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New Norwegian national guidelines for antibiotic
use in primary carePresentation 14.5.09,
Nordisk kongress, KøbenhavnMorten
Lindbækprofessor in general practice, UiOleader
Antibiotic Centre for primary care
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Background

• 1999 National plan to stop antibiotic resistance
  
• 90 of all antibiotics in Norway is prescribed
  in primary care and 60 for resp. tract
  infections
• 2 guidelines were proposed
• One for primary care
• One for hospital care

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Goals

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

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Important trends in antibiotic use Norway
1999-2006

• Total use up from 16.6 DDD to 19,0 DDD (14)
• Penicillin extended spectrum (amoxicillin) up
  1,96-2,74 (40)
• Penicillin V down 5,01 4,63 (8)
• Kloxa/dikloxa up 0,32-0,66 (100)
• Tetracykliner up 3,19 3,24 (2)
• Makrolider up 1,59-2,24 (40)

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Relation between antibiotic consumption and
proportion resistant pneumococci In some European
countries(Goossens et al, Lancet
2005 365579-587 )
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Prevalence of av erythromycin resistance in
pneumococci in blood culturs in Norway 2000-2006
NORM 2006
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Joint edition between the Directorate of health
and ASP

• On behalf of the government ASP was asked to
  revise the guidelines in February 2007.
• The health directorate and ASP act as joint
  editors.
• The new guidelines get a higher status as
  National professional guidelines

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EØS/EU

• An increasing number of new antibiotics are
  introduced in the market.
• Due to the EØS-treaty Norwegian authorities can
  no longer stop marketing of new antibiotics,
  which was done previously Behovsparagrafen.
  (Paragraph of need)
• The national drug authorities have therefore
  decided that the following sentence shall be
  included in all presentations of antibacterials
• Official national guidelines shall be taken into
  account in the choice of antibacterials in
  practice
• Example liberal prescription of ciprofloxacin

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Plan for the work

• Pairs of academic GP and an organ specialist for
  each chapter, in all 30 persons
• Many persons involved in Norsk Elektronisk
  Legehåndboks (NEL) coworkers were asked

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Grading of evidence
Knowledge 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 A
Knowledge 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
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Implementation

• Written guidelines in book
• Electronic format on CD and on the web, at
• www.antibiotikasentret.no
• Short table version in A4-format, with the most
  common diagnoses and antibiotics
• Distribution to all Norwegian GPs, doctors in
  nursing homes, health stations and emergency
  rooms
• Distribution to all Norwegian medical students
  and to doctors educated abroad
• Guidelines are integrated also in CME for general
  practice specialisation

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Implementation

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

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Whats new? General chapters

• Antibiotic resistance
• MRSA
• Microbiologic diagnostics in GP office
• Infections in nursing homes (iv treatment?)
• Antibiotics for pregnant and breast-feeding
• Delayed prescriptions (half of the patients do
  not start treatment)
• Interactions

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Some important highlights in respiratory tract
infections

• Acute otitis media
• Acute sinusitis
• Acute tonsillitis
• Acute bronchitis Pneumonia
• Exacerbations of COLD
• (Acute conjunctivitis)

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General considerations

• Use of penicillin V as first choice in
  respiratory tract infections is unchanged
• Important to keep the low rate of resistant
  bacteriae, especially pneumococci and Hæmophilus
  Influenzae
• Macrolides only in patients with penicillin
  allergy or documented atypicals (LRTI)

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Dosage of penicillin V

• The antibacterial effect of penicillin V is time
  dependent (minutes over MIC-value). With a short
  half time, the number of sdosages is crucial.
• Norwegian tradition with dosage 112 (mill.IE)
  is obsolete. Swedish tradition has been 2x2 mill
  IE, Denmark? Finland?
• Best er 1111, alternatively 111.
• Problem If we recommend this for all conditions,
  we might reduce the use of penicillin V and get
  more amoxicillin and macrolide use
• In the new guidelines we recommend x 4 for
  pneumonia, erysipelas (and GAS-tonsilitis).
• For other diagnoses we recommend 1 mill IE x
  3-4
• The challenge is compliance

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Otitis media

• Children with fever deteriorated general
  condition
• Children under 1 year
• Ear children (recurrent infections)
• perforation gt 3 days.
• However Study by Rovers et al Meta-analysis of
  individual patient data demonstrated that
  children with bilateral otitis and children under
  2 would benefit more from antibiotics

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Acute sinusitis

• Generalised infection and deteriorated general
  condition
• Symptom duration gt 10 days.
• Steroid nasal spray? Has only been demonstrated
  to be beneficial in addition to amoxicillin in US
  patients with recurrent infections.
• Delayed prescription good strategy?
• Meta-analysis of individual patient data
  demonstrated (Young et al) found no subgroups to
  benefit from antibiotic treatment.

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Acute tonsillitis

• Only treatment of streptococci.
• Use of 4 Centor criteria, Strep test only if 2-3
  present.
• Low dosage, 10 days treatment to avoid recurrency
• However Strep GC same clinical course
• Children No benefit from pencillin (Zwart BMJ)
• Potential of delayed prescription?

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Acute bronchitis - pneumonia

• No antibiotics for acute bronchitis.
  Beta2-agonist? Stop smoking
• Improve diagnostics for pneumonia.
• Use CRP og SR, may X-ray thorax.
• Penicillin as first choice.
• Atypical LRTI Await test results? PCR?
  Erytromycin.

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COLD-exacerbationchange in guideline

• Antonisen criteria Increase in dyspnea,
  expectoration or purulent secretion. In addition
  use CRP/ESR.
• If all 3 good effect of antibiotics, if 2
  doubtful, if 1 no effect
• Amoxicillin as first choice. Doxycyclin second
  choice or by penicillin allergy.

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Conjunctivitis and kinder garten

• Controversies between kinder gartens and
  parents/doctors whenter children with
  conjunctivitis should be allowed to og to kinder
  garten.
• Has led to very strict rules in some kinder
  gartens Children with some pus in the eye should
  og to doctor and should start treatment before
  coming back.
• Our response
• The doctor shall decide whether treatment is
  needed. If moderate symptoms, no treatment or
  delayed prescription (ref BMJ 2006)
• The danger of contagious disease is possibly
  exaggerated
• The kinder garten cannot demand that parents
  should og to doctor

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Controversies not covered here

• Skin infections
• Empiric treatment of urethritis
• Bacterial vaginosis in pregnancy
• Screening for symptomatic bacteriuria in pregnancy

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• Thanks for your attention