1 do you vote for penicillin? an interactive workshop on treatment of upper respiratory tract...

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Do you vote for Do you vote for Penicillin?Penicillin?

An interactive workshop on An interactive workshop on treatment of upper respiratory treatment of upper respiratory

tract infectionstract infections

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What did you have for breakfast What did you have for breakfast today?today?

Danish morgenmadDanish morgenmad Continental breakfastContinental breakfast Full hotel breakfastFull hotel breakfast NothingNothing

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What is your occupation?What is your occupation?

Family doctorFamily doctor TraineeTrainee Doctor in other specialtyDoctor in other specialty OtherOther

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Where do you work?Where do you work?

DenmarkDenmark NorwayNorway SwedenSweden FinlandFinland IcelandIceland Other countryOther country

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Did you take part in Happy Audit?Did you take part in Happy Audit?

YesYes NoNo What is Happy Audit?What is Happy Audit?

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Case 1Case 1

Sore throatSore throat

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Case 1Case 1 28 year old mother with sore throat28 year old mother with sore throat 2 children, 2 and 6 years. Strep disease in the 2 children, 2 and 6 years. Strep disease in the

kindergarden kindergarden Fever and pain in throat since 3 days, no other Fever and pain in throat since 3 days, no other

problems from respiratory tract.problems from respiratory tract. MalaiseMalaise Temp 38,6 CTemp 38,6 C Swollen tonsils with exudateSwollen tonsils with exudate Lymfnodes swollen and painfulLymfnodes swollen and painful

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Case 1 – What do you do?Case 1 – What do you do?

CRPCRP Quicktest for Strep AQuicktest for Strep A 1+21+2 Bacterial culture for Strep ABacterial culture for Strep A Treat w Penicillin V without investigationsTreat w Penicillin V without investigations Treat w Amoxicillin without investigationsTreat w Amoxicillin without investigations No test – no treatmentNo test – no treatment

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Case 1.1 – her 2 year old childCase 1.1 – her 2 year old child

CRPCRP Quicktest for Strep AQuicktest for Strep A 1+21+2 Bacterial culture for Strep ABacterial culture for Strep A Treat w Penicillin V without investigationsTreat w Penicillin V without investigations Treat w Amoxicillin without investigationsTreat w Amoxicillin without investigations No test – no treatmentNo test – no treatment

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Case 1.2Case 1.2 28 year old man with sore throat28 year old man with sore throat Children in the same institution as beforeChildren in the same institution as before Slight pain in throat since 3 days, no other Slight pain in throat since 3 days, no other

problems from respiratory tractproblems from respiratory tract Temp 37.1Temp 37.1 Slight redness of tonsils.Slight redness of tonsils. No exsudateNo exsudate No swollen and painful lymf glandsNo swollen and painful lymf glands Positive quicktest Strep APositive quicktest Strep A

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Case 1.2 – What do you do?Case 1.2 – What do you do?

CRPCRP Bacterial culture for Strep ABacterial culture for Strep A Treat w Penicillin V without investigationsTreat w Penicillin V without investigations Treat w Amoxicillin without investigationsTreat w Amoxicillin without investigations No treatmentNo treatment

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Case 1 Case 1

What did the participants in Happy Audit do?What did the participants in Happy Audit do?

Use of Strep A in patients with sore Use of Strep A in patients with sore throatthroat

Patients StrepA performed

Percentage with Strep A

Argentina 1500 33 2.2%

Denmark 1061 822 77.5%

Lithuania 803 0 0.0%

Russia 764 4 0.5%

Spain 7052 96 1.4%

Sweden 501 319 63.7%

Total 11681 1274 10.9%

Centor criteria*:Centor criteria*:

1.1. FeverFever2.2. Tender angular glands Tender angular glands 3.3. Tonsil Coatings Tonsil Coatings 4.4. Absence of cough Absence of cough

*Described by dr. Robert Centor *Described by dr. Robert Centor of the University of Alabamaof the University of Alabama

Centor criteria and probability of Centor criteria and probability of StreptococciStreptococci

Number of Centor Criteria

Probability of Streptococci

Recommandation

0 2% No test – no treatment

1 3% No test – no treatment

2 8% Test and treat

3 19% Test and treat

4 41% Test and treat

Patients with 0-1 Centor criteria should not be tested with Strep A

Strep A test in DenmarkStrep A test in Denmark

Strep A test in SwedenStrep A test in Sweden

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Case 2Case 2

Otitis mediaOtitis media

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Case 2Case 2

4 year old child, no previous ear infection4 year old child, no previous ear infection Running nose since 5 days.Running nose since 5 days. Last night severe pain in one earLast night severe pain in one ear Temp 38.1 CTemp 38.1 C No swollen tonsilsNo swollen tonsils Small lymfnodes slightly swollen and Small lymfnodes slightly swollen and

painfulpainful

2525http://commons.wikimedia.org/wiki

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CRPCRP Nasopharyngeal culture Nasopharyngeal culture Treat w Penicillin V without investigationsTreat w Penicillin V without investigations Treat w Amoxicillin without investigationsTreat w Amoxicillin without investigations Delayed prescription – just in caseDelayed prescription – just in case No antibiotic, adviceNo antibiotic, advice No antibiotic, new appointment in three No antibiotic, new appointment in three

daysdays

Use of CRP in patients with OtitisUse of CRP in patients with Otitis

Patients CRP performed Percentage with CRP


Denmark 270 16 5.6%

Lithuania 79 2 2.5%

Russia 77 0 0.0%

Spain 416 0 0.0%

Sweden 196 15 7.1%

Total 1222 33 1.3%

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Case 3Case 3

CoughCough

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Case 3Case 3

37 year old man 37 year old man Smokes at parties and business meetingsSmokes at parties and business meetings No previous problems from respiratory No previous problems from respiratory

tract, but ”always bothered by cough” and tract, but ”always bothered by cough” and ”prolonged colds””prolonged colds”

Troublesome coughing, esp at night.Troublesome coughing, esp at night. No fever, normal breathing.No fever, normal breathing. Normal lung auscultationNormal lung auscultation

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CRPCRP Chest X-rayChest X-ray 1+21+2 Penicillin V without further investigationsPenicillin V without further investigations Other antibiotic without further investigationsOther antibiotic without further investigations Delayed prescription – just in caseDelayed prescription – just in case No antibiotic, adviceNo antibiotic, advice

Use of CRP in patients with acute Use of CRP in patients with acute BronchitisBronchitis



Denmark 391 181 46.3%


Russia 325 1 0.3%

Spain 2109 0 0.0%

Sweden 223 120 53.8%

Total 1222 328 8.2%

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• Acute Bronchitis is an acute respiratory tract Acute Bronchitis is an acute respiratory tract infection caused by virus, and should, in infection caused by virus, and should, in general, not be treated with antibioticsgeneral, not be treated with antibiotics

• CRP may be helpful to distinguish between CRP may be helpful to distinguish between acute bronchits and pneumoniaacute bronchits and pneumonia

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Case 4Case 4

SinusitisSinusitis

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Case 4 - sinusitisCase 4 - sinusitis

Woman, 28 years old, non-smoker, two Woman, 28 years old, non-smoker, two small childrensmall children

Often suffers from sinusitis and always Often suffers from sinusitis and always needs antibiotic treatment to recover…needs antibiotic treatment to recover…

Now nasal congestion > 7 daysNow nasal congestion > 7 days Pain under left eye. Worsening when she Pain under left eye. Worsening when she

is leaning forwardis leaning forward Less relief from OTC nasal sprayLess relief from OTC nasal spray

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CRPCRP Sinus X-ray / CT – antibiotics if +iveSinus X-ray / CT – antibiotics if +ive Penicillin V without further investigationsPenicillin V without further investigations Other antibiotic without further investigationsOther antibiotic without further investigations Delayed prescription – just in caseDelayed prescription – just in case No antibiotic, adv: saline nasal wash, steam etcNo antibiotic, adv: saline nasal wash, steam etc Nasal steroid sprayNasal steroid spray

Use of CRP in patients with acute Use of CRP in patients with acute SinusitisSinusitis



Denmark 272 155 57.0%

Lithuania 74 1 1.4%

Russia 134 0 0.0%

Spain 445 0 0.0%

Sweden 120 11 9.2%

Total 1150 167 14.5%

Duration of symptoms at first Duration of symptoms at first consultation for patients with sinusitisconsultation for patients with sinusitis

Median 25% percentile 75% percentile

Argentina 4 2 5

Denmark 7 4 12

Litauen 5 3 7

Russia 3 2 5

Spain 5 3 8,5

Sweden 10 7 14

Total 5 3 10

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Case 5Case 5

Exacerbation of COPDExacerbation of COPD

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Case 5Case 5 76 years old, previous smoker76 years old, previous smoker FEV1/FVC = 0.58 at last spirometryFEV1/FVC = 0.58 at last spirometry FEV1 45% of expectedFEV1 45% of expected Has inhaled anticholinergic, beta2 and steroid Has inhaled anticholinergic, beta2 and steroid

treatment. treatment. Gets exacerbation 1-2/year often needs Gets exacerbation 1-2/year often needs

antibiotic treatment to recover…antibiotic treatment to recover… Now cough and short of breath 4 daysNow cough and short of breath 4 days Increased volume of white, foaming sputumIncreased volume of white, foaming sputum Temp 37.9Temp 37.9

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Case 5Case 5

CRP 45CRP 45 Chest X-ray: No signs of pneumoniaChest X-ray: No signs of pneumonia PaO2 92%PaO2 92% Inhalation of bronchodilatator in practice Inhalation of bronchodilatator in practice

does not relief patients symptoms does not relief patients symptoms

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Penicillin VPenicillin V Amoxicillin Amoxicillin Amoxi-ClavAmoxi-Clav Other antibiotic without further investigationsOther antibiotic without further investigations Referral to hospitalReferral to hospital No antibiotic treatmentNo antibiotic treatment

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Case 5 – Systemic steroidsCase 5 – Systemic steroids

AcuteAcute Acute and short courseAcute and short course Acute and start continuous treatmentAcute and start continuous treatment No systemic steroids, increase inhaled No systemic steroids, increase inhaled

steroids insteadsteroids instead

Use of CRP in patients with acute Use of CRP in patients with acute exacerbation of COPDexacerbation of COPD



Denmark 90 59 65.6%


Russia 168 0 0.0%

Spain 732 0 0.0%

Sweden 33 13 39.4%

Total 1233 89 1.2%

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Anthonisen’s criteria*:Anthonisen’s criteria*:

1.1. Increased dyspnoeaIncreased dyspnoea2.2. Increased sputum volume Increased sputum volume 3.3. Increase sputum purulenceIncrease sputum purulence

• Anthonisen NR, Manfreda J, Warren CPW et al.: Anthonisen NR, Manfreda J, Warren CPW et al.: Antibiotic therapy in Antibiotic therapy in exacerbations of chronic obstructive pulmonary exacerbations of chronic obstructive pulmonary

disease. Ann Intern Med disease. Ann Intern Med 1987; 106: 196-2041987; 106: 196-204..

Anthonisen criteria and antibiotic prescribing in Anthonisen criteria and antibiotic prescribing in patients with exacerbation of COPDpatients with exacerbation of COPD

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Evaluationof the workshopEvaluationof the workshop

RelevanceRelevance Use of voting deviceUse of voting device Overall qualityOverall quality

This workshop was very This workshop was very relevant for merelevant for me

Totally disaggreeTotally disaggree Partly disagreePartly disagree Somewhat disagreeSomewhat disagree IndifferentIndifferent Somewhat agreeSomewhat agree Partly agreePartly agree Totally agreeTotally agree

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The use of the voting device The use of the voting device was goodwas good


6262

The overall quality was The overall quality was satisfyingsatisfying

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1 do you vote for penicillin? an interactive workshop on treatment of upper respiratory tract...

Documents

treatment slide

days slide

painful slide

sweden slide

denmark slide

country slide

orgwiki slide

sore throat slide