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Background: A key component of strategies to reduce antimicrobial resistance is better antimicrobial prescribing. The majority of antibiotics are prescribed in primary care. While many existing surveillance systems can monitor trends in the quantities of antibiotics prescribed in this setting, it can be difficult to monitor the quality of prescribing as data on the condition for which prescriptions are issued are often not available. We devised a standardized methodology to facilitate the monitoring of condition-specific antibiotic prescribing in primary care., Methods: We used a large computerized general practitioner database to develop a standardized methodology for routine monitoring of antimicrobial prescribing linked to clinical indications in primary care in the UK. Outputs included prescribing rate by syndrome and percentages of consultations with antibiotic prescription, for recommended antibiotic, and of recommended treatment length., Results: The standardized methodology can monitor trends in proportions of common infections for which antibiotics were prescribed, the specific drugs prescribed and duration of treatment. These data can be used to help assess the appropriateness of antibiotic prescribing and to assess the impact of prescribing guidelines., Conclusions: We present a standardized methodology that could be applied to any suitable national or local database and adapted for use in other countries.

Objectives: To measure trends in antibiotic prescribing in UK primary care in relation to nationally recommended best practice., Patients and Methods: A descriptive study linking individual patient data on diagnosis and prescription in a large primary care database, covering 537 UK general practices during 1995-2011., Results: The proportion of cough/cold episodes for which antibiotics were prescribed decreased from 47% in 1995 to 36% in 1999, before increasing to 51% in 2011. There was marked variation by primary care practice in 2011 [10th-90th percentile range (TNPR) 32%-65%]. Antibiotic prescribing for sore throats fell from 77% in 1995 to 62% in 1999 and then stayed broadly stable (TNPR 45%-78%). Where antibiotics were prescribed for sore throat, recommended antibiotics were used in 69% of cases in 2011 (64% in 1995). The use of recommended short-course trimethoprim for urinary tract infection (UTI) in women aged 16-74 years increased from 8% in 1995 to 50% in 2011; however, a quarter of practices prescribed short courses in ≤16% of episodes in 2011. For otitis media, 85% of prescriptions were for recommended antibiotics in 2011, increasing from 77% in 1995. All these changes in annual prescribing were highly statistically significant (P < 0.001)., Conclusions: The implementation of national guidelines in UK primary care has had mixed success, with prescribing for coughs/colds, both in total and as a proportion of consultations, now being greater than before recommendations were made to reduce it. Extensive variation by practice suggests that there is significant scope to improve prescribing, particularly for coughs/colds and for UTIs., (© Crown copyright 2014.)

Background: The representativeness of practice networks is important when using the information obtained to guide health policy., Aim: To develop a model for examining the representativeness of practice networks., Methods: Comparison of surveyed population, practice structure and prescribing characteristics with the national data using the Weekly Returns Service (WRS) for 2006 as an example of practice network. The population monitored was compared with the national PCT population. The practice postcode was linked to the Index of Multiple Deprivation and the distribution compared with the national equivalents. Doctor and practice-specific structural data (obtained by questionnaire) and practice-prescribing data were compared with the national equivalents. The significance of differences was evaluated using non-parametric tests., Results: The WRS population was closely matched with the national data by age, gender and deprivation index. Compared with the national equivalents, WRS practices, included more younger GPs, had a larger average list per GP and fewer practices with a list of less than 1499 per GP. Prescribing patterns were similar to their PCT equivalents excepting for small reductions of antibacterial prescribing (items 7% and cost 5%)., Conclusion: We demonstrate a low-cost model methodology for examining the representativeness of practice networks using independent data with minimum practice input.

Background: Hospitals experience winter surges in admissions due to respiratory infections. The roles of acute bronchitis and influenza-like illness (ILI) in the timing and severity of these surges are examined over the years 1990-91 to 2004-05., Methods: Respiratory admissions of persons aged > or =65 years in England and Wales were analysed in relation to patients with ILI or acute bronchitis diagnosed by community-based general practitioners from a sentinel surveillance network., Results: Acute bronchitis and ILI accounted for 46 and 7% of the variation in respiratory admissions, respectively: when admissions were lagged by 1 week, these estimates were 20 and 14%, respectively. Admissions peaked in weeks 52, 01 or 02 (late December to early January) in 14 of the 15 winters. Acute bronchitis peaked during weeks 01 or 02; ILI exhibited greater variability and peaks ranged from weeks 46 (mid-November) to 07 (mid-February). During winters where acute bronchitis and ILI peaked concurrently, surges on hospitals were most severe., Conclusions: During each winter acute bronchitis provides a consistent and major contribution to the winter admissions surge in the elderly. The variable incidence of ILI can increase the surge in admissions, especially when ILI and acute bronchitis peak together.

This article summarizes personal reflections from the perspective of general practice on developments with regard to antibiotic resistance and the containment of antibiotic prescribing during the lifetime of the Specialist Advisory Committee on Antimicrobial Resistance in England. These reflections concern the entry of antibiotics into the food chain, recent extensions of prescribing responsibilities and developments towards improved surveillance and reduced antibiotic prescribing. A large gap remains between the scientific appreciation of the risks from antimicrobial resistance and effective means to measure it and thereby hopefully control it.

Background: Impetigo is one of the commonest childhood skin infections. Insect bites are commonly implicated in the development of impetigo. There are, however, very few data available to describe the seasonal incidences and association between the two conditions., Objectives: To describe the seasonal incidence of impetigo in England and Wales and to investigate the reported association with insect bites., Methods: Clinical diagnoses of impetigo and insect bites were recorded from a sentinel GP network over the years 1999-2003., Results: The highest mean weekly rates of impetigo were in children aged 0-4 years (84 per 100 000) and in those aged 5-14 years (54 per 100 000). In contrast, the incidence of insect bite only varied between 3 and 5 per 100 000 for males and between 5 and 9 per 100 000 for females. The relative risk (RR) for females consulting over males with impetigo was similar in children [RR 0.99 (95% CI 0.96-1.02)] and adults [RR 1.20 (1.16-1.25)]; the RR of insect bite was similar in children [RR 1.21 (1.09-1.34)] but almost twice as likely in adults [RR 2.13 (2.02-2.25)]. Insect bite peaked almost coincidentally with temperature whereas there was a lag of one-to-two 4-week periods between impetigo and temperature., Conclusion: There is suggestion of some degree of association between impetigo and insect bites. The improved management of patients consulting with insect bites and better use of antiseptic treatments might provide the basis for reducing the incidence of impetigo in the community.

Background: In many European countries, primary care surveillance networks play a role in public health surveillance., Objectives: To update an inventory of surveillance networks, to describe them and to report on their organization and function in a standardized way. To investigate whether and under what conditions their information can contribute to surveillance at a European level., Methods: Surveillance networks were defined as 'A network of practices or community based primary care physicians who monitor one or more specific illness problems on a regular and continuing basis'. For the inventory questionnaires were sent out, followed by site visits to seven networks using a standardized audit checklist., Results: We sent out 75 questionnaires and received 57 back (73% response rate), with 33 (58% of responders) fitting our selection criteria. National surveillance networks were identified in 11 countries. Many had an infectious disease surveillance component, particularly for influenza. Most were funded by the Ministry of Health, some by research funds. The median number of general practitioners was 120, comprising a stable group of general practitioners and covering a representative sample of the general population. The frequency of reporting varied from daily to annually, depending on the purpose of the network., Conclusions: A large number of primary care surveillance networks exist in Europe. Their value has been shown with the surveillance of influenza, but the challenge is now to extend their use to other diseases. When fulfilling identical minimal criteria they can provide comparable estimates of morbidity, ultimately leading to improved national and European surveillance.

Background: In many European countries, maturity onset diabetes mellitus (DM) is to a large extent managed in general practice., Objective: Our aim was to compare management of DM in general practice in five European countries in order to contribute to international guidelines on the management of DM by GPs., Methods: Routine monitoring of patients presenting with DM was performed during a 12 month period (1999-2000) to GPs in established sentinel practice surveillance networks in five European countries (Belgium, Croatia, England, Spain and The Netherlands). Results were stratified by age and country., Results: The proportion of patients treated by diet only varied from 13% (The Netherlands) to 25% (Spain); diet and oral antidiabetics from 51% (England) to 62% (Belgium); a combination of diet and insulin varied from 15% (Belgium and Croatia) to 26% (The Netherlands); and a combination of diet, oral antidiabetics and insulin was <10% in all countries. In the older age groups, insulin is prescribed most frequently in The Netherlands. Spain and Croatia show high consultation rates for DM; England and The Netherlands show low rates. Referral percentages vary considerably between countries (highest in Croatia)., Conclusions: National differences found included the use of insulin in the elderly, the consultation frequency in general practice and the referral rate to ophthalmologist and diabetic specialists. Further quantitative and qualitative studies are needed to explore the needs for support in diabetes management in general practice in Europe.

Background: The prevalence of diabetes has been proposed as a European Community Health Indicator. The prevalence of diabetes known to general practitioners (GPs) in different European countries has been investigated and the usefulness of sentinel practice networks in delivering prevalence data on diabetes has been evaluated., Methods: Patients presenting with diabetes in a 12 month period (1999/2000) to GPs in established European sentinel practice surveillance networks in eight European countries were registered. Estimates of prevalence were standardized to the 1998 European population., Results: All-age prevalence reported in the network populations was lowest in Slovenia (male 16, female 16 per 1000) and highest in Belgium (male 31, female 34). The range of estimates obtained in this study was narrower than that published by the WHO in the Health For All database. The range was further reduced by age standardization. In males aged 45 years and over, age standardized prevalence ranged from 39 (Slovenia) to 76 (Belgium) and in females from 37 (Slovenia) to 75 (Belgium). There were no consistent gender differences in national prevalence rates., Conclusions: The study demonstrates the capacity of sentinel practice networks to deliver data on the prevalence of known diabetes in persons over 45 years. National differences in prevalence are less than hitherto reported. Prevalence in Belgium measured in all ages and in 45 years and over males and females was higher than in the seven other countries.

Background: The Royal College of General Practitioners Weekly Returns Service (WRS) is a network of sentinel general practices providing weekly data on illnesses diagnosed in general practice across England and Wales. The WRS contributes to the surveillance of infectious disease, most notably influenza. We use Geographical Information Systems (GIS) techniques to establish whether the practice populations of the current WRS are representative of the general population., Methods: This study compares the practice population with the general population using the Department of the Environment, Transport and Regions (DETR) Indices of Deprivation 2000 scores for English wards., Results: Comparisons at the national level reveal that the WRS population is less deprived than the general population. At a supra-regional level the WRS practice population shows the same North-South differences as the national population, but the proportions of patients in the more deprived and least deprived wards are more exaggerated in the WRS population. A supplementary analysis reveals that the WRS has no patients in the most deprived wards of London., Conclusion: The differences have implications for the future recruitment of practices to the WRS. Previous studies have demonstrated the effect of socio-economic deprivation on GP consultation rates. To ensure that the consultation rates reported by the WRS will better reflect consulting patterns in the general population the WRS will need to recruit practices with patients in the most deprived areas of the South and less deprived areas in the North of England. This study demonstrates the value of GIS in the establishment of surveillance systems.

Background: The health monitoring programme of the European Commission has proposed a set of health indicators whereby the health status of member states can be measured. As part of that programme we considered how primary care might contribute relevant data., Methods: Using a questionnaire distributed to personal contacts and health authorities, we investigated the activities of sentinel practice networks and sought opinions on the place of primary care as a provider of information on health indicators. Studies on the prevalence of diabetes mellitus and on the incidence of chickenpox were undertaken within selected networks., Results: 33 networks were found who provided relevant information on a timely and continuing basis. Contributions varied; some were limited to monitoring influenza but others recorded morbidity data from every consultation. Recording methods ranged from the paper based to fully automated systems in which all morbidity was coded electronically at data entry. The study of diabetes mellitus showed less variation between national networks than currently suggested on the WHO database. For chickenpox we estimated the incidence of cases not presenting to general practitioners ranged between 3 and 27%., Conclusions: Information on health indicators needs to come from the place where relevant care is delivered; for many conditions that is from primary care. It can be delivered from appropriately resourced practices where the population is defined, the practice populations are nationally representative and data collection is automated.

Background: The WHO have set health standards in the form of 21 targets--Health 21--and the EU are developing a set of health indicators whereby national health status can be measured. Data from Slovenia and from England and Wales assessing information systems in primary care and their capacity to deliver the requirements of these initiatives have been examined. In both countries, primary care is provided through a state-led service., Methods: Consultation data from the annual report of the Department of Health Slovenia (1999) are compared in respect of relevant targets with data from the Fourth National Morbidity Survey (1992) in England and Wales. Consultation rates were standardized to the European Union 15 country population (1998)., Results: Consultation rates in females were similar in the two countries whereas in males rates were higher in Slovenia. The proportionate distributions of consultations by chapter of the International Classification of Diseases (ICD) were similar in both countries, respiratory (17%) and musculoskeletal (9%) disorders ranked first and second. For eye diseases, injury and poisoning, factors influencing health status (e.g. medical examination). proportions were higher in Slovenia: for mental disorders higher in England and Wales. The relativity of male to female consultation rates was broadly similar with higher rates in females in most ICD chapters. These differences are considered in detail against the background of WHO targets., Conclusions: Data gathered systematically from the surveillance of consultations in primary care are important to the measurement of WHO 'Health 21' targets.

A double-blind, randomized study of inhaled zanamivir for the prevention of influenza in families was conducted. Once a person with a suspected case of influenza was identified (index patient), treatment of all other household members (contacts) > or =5 years old was initiated. Contacts received either 10 mg zanamivir or placebo inhaled once daily for 10 days. Index patients received relief medication only. In total, 487 households (242 placebo and 245 zanamivir) were enrolled, with 1291 contacts randomly assigned to receive prophylaxis. Four percent of zanamivir versus 19% of placebo households (P<.001) had at least 1 contact who developed symptomatic, laboratory-confirmed influenza, representing 81% protective efficacy (95% confidence interval, 64%-90%). Protective efficacy was similarly high for individuals (82%) and against both influenza types A and B (78% and 85%, respectively, for households). Zanamivir was well tolerated and was effective in preventing influenza types A and B within households where the index patient was not treated.

Influenza is common, causing considerable morbidity and sickness absence from work in most winters. Influenza vaccines have been available for >40 years, but are not extensively used in the workforce (in the UK). Amantadine has been available for 25 years as a treatment and prophylactic against influenza A infection, but has scarcely been used. In the last 3 years, two neuraminidase inhibitor antivirals, zanamivir and oseltamivir, have been introduced to the market for the treatment and prophylaxis of influenza A and B infections. This review focuses on aspects of prevention and treatment of influenza appropriate to people of working age. Decisions based on the cost-effectiveness of prevention and treatment options differ when viewed from the perspective of the healthcare provider, the employer or the employee. Options currently available need to be directed to a wider range of people than those conventionally regarded as the target risk group.

The efficacy and safety of zanamivir, administered 2x or 4x daily over 5 days, was evaluated in the treatment of influenza infections. A total of 1256 patients entered the study; 57% of those randomized had laboratory-confirmed influenza infection. The primary end point, "alleviation of major symptoms," was created to evaluate differences in clinical impact. In the overall population with or without influenza infection, zanamivir reduced the median number of days to reach this end point by 1 day (P=.012 2x daily vs. placebo; P=.014 4x daily vs. placebo). The reduction was greater in patients treated within 30 h of symptom onset, febrile at study entry, and in defined high-risk groups. Zanamivir reduced nights of disturbed sleep, time to resumption of normal activities, and use of symptom relief medications. It was well tolerated. These results suggest that zanamivir can significantly reduce the duration and overall symptomatic effect of influenza.

Background: The spread of influenza is of major public health concern. Surveillance programmes exist in many countries. We here describe an international collaboration sharing information from Belgium, France, The Netherlands, Portugal and the United Kingdom during the influenza A(H3N2) epidemic occurring in Europe at the end of 1993., Methods: Procedures for clinical and virological surveillance in each country are described. National data were assembled at one point in each country and entered on a computerized data base in Paris for integration. A background rate of influenza was identified from the two previous winters (1991-1992 and 1992-1993) using the measurement of incidence routinely used in each country. The epidemic in late 1993 was described in relation to the background rate. The proportion of cases in each of three age groups (0-14, 15-44 and 65 years and over) was compared in different stages of the epidemic., Results: All national systems effectively identified the onset and monitored the course of the epidemic. Standardization of incidence data gave only limited assistance to the interpretation of the data. The distribution of cases by age group was similar in the early and late periods of the epidemic in all countries. Increased clinical incidence was matched by a simultaneous increase in positive virus identifications in all countries except England and Wales, where the interval between the week of peak clinical incidence and of peak virus reports is mainly due to a reporting procedure based on date of report received at the Central Public Health Laboratory rather than date of specimen capture., Conclusion: An international early warning system for monitoring influenza has been established.

Prescription forms were obtained for 34 doctors who had been involved in a self-audit of psychotropic prescribing using the practice activity analysis method during the last week of February and the first of March, 1980. The forms were provided by the UK Prescription Pricing Authority after the consent of the participating doctors had been obtained. For 11 of the recorders (group 1) prescription forms were available for February and for the remaining 23 (group 2) for March. For group 1 recorders the two control weeks in the study preceded the observation week and for group 2 recorders they followed it. The total number of prescription forms issued, the number including a psychotropic drug and the number including an antibiotic were compared in the respective observation and control weeks. In group 1 there were uniform reductions of all prescribing during the observation period as compared with the controls. The reduction was attributed to a shortfall in prescription forms identified in the last week of the month. In group 2 there were no differences. The pattern of prescribing indicated by the proportions of drugs in the various categories was consistent throughout. Thus the task of undertaking self-audit did not appear to influence the underlying activity audited.

Different denominators for morbidity studies were compared from two large studies in Britain. From the second national morbidity survey, data from 24 single-handed doctors showed a close correlation between the denominators 'persons consulting' and 'list size' (r greater than 0.9) in both years of the survey, but a weaker correlation between 'consultations' and 'list size' (r = 0.6). However, when examining rank order statistics for visiting and out-patient referral rates, it was immaterial for most doctors which denominator was chosen. Only for recorders with a consultation rate at the extremes of the range was the choice of denominator critical to the interpretation of the data. In the practice activity analysis study, based on 47 doctors and a mean of 284 consultations in two weeks, the correlation between 'persons consulting' and 'total consultations' was 0.99. Thus the number of consultations provided a satisfactory proxy for persons consulting in a two-week study. These results justify the use of 'consultations' over two weeks as a denominator in general practice audit in circumstances where rank order is appropriate for the interpretation of data.