New Norwegian national guidelines for New Norwegian national guidelines for antibiotic use in primary careantibiotic use in primary care

Presentation 14.5.09, Presentation 14.5.09, Nordisk kongress, KøbenhavnNordisk kongress, København

Morten LindbækMorten Lindbækprofessor in general practice, UiOprofessor in general practice, UiO

leader Antibiotic Centre for primary careleader Antibiotic Centre for primary care

BackgroundBackground

1999: National plan to stop antibiotic resistance 1999: National plan to stop antibiotic resistance 90 % of all antibiotics in Norway is prescribed in 90 % of all antibiotics in Norway is prescribed in

primary care and 60 % for resp. tract infectionsprimary care and 60 % for resp. tract infections 2 guidelines were proposed2 guidelines were proposed

One for primary careOne for primary care One for hospital care One for hospital care

GoalsGoals

1999: ”It would be desirable to reduce the 1999: ”It would be desirable to reduce the antibiotic consumption by 30 % from antibiotic consumption by 30 % from todays 16 DDD per 1000 inhabitants per todays 16 DDD per 1000 inhabitants per day to 10 DDD, corresponding to the level day to 10 DDD, corresponding to the level of consumption in Holland”.of consumption in Holland”.

Important trends in antibiotic Important trends in antibiotic use Norway 1999-2006use Norway 1999-2006

Total use up from 16.6 DDD to 19,0 DDD Total use up from 16.6 DDD to 19,0 DDD (14%)(14%)

Penicillin extended spectrum (amoxicillin) Penicillin extended spectrum (amoxicillin) up 1,96-2,74 (40%)up 1,96-2,74 (40%)

Penicillin V down 5,01 – 4,63 (8%)Penicillin V down 5,01 – 4,63 (8%) Kloxa/dikloxa up 0,32-0,66 (100%)Kloxa/dikloxa up 0,32-0,66 (100%) Tetracykliner up 3,19 – 3,24 (2%)Tetracykliner up 3,19 – 3,24 (2%) Makrolider up 1,59-2,24 (40%)Makrolider up 1,59-2,24 (40%)

Relation between antibiotic consumption and proportion resistant pneumococciIn some European countries(Goossens et al, Lancet 2005; 365:579-587 )

Prevalence of av erythromycin resistance in pneumococci in blood culturs in Norway 2000-2006

NORM 2006

Joint edition between the Joint edition between the Directorate of health and ASPDirectorate of health and ASP

On behalf of the government ASP was On behalf of the government ASP was asked to revise the guidelines in February asked to revise the guidelines in February 2007.2007.

The health directorate and ASP act as The health directorate and ASP act as joint editors.joint editors.

The new guidelines get a higher status as The new guidelines get a higher status as ”National professional guidelines””National professional guidelines”

EØS/EUEØS/EU An increasing number of new antibiotics are An increasing number of new antibiotics are

introduced in the market. introduced in the market. Due to the EØS-treaty Norwegian authorities Due to the EØS-treaty Norwegian authorities

can no longer stop marketing of new antibiotics, can no longer stop marketing of new antibiotics, which was done previously which was done previously Behovsparagrafen. Behovsparagrafen. (Paragraph of need)(Paragraph of need)

The national drug authorities have therefore The national drug authorities have therefore decided that the following sentence shall be decided that the following sentence shall be included in all presentations of antibacterialsincluded in all presentations of antibacterials ””Official national guidelines shall be taken into Official national guidelines shall be taken into

account in the choice of antibacterials in practiceaccount in the choice of antibacterials in practice” ”

Example liberal prescription of ciprofloxacinExample liberal prescription of ciprofloxacin

Plan for the workPlan for the work

Pairs of academic GP and an organ Pairs of academic GP and an organ specialist for each chapter, in all 30 specialist for each chapter, in all 30 personspersons

Many persons involved in Norsk Many persons involved in Norsk Elektronisk Legehåndboks (NEL) Elektronisk Legehåndboks (NEL) coworkers were askedcoworkers were asked

Grading of evidenceGrading of evidenceKnowledge based on systematic reviews and metaanalyses of randomised, controlled studies.

Level 1 a A

Knowledge based on at least one randomised, controlled study. Level 1 b AKnowledge based on at least one well performed controlled study without randomisation.

Level 2 a B

Knowledge based on at least one other type well performed quasi-experimental study.

Level 2 b B

Knowledge based on other types of well performed non-experimental studies, such as comparative studies, correlation studies and case studies.

Level 3 C

Knowledge based on reports or opnions from expert committees, and/or clinical expertise in respected authorities.

Level 4 D

ImplementationImplementation

Written guidelines in bookWritten guidelines in book Electronic format on CD and on the web, atElectronic format on CD and on the web, at

www.antibiotikasentret.nowww.antibiotikasentret.no Short table version in A4-format, with the most Short table version in A4-format, with the most

common diagnoses and antibiotics common diagnoses and antibiotics Distribution to all Norwegian GPs, doctors in Distribution to all Norwegian GPs, doctors in

nursing homes, health stations and emergency nursing homes, health stations and emergency roomsrooms

Distribution to all Norwegian medical students Distribution to all Norwegian medical students and to doctors educated abroad and to doctors educated abroad

Guidelines are integrated also in CME for general Guidelines are integrated also in CME for general practice specialisation practice specialisation

ImplementationImplementation

Harmonizing with other guidelines such as Harmonizing with other guidelines such as those in NEL and other guidelines for those in NEL and other guidelines for other specialisties (pediatrics, skin other specialisties (pediatrics, skin infections and gynecology, ENT) infections and gynecology, ENT)

What’s new? General chapters What’s new? General chapters

Antibiotic resistanceAntibiotic resistance MRSAMRSA Microbiologic diagnostics in GP officeMicrobiologic diagnostics in GP office Infections in nursing homes (iv treatment?)Infections in nursing homes (iv treatment?) Antibiotics for pregnant and breast-feedingAntibiotics for pregnant and breast-feeding Delayed prescriptions (half of the patients Delayed prescriptions (half of the patients

do not start treatment)do not start treatment) InteractionsInteractions

Some important highlights in Some important highlights in respiratory tract infectionsrespiratory tract infections

Acute otitis mediaAcute otitis media Acute sinusitisAcute sinusitis Acute tonsillitisAcute tonsillitis Acute bronchitis PneumoniaAcute bronchitis Pneumonia Exacerbations of COLDExacerbations of COLD (Acute conjunctivitis)(Acute conjunctivitis)

General considerationsGeneral considerations

Use of penicillin V as first choice in Use of penicillin V as first choice in respiratory tract infections is unchangedrespiratory tract infections is unchanged

Important to keep the low rate of resistant Important to keep the low rate of resistant bacteriae, especially pneumococci and bacteriae, especially pneumococci and Hæmophilus InfluenzaeHæmophilus Influenzae

Macrolides only in patients with penicillin Macrolides only in patients with penicillin allergy or documented atypicals (LRTI)allergy or documented atypicals (LRTI)

Dosage of penicillin VDosage of penicillin V The antibacterial effect of penicillin V is time dependent The antibacterial effect of penicillin V is time dependent

(minutes over MIC-value). With a short half time, the (minutes over MIC-value). With a short half time, the number of sdosages is crucial. number of sdosages is crucial.

Norwegian tradition with dosage 1+1+2 (mill.IE) is Norwegian tradition with dosage 1+1+2 (mill.IE) is obsolete. Swedish tradition has been 2x2 mill IE, obsolete. Swedish tradition has been 2x2 mill IE, Denmark? Finland?Denmark? Finland?

Best er 1+1+1+1, alternatively 1+1+1. Best er 1+1+1+1, alternatively 1+1+1. Problem: If we recommend this for all conditions, we Problem: If we recommend this for all conditions, we

might reduce the use of penicillin V and get more might reduce the use of penicillin V and get more amoxicillin and macrolide useamoxicillin and macrolide use

In the new guidelines we recommend x 4 for In the new guidelines we recommend x 4 for pneumoniapneumonia, , erysipelaserysipelas (and GAS-tonsilitis). (and GAS-tonsilitis).

For other diagnoses we recommend 1 mill IE x 3-4……For other diagnoses we recommend 1 mill IE x 3-4…… The challenge is compliance…The challenge is compliance…

Otitis mediaOtitis media

Children with fever + deteriorated general conditionChildren with fever + deteriorated general condition Children under 1 year Children under 1 year ””Ear children” (recurrent infections)Ear children” (recurrent infections) perforation > 3 days. perforation > 3 days.

However: Study by Rovers et al: Meta-analysis of However: Study by Rovers et al: Meta-analysis of individual patient data demonstrated that children individual patient data demonstrated that children with bilateral otitis and children under 2 would with bilateral otitis and children under 2 would benefit more from antibioticsbenefit more from antibiotics

Acute sinusitisAcute sinusitis

Generalised infection and deteriorated general Generalised infection and deteriorated general condition condition

Symptom duration > 10 days. Symptom duration > 10 days. Steroid nasal spray? Has only been Steroid nasal spray? Has only been

demonstrated to be beneficial in addition to demonstrated to be beneficial in addition to amoxicillin in US patients with recurrent amoxicillin in US patients with recurrent infections.infections.

Delayed prescription good strategy? Delayed prescription good strategy? Meta-analysis of individual patient data Meta-analysis of individual patient data

demonstrated (Young et al) found no subgroups demonstrated (Young et al) found no subgroups to benefit from antibiotic treatment.to benefit from antibiotic treatment.

Acute tonsillitisAcute tonsillitis

Only treatment of streptococci. Only treatment of streptococci. Use of 4 Centor criteria, Strep test only if 2-3 present. Use of 4 Centor criteria, Strep test only if 2-3 present. Low dosage, 10 days treatment to avoid recurrencyLow dosage, 10 days treatment to avoid recurrency

However: Strep G&C – same clinical courseHowever: Strep G&C – same clinical course Children: No benefit from pencillin (Zwart BMJ)Children: No benefit from pencillin (Zwart BMJ) Potential of delayed prescription?Potential of delayed prescription?

Acute bronchitis - pneumoniaAcute bronchitis - pneumonia

No antibiotics for acute bronchitis. BetaNo antibiotics for acute bronchitis. Beta22--

agonist? Stop smokingagonist? Stop smoking Improve diagnostics for pneumonia. Improve diagnostics for pneumonia.

Use CRP og SR, may X-ray thorax.Use CRP og SR, may X-ray thorax.

Penicillin as first choice.Penicillin as first choice. Atypical LRTI: Await test results? PCR? Atypical LRTI: Await test results? PCR?

Erytromycin.Erytromycin.

COLD-exacerbationCOLD-exacerbationchange in guidelinechange in guideline

Antonisen criteria: Increase in dyspnea, Antonisen criteria: Increase in dyspnea, expectoration or purulent secretion. In expectoration or purulent secretion. In addition use CRP/ESR.addition use CRP/ESR.

If all 3 good effect of antibiotics, if 2 doubtful, If all 3 good effect of antibiotics, if 2 doubtful, if 1 no effect if 1 no effect

Amoxicillin as first choice. Doxycyclin second Amoxicillin as first choice. Doxycyclin second choice or by penicillin allergy.choice or by penicillin allergy.

Conjunctivitis and kinder gartenConjunctivitis and kinder garten

Controversies between kinder gartens and Controversies between kinder gartens and parents/doctors whenter children with conjunctivitis parents/doctors whenter children with conjunctivitis should be allowed to og to kinder garten.should be allowed to og to kinder garten.

Has led to very strict rules in some kinder gartens: Has led to very strict rules in some kinder gartens: Children with some pus in the eye should og to doctor Children with some pus in the eye should og to doctor and should start treatment before coming back.and should start treatment before coming back.

Our response: Our response:

The doctor shall decide whether treatment is needed. If The doctor shall decide whether treatment is needed. If moderate symptoms, no treatment or delayed prescription moderate symptoms, no treatment or delayed prescription (ref BMJ 2006)(ref BMJ 2006)

The danger of contagious disease is possibly exaggeratedThe danger of contagious disease is possibly exaggerated The kinder garten cannot demand that parents should og to The kinder garten cannot demand that parents should og to

doctordoctor

Controversies not covered hereControversies not covered here

Skin infectionsSkin infections Empiric treatment of urethritisEmpiric treatment of urethritis Bacterial vaginosis in pregnancyBacterial vaginosis in pregnancy Screening for symptomatic bacteriuria in Screening for symptomatic bacteriuria in

pregnancypregnancy

Thanks for your attentionThanks for your attention