Transcript ANTIBIOTIC USE IN COMMUNITY ACQUIRED PNEUMONIA (CAP) IN

ANTIBIOTIC USE IN COMMUNITY
ACQUIRED PNEUMONIA (CAP) IN
PRIMARY CARE
Nena Kopcavar Gucek, MD, Msc
Community Health Center Ljubljana
and
Department of Family Medicine
Medical School
University of Ljubljana
Contents of presentation
1. Drugs prescribing in GP/FM
2. Primary care in Slovenia-basic data
3. Guidelines and recommendations for
treatment of CAP on primary level
4. Adherence to recommendations
5. Proposals for improvement
Contributing factors for the pattern of drugs
prescribing in GP/FP(1)-PERMANENT
-prescription as a symbol (token, proof of
severity of condition)
-influence of a (long-term)relationship
between doctor and patient: trust and
partnership
-time factor
-characteristics of the practice: rural vs city,
student clinic vs nursing home etc.)
Contributing factors for the pattern of drugs
prescribing in GP/FP(2)-VARYING
-professional guidelines and recommendations
-the register of available drugs in Slovernia
(IPH; every 2 years)
-List of drugs in Slovenia (Slovenian Health
Insurance Cmpany, every 6 months)
-epidemiology, resistance
-ageing of the population
-development of new drugs (and diseases)
-….?
Slovenian GP/FP (1)-general
data
-890 physicians (general/family practice) per 2 mio
inhabitants
-specialty for practising GP/FP required since 2007
-role in the healthcare scheme-»gatekeeper«»coordinator«
Švab I, Petek Šter M, Kersnik J, Živčec Kalan G, Car J. A crosssectional study of performance of Slovene general practitioners.
Zdrav Var 2005; (44): 183-92.
Slovenian GP/FP (2)-workload
-42 doctors registered 300 consecutive visits
-12.296 consultations in GP/FP were analysed
-on average 46,5 consulationsper doctor per day
-average time per consultation measured 7,08 min
(8,5 min exam)
-20,2% of visitors were referred to secondary level
(83% urgent)
Švab I, Petek Šter M, Kersnik J, Živčec Kalan G, Car J. A crosssectional study of performance of Slovene general practitioners.
Zdrav Var 2005; (44): 183-92.
Slovenian GP/FP (3)- Statistics
of health problems
-27,8% of visitors diagnosed with acute disease
-16,8% of all visitors were diagnosed with
respiratory disease (cardiovasc 26,5% and
musculoscelet 24,7%)
-out of all, 58,1% of visitors received prescription(s)
-1,95 prescription per visitor (1 to 9, SD 1,342)
Švab I, Petek Šter M, Kersnik J, Živčec Kalan G, Car J.
A cross-sectional study of performance of Slovene
general practitioners. Zdrav Var 2005; (44): 18392.
Slovenian GP/FP(4)-Issues in
prescribing drugs
-FP/GP prescribe more than 70% of all drugs in the
outpatient settings
-72% inhabitants of R Slovenia receive at least 1
precription per year (MEDICALISATION?)
-23.000 Slovenians were prescriberd more than 10
different drugs (INTERACTIONS?)
-such pattern of prescribing was observed in 500
Slovenian doctors (RATIONALITY?)
Jurij Fuerst, ISIS 20 (7):14-6.
Guidelines and recommendations for
treating CAP on primary level
1. Čižman M, Beović B. Manual for prescribing of
antimicrobal drugs in primary setting.
Ljubljana, Arcadia, 2002.
2. Mušič M, Osolnik K, Tomič V, Eržen R, Košnik M,
Beović B, Lejko Zupanc T, Strle F, Vodopivec
Jamšek V, Živčec Kalan G, Švab I, Sočan M.
Recommendations for the management of
community acquired pneumonia in adults
3.http://www.szd.si/user_files/vsebina/Zdravniski_
Vestnik/2010/marec/245-64.pdf
Sensitivity of causing agents for lower respitarory tract
infections in Slovenia in 2004
(Seme K and al, Infectologic Symposium
Ljubljana 2004)
 H. influenzae S for
ampicillin(amoxicillin=97,7%
 M. catharralis S for
ampicillin/amoxicillin=65%
Prospective study (1)
-109 GP/FP included 1000 pts
-doble data uptake: questionnaire for doctors
and questionnaire for patiens
-2 focuses: use of antibiotics and impact of
antibiotics on patients˙recovery
KLEMENC-KETIŠ, Zalika, DREŠČEK, Marko, KLEMEN, Maja,
KERSNIK, Janko. Impact of antibiotic treatment on lower
respiratory tract symptoms. V: POPLAS-SUSIČ, Tonka (ur.),
VAJD, Rajko (ur.). [Zbornik predavanj], (Medicinski
razgledi, Supplement, letn. 50, suppl. 1). Ljubljana:
Medicinski razgledi, 2011, str. 57-61.
Prospective study (2)
Prescribing of antibiotics in patients with
pneumonia:
 -penicillin 42,4%
 -penicillin and clavulonic acid 18%
 -macrolids 33,3%
 -quinolones 6,1% (sensitivity to penicillin only
in 10% of Slovenian population!)
Prospective study (3)
 Longer duration of symptoms was not related
to prescription of antibiotic.
 Contributing factors to longer duration of
respiratory tract infection were strongly
correlated with:
-pneumonia
-duration of symptoms prior to visit to GP/FP
-presence of asthma
PROTIMIKROBNA ZDRAVILA
št. DDD/1000 prebiv. na dan
poraba zdravil v letu 2008 v štev. DDD na 1000 prebiv. na dan
18
16
14
12
10
8
6
4
2
0
CE
KK
tetraciklini
amoksicilin in klavul. k.
piranozidi
KP
KR
LJ
širokospektralni p.
cefalosporini
kinoloni
MB
MS
NG
fenoksimetilpenicilin
TMP/SMX
NM
RK
SLO
antistafilokokni p.
makrolidi
PROTIMIKROBNA ZDRAVILA
poraba zdravil v letih 2006, 2007 in 2008 v štev. DDD na 1000 prebiv. na dan
20
18
št. DDD/1000 prebiv. na dan
16
14
12
10
8
6
4
2
0
NG
NM
KR
KP
MB
2006
RK
2007
SLO
CE
2008
LJ
KK
MS
Kinoloni (ciprofloksacin, norfloksacin, pefloksacin) ter sulfometoksazol s trimetoprimom
poraba zdravil v letu 2008 v štev. DDD na 1000 prebiv. na dan
št. DDD/1000 prebiv. na dan
3
2,5
2
1,5
1
0,5
0
CE
KK
KP
KR
LJ
MB
uro kinoloni
MS
TMP/SMX
NG
NM
RK
SLO
Primerjava med porabo amoksicilina ter kombinacije amoksicilina s
klavulansko kislino
poraba zdravil v letu 2008 v štev. DDD na 1000 prebiv. na dan
10
št. DDD/1000 prebiv. na dan
9
8
7
6
5
4
3
2
1
0
CE
KK
KP
KR
LJ
amoksicilin
MB
MS
NG
amoksicilin in klavul. k.
NM
RK
SLO
Primerjava med porabo amoksicilina ter kombinacije amoksicilina s
klavulansko kislino
poraba zdravil v letu 2008 v deležu štev. DDD na 1000 prebiv. na dan
100%
90%
št. DDD/1000 prebiv. na dan
80%
70%
60%
50%
40%
30%
20%
10%
0%
CE
KK
KP
KR
LJ
amoksicilin
MB
MS
NG
amoksicilin in klavul. k.
NM
RK
SLO
Poraba antibiotikov po OE v DDD
pri otrocih do 19. leta in odraslih v 2008
20
DDD/1000 inh./day
18
16
14
12
10
8
6
4
2
0
KR
NG
NM
KP
SLO
LJ
CHILDREN
CE
ADULTS
RK
KK
MB
MS
CONCLUSION
-Antibiotics in CAP in Slovenia are not
prescribed in accordance with guidelines and
recommendations.
-Education on several levels could improve the
pattern of prescribing.
- Not only professional, but also lay public
should and already has been targeted.
-Common goals among policy makers, health
professional and patients should be
emphasized.
A great secret of success is to go through life
as a man who never gets used up.
A. Schweitzer