Increasing antibiotic resistance represents a major public health threat that jeopardises the future treatment of bacterial infections. This study aims to describe the adherence to recommendations proposed by the World Health Organization (WHO) Advisory Group on Integrated Surveillance of Antimicrobial Resistance (AGISAR), in Spain and Denmark, and to analyse the relation between the outpatient use of Critically Important Antimicrobials (CIA) and the bacterial resistance rates to these agents.
The Antimicrobial consumption interactive database (ESAC-Net) and Antimicrobial resistance interactive database (EARS-Net) provided data on outpatient use (2010-2013) of CIA (fluoroquinolones, macrolides, and 3rd and 4th generation cephalosporins) and the percentages of isolates of the main pathogens causing serious infections, resistant to these agents.
The use of cephalosporins and fluoroquinolones, as well as the percentage of bacteria resistant, is higher in Spain than in Denmark. Although consumption of macrolides in both countries is similar, the proportion of Streptococcus pneumoniae resistant to macrolides is significantly higher in Spain.
The high outpatient consumption of CIA agents in Spain deviates substantially from the WHO recommendations. Moreover, it has the effect of elevated rates of antimicrobial resistance, that are lower in Denmark.
OBJECTIVE: To compare antibiotic prescribing in primary care in two European populations, one in Denmark (Funen), the other in Italy (Ravenna). METHODS: Reimbursement data (1999) were retrieved from the Odense Pharmacoepidemiologic Database (Denmark) and the Emilia Romagna Health Authority Database (Italy). The extent of antibiotic use (ATC J01) was analysed as the number of defined daily doses per 1000 inhabitants per day (DDD/1000 inhabitants/day), and as annual prevalence of use. A qualitative analysis was carried out according to the Drug Utilization 90% (DU90%) approach. RESULTS: Antibiotic consumption was 16.5 DDD/1000 inhabitants/day in Ravenna and 10.4 DDD/1000 inhabitants/day in Funen; the annual prevalence of use was 40 and 30 subjects/100 inhabitants, respectively. Italian children received a greater amount (four-fold in DDDs) of antibiotics than Danish ones, whereas consumption was only slightly higher in Italy than in Denmark in the other age groups. In Italy, injectable antibiotics (third generation cephalosporins or aminoglycosides) accounted for 4% of total DDDs and 11% of exposed subjects. In Funen, use of injectable antibiotics was negligible. The bulk of prescription (90% of total DDDs) was made up of eight (out of 38) different antibiotics in Denmark, mainly narrow-spectrum penicillins and macrolides (1st: phenoxymethylpenicillin), and of 18 (out of 74) antibiotics in Italy, mainly broad-spectrum penicillins, macrolides, fluoroquinolones and cephalosporins. CONCLUSIONS: These data show remarkable differences in antibiotic prescribing between Italy and Denmark, and suggest possible overuse and misuse of antibiotics in Italy.
OBJECTIVE: There is evidence that Chlamydia pneumoniae (CP) is involved in the aetiology of myocardial infarction (MI). Randomised trials do not support a beneficial effect of antibiotics in secondary prevention of MI, but the evidence for an effect on primary prevention is conflicting. We investigated if past use of antibiotics active against CP is associated with a decreased risk of developing MI. METHODS: We conducted a population-based case-control study of 4166 patients hospitalised due to MI from 1 January 1994 to 1 September 1999 in the County of Funen, Denmark. Controls (n=16,664) were a random sample of inhabitants, matched for age and sex. Confounders controlled for in the analysis were gender, age, obstructive pulmonary disease, diabetes, previous MI and known atherosclerotic antecedents. Previous use of antibiotics active against CP (macrolides, tetracyclines and quinolones) and of antibiotics not active against CP (penicillins) was analysed among the cases and controls. RESULTS: The risk of MI was not associated with previous exposure to macrolides (OR: 1.0; CI: 0.9-1.1), tetracyclines (OR: 1.0; CI: 0.9-1.2) or quinolones (OR: 1.0; CI: 0.9-1.2) or combinations of the three drugs (OR: 1.0; CI: 0.9-1.1). There was no sign of a protective effect in subgroups defined by high cumulative doses of antibiotics, various time-windows of exposure, risk factors of MI or other co-morbidity. OR was 1.1 (0.9-1.3) in persons with no atherosclerotic antecedents. CONCLUSION: The study does not support the hypothesis of a decreased risk of MI in patients exposed to antibiotics active against CP.
To compare the appropriateness of antibiotic prescribing for upper respiratory tract infections (URTIs) in two countries with different prevalence of antimicrobial resistance: Denmark and Iceland.
A cross-sectional study.
General practitioners (GPs) in Denmark (n = 78) and Iceland (n = 21) registered all patients with URTI according to the Audit Project Odense (APO) method during a three-week period in the winter months of 2008 and 2009.
Appropriateness of antibiotic prescribing in patients with URTI in Denmark and Iceland.
A total of 1428 patients were registered (Denmark: n = 1208; Iceland: n = 220). A majority of patients in both countries were prescribed antibiotics, and only a minority of the prescriptions could be classified as appropriate prescribing. In general, Icelandic GPs more often prescribed antibiotics (Iceland = 75.8% vs. Denmark = 59.3%), but Danish GPs had a higher percentage of inappropriate antibiotic prescribing for sinusitis, and Icelandic GPs for pharyngotonsillitis. No differences were found for acute otitis media (AOM). The different antibiotic prescribing patterns between Denmark and Iceland could not fully be explained by different symptoms and signs among patients.
Icelandic GPs have a higher antibiotic prescribing rate compared with Danish GPs, but the percentage of inappropriate antibiotic prescribing is highest in Denmark for sinusitis, and in Iceland for pharyngotonsillitis. Key points Within the Nordic countries there are marked differences in antimicrobial resistance and antibiotic use. Iceland differs from Denmark by a higher antibiotic prescribing rate and a higher prevalence of antimicrobial resistance. The majority of antibiotics are prescribed in primary care and most often for upper respiratory infections (URTIs). Only a minor amount of antibiotic prescriptions for URTIs can be classified as appropriate; inappropriate antibiotic prescribing is higher in Denmark than in Iceland for sinusitis and the opposite for pharyngotonsillitis. The different antibiotic prescribing patterns between Denmark and Iceland cannot be fully explained by different clinical criteria among patients.
Cites: Scand J Prim Health Care. 2003 Dec;21(4):196-814695067
Cites: Scand J Prim Health Care. 2004 Jun;22(2):122-715255494
Cites: Br J Gen Pract. 2004 Sep;54(506):659-6215353050
Cites: Tidsskr Nor Laegeforen. 1991 Sep 30;111(23):2830-11948877
Cites: Scand J Prim Health Care. 1998 Mar;16(1):2-69612871
Cites: Lancet. 2005 Feb 12-18;365(9459):579-8715708101
Cites: BMC Fam Pract. 2005 Feb 7;6(1):615698471
Cites: Respir Med. 2005 Mar;99(3):255-6115733498
Cites: Prim Care Respir J. 2008 Jun;17(2):79-8918438594
Urinary tract infections (UTI) account for 2-5% of consultations in general practice, but only about half the patients with dysuria have significant bacteriuria (> 100,000 bacteria per ml). A microbiological diagnosis can be made by examination of a urine sample, and in Danish family practice the diagnosis of UTI is often reached by a microscopic analysis or a dip-slide culture test. These methods have a high validity when performed in hospital, but we need knowledge about the validity of microbiological urine examinations when performed in general practice. The aim of this study was to validate detection of bacteriuria by urine microscopy and dip-slide culture in general practice.
Urine specimens artificially produced by adding a known quantity of bacteria (Escherichia coli, Proteus mirabilis, Enterobacter cloacae, Staphylococcus epidermidis and Enterococcus faecalis) to sterile urine were sent to 25 general practices for microscopic examination and dip-slide culture. No prior instruction in testing procedure was given. As the gold standard, the results of a standardised culture method performed by skilled laboratory technicians at the Department of Microbiology, University of Southern Denmark, were used.
Significant bacteriuria was identified by microscopy with a sensitivity of 95% and a specificity of 83%. The corresponding figures for urine culture were 95% and 96%. The morphology of bacteria was interpreted correctly in 80% of microscopic examinations, and 60% of the bacteria strains were classified correctly in terms of their motility.
The results of urine microscopy and culture performed in general practice are to be relied on.
Comment In: Ugeskr Laeger. 2002 May 27;164(22):2930-112082826
Comment In: Ugeskr Laeger. 2002 May 27;164(22):2931-2; author reply 293212082827
INTRODUCTION: General practitioners have an important role in the prevention of cardiovascular disorders, and it is a precondition for motivating patients to preventive issues that doctors are aware of the prevalent risk factors. The aim of the study was to analyse agreement between patients' and general practitioners' (GPs) perception of risk factors and overall risk of ischemic heart diseases (IHD). MATERIAL AND METHODS: The data consisted of records from an audit in May 1999. The GPs (n = 26) registered all enquiries from patients with IHD (n = 252) and a sample of healthy individuals (n = 1239). Both doctors and patients were asked to register the occurrence of cardiovascular risk factors (smoking, weight, stress, family history) and they were asked to evaluate the state of health and to estimate the overall risk of IHD. The agreement was evaluated by Kappa statistics. RESULTS: The level of agreement between GPs and patients varied from 70 to 97 per cent. Disagreement was observed most often for patients with IHD and patients listed with elderly GPs. (> 50 years). Disagreement was predominantly caused by a lower detection rate of the risk factors by the GPs. The patients' perception of overall risk of IHD was badly correlated to doctors' perception. Generally, patients perceived the overall risk of IHD lower than their doctors, and in more than half of the patients with a perception of low risk the GP estimated the risk as high. DISCUSSION: Patients and GPs have different perceptions of the risk of IHD. This may be due to the fact that GPs do not have all the information about their patients' lifestyle. It may also be due to different perception of the importance of specific risk factors and different reference frames for risk perception. GPs have an important role in communicating cardio-preventive issues and the meaning of risk factors. Interventions should be considered to improve risk communication in general practice.
Inappropriate use of antibiotics is contributing to the increasing rates of antimicrobial resistance. Several Danish guidelines on antibiotic prescribing for acute respiratory tract infections in general practice have been issued to promote rational prescribing of antibiotics, however it is unclear if these recommendations are followed. We aimed to characterise the pattern of antibiotic prescriptions for patients diagnosed with acute respiratory tract infections, by means of electronic prescriptions, labeled with clinical indications, from Danish general practice. Acute respiratory tract infections accounted for 456,532 antibiotic prescriptions issued between July 2012 and June 2013. Pneumonia was the most common indication with 178,354 prescriptions (39%), followed by acute tonsillitis (21%) and acute otitis media (19%). In total, penicillin V accounted for 58% of all prescriptions, followed by macrolides (18%) and amoxicillin (15%). The use of second-line agents increased with age for all indications, and comprised more than 40% of the prescriptions in patients aged?>75 years. Women were more often prescribed antibiotics regardless of clinical indication. This is the first Danish study to characterise antibiotic prescription patterns for acute respiratory tract infections by data linkage of clinical indications. The findings confirm that penicillin V is the most commonly prescribed antibiotic agent for treatment of patients with an acute respiratory tract infection in Danish general practice. However, second-line agents like macrolides and amoxicillin with or without clavulanic acid are overused. Strategies to improve the quality of antibiotic prescribing especially for pneumonia, acute otitis media and acute rhinosinusitis are warranted.
TRACKING THE OVERUSE OF ANTIBIOTICS: Better adherence to guidelines for prescribing antibiotics for different respiratory tract infections are warranted in Danish general practice. The over-use of antibiotics, particularly so-called 'second-line' agents such as amoxicillin, increases resistance and may lead to a potentially catastrophic scenario where antibiotics are no longer effective. Exactly how widespread the over-use of antibiotics is for different infections, however, is not clear. Rune Aabenhus at the University of Copenhagen and co-workers analyzed primary care data regarding antibiotic prescriptions for acute respiratory tract infections including pneumonia and ear infections in Denmark. They found that penicillin V-the current recommended first-line drug in Scandinavian countries-accounted for 58 per cent of prescriptions, a figure which should be improved. Amoxicillin and macrolides were over-prescribed, particularly in elderly patients. The team also call for further analysis of prescriptions given by out-of-hours clinics.
Cites: Scand J Prim Health Care. 2014 Dec;32(4):200-7 PMID 25350313
To assess the availability and applicability of clinical indications from electronic prescriptions on antibiotic use in Danish general practice.
Retrospective cohort register-based study including the Danish National Prescription Register.
Population-based study of routine electronic antibiotic prescriptions from Danish general practice.
All 975,626 patients who redeemed an antibiotic prescription at outpatient pharmacies during the 1-year study period (July 2012 to June 2013).
Number of prescriptions per clinical indication. Number of antibiotic prescriptions per 1000 inhabitants by age and gender. Logistic regression analysis estimated the association between patient and provider factors and missing clinical indications on antibiotic prescriptions.
A total of 2.381.083 systemic antibiotic prescriptions were issued by Danish general practitioners in the study period. We identified three main clinical entities: urinary tract infections (n?=?506.634), respiratory tract infections (n?=?456.354) and unspecified infections (n?=?416.354). Women were more exposed to antibiotics than men. Antibiotic use was high in children under 5 years and even higher in elderly people. In 32% of the issued prescriptions, the clinical indication was missing. This was mainly associated with antibiotic types. We found that a prescription for a urinary tract agent without a specific clinical indication was uncommon.
Clinical indications from electronic prescriptions are accessible and available to provide an overview of drug use, in casu antibiotic prescriptions, in Danish general practice. These clinical indications may be further explored in detail to assess rational drug use and congruence with guidelines, but validation and optimisation of the system is preferable.
Cites: BMC Med. 2014 Jun 11;12:96 PMID 24916809
Cites: Lancet. 2005 Feb 12-18;365(9459):579-87 PMID 15708101
Antibiotic use and misuse are linked to pathogen resistance and, as such, both constitute a public health issue with local, national, and global dimensions. Early studies have shown striking variations in the use of these drugs between Nordic and Mediterranean countries. The aim of the present study was to describe and compare antibiotic prescribing in Primary Care in Denmark and Aragón (a North-eastern Spanish region).
Outpatient antibiotic prescription data (2010) were obtained from the National Institute for Health Data and Disease Control (Denmark), and the Information System on Medication Consumption in Aragón. The consumption of antibiotics (ATC J01) was analyzed from the prescription rates and the number of defined daily dose (DDD) per 1000 inhabitants/day (DID).
The rate of antibiotic prescription in 2010 in Aragón was greater than in Denmark (407 compared to 315 exposed individuals/1000 inhabitants). There were significant differences as regards overall consumption of antibiotics (23.2 DID in Aragón and 17.0 DID in Denmark), as well as the therapeutic group selection. There was an elevated use of broad spectrum penicillins, quinolones and cephalosporins in the Spanish region while, in Denmark, the most-consumed antibiotic was narrow spectrum penicillin.
The use of antibiotics in the Spanish region is very high, and there are marked differences in the choice of drug between this region and Denmark. Interventions are needed that promote the rational use of these drugs to reduce potential bacterial resistance, and to avoid unnecessary risks to patients.
OBJECTIVE: To analyse agreement between patients' and GPs' perceptions of risk factors and overall risk of ischaemic heart disease (IHD). DESIGN: Cross-sectional study based on paired information from patients and GPs. SETTING: Twenty-six GPs in the County of Ringkøbing, Denmark, participating in a medical audit during 3 weeks in May 1999. SUBJECTS: 252 patients with IHD and 1239 without IHD. MAIN OUTCOME MEASURES: GPs and patients were asked about specific risk factors for IHD and their perception of overall risk. Their agreement was evaluated by Kappa statistics. RESULTS: Agreement between GPs and patients varied from 70% to 97%. Disagreement was observed most often for patients with IHD and patients listed with elderly GPs ( > 50 years). Generally, patients perceived the overall risk of IHD lower than their doctors, and for most patients with a perception of low risk the GP estimated the risk as high. CONCLUSIONS: Patients and GPs have different perceptions of the risk of [HD. This may be due to different perceptions of the importance of specific risk factors and different reference frames for risk perception. GPs have an important role in communicating the meaning of risk factors and interventions should be considered to improve risk communication in general practice.