECTIVES: Antibiotic overprescribing is a significant problem. Multifaceted interventions improved antibiotic prescribing quality; their implementation and sustainability, however, have proved difficult. We analysed the effectiveness of an intervention embedded in the quality cycle of primary care practice accreditation on quantity and quality of antibiotic prescribing for respiratory tract and ear infections (RTIs). METHODS: This was a pragmatic, cluster-randomized intervention trial in 88 Dutch primary care practices. The intervention (physician education and audit/feedback on antibiotic prescribing quantity and quality) was integrated in practice accreditation by defining an improvement plan with respect to antibiotic prescribing for RTIs. Numbers and types of dispensed antibiotics were analysed from 1 year prior to the intervention to 2 years after the intervention (pharmacy data). Overprescribing, underprescribing and non-first-choice prescribing for RTIs were analysed at baseline and 1 year later (self-registration). RESULTS: There were significant differences between intervention and control practices in the changes in dispensed antibiotics/1000 registered patients (first year: -7.6% versus -0.4%, P = 0.002; second year: -4.3% versus +2%, P = 0.015), which was more pronounced for macrolides and amoxicillin/clavulanate (first year: -12.7% versus +2.9%, P = 0.001; second year: -7.8% versus +6.7%, P = 0.005). Overprescribing for RTIs decreased from 44% of prescriptions to 28% (P < 0.001). Most general practitioners (GPs) envisaged practice accreditation as a tool for guideline implementation. CONCLUSIONS: GP education and an audited improvement plan around antibiotics for RTIs as part of primary care practice accreditation sustainably improved antibiotic prescribing. Tools should be sought to further integrate and facilitate education and audit/feedback in practice accreditation

Improving antibiotic prescribing quality by an intervention embedded in the primary care practice accreditation : the ARTI4 randomized trial

OBJECTIVES: Antibiotic overprescribing is a significant problem. Multifaceted interventions improved antibiotic prescribing quality; their implementation and sustainability, however, have proved difficult. We analysed the effectiveness of an intervention embedded in the quality cycle of primary care practice accreditation on quantity and quality of antibiotic prescribing for respiratory tract and ear infections (RTIs). METHODS: This was a pragmatic, cluster-randomized intervention trial in 88 Dutch primary care practices. The intervention (physician education and audit/feedback on antibiotic prescribing quantity and quality) was integrated in practice accreditation by defining an improvement plan with respect to antibiotic prescribing for RTIs. Numbers and types of dispensed antibiotics were analysed from 1 year prior to the intervention to 2 years after the intervention (pharmacy data). Overprescribing, underprescribing and non-first-choice prescribing for RTIs were analysed at baseline and 1 year later (self-registration). RESULTS: There were significant differences between intervention and control practices in the changes in dispensed antibiotics/1000 registered patients (first year: -7.6% versus -0.4%, P = 0.002; second year: -4.3% versus +2%, P = 0.015), which was more pronounced for macrolides and amoxicillin/clavulanate (first year: -12.7% versus +2.9%, P = 0.001; second year: -7.8% versus +6.7%, P = 0.005). Overprescribing for RTIs decreased from 44% of prescriptions to 28% (P < 0.001). Most general practitioners (GPs) envisaged practice accreditation as a tool for guideline implementation. CONCLUSIONS: GP education and an audited improvement plan around antibiotics for RTIs as part of primary care practice accreditation sustainably improved antibiotic prescribing. Tools should be sought to further integrate and facilitate education and audit/feedback in practice accreditation