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Background: We previously performed a pragmatic cluster randomized controlled trial (RCT) in general practices and older adult care organizations in Poland, the Netherlands, Norway, and Sweden. We found that a multifaceted antibiotic stewardship intervention (ASI) substantially reduced antibiotic use for suspected urinary tract infections (UTIs) in frail older adults compared with usual care. We aimed to evaluate the implementation process of the ASI to provide recommendations for clinical practice. Methods: We conducted a process evaluation alongside the cluster RCT. The ASI consisted of a decision-tool and a toolbox, which were implemented using a participatory-action-research (PAR) approach with sessions for education and evaluation. We documented the implementation process of the intervention and administered a questionnaire to health care professionals (HCPs) from participating organizations in the intervention and usual care clusters. We evaluated the multiple components of the intervention and its implementation following a structured framework. Results: The questionnaire was completed by 254 HCPs from the 38 participating clusters. All components were largely delivered according to plan and evaluated as useful. The decision-tool and toolbox materials were reported to facilitate decision-making on UTIs. Regarding the PAR approach, educational sessions focusing on the distinction between UTIs and asymptomatic bacteriuria were held in all 19 intervention clusters. In 17 out of these 19 clusters, evaluation sessions took place, which were reported to help remind HCPs to implement the ASI. During both sessions, HCPs valued the reflection that took place and the resulting awareness of their behavior. It allowed them to explore implementation barriers and to tailor their local implementation process to overcome these. For example, HCPs organized extra educational sessions or revised local policies to incorporate the use of the decision-tool. Various HCPs took key roles in implementation. Staff changes and the COVID-19 pandemic were important contextual barriers. Conclusions: We found each component of the multifaceted ASI and its implementation to have added value in the process to improve antibiotic prescribing for suspected UTIs in a heterogeneous older adult care setting. We recommend using a multifaceted, multidisciplinary approach that enables HCPs to reflect on their current practice and accordingly tailor local implementation. Trial registration: ClinicalTrials.gov NCT03970356. Registered on May 31, 2019. [ABSTRACT FROM AUTHOR]

We explored the impact of an antibiotic quality improvement intervention across 33 nursing homes (NHs) in one Norwegian county, compared against four control counties. This 12-month multifaceted intervention consisted of three physical conferences, including educational sessions, workshops, antibiotic feedback reports, and academic detailing sessions. We provided clinical guiding checklists to participating NHs. Pharmacy sales data served as a measure of systemic antibiotic use. The primary outcome was a change in antibiotic use in DDD/100 BD from the baseline through the intervention, assessed using linear mixed models to identify changes in antibiotic use. Total antibiotic use decreased by 15.8%, from 8.68 to 7.31 DDD/100BD (model-based estimated change (MBEC): −1.37, 95% CI: −2.35 to −0.41) in the intervention group, albeit not a significantly greater reduction than in the control counties (model-based estimated difference in change (MBEDC): −0.75, 95% CI: −1.91 to 0.41). Oral antibiotic usage for urinary tract infections (UTI-AB) decreased 32.8%, from 4.08 to 2.74 DDD/100BD (MBEC: −1.34, 95% CI: −1.85 to −0.84), a significantly greater reduction than in the control counties (MBEDC: −0.9, 95% CI: −1.28 to −0.31). The multifaceted intervention may reduce UTI-AB use in NHs, whereas adjustments in the implementation strategy may be needed to reduce total antibiotic use. [ABSTRACT FROM AUTHOR]

Background: Oseltamivir is usually not often prescribed (or reimbursed) for non-high-risk patients consulting for influenza-like-illness (ILI) in primary care in Europe. We aimed to evaluate the cost-effectiveness of adding oseltamivir to usual primary care in adults/adolescents (13 years +) and children with ILI during seasonal influenza epidemics, using data collected in an open-label, multi-season, randomised controlled trial of oseltamivir in 15 European countries. Methods: Direct and indirect cost estimates were based on patient reported resource use and official country-specific unit costs. Health-Related Quality of Life was assessed by EQ-5D questionnaires. Costs and quality adjusted life-years (QALY) were bootstrapped (N = 10,000) to estimate incremental cost-effectiveness ratios (ICER), from both the healthcare payers' and the societal perspectives, with uncertainty expressed through probabilistic sensitivity analysis and expected value for perfect information (EVPI) analysis. Additionally, scenario (self-reported spending), comorbidities subgroup and country-specific analyses were performed. Results: The healthcare payers' expected ICERs of oseltamivir were €22,459 per QALY gained in adults/adolescents and €13,001 in children. From the societal perspective, oseltamivir was cost-saving in adults/adolescents, but the ICER is €8,344 in children. Large uncertainties were observed in subgroups with comorbidities, especially for children. The expected ICERs and extent of decision uncertainty varied between countries (EVPI ranged €1–€35 per patient). Conclusion: Adding oseltamivir to primary usual care in Europe is likely to be cost-effective for treating adults/adolescents and children with ILI from the healthcare payers' perspective (if willingness-to-pay per QALY gained > €22,459) and cost-saving in adults/adolescents from a societal perspective. [ABSTRACT FROM AUTHOR]

Background: Primary care is a critical partner for antimicrobial stewardship efforts given its high human antibiotic usage. Peer comparison audit and feedback (A&F) is often used to reduce inappropriate antibiotic prescribing. The design and implementation of A&F may impact its effectiveness. There are no best practice guidelines for peer comparison A&F in antibiotic prescribing in primary care. Objective: To develop best practice guidelines for peer comparison A&F for antibiotic prescribing in primary care in high income countries by leveraging international expertise via the Joint Programming Initiative on Antimicrobial Resistance—Primary Care Antibiotic Audit and Feedback Network. Methods: We used a modified Delphi process to achieve convergence of expert opinions on best practice statements for peer comparison A&F based on existing evidence and theory. Three rounds were performed, each with online surveys and virtual meetings to enable discussion and rating of each best practice statement. A five-point Likert scale was used to rate consensus with a median threshold score of 4 to indicate a consensus statement. Results: The final set of guidelines include 13 best practice statements in four categories: general considerations (n = 3), selecting feedback recipients (n = 1), data and indicator selection (n = 4), and feedback delivery (n = 5). Conclusion: We report an expert-derived best practice recommendations for designing and evaluating peer comparison A&F for antibiotic prescribing in primary care. These 13 statements can be used by A&F designers to optimize the impact of their quality improvement interventions, and improve antibiotic prescribing in primary care. [ABSTRACT FROM AUTHOR]

There is a very large body of publications discussing the management of patients with an acute sore throat. Advocates for a restrictive antibiotic policy and advocates for a more liberal use of antibiotics emphasise different and valid arguments and to date have not been able to unite in a consensus. Contradicting guidelines based on the same body of knowledge is not logical, may cause confusion and cause unwanted variation in clinical management. In multiple video meetings and email correspondence from March to November 2022 and finally in a workshop at the annual meeting for the North American Primary Care Group in November 2022, experts from different countries representing different traditions agreed on how the current evidence should be interpreted. This critical analysis identifies that the problem can be resolved by introducing a new triage scheme considering both the acute risk for suppurative complications and sepsis as well as the long-term risk of developing rheumatic fever. The new triage scheme may solve the long-standing problem of advocating for a restrictive use of antibiotics while also satisfying concerns that critically ill patients might be missed with severe consequences. We acknowledge that the perspective of this problem is vastly different between high- and low-income countries. Furthermore, we discuss the new trend which allows nurses and pharmacists to independently manage these patients and the increased need for safety netting required for such management. [ABSTRACT FROM AUTHOR]

Asking about fears and expectations of patients is of course important, as is adequate patient information in word and if available, leaflets/online patient information. I Our reply: i Apart from the asterisk in Figure 2, we also wrote in the text under the heading, "Apparently uncomplicated acute sore throat": 'There are two principally different approaches to antibiotic prescribing to patients attending with apparently uncomplicated acute sore throat. [Extracted from the article]

Urinary tract infection (UTI) is the most common bacterial infection in women. In Norwegian general practice, methenamine has been prescribed for many years as long-term prevention and accounted for 20% of the total antibiotic prescribing in 2015, as measured in defined daily dosages (DDDs). The efficacy of methenamine is unknown. If shown to be effective, this drug may become an important preventive against UTI. To examine whether methenamine is preventive against recurrent UTI in women. Data for all antibiotics used for UTIs dispensed from all pharmacies from 2005 to 2015 were collected from the Norwegian prescription database (NorPD). Women aged ≥ 40 years with recurrent UTI, defined as ≥3 courses of UTI antibiotic/year, were included. Patients using methenamine (cases) and those not using methenamine (controls) were compared. The numbers of UTI prescriptions during the 2 years before and after inclusion were analysed. Results: The yearly prevalence for recurrent UTI was 2.4% in women ≥ 40 years. The change in antibiotic use from 2 years before to 2 years after inclusion in the study differed significantly between groups: 44.6 and 34.9% reductions in the number of antibiotic prescriptions for UTI in the methenamine and control groups, respectively. The decrease in UTI antibiotic prescriptions (58.9%) was greater in patients with a higher consumption of antibiotics before starting methenamine. Methenamine seems to be effective against recurrent UTI over the time span studied. The effect seems to be greater in patients with the highest number of recurrent UTIs. Methenamine has been used for many years for prevention of recurrent UTI, but no studies have demonstrated a significant preventive effect of long time use. This study shows that methenamine seems to be effective for prevention in patients having recurrent UTI over 2 years or more. The effect seems to be larger in patients with a high number of UTIs over 2 years. [ABSTRACT FROM AUTHOR]

Background: Antibiotics are overused in patients with acute rhinosinusitis (ARS) as it is difficult to identify those who benefit from antibiotic treatment.Aim: To develop prediction models for computed tomography (CT)-confirmed ARS and culture-confirmed acute bacterial rhinosinusitis (ABRS) in adults presenting to primary care with symptoms suggestive of ARS.Design and Setting: This was a systematic review and individual participant data meta-analysis.Method: CT-confirmed ARS was defined as the presence of fluid level or total opacification in any maxillary sinuses, whereas culture-confirmed ABRS was defined by culture of fluid from antral puncture. Prediction models were derived using logistic regression modelling.Results: Among 426 patients from three studies, 140 patients (32.9%) had CT-confirmed ARS. A model consisting of seven variables: previous diagnosis of ARS, preceding upper respiratory tract infection, anosmia, double sickening, purulent nasal discharge on examination, need for antibiotics as judged by a physician, and C-reactive protein (CRP) showed an optimism-corrected c-statistic of 0.73 (95% confidence interval [CI] = 0.69 to 0.78) and a calibration slope of 0.99 (95% CI = 0.72 to 1.19). Among 225 patients from two studies, 68 patients (30.2%) had culture-confirmed ABRS. A model consisting of three variables: pain in teeth, purulent nasal discharge, and CRP showed an optimism-corrected c-statistic of 0.70 (95% CI = 0.63 to 0.77) and a calibration slope of 1.00 (95% CI = 0.66 to 1.52). Clinical utility analysis showed that both models could be useful to rule out the target condition.Conclusion: Simple prediction models for CT-confirmed ARS and culture-confirmed ABRS can be useful to safely reduce antibiotic use in adults with ARS in high-prescribing countries. [ABSTRACT FROM AUTHOR]

Background a suspected urinary tract infection (UTI) is the most common reason to prescribe antibiotics in a frail older patient. Frequently, antibiotics are prescribed unnecessarily. To increase appropriate antibiotic use for UTIs through antibiotic stewardship interventions, we need to thoroughly understand the factors that contribute to these prescribing decisions. Objectives (1) to obtain insight into factors contributing to antibiotic prescribing for suspected UTIs in frail older adults. (2) To develop an overarching model integrating these factors to guide the development of antibiotic stewardship interventions for UTIs in frail older adults. Methods we conducted an exploratory qualitative study with 61 semi-structured interviews in older adult care settings in Poland, the Netherlands, Norway and Sweden. We interviewed physicians, nursing staff, patients and informal caregivers. Results participants described a chain of decisions by patients, caregivers and/or nursing staff preceding the ultimate decision to prescribe antibiotics by the physician. We identified five themes of influence: (1) the clinical situation and its complexity within the frail older patient, (2) diagnostic factors, such as asymptomatic bacteriuria, (3) knowledge (gaps) and attitude, (4) communication: interprofessional, and with patients and relatives and (5) context and organisation of care, including factors such as availability of antibiotics (over the counter), antibiotic stewardship efforts and factors concerning out-of-hours care. Conclusions decision-making on suspected UTIs in frail older adults is a complex, multifactorial process. Due to the diverse international setting and stakeholder variety, we were able to provide a comprehensive overview of factors to guide the development of antibiotic stewardship interventions. [ABSTRACT FROM AUTHOR]

To study the feasibility of a structured conversation tool (ICIT) in Norwegian general practice. 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. The aim of our study was to examine any benefit and the feasibility of the ICIT in general practice. 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. 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. GPs 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. [ABSTRACT FROM AUTHOR]

Background: Antibiotic prescribing by physicians in primary care institutions is common and affected by several factors. Diagnosis and treatment of infections in a nursing home (NH) resident is challenging, with the risk of both under- and overtreatment. Identifying barriers and facilitators of appropriate antibiotic prescribing in NHs and municipal acute care units (MACUs) is essential to ensure the most adequate antibiotic treatment possible and develop future antibiotic stewardship programs.Methods: After implementing a one-year antibiotic quality improvement program, we conducted six semi-structured focus group interviews with physicians (n = 11) and nurses (n = 14) in 10 NHs and 3 MACUs located in the county of Østfold, Norway. We used a semi-structured interview guide covering multiple areas influencing antibiotic use to identify persistent barriers and facilitators of appropriate antibiotic prescribing after the intervention. The interviews were audio-recorded and transcribed verbatim. The content analysis was performed following the six phases of thematic analysis developed by Braun and Clarke.Results: We identified thirteen themes containing barriers and facilitators of the appropriateness of antibiotic use in primary care institutions. The themes were grouped into four main levels: Barriers and facilitators 1) at the clinical level, 2) at the resident level, 3) at the next of kin level, and 4) at the organisational level. Unclear clinical presentation of symptoms and lack of diagnostic possibilities were described as essential barriers to appropriate antibiotic use. At the same time, increased availability of the permanent nursing home physician and early and frequent dialogue with the residents' next of kin were emphasized as facilitators of appropriate antibiotic use. The influence of nurses in the decision-making process regarding infection diagnostics and treatment was by both professions described as profound.Conclusions: Our qualitative study identified four main levels containing several barriers and facilitators of appropriate antibiotic prescribing in Norwegian NHs and MACUs. Diagnostic uncertainty, frequent dialogue with next of kin and organisational factors should be targeted in future antibiotic stewardship programs in primary care institutions. In addition, for such programs to be as effective as possible, nurses should be included on equal terms with physicians. [ABSTRACT FROM AUTHOR]

Background: The role of oral beta-lactam antibiotics in treating febrile urinary tract infections (UTI) is not yet definite. Today, fluoroquinolones together with trimethoprim-sulfamethoxazole (TMP-MTX) are considered standard of care and often the only available evidence-based oral treatment for febrile UTI. This study clarifies the efficacy and safety of pivmecillinam (PIV) used as step-down therapy for bacteremic urinary tract infection (UTI).Methods: A single-arm, uncontrolled treatment trial was conducted in the period September 2017-March 2020. Candidates for inclusion were men and women suffering from E. coli bacteremia due to UTI and were consecutively included in a Norwegian hospital. Exclusion criteria were among others: other ongoing bacterial infection, septic shock, pyonephrosis/abscess and pregnancy. After 3 days of parenteral antibiotic, the treatment was converted to the study drug; oral PIV 400 mg QID for 1 week. Primary endpoint was a combination of three elements; afebrility, no need for retreatment and improvement in self-reported health status. Test Of Cure (TOC) was 1 week post-treatment. Secondary endpoints included among others microbiological efficacy and CRP value < 30 mg/L.Results: Of 476 screened subjects, 53 patients were included. Median age was 67 years, 28 (56%) were women. 50 patients were evaluated for per-protocol analysis. 44 of 50 patients (88%) (95% CI [75.7-95.5]) reached the primary endpoint on TOC. 14 of 48 patients (29.2%) had significant growth (> 103 CFU/mL) of E.coli on TOC. CRP-level was strongly associated to treatment outcome, (OR 0.006 [95% CI 0.00-0.11], p < 0.001).Conclusions: This trial documents that PIV 400 mg QID given for 1 week following 3 days of parenteral antibiotics, is a suitable treatment option in patients suffering from bacteremic UTI due to E. coli. Randomised clinical trials studying the efficacy of PIV vs standard of care of febrile UTI are warranted. Trial registration The trial was registered at ClinicalTrials.gov under the identifier: NCT03282006 13/09/2017 and approved by The Regional Committees for Medical Research Ethics South East Norway (2015/2384/REK sør-øst) and the Norwegian Medicines Agency (SLV; reference No 16/06018-09; EudraCT No 2016-000984-18) before initiation. [ABSTRACT FROM AUTHOR]

Background: There is little evidence about the relationship between aetiology, illness severity, and clinical course of respiratory tract infections (RTIs) in primary care. Understanding these associations would aid in the development of effective management strategies for these infections.Aim: To investigate whether clinical presentation and illness course differ between RTIs where a viral pathogen was detected and those where a potential bacterial pathogen was found.Design and Setting: Post hoc analysis of data from a pragmatic randomised trial on the effects of oseltamivir in patients with flu-like illness in primary care (n = 3266) in 15 European countries.Method: Patient characteristics and their signs and symptoms of disease were registered at baseline. Nasopharyngeal (adults) or nasal and pharyngeal (children) swabs were taken for polymerase chain reaction analysis. Patients were followed up until 28 days after inclusion. Regression models and Kaplan-Meier curves were used to analyse the relationship between aetiology, clinical presentation at baseline, and course of disease including complications.Results: Except for a less prominent congested nose (odds ratio [OR] 0.55, 95% confidence interval [CI] = 0.35 to 0.86) and acute cough (OR 0.42, 95% CI = 0.27 to 0.65) in patients with flu-like illness in whom a possible bacterial pathogen was isolated, there were no clear clinical differences in presentations between those with a possible bacterial aetiology compared with those with a viral aetiology. Also, course of disease and complications were not related to aetiology.Conclusion: Given current available microbiological tests and antimicrobial treatments, and outside pandemics such as COVID-19, microbiological testing in primary care patients with flu-like illness seems to have limited value. A wait-and-see policy in most of these patients with flu-like illness seems the best option. [ABSTRACT FROM AUTHOR]

Recovery time and treatment effect of oseltamivir in influenza-like illness (ILI) differs between patient groups. A point-of-care test to better predict ILI duration and identify patients who are most likely to benefit from oseltamivir treatment would aid prescribing decisions in primary care. This study aimed to investigate whether a C-reactive protein (CRP) concentration of ≥30 mg/L can predict (1) ILI disease duration, and (2) which patients are most likely to benefit from oseltamivir treatment. Secondary analysis of randomized controlled trial data. Primary care in Lithuania, Sweden and Norway during three consecutive influenza seasons 2016–2018. A total of 277 ILI patients aged one year or older and symptom duration of ≤72 h. Capillary blood CRP concentration at baseline, and ILI recovery time defined as having 'returned to usual daily activity' with residual symptoms minimally interfering. At baseline, 20% (55/277) had CRP concentrations ≥30mg/L (range 0–210). CRP concentration ≥30 mg/L was not associated with recovery time (adjusted hazards ratio (HR) 0.80: 95% CI 0.50–1.3; p = 0.33). Interaction analysis of CRP concentration ≥30 mg/L and oseltamivir treatment did not identify which patients benefit more from oseltamivir treatment (adjusted HR 0.69: 95% CI 0.37–1.3; p = 0.23). There was no association between CRP concentration of ≥30 mg/L and recovery time from ILI. Furthermore, CRP could not predict which ILI patients benefit more from oseltamivir treatment. Hence, we do not recommend CRP testing for predicting ILI recovery time or identifying patients who will receive particular benefit from oseltamivir treatment. Predicting disease course of influenza-like illness (ILI), and identifying which patients benefit from oseltamivir treatment is a challenge for physicians. • There was no association between CRP concentration at baseline and recovery time in patients consulting with ILI in primary care. • There was no association between CRP concentration at baseline and benefit from oseltamivir treatment. • We, therefore, do not recommend CRP testing for predicting recovery time or in decision-making concerning oseltamivir prescribing in ILI patients. [ABSTRACT FROM AUTHOR]

When patented, brand-name antibiotics lose market exclusivity, generics typically enter the market at lower prices, which may increase consumption of the drug. To examine the effect of generic market entry on antibiotic consumption in the United States, we conducted an interrupted time series analysis of the change in the number of prescriptions per month for antibiotics for which at least one generic entered the US market between 2000 and 2012. Data were acquired from the IQVIA Xponent database. Thirteen antibiotics were analyzed. Here, we show that one year after generic entry, the number of prescriptions increased for five antibiotics (5 to 406%)—aztreonam, cefpodoxime, ciprofloxacin, levofloxacin, ofloxacin—and decreased for one drug: cefdinir. These changes were sustained two years after. Cefprozil, cefuroxime axetil and clarithromycin had significant increases in trend, but no significant level changes. No consistent pattern for antibiotic use following generic entry in the United States was observed. Generics contribute to increased availability of antibiotics, benefiting healthcare systems but potentially leading to increased consumption with implications for antibiotic stewardship and resistance. Here, the authors found no consistent changes in prescribing patterns of the 13 antibiotics that entered the US market as generics from 2000–2012. [ABSTRACT FROM AUTHOR]

Identifying influenza A or B as cause of influenza-like illness (ILI) is a challenge due to non-specific symptoms. An accurate, cheap and easy to use biomarker might enhance targeting influenza-specific management in primary care. The aim of this study was to investigate if C-reactive protein (CRP) is associated with influenza A or B, confirmed with PCR testing, in patients presenting with ILI. Cross-sectional study. Primary care in Lithuania, Norway and Sweden. A total of 277 patients at least 1 year of age consulting primary care with ILI during seasonal influenza epidemics. Capillary blood CRP analysed as a point-of-care test and detection of influenza A or B on nasopharyngeal swabs in adults, and nasal and pharyngeal swabs in children using PCR. The prevalence of positive tests for influenza A among patients was 44% (121/277) and the prevalence of influenza B was 21% (58/277). Patients with influenza A infection could not be identified based on CRP concentration. However, increasing CRP concentration in steps of 10 mg/L was associated with a significantly lower risk for influenza B with an adjusted odds ratio of 0.42 (0.25–0.70; p<.001). Signs of more severe symptoms like shortness of breath, sweats or chills and dizziness were associated with higher CRP. There was no association between CRP and influenza A. Increased concentration of CRP was associated with a lower risk for having influenza B, a finding that lacks clinical usefulness. Hence, CRP testing should be avoided in ILI, unless bacterial pneumonia is suspected. Identifying influenza A or B as cause of influenza-like illness (ILI) is a challenge due to non-specific symptoms. There was no association between concentration of CRP and influenza A. Increased concentration of CRP was associated with a lower risk for having influenza B, a finding that lacks clinical usefulness. A consequence is that CRP testing should be avoided in ILI, unless bacterial pneumonia or similar is suspected. [ABSTRACT FROM AUTHOR]

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 accurate. [ABSTRACT FROM AUTHOR]

Objective: To identify baseline predictors of symptom duration after empirical treatment for uncomplicated urinary tract infection (UTI) and significant bacteriuria in a cohort of women treated for UTI. Design: Prospective single-centre cohort study. Setting: Outpatient clinic in Norway. Patients: From September 2010 to November 2011, 441 women aged 16-55 years with symptoms of uncomplicated UTI were included. Results: Dipstick findings of leukocyte esterase 1 + (incidence rate ratio (IRR) 1.93, 95% confidence interval (CI) 1.23-3.01, p < 0.01) and microbe resistant to mecillinam treatment (IRR 1.41, 95% CI 1.07-1.89, p = 0.02) predicted longer symptom duration. More pronounced symptoms did not predict longer symptom duration (IRR 1.18, 95% CI 0.94-1.46, p = 0.15) or significant bacteriuria (odds ratio [OR] 1.16, 95% CI 0.72-1.88, p = 0.54). Leukocyte esterase 2 + (OR 2.51, 95% CI 0.92-6.83, p = 0.07) or 3 + (OR 2.40, 95% CI 0.88-6.05, p = 0.09) and nitrite positive urine dipstick test (OR 3.22, 95% CI 1.58-7.01, p = <0.01) were associated with bacteriuria. Conclusion: More pronounced symptoms did not correlate with significant bacteriuria or symptom duration after empirical treatment for acute cystitis. One might reconsider the current practice of treating uncomplicated UTI based on symptoms alone. Key Points: Treatment strategies for milder infectious diseases must consider ways of reducing antibiotic consumption to decelerate the increase in antibiotic resistance. Our findings suggest that more emphasis should be put on urine dipstick results and bacteriological findings in the clinical setting. One might reconsider the current practice of treating uncomplicated UTIs based on symptoms alone. [ABSTRACT FROM AUTHOR]

Background: Despite the urgent need for new, effective antibiotics, few antibiotics of value have entered the market during the past decades. Therefore, incentives have been developed to stimulate antibiotic R&D. For these incentives to be effective, geographic availability for recently approved antibiotics needs to be better understood. In this study, we analyze geographic availability and market introduction of antibiotics approved between 1999 and 2014. Material and method: We identified antibiotics, considered new chemical entities (NCEs) for systemic use approved globally between 1999 and 2014, from national medicine agencies’ lists of approved drugs, and data from the WHO Collaborating Center for Drug Statistics. Geographic availability was mapped using sales data from IQVIA, and analyzed with regards to class, indication, safety, and origin. Results: Of the 25 identified NCEs, only 12 had registered sales in more than 10 countries. NCEs with the widest geographic availability had registered sales in more than 70 countries within a ten-year timeframe and 30 countries within a three-year timeframe, spreading across five different geographic regions and three country income classes. Half (52%) of the NCEs had an indication for infections caused by antibiotic- resistant bacteria, little diversity was seen regarding target pathogen and indication. Antibiotics originated from and/or marketed by companies from the US or Europe had greater geographic availability compared to Japanese antibiotics, which seldom reached outside of Asia. For 20 NCEs developers chose to fully or partially sublicense marketing rights to a number of companies of different sizes. Conclusion: Our findings show great variation in geographic availability of antibiotics, indicating that availability in multiple regions and country income classes is possible, but rarely seen within a few years of market authorization. Sublicensing agreements between multiple companies was common practice. Moreover, differences were seen between countries regarding benefit/risk evaluations and company behavior. These findings could be a potential source of uncertainties, and create barriers to assure that working antibiotics are developed and made available according to public health needs. [ABSTRACT FROM AUTHOR]

Objectives: To compare the clinical and bacteriological outcomes of pivmecillinam treatment for community-acquired urinary tract infections (UTIs) caused by ESBL-producing Escherichia coli versus non-ESBL-producing E. coli in an outpatient setting.Methods: A prospective, multicentre, observational cohort study of women aged ≥16 years, with pivmecillinam-treated community-acquired UTIs caused by E. coli with or without ESBL production, recruited from primary care, was conducted in the period from April 2013 to August 2016. Eighty-eight women (mean age 49.4 years) with community-acquired UTIs caused by ESBL-producing E. coli were compared with a control group of 74 women (mean age 50.1 years).Trial registration: Regional Committees for Medical and Health Research Ethics (REC) in Norway, ID 2011/2214, and ClinicalTrials.gov, ID NCT01531023.Results: The median time until symptom resolution after treatment initiation was 5 days for the ESBL cases and 3 days for the non-ESBL controls (P < 0.01). The proportion of women warranting a second antibiotic prescription in the follow-up period was higher for the ESBL cases [30/88 (34.1%) versus 10/72 (13.9%), P < 0.01]. Persistent bacteriuria was non-significantly more common among ESBL cases than in the control group [15/81 (18.5%) versus 6/67 (9.0%), P = 0.10]. A pivmecillinam dosage of 200 mg given three times daily for ≤5 days was associated with treatment failure (OR 4.77, 95% CI 1.40-19.44, P = 0.03) for the ESBL E. coli group. For the subgroup treated with 400 mg of pivmecillinam given three times daily there was no significantly increased OR for treatment failure between ESBL cases and the control group irrespective of treatment duration.Conclusions: Pivmecillinam given at 400 mg three times daily gave comparable clinical and bacteriological cure rates in women with community-acquired E. coli UTIs irrespective of ESBL production. [ABSTRACT FROM AUTHOR]

Background: Although uncomplicated urinary tract infections (UTIs) are often self-limiting, most patients will be prescribed antibiotic treatment. We assessed whether treatment with ibuprofen was non-inferior to pivmecillinam in achieving symptomatic resolution by day 4, with a non-inferiority margin of 10%.Methods and Findings: This was a randomized, controlled, double-blind non-inferiority trial. We recruited patients from 16 sites in a general practice setting in Norway, Sweden, and Denmark. Non-pregnant women aged 18-60 years presenting with symptoms of uncomplicated UTI were screened for eligibility from 11 April 2013 to 22 April 2016. Patients with informed consent were randomized (1:1 ratio) to treatment with either 600 mg ibuprofen or 200 mg pivmecillinam 3 times a day for 3 days. The patient, treating physician, and study personnel were blinded to treatment allocation. The primary outcome was the proportion of patients who felt cured by day 4, as assessed from a patient diary. Secondary outcomes included the proportion of patients in need of secondary treatment with antibiotics and cases of pyelonephritis. A total of 383 women were randomly assigned to treatment with either ibuprofen (n = 194, 181 analyzed) or pivmecillinam (n = 189, 178 analyzed). By day 4, 38.7% of the patients in the ibuprofen group felt cured versus 73.6% in the pivmecillinam group. The adjusted risk difference with 90% confidence interval was 35% (27% to 43%) in favor of pivmecillinam, which crossed the prespecified non-inferiority margin. Secondary endpoints were generally in favor of pivmecillinam. After 4 weeks' follow-up, 53% of patients in the ibuprofen group recovered without antibiotic treatment. Seven cases of pyelonephritis occurred, all in the ibuprofen group, giving a number needed to harm of 26 (95% CI 13 to 103). Five of these patients were hospitalized and classified as having serious adverse events; 2 recovered as outpatients. A limitation of the study was the extensive list of exclusion criteria, eliminating almost half of the patients screened. We did not register symptoms in the screening process; hence, we do not know the symptom burden for those who declined to participate. This might make our results less generalizable.Conclusions: Ibuprofen was inferior to pivmecillinam for treating uncomplicated UTIs. More than half of the women in the ibuprofen group recovered without antibiotics. However, pyelonephritis occurred in 7 out of 181 women using ibuprofen. Until we can identify those women who will develop complications, we cannot recommend ibuprofen alone as initial treatment to women with uncomplicated UTIs.Trial Registration: ClinicalTrials.gov NCT01849926 EU Clinical Trials Register (EU-CTR), EudraCT Number 2012-002776-14. [ABSTRACT FROM AUTHOR]

Objectives: Hospitalization is potentially detrimental to nursing home patients and resource demanding for the specialist health care. This study assessed if a brief training program in administrating intravenous fluids and antibiotics in nursing homes could reduce hospital transfers and ensure high quality care locally. Design: A pragmatic and modified cluster randomized stepped-wedge trial with randomization on nursing home level. Participants: 330 cases in 296 nursing home residents from 30 nursing homes were included. Cases were patients provided intravenous antibiotics or intravenous fluids, in nursing home or hospital. Primary outcome was localization of treatment, secondary outcomes were number of days treated, days of hospitalization among admitted patients, type of antibiotics used and 30-day mortality. Intervention: The nursing homes sequentially received a one-day educational program for the health workers including theory and practical training in intravenous treatment of dehydration and infection, run by two skilled nurses. After completing the training program, the nursing homes had competence to provide intravenous treatment locally. Results: The intervention had a highly significant effect on treatment in nursing homes (OR 8.35, 2.08 to 33.6; P<0.01, or RR 2.23, 1.48 to 2.56). The number treated in nursing homes was stable over time; the number treated in hospital gradually decreased (chi square for trend P< 0.001). Among patients receiving intravenous antibiotics in the nursing homes, 50 (46%) died within 30 days, compared to 30 (36%) treated in the hospital (P = 0.19). Among patients receiving intravenous fluids locally, 21 (19%) died within 30 days, compared to 2 (8%) in the hospital group (P = 0.34). Mortality was associated with reduced consciousness and elevated c-reactive protein. Conclusions: A brief educational program delivered to nursing home personnel was feasible and effective in reducing acute hospital admissions from nursing homes for treatment of dehydration and infections. [ABSTRACT FROM AUTHOR]

In this prospective, observational study on previously healthy children <18 years, we aimed to study the diagnostic ability of clinical features and inflammatory markers to (i) predict pathologic chest radiography in suspected pneumonia and (ii) differentiate etiology in radiological proven pneumonia. In 394 cases of suspected pneumonia, 265 (67%) had radiographs consistent with pneumonia; 34/265 had proof of bacterial etiology. Of the cases, 86.5% had received pneumococcal conjugate vaccine. In suspected pneumonia, positive chest radiography was significantly associated with increasing C-reactive protein (CRP) values, higher age, and SpO2 ≤92% in multivariate logistic regression, OR 1.06 (95% CI 1.03 to 1.09), OR 1.09 (95% CI 1.00 to1.18), and OR 2.71 (95% CI 1.42 to 5.18), respectively. In proven pneumonia, bacterial pneumonia was significantly differentiated from viral/atypical pneumonia by increasing CRP values and SpO2 >92% in multivariate logistic regression, OR 1.09 (95% CI 1.05 to 1.14) and OR 0.23 (95% CI 0.06 to 0.82), respectively. Combining high CRP values (>80 mg/L) and elevated white blood cell (WBC) count provided specificity >85%, positive likelihood ratios >3, but sensitivity <46% for both radiographic proven and bacterial pneumonia.Conclusion: With relatively high specificity and likelihood ratio CRP, WBC count and hypoxemia may be beneficial in ruling in a positive chest radiograph in suspected pneumonia and bacterial etiology in proven pneumonia, but with low sensitivity, the clinical utility is limited. What is Known: • Pneumonia is recommended to be a clinical diagnosis, and neither clinical features nor inflammatory markers can reliably distinguish etiology. • The etiology of pneumonia has changed after routine pneumococcal conjugate vaccine. What is New: • High CRP and WBC counts were associated with infiltrates in children with suspected pneumonia and with bacterial infection in proven pneumonia. • In the post-pneumococcal vaccination era, viral etiology is expected, and in cases of pneumonia with low CRP and WBC counts, a watch-and-wait strategy for antibiotic treatment may be applied. [ABSTRACT FROM AUTHOR]

Objective:Promptly treated erythema migrans (EM) has good prognosis. However, some patients report persistent symptoms. Do patients with EM have more symptoms than the general population? We describe individual symptoms and general function in EM-patients at time of diagnosis and one year after treatment. Design:Prospective study with 1-year follow up after treatment. Questionnaires included a modified version of the Subjective Health Complaints Inventory, comprising three additional Lyme borreliosis (LB) related symptoms. General function was assessed using a five-point scale modified from the COOP/WONCA charts. Setting:Norwegian general practice. Subjects:A total of 188 patients were included in a randomized controlled trial comparing three antibiotic regimens for EM, of whom 139 had complete data for this study. Main outcome measures:Individual symptoms, symptom load and general function. Results:Mild symptoms were common, reported by 84.9% at baseline and by 85.6% at follow-up. At baseline, patients reported a mean of 5.4 symptoms, compared with 6.2 after one year. Severely bothersome symptoms and severely impaired general function were rare. Tiredness was the most reported symptom both at baseline and at follow-up. Palsy (other than facial) was the least reported symptom, but the only one with a significant increase. However, this was not associated to the EM. Conclusion:The symptom load was comparable to that reported in the general population. We found an increase in symptom load at follow-up that did not significantly affect general function. Implication: Monitoring patients’ symptom loads prior to treatment reduce the probability of attributing follow-up symptoms to LB.Key pointsErythema migrans has a good prognosis.Patients treated for erythema migrans have a slight increase in symptom load one year after treatment.This increase does not affect general function.The levels of subjective health complaints in patients treated for erythema migrans are comparable to the background population. [ABSTRACT FROM PUBLISHER]

Background: Asymptomatic carriage has been recognised as an important risk factor for infection caused by antibiotic resistant bacteria. A 14% global prevalence of Extended-Spectrum Beta-lactamase (ESBL) carriage was recently reported, but large intra-and interregional variations were observed. We investigated the faecal carriage rates of ESBL-, AmpC-producing and ciprofloxacin non-susceptible Escherichia coli and Klebsiella spp. in healthy Norwegians. Methods: Rectal samples were obtained from 284 volunteers, together with demographic data and information on recent travel history. The rectal samples were screened by selective plating and E. coli and Klebsiella spp. identified using MALDI-TOF. Phenotypic and molecular characterization of resistant isolates was also performed. Results: ESBL- or AmpC-producing E. coli and Klebsiella spp. were isolated from 4.9% and 3.2% of the study population, respectively. Carriage of ciprofloxacin non-susceptible isolates was detected in 9.9% of the volunteers. Molecular typing of ESBL/plasmid-mediated AmpC (pAmpC)-producing isolates suggested an allodemic situation rather than the dissemination of a specific clone in the Norwegian community. In concurrence with previous findings, travel to South-East Asia was associated with increased risk of carrying resistant E. coli or Klebsiella spp., highlighting the contribution of factors such as increased global mobility in erasing the boundaries between healthcare and community settings when it comes to spread of resistant bacteria. Conclusions: Overall, our study recognised Norway as a low-incidence country for faecal carriage of resistant bacteria among healthy individuals. Furthermore, our work denoted the importance of healthy humans as a reservoir for transmission of antibiotic resistant E. coli and Klebsiella spp. [ABSTRACT FROM AUTHOR]

Objective:To analyse if peer academic detailing by experienced general practitioners (GPs) could be a useful way to change Medical Doctors, (MDs) prescription of antibiotics for acute respiratory tract infections (ARTIs) in out-of-hours service.Method:An educational Intervention study based on prescription data among MDs working in an out-of-hours service from June 2006 through October 2008. Specially trained GPs lectured a peer educational program (3 × 45 minutes) about use of antibiotics for ARTIs according to national recommendations.Outcome measures:The type and frequency of antibiotics prescribed for different ARTIs before and after intervention comparing the intervention group with the control group.Subjects:22 MDs in the intervention group and 31 MDs in the control group.Results:The intervention group showed an overall statistically significantly absolute increase in the use of penicillin V (Penicillin V) of 9.8% (95% CI: 2.3%–17.4% p < 0.05), and similarly an statistically significantly absolute decrease in the use of macrolides and lincosamides of 8.8% (95% CI: 2.6%–14.9.2% p < 0.05) for all diagnoses. For subgroups of ARTIs we found a significant increase in the use of Penicillin V for acute otitis media, sinusitis, pneumonia and upper ARTIs. There was no significant changes in total prescription rates in the two groups. 41% of all consultations with respiratory tract infections resulted in antibiotic prescription.Conclusions:Using trained GPs to give peer academic detailing to colleagues in combination with open discussion on prescription, showed a significant change in prescription of antibiotics towards national guidelines.Key pointsPhenoxymethylpenicillin is the first choice for the most of respiratory tract infections when indicated.Despite the guidelines for the choice of antibiotics in Norway, general practitioners’ choice often differs from these.We showed that a session of three times 45 min of peer academic detailing changed significantly the choice of antibiotics towards the National Guidelines in an urban Norwegian out-of-hours service. [ABSTRACT FROM PUBLISHER]

Objective: Feedback may be scarce and unsystematic during students' clerkship periods. We wanted to explore general practitioners' (GPs) and medical students' experiences with giving and receiving supervision and feedback during a clerkship in general practice, with a focus on their experiences with using a structured tool (StudentPEP) to facilitate feedback and supervision. Design: Qualitative study. Setting: Teachers and students from a six-week clerkship in general practice for fifth year medical students were interviewed in two student and two teacher focus groups. Subjects: 21 GPs and nine medical students. Results: We found that GPs first supported students' development in the familiarization phase by exploring the students' expectations and competency level. When mutual trust had been established through the familiarization phase GPs encouraged students to conduct their own consultations while being available for supervision and feedback. Both students and GPs emphasized that good feedback promoting students' professional development was timely, constructive, supportive, and focused on ways to improve. Among the challenges GPs mentioned were giving feedback on behavioral issues such as body language and insensitive use of electronic devices during consultations or if the student was very insecure, passive, and reluctant to take action or lacked social or language skills. While some GPs experienced StudentPEP as time-consuming and unnecessary, others argued that the tool promoted feedback and learning through mandatory observations and structured questions. Conclusion: Mutual trust builds a learning environment in which supervision and feedback may be given during students' clerkship in general practice. Structured tools may promote feedback, reflection and learning. Observing the teacher and being supervised are essential components of Medical students' learning during general practice clerkships. Teachers and students build mutual trust in the familiarization phase. Good feedback is based on observations, is timely, encouraging, and instructive. StudentPEP may create an arena for structured feedback and reflection. [ABSTRACT FROM AUTHOR]

Background: Inappropriate antibiotic prescribing, particularly for respiratory tract infections (RTI) in ambulatory care, has become a worldwide public health threat due to resulting antibiotic resistance. In spite of various interventions and campaigns, wide variations in antibiotic use persist between European countries. Cultural determinants are often referred to as a potential cause, but are rarely defined. To our knowledge, so far no systematic literature review has focused on cultural determinants of antibiotic use. The aim of this study was to identify cultural determinants, on a country-specific level in ambulatory care in Europe, and to describe the influence of culture on antibiotic use, using a framework of cultural dimensions.Method: A computer-based systematic literature review was conducted by two research teams, in France and in Norway. Eligible publications included studies exploring antibiotic use in primary care in at least two European countries based on primary study results, featuring a description of cultural determinants, and published between 1997 and 2015. Quality assessment was conducted independently by two researchers, one in each team, using appropriate checklists according to study design. Each included paper was characterized according to method, countries involved, sampling and main results, and cultural determinants mentioned in each selected paper were extracted, described and categorized. Finally, the influence of Hofstede's cultural dimensions associated with antibiotic consumption within a primary care setting was described.Results: Among 24 eligible papers, 11 were rejected according to exclusion criteria. Overall, 13 papers meeting the quality assessment criteria were included, of which 11 used quantitative methods and two qualitative or mixed methods. The study participants were patients (nine studies) and general practitioners (two studies). This literature review identified various cultural determinants either patient-related (illness perception/behaviour, health-seeking behaviour, previous experience, antibiotic awareness, drug perception, diagnosis labelling, work ethos, perception of practitioner) or practitioner-related (RTI management, initial training, antibiotic awareness, legal issues, practice context) or both (antibiotic awareness).Discussion and Conclusion: Cultural factors should be considered as exerting an ubiquitous influence on all the consecutive stages of the disease process and seem closely linked to education. Interactions between determinant categories, cultural dimensions and antibiotic use in primary care are multiple, complex and require further investigation within overlapping disciplines. The context of European projects seems particularly relevant. [ABSTRACT FROM AUTHOR]

Background: Antibiotic resistance is a problem in nursing homes. Presumed urinary tract infections (UTI) are the most common infection. This study examines urine culture results from elderly patients to see if specific guidelines based on gender or whether the patient resides in a nursing home (NH) are warranted. Methods: This is a cross sectional observation study comparing urine cultures from NH patients with urine cultures from patients in the same age group living in the community. Results: There were 232 positive urine cultures in the NH group and 3554 in the community group. Escherichia coli was isolated in 145 urines in the NH group (64%) and 2275 (64%) in the community group. There were no clinically significant differences in resistance. Combined, there were 3016 positive urine cultures from females and 770 from males. Escherichia coli was significantly more common in females 2120 (70%) than in males 303 (39%)(p < 0.05). Enterococcus faecalis was significantly less common in females 223(7%) than males 137 (18%) (p < 0.05). For females, there were lower resistance rates to ciprofloxacin among Escherichia coli (7% vs 12%; p < 0.05) and to mecillinam among Proteus mirabilis (3% vs 12%; p < 0.05). Conclusions: Differences in resistance rates for patients in the nursing home do not warrant separate recommendations for empiric antibiotic therapy, but recommendations based on gender seem warranted. [ABSTRACT FROM AUTHOR]

Background: Lateral epicondylitis of the elbow is a frequent condition with long-lasting symptoms. Corticosteroid injection is increasingly discouraged and there is little knowledge on the combined effect of corticosteroid injection and physiotherapy for acute conditions. We wanted to investigate the efficacy of physiotherapy alone and combined with corticosteroid injection for acute lateral epicondylitis. Methods: A randomized, controlled study with one-year follow-up was conducted in a general practice setting in Sarpsborg, Norway. We included 177 men and women aged 18 to 70 with clinically diagnosed lateral epicondylitis of recent onset (2 weeks to 3 months). They were randomly assigned to one of three treatments: physiotherapy with two corticosteroid injections, physiotherapy with two placebo injections or wait-and-see (control). Physiotherapy consisted of deep transverse friction massage, Mills manipulation, stretching, and eccentric exercises. We used double blind injection of corticosteroid and single blind assessments. The main outcome measure was treatment success defined as patients rating themselves completely recovered or much better on a six-point scale. Results: One hundred fifty-seven patients (89 %) completed the trial. Placebo injection with physiotherapy showed no significant difference compared to control or to corticosteroid injection with physiotherapy at any follow-up. Corticosteroid injection with physiotherapy had a 10.6 times larger odds for success at six weeks (odds ratio 10.60, p < 0.01) compared to control (NNT = 3, 99 % CI 1.5 to 4.2). At 12 weeks there was no significant difference between these groups, but at 26 weeks the odds for success were 91 % lower (OR 0.09, p < 0.01) compared to control, showing a large negative effect (NNT = 5, 99 % CI 2.1 to 67.4). At 52 weeks there was no significant difference. Both control and placebo injection with physiotherapy showed a gradual increase in success. Conclusions: Acute lateral epicondylitis is a self-limiting condition where 3/4 of patients recover within 52 weeks. Physiotherapy with deep transverse friction massage, Mills manipulation, stretching, and eccentric exercises showed no clear benefit, and corticosteroid injection gave no added effect. Corticosteroid injections combined with physiotherapy might be considered for patients needing a quick improvement, but intermediate (12 to 26 weeks) worsening of symptoms makes the treatment difficult to recommend. Trial registration: ClinicalTrials.gov Identifier: NCT00826462 [ABSTRACT FROM AUTHOR]

Objective. To compare the clinical outcome of patients presenting with symptoms of uncomplicated cystitis who were seen by a doctor, with patients who were given treatment following a diagnostic algorithm. Design. Randomized controlled trial. Setting. Out-of-hours service, Oslo, Norway. Intervention. Women with typical symptoms of uncomplicated cystitis were included in the trial in the time period September 2010-November 2011. They were randomized into two groups. One group received standard treatment according to the diagnostic algorithm, the other group received treatment after a regular consultation by a doctor. Subjects. Women (n = 441) aged 16-55 years. Mean age in both groups 27 years. Main outcome measures. Number of days until symptomatic resolution. Results. No significant differences were found between the groups in the basic patient demographics, severity of symptoms, or percentage of urine samples with single culture growth. A median of three days until symptomatic resolution was found in both groups. By day four 79% in the algorithm group and 72% in the regular consultation group were free of symptoms (p = 0.09). The number of patients who contacted a doctor again in the follow-up period and received alternative antibiotic treatment was insignificantly higher (p = 0.08) after regular consultation than after treatment according to the diagnostic algorithm. There were no cases of severe pyelonephritis or hospital admissions during the follow-up period. Conclusion. Using a diagnostic algorithm is a safe and efficient method for treating women with symptoms of uncomplicated cystitis at an out-of-hours service. This simplification of treatment strategy can lead to a more rational use of consultation time and a stricter adherence to National Antibiotic Guidelines for a common disorder. [ABSTRACT FROM AUTHOR]

Background: Lateral epicondylitis of the elbow is a frequent condition with long-lasting symptoms. Corticosteroid injection is increasingly discouraged and there is little knowledge on the combined effect of corticosteroid injection and physiotherapy for acute conditions. We wanted to investigate the efficacy of physiotherapy alone and combined with corticosteroid injection for acute lateral epicondylitis. Methods: A randomized, controlled study with one-year follow-up was conducted in a general practice setting in Sarpsborg, Norway. We included 177 men and women aged 18 to 70 with clinically diagnosed lateral epicondylitis of recent onset (2 weeks to 3 months). They were randomly assigned to one of three treatments: physiotherapy with two corticosteroid injections, physiotherapy with two placebo injections or wait-and-see (control). Physiotherapy consisted of deep transverse friction massage, Mills manipulation, stretching, and eccentric exercises. We used double blind injection of corticosteroid and single blind assessments. The main outcome measure was treatment success defined as patients rating themselves completely recovered or much better on a six-point scale. Results: One hundred fifty-seven patients (89 %) completed the trial. Placebo injection with physiotherapy showed no significant difference compared to control or to corticosteroid injection with physiotherapy at any follow-up. Corticosteroid injection with physiotherapy had a 10.6 times larger odds for success at six weeks (odds ratio 10.60, p < 0.01) compared to control (NNT = 3, 99 % CI 1.5 to 4.2). At 12 weeks there was no significant difference between these groups, but at 26 weeks the odds for success were 91 % lower (OR 0.09, p < 0.01) compared to control, showing a large negative effect (NNT = 5, 99 % CI 2.1 to 67.4). At 52 weeks there was no significant difference. Both control and placebo injection with physiotherapy showed a gradual increase in success. Conclusions: Acute lateral epicondylitis is a self-limiting condition where 3/4 of patients recover within 52 weeks. Physiotherapy with deep transverse friction massage, Mills manipulation, stretching, and eccentric exercises showed no clear benefit, and corticosteroid injection gave no added effect. Corticosteroid injections combined with physiotherapy might be considered for patients needing a quick improvement, but intermediate (12 to 26 weeks) worsening of symptoms makes the treatment difficult to recommend. [ABSTRACT FROM AUTHOR]

Background Although uncomplicated cystitis is often self-limiting, most such patients will be prescribed antibiotic treatment. We are investigating whether treatment of cystitis with an NSAID is as effective as an antibiotic in achieving symptomatic resolution. Methods/Design This is a randomized, controlled, double blind trial following the principles of Good Clinical Practice. Women between the ages of 18 to 60 presenting with symptoms of uncomplicated cystitis are screened for eligibility. 500 women from four sites in Norway, Sweden and Denmark are allocated to treatment with 600 mg ibuprofen three times a day or 200 mg mecillinam three times a day for three days. Allocation is conducted using block randomization. The primary outcome is the number of patients who feel cured by day four as recorded in a diary. Adverse events will be handled and reported in accordance with Good Clinical Practice. Discussion If treatment of uncomplicated cystitis with ibuprofen is as effective as mecillinam for symptom relief, we can potentially reduce the use of antibiotics on a global scale. [ABSTRACT FROM AUTHOR]

Background: According to Norwegian guidelines for antibiotic use in primary care, ciprofloxacin is reserved for complicated urinary tract infections (UTI). Despite these recommendations, ciprofloxacin use has increased in Norway in recent years. We aimed to reduce inappropriate ciprofloxacin prescribing in the emergency department. Methods: An intervention study was performed by removing ciprofloxacin from the local antibiotic formulary and including a suggestion list for antibiotic use with all point of care urine dipstick testing in an emergency department. An emergency department in the neighbouring county served as the control. Prescriptions for UTI were registered 1 y prior to and 1 y after the intervention. Results: In the targeted emergency department, there was a significant ( p < 0.0001) reduction in ciprofloxacin prescribing for cystitis, while the use of mecillinam increased ( p = 0.042). In the control department, prescribing of ciprofloxacin doubled ( p < 0.0001). Conclusions: An intervention based on a therapy suggestion list and on limiting the availability of ciprofloxacin in the local formulary, resulted in treatment more in line with national guidelines by reducing ciprofloxacin and increasing mecillinam prescribing. [ABSTRACT FROM AUTHOR]

Background Delayed antibiotic prescribing is an effective method of reducing the consumption of antibiotics for respiratory tract infections (RTIs). However, interventions to promote its use remain unexplored. Aim To measure the effects of a GP educational intervention and a computer delayed-prescribing pop-up reminder on antibiotic-dispensing rates. The study also aimed to identify factors influencing GPs' decisions to issue delayed prescriptions and patients' decisions to fill their prescriptions. Design and setting Controlled trial nested within a clusterrandomised controlled trial in urban and rural practices in 11 counties in southern Norway. Method Educational intervention and control groups were randomly populated from 81 continuing medical education groups. Within the intervention arm, 107 of the 156 participating GPs were assigned, based on the electronic patient-record system they used, to having a pop-up reminder installed on their computers. Data on prescribed and dispensed antibiotics from 1 year before, and 1 year during, the intervention were collected and linked. Results Valid data were obtained from 328 GPs (75%). At baseline, 92.1% of prescriptions were filled at pharmacies. The effect of the educational intervention was a 1% reduction in approximated risk (risk ratio [RR] 0.99, 95% confidence interval [CI] = 0.96 to 1.01) of antibiotics being dispensed, while the combined effect of the educational and pop-up reminder intervention was a 4% reduction in approximated risk (RR 0.96, 95% CI = 0.94 to 0.98). In the pop-up intervention group, 11.0% of the prescriptions were issued as delayed prescriptions and 59.2% of these were filled. Upper RTI, sinusitis, and otitis gave highest odds for delayed prescribing and lowest odds for dispensing. Conclusion Promoting delayed prescribing among GPs results in a small decrease in antibiotic dispensing. The savings potential is greatest for upper RTI, sinusitis, and otitis [ABSTRACT FROM AUTHOR]

Objectives: To evaluate the current evidence for the efficacy of corticosteroid injection and nonelectrotherapeutic physiotherapy compared with control for treating lateral epicondylitis. Design: Systematic review. Participants: We searched five databases in September 2012 for randomised controlled studies with a minimum quality rating. Of the 640 studies retrieved, 11 were included, representing 1161 patients of both sexes and all ages. Interventions: Corticosteroid injection and nonelectrotherapeutic physiotherapy. Outcome measures: Relative risk (RR) or standardised mean difference (SMD) for overall improvement, pain and grip strength at 4-12, 26 and 52 weeks of follow-up. Results: Corticosteroid injection gave a short-term reduction in pain versus no intervention or nonsteroidal anti-inflammatory drugs (SMD -1.43, 95% CI -1.64 to -1.23). At intermediate follow-up, we found an increase in pain (SMD 0.32, 95% CI 0.13 to 0.51), reduction in grip strength (SMD -0.48, 95% CI -0.73 to -0.24) and negative effect on the overall improvement effect (RR 0.66 (0.53 to 0.81)). For corticosteroid injection versus lidocaine injection, the evidence was conflicting. At long-term follow-up, there was no difference on overall improvement and grip strength, with conflicting evidence for pain. Manipulation and exercise versus no intervention showed beneficial effect at short-term follow-up (overall improvement RR 2.75, 95% CI 1.30 to 5.82), but no significant difference at intermediate or longterm follow-up. We found moderate evidence for shortterm and long-term effects of eccentric exercise and stretching versus no intervention. For exercise versus no intervention and eccentric or concentric exercise and stretching versus stretching alone, we found moderate evidence of no short-term effect. Conclusions: Corticosteroid injections have a shortterm beneficial effect on lateral epicondylitis, but a negative effect in the intermediate term. Evidence on the long-term effect is conflicting. Manipulation and exercise and exercise and stretching have a short-term effect, with the latter also having a long-term effect. [ABSTRACT FROM AUTHOR]

Scand J Caring Sci; 2013; 27; 285-294 Behaviour among children of substance-abusing women attending a Special Child Welfare Clinic in Norway, as assessed by Child Behavior Checklist (CBCL) Background: A Special Child Welfare Clinic (SCWC) in Norway provides care for pregnant women with substance abuse problems. Treatment is given without substitution. This investigation assesses the behaviour of the children between the ages 6 and 13 years of women who attended the clinic. It also explores the correlation between the behaviour and a neuropsychological screening performed one and a half year earlier. The study was set up to investigate the influence of prenatal substance exposure. Method: Thirty-eight SCWC children and 63 children in a comparison group were scored by Child Behavior Check List (CBCL). Twenty-one (55%) SCWC mothers were classed as short-term users (ceased substance abuse before the end of first trimester), and 17 (45%) were classed as long-term users (continued a moderate substance abuse throughout pregnancy). Thirteen (77%) of the children of the long-term users were living in foster homes at the time of the investigation. Results: SCWC children were scored within normal ranges for most items, but their scores were significantly worse than those of the comparison group. Children of short-term users were given lower scores than comparisons on more issues in CBCL than were children of long-term users. The SCWC children were breastfed for a shorter time (p = 0.023) and had moved house more often (p < 0.001) than comparisons. SCWC children living with their biological mothers received more special education or remedial classes (p ≤ 0.001) than children of the comparisons. Conclusion: Most children of long-term users were living in foster homes. Notably, children of short-term users, that is, children living with their biological mothers, were given lower scores than comparisons in CBCL. Children of short-term users were more likely to receive special education than children of comparisons. More research is needed on how to reveal parenting problems and how to guide mothers with previous or present substance abuse problems. [ABSTRACT FROM AUTHOR]

Scand J Caring Sci; 2013; 27; 285-294 Behaviour among children of substance-abusing women attending a Special Child Welfare Clinic in Norway, as assessed by Child Behavior Checklist (CBCL) Background: A Special Child Welfare Clinic (SCWC) in Norway provides care for pregnant women with substance abuse problems. Treatment is given without substitution. This investigation assesses the behaviour of the children between the ages 6 and 13 years of women who attended the clinic. It also explores the correlation between the behaviour and a neuropsychological screening performed one and a half year earlier. The study was set up to investigate the influence of prenatal substance exposure. Method: Thirty-eight SCWC children and 63 children in a comparison group were scored by Child Behavior Check List (CBCL). Twenty-one (55%) SCWC mothers were classed as short-term users (ceased substance abuse before the end of first trimester), and 17 (45%) were classed as long-term users (continued a moderate substance abuse throughout pregnancy). Thirteen (77%) of the children of the long-term users were living in foster homes at the time of the investigation. Results: SCWC children were scored within normal ranges for most items, but their scores were significantly worse than those of the comparison group. Children of short-term users were given lower scores than comparisons on more issues in CBCL than were children of long-term users. The SCWC children were breastfed for a shorter time (p = 0.023) and had moved house more often (p < 0.001) than comparisons. SCWC children living with their biological mothers received more special education or remedial classes (p ≤ 0.001) than children of the comparisons. Conclusion: Most children of long-term users were living in foster homes. Notably, children of short-term users, that is, children living with their biological mothers, were given lower scores than comparisons in CBCL. Children of short-term users were more likely to receive special education than children of comparisons. More research is needed on how to reveal parenting problems and how to guide mothers with previous or present substance abuse problems. [ABSTRACT FROM AUTHOR]

Objectives: To investigate the antibiotic prescription pattern and factors that influence the physicians' choice of antibiotic. Design: Observational study. Setting: Primary healthcare in Norway, December 2004 through November 2005. Participants: 426 general practitioners, GPs, in Norway, giving 24 888 respiratory tract infection episodes with 19 938 children aged 0-6 years. Outcome measures: Assess antibiotic prescription details and patient and GP characteristics associated with broad-spectrum and narrow-spectrum antibiotic use. Results: Of the 24 888 episodes in the study, 26.2% (95% CI 25.7% to 26.8%) included an antibiotic prescription. Penicillin V accounted for 42% and macrolide antibiotics for 30%. The prescription rate varied among the physicians, with a mean of 25.5% (95% CI 24.2% to 26.7%). Acute tonsillitis gave the highest odds for a prescription, OR 33.6 (95% CI 25.7% to 43.9%), compared to 'acute respiratory tract infections and symptoms' as a reference group. GPs with a prescription rate of 33.3% or higher had the larger probability for broad-spectrum antibiotic prescriptions, OR 3.33 (95% CI 2.01% to 5.54%). Antibiotic prescriptions increased with increasing patient age. Conclusions: We found a low antibiotic prescription rate for childhood respiratory tract infections. However, our figures indicate an overuse of macrolide antibiotics and penicillins with extended spectrum, more so than in the corresponding study including the adult population. Palatability of antibiotic suspensions and other administrative challenges affect medication compliance in children. To help combat antibiotic resistance, guidelines need to be followed, in particular for our youngest patients. Trial registration number (clinicaltrials.org): NCT00272155. [ABSTRACT FROM AUTHOR]

WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT • It has generally been regarded as safe to take erythromycin during pregnancy. A recent study from Sweden found that erythromycin exposure in the first trimester was associated with congenital cardiovascular defects. The results led to warnings against using erythromycin in the first trimester from both the Swedish and Norwegian governments. WHAT THIS STUDY ADDS • This large, population-based register study did not find that erythromycin or macrolide use in pregnancy was significantly associated with congenital malformations, cardiovascular malformations or any other specific malformation. AIMS Erythromycin is a macrolide antibiotic indicated for respiratory tract infections, genital chlamydia and skin infections. It has recently been suggested that erythromycin use in the first trimester of pregnancy can increase the risk of congenital cardiovascular malformations. This study aimed to determine whether erythromycin exposure in the first trimester is associated with cardiovascular or other malformations. METHODS We studied 180 120 women in Norway who were pregnant during 2004-2007. Data on all live births stillbirths and induced abortions after 12 gestational weeks from The Medical Birth Registry of Norway (MBRN) were linked to information from the Norwegian prescription database (NorPD). We compared the pregnancy outcomes of women who had taken erythromycin ( n= 1786, 1.0%), penicillin V ( n= 4921, 2.7%) or amoxicillin ( n= 1599, 0.9%) in their first trimester with outcomes of women who had not taken any systemic antibiotics ( n= 163 653, 90.9%) during this period. RESULTS The risk of cardiovascular malformations was not significantly different with or without exposure to erythromycin in the first trimester (adjusted OR = 1.2 [95% CI 0.8, 1.8]) or in the most vulnerable period of heart formation (adjusted OR = 1.6 [95% CI 0.9-3.0]). Sub-analyses showed that the risk for any specific malformations was not increased with erythromycin, macrolides, penicillin V or amoxicillin compared with no antibiotic use in first trimester. CONCLUSIONS This large, population-based register study did not find that exposure to erythromycin or macrolides in the first trimester of pregnancy was associated with fetal cardiovascular or other malformations. These results suggest that the risk of erythromycin use during early pregnancy, if any, is low. [ABSTRACT FROM AUTHOR]

Purpose: To compare the outcome of multi-disciplinary, structured rehabilitation of older patients in a district inpatient rehabilitation centre (Model 1) versus standard primary health care rehabilitation (Model 2). Method: Open, prospective, comparative observational study. Totally 302 patients, 202 in Model 1 and 100 in Model 2, aged ≥65 years, with stroke, osteoarthritis, hip fracture or other chronic diseases, considered to have a rehabilitation potential. Referred from district hospital, nursing- or own homes. Outcomes: Primary: Sunnaas ADL Index (SI). Secondary: Umeaa Life Satisfaction Checklist (LSC). Cognitive (MMSE), emotional (SCL-10) and marital status, residence, length of rehabilitation and hours/week care services. Follow-up 3 months after end of rehabilitation. Results: Patients in Model 1 improved and persisted 1.9 points higher in SI (CI (1.0, 2.8), p < 0.001) compared to Model 2, with 2.4 weeks shorter rehabilitation (CI (1.6, 3.1), p < 0.001). LSC indicated similar satisfaction within both models. Fewer Model 1 patients received home care services >3 h/week (OR = 0.6 CI (0.4, 0.8), p = 0.002). Cognitive status predicted the SI gain positively, and level of care services negatively, in both models. Conclusions: Disabled older patients increase their independency significantly more within shorter time upon structured, multi-disciplinary rehabilitation in a district inpatient centre compared to standard primary health care rehabilitation. [ABSTRACT FROM AUTHOR]

Objective. To examine antibiotic prescribing in nursing homes and determine to what degree the prescribing was in accordance with the national guidelines for antibiotic prescribing. Design. Retrospective examination of patients' records who were prescribed antibiotics in the period 1 March 2007 to 28 February 2008. Setting and patients. Patients residing in the nursing homes of Arendal, Norway. Main outcome measures. Choice of antibiotic in respect of the recommendations in the national guidelines for antibiotic prescribing. Results. A total of 714 antibiotic courses were prescribed to 327 patients yielding a prevalence of 6.6%. Compliant prescribing was 77% for urinary tract infections (UTI), 79% for respiratory tract infections (RTI), and 76% for skin and soft tissue infections (SSTI). Ciprofloxacin was responsible for 63% of non-compliant prescribing. On the respite wards there was a higher rate of total prescribing, non-compliant prescribing, and prescribing by physicians employed at the local hospital. Conclusion. Guidelines for antibiotic use must be implemented actively and efforts to improve antibiotic prescribing in nursing homes must be aimed at both nursing home and hospital physicians. [ABSTRACT FROM AUTHOR]

Objectives To examine general practitioners’ (GPs’) antibiotic prescribing patterns for acute respiratory tract infections (ARTIs) as compared with national guidelines. We also wanted to explore possible predictors of antibiotic prescription patterns. Methods Observational study based on prescription data from 440 Norwegian GPs in December 2004 through to November 2005. Outcome measures were the type and frequency of antibiotic prescriptions for various ARTI diagnoses, with patients’ and GPs’ characteristics as explanatory variables. Results In the study period, the 440 GPs treated a total of 142 900 ARTI episodes. In 33.5% [95% confidence interval (CI): 31.9%–35.1%] of these episodes an antibiotic was issued, of which penicillin V (pcV) accounted for 41.2% (95% CI: 37.4%–44.9%). GPs with a high number of total annual encounters had higher antibiotic prescription rates for ARTIs and used more non-pcV antibiotics compared with GPs with fewer annual patient encounters. GPs in the highest quintile with respect to the total annual encounter rate had 1.6 times the odds of prescribing antibiotics compared with GPs in the lowest quintile. Correspondingly, the odds of choosing a non-pcV antibiotic were 2.8 times higher in the top quintile of GPs compared with GPs in the bottom quintile with respect to antibiotic prescription rates. Conclusions ARTIs are frequently treated with antibiotics and often with broader spectrum agents than pcV, which is the recommended first-line antibiotic in the Norwegian guidelines. GPs with a high practice activity are, in general, more liberal with respect to the prescription of antibiotics for ARTIs, and the higher the antibiotic prescription rate, the larger the share of non-pcV agents. [ABSTRACT FROM PUBLISHER]

Objectives: To examine the effect of opioid maintenance treatment (OMT) on somatic morbidity in a cohort of OMT patients. Design: Retrospective cohort study. Setting: OMT programme in two Norwegian counties. Participants: 200 OMT patients, participation rate 71.2%. Main outcome measures: Incidence rates (IR) before, during and after OMT for acute/subacute hospital-treated somatic disease incidents (drug-related, non-drug-related, injuries) and rates for inpatient days and outpatient treatment contacts. Results: IR for drug-related hospital treatment episodes were 76% lower during compared to before OMT (before versus during incidence rate ratio (IRR) 4.2 (95% CI 2.9 to 6.2), p<0.001) and 11 times higher after compared to during OMT (after versus during IRR 11.1 (6.6 to 18.5), p<0.001). For non-drug-related treatment episodes, IR were 35% higher during than before OMT (before versus during IRR 0.7 (0.6 to 1.0), p=0.02) and 32% higher after compared to during OMT (IRR 1.4 (0.9 to 2.2), p=0.15), while injuries showed little change according to OMT status. Although patients with on-going drug-taking during OMT showed less reduction in drug-related hospital-treated incidents during treatment than patients not using illicit drugs, the quartile with most drug-taking showed a significant reduction (before versus during IRR 3.6 (2.4 to 5.3)). Patients who had experienced cessation of OMT showed a significant reduction in drug-related treatment episodes during OMT (before versus during IRR 1.7 (1.0 to 2.9)), although less than patients without OMT interruptions (before versus during IRR 6.1 (3.6 to 10.6)), and a significant increase after OMT cessation compared with during OMT (IRR 5.4 (3.0 to 9.7)). Conclusion: Acute/subacute drug-related somatic morbidity is reduced during compared to before OMT. This was also found for patients with on-going drug-taking during OMT. However, acute drug-related health problems show an increase after OMT cessation, and this is a matter of concern. Further studies on somatic morbidity after OMT cessation should be carried out. [ABSTRACT FROM AUTHOR]

Background: Delayed prescribing of antibiotics for respiratory tract infections (RTIs) lowers the amount of antibiotics consumed. Several national treatment guidelines on RTIs recommend the strategy. When advocating treatment innovations, the feasibility and credibility of the innovation must be taken into account. The objective of this study was to explore GPs use and patients uptake of wait-and-see prescriptions for RTIs, and to investigate the feasibility of the strategy from GPs' and patients' perspectives. Methods: Questionnaire survey among Norwegian GPs issuing and patients receiving a wait-and-see-prescription for RTIs. Patients reported symptoms, confidence and antibiotics consumption, GPs reported diagnoses, reason for issuing a wait-and-see-prescription and their opinion about the method. Results: 304 response pairs from consultations with 49 GPs were received. The patient response rate was 80%. The most common diagnosis for the GPs to issue a wait-and-see prescription was sinusitis (33%) and otitis (21%). 46% of the patients reported to consume the antibiotics. When adjusted for other factors, the diagnosis did not predict antibiotic consumption, but both being 16 years or more (p = 0,006) and reporting to have a fever (p = 0,012) doubled the odds of antibiotic consumption, while feeling very ill more than quadrupled the odds (p = 0,002). In 210 cases (69%), the GP found delayed prescribing a very reasonable strategy, and 270 patients (89%) would prefer to receive a wait-and-see prescription in a similar situation in the future. The GPs found delayed prescribing very reasonable most frequently in cases of sinusitis (79%, p = 0,007) and least frequently in cases of lower RTIs (49%, p = 0,002). Conclusion: Most patients and GPs are satisfied with the delayed prescribing strategy. The patients' age, symptoms and malaise are more important than the diagnosis in predicting antibiotic consumption. The GP's view of the method as a reasonable approach depends on the patient's diagnosis. In our setting, delayed prescribing seems to be a feasible strategy, especially in cases of sinusitis and otitis. Educational efforts to promote delayed prescribing in similar settings should focus on these diagnoses. [ABSTRACT FROM AUTHOR]