Infections In Primary Care Research Articles

Clinic Characteristics and Antibiotic Prescribing for Acute Respiratory Infections in Japan

This cross-sectional study examined clinic characteristics associated with antibiotic prescribing for acute respiratory infections in primary care in Japan.

Point-of-care tests to manage acute respiratory tract infections in primary care: a systematic review and qualitative synthesis of healthcare professional and patient views.

To review the evidence on healthcare professionals' (HCPs) and patients' views of the use of point-of-care tests (POCTs) in the management of acute respiratory tract infections (RTIs) in primary care settings. We conducted a systematic review of studies up to 28 April 2023. We included studies that included qualitative methods and results; focused on HCPs' and/or patients' views/experiences of POCTs for acute RTIs; and were conducted in primary care settings. We conducted a thematic synthesis to identify how their views on POCTs and interventions can support test use (PROSPERO registration: CRD42019150347). We included 33 studies, developing 9 categories each for HCP and patient data. We identified 38 factors affecting POCT use: 28 from HCPs and 10 from patients. Factors exist outside and within consultations, and post-consultations, illustrating that some cannot be addressed by HCPs alone. Fourteen interventions were identified that could address factors and support POCT use, with 7 interventions appearing to address the most factors. Some interventions were beyond the scope of HCPs and patients and needed to be addressed at system and organizational levels. Both groups had mixed views on the use of POCTs and highlighted implementation challenges. This review highlights numerous factors affecting POCT use in primary care. Policy-makers planning to implement POCTs are likely to achieve more by providing multi-faceted interventions that target factors outside, within, and post-consultation. Some interventions may need to be already established before POCT introduction. Whilst evidence beyond general practice is limited, similar factors suggest that similar context-tailored interventions would be appropriate.

The effect and implementation of the COVID Box, a remote patient monitoring system for patients with a COVID-19 infection in primary care: a matched cohort study

The effect and implementation of the COVID Box, a remote patient monitoring system for patients with a COVID-19 infection in primary care: a matched cohort study

Risk of unintended consequences from lower antibiotic prescribing for respiratory tract infections in primary care

About 60% of antibiotic prescribing in primary care is for respiratory tract infections (RTIs), some of which is likely unnecessary. There is limited evidence on the association between reduced antibiotic prescribing and adverse events. We aimed to identify associations between practice-level prescribing rates for RTIs in general practice, and patient-level adverse outcomes. We included 1471 English General Practitioner (GP) practices, linked to hospital admissions in England, from the Clinical Practice Research Datalink for 2005 to 2019. Outcomes were hospitalisations, RTI-related re-consultations and additional antibiotic prescriptions, adjusted for practice level case-mix prescribing. Prescribing rates for practices falling within the lowest and highest prescribing quintiles were 52 and 139 prescriptions per 1000 RTI-related consultations. Patients from practices in the lowest prescribing quintile did not have significantly higher risk of hospitalisation, adjusted odds ratio 0·99 (95% CI 0·96 to 1·02). Re-consultations within 30 days were significantly higher for the lowest prescribing practices, adjusted odds ratio 1·209 (1·206 to 1·212). Additional antibiotic prescriptionsand subsequent prescriptions upon re-consultationwere significantly lower for the lowest prescribing practices, adjusted odds ratio 0·317 (0·314 to 0·321) and 0·706 (0·699 to 0·712), respectively. Our results contribute to evidence on the safety of reduced antibiotic prescribing for RTIs in primary care. Results suggest that for the majority of practices, further reductions in RTI-related antibiotic prescribing should be possible without an increase in hospitalisation for pneumonia.

Nirmatrelvir/ritonavir treatment and risk for postacute sequelae of COVID-19 in older Singaporeans

ObjectivesSignificant heterogeneity has been reported in cohort studies evaluating the impact of early oral antiviral treatment on preventing postacute sequelae after COVID-19. We evaluated the impact of early nirmatrelvir/ritonavir on risk of postacute cardiovascular, neurological, respiratory, and autoimmune diagnoses, as well as postacute symptoms amongst older Singaporeans. MethodsNational COVID-19 registries and healthcare claims databases were used to construct a retrospective population-based cohort enrolling all Singaporeans aged ≥60 years diagnosed with SARS-CoV-2 infection in primary care during Omicron transmission (18 March 2022–4 August 2023). The cohort was divided into nirmatrelvir/ritonavir-treated and untreated groups. Between-group differences in baseline characteristics were adjusted using overlap weighting. Risks of postacute cardiovascular, neurological, respiratory, and autoimmune diagnoses and postacute symptoms (31–180 days) after SARS-CoV-2 infection were contrasted in treated/untreated groups using competing risks regressions (adjusted for demographics/vaccination status/comorbidities). ResultsA total of 188 532 older Singaporeans were included; 5.8% (10 905/188 532) received nirmatrelvir/ritonavir. No significantly decreased risk of postacute sequelae (any sequelae: adjusted hazards ratio [aHR], 1.06; 0.94–1.19; cardiovascular sequelae: aHR, 1.01; 0.83–1.24; neurological sequelae: aHR, 1.09; 0.95–1.27; respiratory sequelae: aHR, 1.14; 0.84–1.55; autoimmune sequelae: aHR, 0.76; 0.53–1.09; or any postacute symptom: aHR, 0.97; 0.80–1.18) was observed up to 180 days post-infection in nirmatrelvir/ritonavir-treated individuals vs. untreated cases. Across all vaccination and age subgroups, no significantly decreased risk of any postacute diagnosis/symptom or any cardiovascular, neurological, respiratory, and autoimmune complications up to 180 days post-infection was observed. DiscussionEarly outpatient receipt of nirmatrelvir/ritonavir did not significantly reduce risk of postacute cardiovascular, neurological, respiratory, and autoimmune sequelae or the risk of postacute symptoms in a boosted cohort of older Singaporeans.

Mapping the evidence about the natural history of acute infections commonly seen in primary care and managed with antibiotics: a scoping review

BackgroundKnowing the natural history of acute infections in primary care, defined as the course of a disease over time in the absence of specific therapy or treatment, can inform clinicians’ and patients’ expectations about illness recovery, but this evidence is fragmented across the literature. This scoping review aimed to map existing research and research gaps relevant to the natural history of acute infections.MethodsWe searched MEDLINE, Embase and CENTRAL using a 2-phase hierarchical search approach. In Phase A, we focused on identifying systematic reviews synthesising natural history data for eligible infections (acute respiratory, urinary, and skin and soft tissue) and systematic reviews of treatment effectiveness (of RCTs with placebo or no treatment arm, or cohort studies). For infections without existing reviews, in Phase B, we searched for primary studies (placebo-controlled RCTs or cohort studies). Two reviewers independently screened and extracted the data (study characteristics, outcome data - e.g., symptom duration, proportion with resolution at various time points).ResultsWe identified 40 systematic reviews, reporting on 45 infections, most commonly (90%) respiratory tract infections. Six (15%) of these aimed to synthesise natural history information. Most reviews reported the proportion of participants with symptom resolution at various time point/s, with 58% providing data on mean symptom duration. Recovery data show the spontaneous resolution of some infections in some people. We found no eligible studies for cellulitis, ecthyma, carbuncle, and erysipelas.ConclusionsOur review has shown that natural history evidence exists for many common acute infections. It can be utilised by clinicians in implementing patient-centred antibiotic stewardship strategies in primary care. Future research should focus on generating natural history evidence for skin and soft tissue infections and urinary tract infections.

Behaviour change interventions addressing antibiotic treatment seeking behaviour for respiratory tract infections in primary care settings: A scoping review protocol

Objective This scoping review aims to synthesise the extent and type of evidence on behaviour change interventions which address antibiotic treatment seeking behaviour for respiratory tract infections in the primary care/community setting. Introduction Antimicrobial Resistance is recognised as a global health and economic threat by the World Health Organization and World Bank. Several lines of evidence point to patient and public demand as a key driver of inappropriate antibiotic use. Current policy initiatives acknowledge the need to prepare for the future by managing public expectations regarding antibiotics, especially for influenza-like illness and other respiratory tract infections. These initiatives emphasise the importance of designing and evaluating effective interventions that generate actionable knowledge for policy and practices related to the appropriate use of antibiotics. Behaviour change interventions, in this context, can aim to modify patients' attitudes, beliefs, and behaviours regarding antibiotics. Inclusion criteria Identified studies will describe behaviour change interventions aimed at potential patients/participants within the primary care/community setting that address patient expectations of antibiotic use for respiratory tract infections. Diagnoses for respiratory tract infections will be classified by ICD-10 criterion. Methods This scoping review will search the literature in Medline, Embase, CINAHL, PsycINFO, Web of Science Core Collection, Scopus, and Google Scholar to explore behaviour change interventions used to reduce expectations of antibiotics for respiratory tract infections in primary care. This review will follow the Joanna Briggs Institute guidelines for scoping reviews. It will be reported according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews.

Impact of C-reactive protein point-of-care testing on antibiotic prescriptions for children and adults with suspected respiratory tract infections in primary care: a French patient-level randomized controlled superiority trial

ObjectivesThe value of C-reactive protein point-of-care testing (CRP POCT) to guide antibiotic prescriptions in adults has previously been emphasized. The aim of this study was to assess the impact of CRP POCT on antibiotic prescriptions by general practitioners (GPs) for suspected lower respiratory tract infections in children ≥3 years old and in adults. MethodsThis was an open-label randomized trial (NCT03540706) conducted in 26 GPs in France between October 2019 and March 2023. Of the 404 participating patients, 207 (51.2%) were randomized to the CRP POCT group and 197 (48.8%) to the control group (i.e. no CRP POCT). During consultations, GPs measured CRP levels in patients randomized to the CRP POCT group. The primary endpoint was the proportion of patients in each group who were prescribed antibiotics by their GP during the consultation. Z-tests were used for comparisons. ResultsThe overall proportion of patients treated with antibiotics was similar in the CRP POCT (n = 89/207, 43% CI: 36.2, 50.0) and in the control group (n = 94/197, 47.7% CI: 40.6, 54.9), difference: −4.7 CI: −14.4, 5.0; p 0.3. Overall, 75% of the GPs followed CRP-based antibiotic prescription recommendations in the CRP POCT group. DiscussionCRP POCT did not reduce antibiotic prescriptions in this trial.

Use of the FebriDx® host-response point-of-care test may reduce antibiotic use for respiratory tract infections in primary care: a mixed-methods feasibility study.

FebriDx® is a CE-marked, single-use point-of-care test with markers for bacterial [C-reactive protein (CRP)] and viral [myxovirus resistance protein A (MxA)] infection, using finger-prick blood samples. Results are available after 10-12 min. We explored the usability and potential impact of FebriDx® in reducing antibiotic prescriptions for lower respiratory tract infection (LRTI) in primary care, and the feasibility of conducting a randomized controlled trial (RCT). Patients (aged ≥1 year) with LRTI deemed likely to receive antibiotic prescription were recruited at nine general practices and underwent FebriDx® testing. Data collection included FebriDx® results, antibiotic prescribing plan (before and after testing) and re-consultation rates. Staff completed System Usability Scale questionnaires. From 31 January 2023 to 9 June 2023, 162 participants participated (median age 57 years), with a median symptom duration of 7 days (IQR 5-14). A valid FebriDx® result was obtained in 97% (157/162). Of 155 patients with available results, 103 (66%) had no detectable CRP or MxA, 28 (18%) had CRP only, 5 (3%) had MxA only, and 19 (12%) had both CRP and MxA. The clinicians' stated management plan was to prescribe antibiotics for 86% (134/155) before testing and 45% (69/155) after testing, meaning a 41% (95% CI: 31%, 51%) difference after testing, without evidence of increased re-consultation rates. Ease-of-use questionnaires showed 'good' user-friendliness. Use of FebriDx® to guide antibiotic prescribing for LRTI in primary care was associated with a substantial reduction in prescribing intentions. These results support a fully powered RCT to confirm its impact and safety.

Use of the FebriDx point-of-care test for lower respiratory tract infections in primary care: a qualitative interview study.

FebriDx is a single-use, analyser-free, point-of-care test with markers for bacterial (C-reactive protein [CRP]) and viral (myxovirus resistance protein A [MxA]) infection, measured on a finger-prick blood sample. As part of a larger feasibility study, we explored the views of healthcare professionals (HCPs) and patients on the use of FebriDx to safely reduce antibiotic prescriptions for lower respiratory tract infections (LRTIs) in primary care. Remote semi-structured qualitative interviews were conducted in South England. In total, 22 individuals (12 patients who underwent FebriDx testing and 10 HCPs from general practices that conducted testing) participated in interviews, which were analysed thematically. Patients and HCPs expressed positive views about use of the test. They felt FebriDx was a useful tool to inform prescribing decisions and provided a visual aid to support shared decision making and appropriate antibiotic use. Most felt it would be feasible to integrate use into routine primary care consultations. Some practical difficulties with blood collection and interpreting results, which impacted on usability, were identified. Some patients' reactions to negative test results suggested the need for better communication alongside use of the test. FebriDx was perceived as a useful tool to guide antibiotic prescribing and support shared decision making. Initial practical problems with testing and communicating results are potential barriers to use. Training and practice on using the test and effective communication are likely to be important elements in ensuring patient understanding and satisfaction, and successful adoption.

Factors influencing antibiotic prescribing for respiratory tract infections in primary care – a comparison of physicians with different antibiotic prescribing rates

Background There has been a notable decrease in antibiotic prescribing in the last thirty years in Sweden. Little is known about factors influencing antibiotic prescribing over several years. Objective To compare primary care physicians who, over time, reduced their antibiotic prescribing for respiratory tract infections with those who remained either high or low prescribers regarding potentially influencing factors. Design and setting A register-based study including all RTI visits in primary care in Region Kronoberg, Sweden 2006–2014. The data were divided into three 3-year periods. Subjects The data comprised all physicians who had diagnosed at least one RTI for each of the three-year periods. The antibiotic prescribing rate adjusted for the patients’ sex and age group was calculated for each physician and period, and based on the change between the first and the third period, the physicians were divided into three prescriber groups: The High Prescribing Group, the Decreasing Prescribing Group, and the Low Prescribing Group. Main outcome measures For the three prescriber groups, we compared factors influencing antibiotic prescribing such as the characteristics of the physicians, their use of point-of-care tests, their choice of diagnoses, and whether the patients returned and received antibiotics. Results The High Prescribing Group ordered more point-of-care tests, registered more potential bacterial diagnoses, prescribed antibiotics at lower C-reactive protein levels, and prescribed antibiotics more often despite negative group A Streptococci test than in the Low Prescribing Group. The Decreasing Prescribing Group was between the High Prescribing Group and the Low Prescribing Group regarding these variables. The lower prescription rate in the Low Prescribing Group did not result in more return visits or new antibiotic prescriptions within 30 days. Conclusion Point-of-care testing and its interpretation differed between the prescriber groups. Focus on interpreting point-of-care test results could be a way forward in antibiotic stewardship.

Treatment failure of Helicobacter pylori in primary care: a retrospective cohort study.

Owing to increasing antibiotic resistance, the worldwide efficacy of Helicobacter pylori (HP) eradication treatment has decreased. To determine antimicrobial resistance of HP in primary care. Retrospective cohort study using real-world routine healthcare data from 80 general practices in the Netherlands. Patients with International Classification of Primary Care (ICPC) codes for gastric symptoms or Anatomical Therapeutic Chemical (ATC) codes for acid inhibition in the period 2010-2020 were selected. Main outcomes were antimicrobial resistance of HP, defined as the prescription of a second eradication treatment within 12 months, and clinical remission of gastric symptoms, defined as no usage of acid inhibition 1 year following eradication therapy. We identified 138 455 patients with gastric symptoms and/or acid inhibition use (mean age 57 years [standard deviation 18.2 years], 43% male). A total of 5224 (4%) patients received an HP eradication treatment. A second treatment was prescribed to 416 (8%) of those patients. From these, 380 patients received amoxicillin-clarithromycin, 16 amoxicillin-metronidazole, and 11 clarithromycin-metronidazole as first regimen and were considered antimicrobial resistant. We observed a 0.8% increment per year of patients requiring a second eradication treatment (P = 0.003, 95% confidence interval = 0.33 to 1.22). After successful eradication, 2329/4808 (48%) patients used acid inhibition compared with 355/416 (85%) patients following treatment failure (P<0.001). Antimicrobial treatment is not successful in almost one-tenth of HP infections in primary care after a first treatment containing clarithromycin and/or metronidazole. Although the treatment failure rate is not as high as reported in secondary care, the increasing trend is concerning and may require revision of the current guidelines.

Positive and negative viral associations in patients with acute respiratory tract infections in primary care: the ECOVIR study.

Acute respiratory infections (ARIs) are the most common viral infections encountered in primary care settings. The identification of causal viruses is still not available in routine practice. Although new strategies of prevention are being identified, knowledge of the relationships between respiratory viruses remains limited. ECOVIR was a multicentric prospective study in primary care, which took place during two pre-pandemic seasons (2018-2019 and 2019-2020). Patients presenting to their General practitioner (GP) with ARIs were included, without selecting for age or clinical conditions. Viruses were detected on nasal swab samples using a multiplex Polymerase Chain Reaction test focused on 17 viruses [Respiratory Syncytial Virus-A (RSV-A), RSV-B, Rhinovirus/Enterovirus (HRV), human Metapneumovirus (hMPV), Adenovirus (ADV), Coronaviruses (CoV) HKU1, NL63, 229E, OC43, Influenza virus (H1 and H3 subtypes), Influenza virus B, Para-Influenza viruses (PIVs) 1-4, and Bocavirus (BoV)]. Among the 668 analyzed samples, 66% were positive for at least one virus, of which 7.9% were viral codetections. The viral detection was negatively associated with the age of patients. BoV, ADV, and HRV occurred more significantly in younger patients than the other viruses (p < 0.05). Codetections were significantly associated with RSV, HRV, BoV, hMPV, and ADV and not associated with influenza viruses, CoV, and PIVs. HRV and influenza viruses were negatively associated with all the viruses. Conversely, a positive association was found between ADV and BoV and between PIVs and BoV. Our study provides additional information on the relationships between respiratory viruses, which remains limited in primary care.

MicroDoc: Developing a guide for managing infections in Zambian rural low-resource health settings

Abstract Lack of access to diagnostic tests and guidelines that are inappropriate for poorly resourced facilities can result in incorrect and excessive prescribing of antimicrobial therapy in rural healthcare settings. On Call Africa (OCA) and Virtual Doctors (VD) are two non-governmental organisations that work in healthcare in Zambia. Volunteers and staff from OCA and VD have collaborated with the Zambian Ministry of Health and local healthcare providers to design a guide to support decisions around management of infections specifically in rural primary healthcare settings in Zambia. Local staff were initially surveyed for their attitudes towards treatment of infections, the content they would like capacity building in, and preferred modes of learning. The team, comprising public health and infectious disease doctors and GPs from Ireland and the UK with experience working in Zambia, have created a guide called MicroDoc which encompasses workshops, PDFs, flowcharts and modules relating to management of infections and antimicrobial prescribing. All the content can be downloaded and accessed offline. The Zambian Standard Treatment Guidelines were consulted for antimicrobial choice, supplemented by NICE and WHO where necessary. Red flags for urgent hospital referral are also incorporated, as well as modules about risks of antimicrobial resistance. Early versions of the guide have been distributed to a range of facilities in Zambia's Southern Province, with promising feedback from healthcare providers. In collaboration with local partners and input from facility staff, MicroDoc will be finalised and rolled out to more health posts and health centres in the region, with a view to eventually expanding to other regions. The OCA team has been conducting clinical audits of prescribing practices in two rural health posts and it is hoped that the MicroDoc guide will contribute to improved antimicrobial stewardship as well as better outcomes for patients. Key messages • Management of infectious presentations is particularly challenging in rural low-resource primary healthcare settings in Sub-Saharan countries such as Zambia. • A team from On Call Africa and Virtual Doctors has created a guide called MicroDoc, in collaboration with Zambian health authorities, to support decision making in managing infections in primary care.

Clinical diagnosis of SARS-CoV-2 infection: An observational study of respiratory tract infection in primary care in the early phase of the pandemic

BackgroundEarly in the COVID-19 pandemic, GPs had to distinguish SARS-CoV-2 from other aetiologies in patients presenting with respiratory tract infection (RTI) symptoms on clinical grounds and adapt management accordingly.ObjectivesTo test the diagnostic accuracy of GPs’ clinical diagnosis of a SARS-CoV-2 infection in a period when COVID-19 was a new disease. To describe GPs’ management of patients presenting with RTI for whom no confirmed diagnosis was available. To investigate associations between patient and clinical features with a SARS-CoV-2 infection.MethodsIn April 2020–March 2021, 876 patients (9 countries) were recruited when they contacted their GP with symptoms of an RTI of unknown aetiology. A swab was taken at baseline for later analysis. Aetiology (PCR), diagnostic accuracy of GPs’ clinical SARS-CoV-2 diagnosis, and patient management were explored. Factors related to SARS-CoV-2 infection were determined by logistic regression modelling.ResultsGPs suspected SARS-CoV-2 in 53% of patients whereas 27% of patients tested positive for SARS-CoV-2. True-positive patients (23%) were more intensively managed for follow-up, antiviral prescribing and advice than true-negatives (42%). False negatives (5%) were under-advised, particularly for social distancing and isolation. Older age (OR: 1.02 (1.01–1.03)), male sex (OR: 1.68 (1.16–2.41)), loss of taste/smell (OR: 5.8 (3.7–9)), fever (OR: 1.9 (1.3–2.8)), muscle aches (OR: 2.1 (1.5–3)), and a known risk factor for COVID-19 (travel, health care worker, contact with proven case; OR: 2.7 (1.8–4)) were predictive of SARS-CoV-2 infection. Absence of loss of taste/smell, fever, muscle aches and a known risk factor for COVID-19 correctly excluded SARS-CoV-2 in 92.3% of patients, whereas presence of 3, or 4 of these variables correctly classified SARS-CoV-2 in 57.7% and 87.1%.ConclusionCorrect clinical diagnosis of SARS-CoV-2 infection, without POC-testing available, appeared to be complicated.

C-reactive protein point-of-care testing and complementary strategies to improve antibiotic stewardship in children with acute respiratory infections in primary care.

This paper provides the perspective of an international group of experts on the role of C-reactive protein (CRP) point-of-care testing (POCT) and complementary strategies such as enhanced communication skills training and delayed prescribing to improve antibiotic stewardship in the primary care of children presenting with an acute illness episode due to an acute respiratory tract infection (ARTI). To improve antibiotics prescribing decisions, CRP POCT should be considered to complement the clinical assessment of children (6 months to 14 years) presenting with an ARTI in a primary care setting. CRP POCT can help decide whether a serious infection can be ruled out, before deciding on further treatments or management, when clinical assessment is unconclusive. Based on the evidence currently available, a CRP value can be a valuable support for clinical reasoning and facilitate communication with patients and parents, but the clinical assessment should prevail when making a therapy or referral decision. Nearly half of children tested in the primary care setting can be expected to have a CRP value below 20 mg/l, in which case it is strongly suggested to avoid prescribing antibiotics when the clinical assessment supports ruling out a severe infection. For children with CRP values greater than or equal to 20 mg/l, additional measures such as additional diagnostic tests, observation time, re-assessment by a senior decision-maker, and specialty referrals, should be considered.

Antibiotic prescribing in remote versus face-to-face consultations for acute respiratory infections in primary care in England: an observational study using target maximum likelihood estimation

The COVID-19 pandemic has led to an ongoing increase in the use of remote consultations in general practice in England. Although the evidence is limited, there are concerns that the increase in remote consultations could lead to more antibiotic prescribing. In this cohort study, we used patient-level primary care data from the Clinical Practice Research Datalink to estimate the association between consultation mode (remote versus face-to-face) and antibiotic prescribing in England for acute respiratory infections (ARI) between April 2021 and March 2022. Eligibility criteria were applied at both practice-level and patient-level. 400 practices in England were sampled at random and then 600,000 patients were randomly sampled from the eligible patients (whose sex was recorded). Consultations for acute respiratory infections were identified. All antibiotic prescriptions were included, with the exception of antituberculosis drugs and antileprotic drugs, as identified through chapter 5.1 of the British National Formulary. The CPRD Aurum data was linked to the COVID-19 ONS infection survey by region. All analyses were done at the individual level. Repeated consultations from the same patient within 7 days were grouped together. We used targeted maximum likelihood estimation, a causal machine learning method with adjustment for infection type and patient-level, clinician-level and practice-level factors. There were 45,997 ARI consultations (34,555 unique patients) within the study period, of which 28,127 were remote and 17,870 were face-to-face. For children, 48% of consultations were remote and, for adults, 66% were remote. For children, 42% of remote and 43% of face-to-face consultations led to an antibiotic prescription; the equivalent values for adults were 52% and 42%, respectively. After adjustment with TMLE, adults with a remote consultation had 23% (odds ratio [OR] 1.23, 95% CI: 1.18-1.29) higher chance of being prescribed antibiotics than if they had been seen face-to-face. We found no significant association between consultation mode and antibiotic prescribing in children (OR 1.04 95% CI: 0.98-1.11). The higher rates of antibiotic prescribing in remote consultations for adults are cause for concern. We see no significant difference in antibiotic prescribing between consultation mode for children. These findings should inform antimicrobial stewardship activities for health-care professionals and policy makers. Future research should examine differences in guideline-compliance between remote and face-to-face consultations to understand the factors driving antibiotic prescribing in different consultation modes. None.

Evidence for using point-of-care diagnostics in the management of respiratory tract infections in primary care: a scoping review protocol.

Background: Antimicrobial resistance (AmR) is widely considered a global health threat and is associated with significant morbidity, mortality and costs. Inappropriate antimicrobial use is the most important modifiable risk factor for AmR. Most human antimicrobial medicines use occurs in primary care [prescribed by general practitioners (GPs), dispensed by community pharmacists (CPs)]. However, up to 50% of use is deemed inappropriate. Point-of-care diagnostic tests are used as a basis for antimicrobial stewardship interventions to improve the diagnostic certainty of respiratory tract infections (RTIs), and therefore ensure prudent antimicrobial use. However, there is a lack of guidance on their use, and they are therefore not routinely used in clinical practice. Objective: A scoping review will be conducted to synthesise the available evidence to inform the development of best practice guidance for using point-of-care diagnostics in the management of RTIs in primary care. Methods: A scoping review will be conducted following guidance from the Joanna Briggs Institute (JBI) and reported using the PRISMA-ScR guidelines. Databases including Web of Science, MEDLINE, CINAHL, EMBASE, the International HTA database and the Cochrane Central Register of Controlled Trials, as well as grey literature, will be searched. Screening will be undertaken independently by two reviewers to identify studies and literature reporting the use of point-of-care diagnostics in the management of RTIs in primary care by GPs and/ or CPs. Findings will be described using narrative synthesis. Conclusion: The findings of this scoping review will be used to produce draft guidance on the use of point-of-care diagnostic tests in primary care, which will undergo further development using a Delphi consensus methodology involving experts in the field of RTIs, antimicrobial stewardship, point-of-care diagnostics and primary care.

The impact of the COVID-19 pandemic on the treatment of common infections in primary care and the change to antibiotic prescribing in England

BackgroundThere is concern that the COVID-19 pandemic altered the management of common infections in primary care. This study aimed to evaluate infection-coded consultation rates and antibiotic use during the pandemic and how any change may have affected clinical outcomes.MethodsWith the approval of NHS England, a retrospective cohort study using the OpenSAFELY platform analysed routinely collected electronic health data from GP practices in England between January 2019 and December 2021. Infection coded consultations and antibiotic prescriptions were used estimate multiple measures over calendar months, including age-sex adjusted prescribing rates, prescribing by infection and antibiotic type, infection consultation rates, coding quality and rate of same-day antibiotic prescribing for COVID-19 infections. Interrupted time series (ITS) estimated the effect of COVID-19 pandemic on infection-coded consultation rates. The impact of the pandemic on non- COVID-19 infection-related hospitalisations was also estimated.ResultsRecords from 24 million patients were included. The rate of infection-related consultations fell for all infections (mean reduction of 39% in 2020 compared to 2019 mean rate), except for UTI which remained stable. Modelling infection-related consultation rates highlighted this with an incidence rate ratio of 0.44 (95% CI 0.36–0.53) for incident consultations and 0.43 (95% CI 0.33–0.54) for prevalent consultations. Lower respiratory tract infections (LRTI) saw the largest reduction of 0.11 (95% CI 0.07–0.17). Antibiotic prescribing rates fell with a mean reduction of 118.4 items per 1000 patients in 2020, returning to pre-pandemic rates by summer 2021. Prescribing for LRTI decreased 20% and URTI increased 15.9%. Over 60% of antibiotics were issued without an associated same-day infection code, which increased during the pandemic. Infection-related hospitalisations reduced (by 62%), with the largest reduction observed for pneumonia infections (72.9%). Same-day antibiotic prescribing for COVID-19 infection increased from 1 to 10.5% between the second and third national lockdowns and rose again during 2022.ConclusionsChanges to consultations and hospital admissions may be driven by reduced transmission of non-COVID-19 infections due to reduced social mixing and lockdowns. Inconsistencies in coding practice emphasises the need for improvement to inform new antibiotic stewardship policies and prevent resistance to novel infections.

Antibiotic treatment failure of uncomplicated urinary tract infections in primary care

BackgroundHigher resistance rates of > 20% have been noted in Enterobacteriaceae urinary isolates towards ciprofloxacin and co-trimoxazole (C + C) in Singapore, compared with amoxicillin-clavulanate and nitrofurantoin (AC + N). This study examined if treatment failure varied between different antibiotics, given different resistant rates, for uncomplicated urinary tract infections (UTIs) managed in primary care. We also aimed to identify gaps for improvement in diagnosis, investigations, and management.MethodsA retrospective cohort study was conducted from 2019 to 2021 on female patients aged 18–50 with uncomplicated UTIs at 6 primary care clinics in Singapore. ORENUC classification was used to exclude complicated UTIs. Patients with uncomplicated UTIs empirically treated with amoxicillin-clavulanate, nitrofurantoin, ciprofloxacin or co-trimoxazole were followed-up for 28 days. Treatment failure was defined as re-attendance for symptoms and antibiotic re-prescription, or hospitalisation for UTI complications. After 2:1 propensity score matching in each group, modified Poisson regression and Cox proportional hazard regression accounting for matched data were used to determine risk and time to treatment failure.Results3194 of 4253 (75.1%) UTIs seen were uncomplicated, of which only 26% were diagnosed clinically. Urine cultures were conducted for 1094 (34.3%) uncomplicated UTIs, of which only 410 (37.5%) had bacterial growth. The most common organism found to cause uncomplicated UTIs was Escherichia coli (64.6%), with 92.6% and 99.4% of isolates sensitive to amoxicillin-clavulanate and nitrofurantoin respectively. Treatment failure occurred in 146 patients (4.57%). Among 1894 patients treated with AC + N matched to 947 patients treated with C + C, patients treated with C + C were 50% more likely to fail treatment (RR 1.49, 95% CI 1.10–2.01), with significantly higher risk of experiencing shorter time to failure (HR 1.61, 95% CI 1.12–2.33), compared to patients treated with AC + N.ConclusionTreatment failure rate was lower for antibiotics with lower reported resistance rates (AC + N). We recommend treating uncomplicated UTIs in Singapore with amoxicillin-clavulanate or nitrofurantoin, based on current local antibiograms. Diagnosis, investigations and management of UTIs remained sub-optimal. Future studies should be based on updating antibiograms, highlighting its importance in guideline development.