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Treatment of Respiratory Tract Infections in Primary Care with special emphasis on Acute Otitis Media
2010 (English)Doktorsavhandling, sammanläggning (Other academic)
Abstract [en]

Background and aims: Most respiratory tract infections (RTI) are self-limiting. Despite this, they are associated with high antibiotic prescription rates in general practice in Sweden. The aim of this thesis was to evaluate the management of respiratory tract infections (RTIs) with particular emphasis on acute otitis media (AOM).

Methods: Paper I: A prospective, open, randomized study of 179 children presenting with AOM and performed in primary care. Paper II & III: Study of 6 years data from primary care in Kalmar County on visits for RTI, retrieved from electronic patient records. Paper IV: Observational, clinical study of 71 children presenting with AOM complicated by perforation, without initial use of antibiotics.

Results: Children with AOM who received PcV had some less pain, used fewer analgesics and consulted less, but the PcV treatment did not affect the recovery time or complication rate (I). Between 1999 and 2005, 240 445 visits for RTI were analyzed (II & III). Antibiotics were prescribed in 45% of visits, mostly PcV (60%) and doxycycline (18%). Visiting rates for AOM and tonsillitis declined by >10%/year, but prescription rates of antibiotics remained unchanged. For sore throat, 65% received antibiotics. Patients tested but without presence of S.pyogenes received antibiotics in 40% of cases. CRP was analyzed in 36% of consultations for RTI. At CRP<50mg/l antibiotics, mostly doxycycline, were prescribed in 54% of visits for bronchitis. Roughly 50% of patients not tested received antibiotics over the years.Twelve of 71 children with AOM and spontaneous perforation completing the trial received antibiotics during the first nine days due to lack of improvement, one child after 16 days due to recurrent AOM and six had new incidents of AOM after 30 days (IV). Antibiotics were used more frequently when the eardrum appeared pulsating and secretion was purulent and abundant. All patients with presence of S.pyogenes received antibiotics.

Results: Children with AOM who received PcV had some less pain, used fewer analgesics and consulted less, but the PcV treatment did not affect the recovery time or complication rate (I). Between 1999 and 2005, 240 445 visits for RTI were analyzed (II & III). Antibiotics were prescribed in 45% of visits, mostly PcV (60%) and doxycycline (18%). Visiting rates for AOM and tonsillitis declined by >10%/year, but prescription rates of antibiotics remained unchanged. For sore throat, 65% received antibiotics. Patients tested but without presence of S.pyogenes received antibiotics in 40% of cases. CRP was analyzed in 36% of consultations for RTI. At CRP<50mg/l antibiotics, mostly doxycycline, were prescribed in 54% of visits for bronchitis. Roughly 50% of patients not tested received antibiotics over the years.Twelve of 71 children with AOM and spontaneous perforation completing the trial received antibiotics during the first nine days due to lack of improvement, one child after 16 days due to recurrent AOM and six had new incidents of AOM after 30 days (IV). Antibiotics were used more frequently when the eardrum appeared pulsating and secretion was purulent and abundant. All patients with presence of S.pyogenes received antibiotics.

Place, publisher, year, pages
Linköping: Linköping University Electronic Press, 2010. 85 p.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1166
Keyword [en]
General practice, respiratory tract infections, acute otitis media, rapid diagnostic tests, CRP, Strep-A, electronic patient records, physician consultations, antibiotic prescription
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-54832 (URN)978-91-7393-446-6 (ISBN)oai:DiVA.org:liu-54832 (OAI)
Public defence
2010-04-23, Aulan N2007, Linnéuniversitetet, Kalmar, 09:00 (English)
Opponent
Supervisors
Available from2010-04-15 Created:2010-04-15 Last updated:2010-04-15Bibliographically approved
List of papers
1. Evaluation of phenoxymethylpenicillin treatment of acute otitis media in children aged 2-16
Open this publication in new window or tab >>Evaluation of phenoxymethylpenicillin treatment of acute otitis media in children aged 2-16
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2007 (English)In: Scandinavian Journal of Primary Health Care, ISSN 0281-3432, E-ISSN 1502-7724, Vol. 25, no 3, 166-171Artikel i tidskrift (Refereed) Published
Abstract [en]

Objective. To study the clinical recovery from acute otitis media (AOM) in children, 2-16 years of age, managed with or without treatment with phenoxymethylpenicillin (PcV).

Design. An open, prospective randomized trial. Children aged between 2 and 16 years, presenting with one- or double-sided AOM (without perforation) with symptom duration of less than four days, were included. The children were randomized to PcV for five days or to no primary antibiotic treatment. A health score and compliance were registered on a daily basis for seven days. Setting. A total of 32 health centres and 72 GPs in south-east Sweden.

Subjects. Children aged 2-16 presenting with earache. Main outcome measures. Recovery time, symptom duration, frequency of complications (up to three months) and consumption of healthcare services independent of treatment with or without antibiotics.

Results. A total of 179 patients carried out the trial, 92 were randomized to PcV, 87 to no primary antibiotic treatment. The median recovery time was four days in both groups. Patients who received PcV had less pain (p <0.001) and used fewer analgesics. There were no significant differences in the number of middle-ear effusions or perforations at the final control after three months. Children randomized to PcV treatment consulted less (p <0.001) during the first seven days.

Conclusions. Our investigation supports that PcV treatment of AOM does not affect the recovery time or complication rates. PcV provided some symptomatic benefit in the treatment of AOM in otherwise healthy children, aged 2-16 years.

Keyword
Acute otitis media, antibiotics, AOM, children, family practice, general practice, PcV, phenoxymethylpenicillin, primary healthcare
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-41536 (URN)10.1080/02813430701267405 (DOI)57214 (Local ID)57214 (Archive number)57214 (OAI)
Available from2009-10-10 Created:2009-10-10 Last updated:2014-01-10
2. Trends in number of consultations and antibiotic prescriptions for respiratory tract infections between 1999 and 2005 in primary healthcare in Kalmar County, Southern Sweden
Open this publication in new window or tab >>Trends in number of consultations and antibiotic prescriptions for respiratory tract infections between 1999 and 2005 in primary healthcare in Kalmar County, Southern Sweden
2009 (English)In: Scandinavian Journal of Primary Health Care, ISSN 0281-3432, E-ISSN 1502-7724, Vol. 27, no 1, 18-24Artikel i tidskrift (Refereed) Published
Abstract [en]

Background: Respiratory tract infections (RTIs) comprise the most common indication for consulting a general practitioner and obtaining an antibiotic prescription.

Objective: To study changes in the number of visits, diagnoses, and antibiotic prescriptions for RTI in primary healthcare during the period 1999-2005.

Design: A retrospective, descriptive, population-based study of electronic patient records.

Setting: County of Kalmar in southeastern Sweden.

Patients: Patients visiting primary healthcare units in Kalmar County for an RTI between 1 July 1999 and 31 December 2005. Main outcome measures. RTI diagnoses, antibiotic prescriptions, age groups.

Results: A total of 240 447 visits for RTI made between 1999 and 2005 were analysed. The yearly consultation rates for the diagnoses acute tonsillitis and AOM decreased by 12% and 10%, respectively (p = 0.001). Of all patients consulting for an RTI diagnosis, 45% received antibiotics. Of all prescribed antibiotics, 60% were for phenoxymethylpenicillin (PcV) and 18% doxycycline. Amoxicillin or amoxicillin + clavulanic acid was prescribed to a lesser extent. The proportion of patients obtaining an antibiotic prescription was almost constant over time (44-46%). The prescriptions of doxycycline showed increasing values (NS). The prescriptions of remaining antibiotics decreased significantly especially for patients up to middle age.

Conclusion: This large population study, comprising more than six years of observations, showed the number of primary healthcare patients receiving an RTI diagnosis decreased during the period 1999-2005, but the proportion of patients receiving an antibiotic prescription remained the same. The large seasonal variations indicate a need for further interventions to decrease antibiotic use for RTIs.

Keyword
Antibiotics, electronic patient records, family practice, general practice, phenoxymethylpenicillin (PcV), primary healthcare, respiratory tract infections
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-17131 (URN)10.1080/02813430802610784 (DOI)
Available from2009-03-07 Created:2009-03-07 Last updated:2014-01-10
3. Use of rapid diagnostic tests and choice of antibiotics in respiratory tract infections in primary healthcare
Open this publication in new window or tab >>Use of rapid diagnostic tests and choice of antibiotics in respiratory tract infections in primary healthcare : A 6-y follow-up study
2010 (English)In: Scandinavian Journal of Infectious Diseases, ISSN 0036-5548, Vol. 42, no 2, 90-96Artikel i tidskrift (Refereed) Published
Abstract [en]

The aim of this retrospective study of electronic patient records in primary health care in Kalmar County, Sweden, was to describe consultations for respiratory tract infections (RTIs) in relation to age, choice of antibiotics and the use of rapid diagnostic tests. During the period 1999-2005, 240,445 visits for RTI were recorded. Children aged andlt;2 y and especially those aged 2-16 y with acute otitis media (AOM), showed decreasing consultations between 2000 and 2005. The consultations for sore throat declined during the study period in all age groups and in 65% of these, antibiotics were prescribed, primarily penicillin V (82%). In sore throat, a positive Strep-A test result was followed by antibiotic prescription in about 92% of cases, when negative, the antibiotic prescription rate was 40%. C-reactive protein (CRP) was analyzed in 36% of all consultations for RTI. In common cold and acute bronchitis, the prescription rates of antibiotics rose with rising CRP. The results show that near-patient tests were used extensively, but often not in accordance with the guidelines. Antibiotic use decreased mainly as a consequence of declined visiting frequencies. This indicates that the new guidelines for AOM and sore throat may have influenced patient consultation habits more than physician prescribing habits.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-54388 (URN)10.3109/00365540903352932 (DOI)000274849700002 (ISI)
Available from2010-03-12 Created:2010-03-12 Last updated:2010-04-15
4. Spontaneously draining acute otitis media in children
Open this publication in new window or tab >>Spontaneously draining acute otitis media in children : An observational study of clinical findings, microbiology and clinical course
Show others...
2011 (English)In: Scandinavian Journal of Infectious Diseases, ISSN 0036-5548, Vol. 43, no 11-12, 891-898Artikel i tidskrift (Refereed) Published
Abstract [en]

Conclusion: The study indicates that an active ‘‘wait and see’’ policy during the first 3 days can be justified in most children with otorrhea but antibiotics should be considered in children who initially present with abundant purulent secretion and pulsating eardrum.

Objectives: To study the clinical recovery of acute otitis media (AOM) with otorrhea in children managed initially without antibiotics.

Methods: Children aged 2-16, presenting with AOM and spontaneous otorrhea, were followed. Specimens for bacterial investigations were obtained, and symptoms were registered on daily basis. The main outcome measures were the frequency of patients treated with antibiotics due to persisting AOM within 9 days in relation to clinical and bacteriologic findings and new AOM within 3 months.

Results: Twelve of 71 children who completed the trial received antibiotics during the first nine days due to lack of improvement, one child after 16 days due to recurrent AOM and six had new AOM after 30 days. A.otitidis was found in 23 samples, S.pneumoniae in 12, S.pyogenes in 6, F.nucleatum in five. M.pneumoniae, C.pneumoniae and F.necrophorum could not be detected Antibiotics were prescribed more extensively to patients with pulsating eardrum and abundant purulent secretion. All patients with presence of S.pyogenes received antibiotics.

Publisher, range
Informa Healthcare, 2011
Keyword
AOM, perforation, spontaneous, otorrhea, microbiology, antibiotics, alloicoccus otitidis
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-54831 (URN)10.3109/00365548.2011.591820 (DOI)000296641500007 (ISI)
Available from2010-04-15 Created:2010-04-15 Last updated:2011-12-16

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