1 7th european congress of chemotherapy and infection florence - italy, october 19-22, 2005 gps in...
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7th European Congress of Chemotherapy and InfectionFlorence - Italy, October 19-22, 2005
GPs in France, clinical evaluation and prescriptions in respiratory tract infections
Pr Christian ChidiacService des Maladies Infectieuses et TropicalesINSERM 0230Hôpital de la Croix Rousse F69317 [email protected]
Mars 2000 Les Outils de la Traçabilité 2
ABT prescriptions in France
Sources : EPPM - INSEE
100
120
140
160
180
200
220
1980
1982
1984
1986
1988
1990
1992
1994
1996
1998
2000
Antibiotic prescriptions GPs French population
3
ABT consumption EU - 2002Utilisationantibiotique en villeen Europe - 2002
0
5
10
15
20
25
30
35
FR GR LU PT IT BE SK HR PL IS IE ES FI BG CZ SI SE HU NO UK DK DE LV AT EE NL
DD
D p
er 1
000
inh
. p
er d
ay
OthersJ01B+J01G+J01X
Sulfonamides andtrimethoprim J01E
Quinolones J01M
Macrolides, Lincosam.,Streptogramins J01F
Tetracyclines J01A
CephalosporinsJ01D
Penicillins J01C
4
Germany Belgium Spain Italy France Netherland
Upper resp infections 36% 42% 41% 33% 56% 33%
Respiratory infections 32% 32% 21% 25% 28% 28%
Skin and soft tissu inf 3% 6% 15% 12% 5% 7%
UTI 17% 9% 13% 18% 7% 17%
Miscellaneous 12% 11% 10% 12% 4% 15%
Source : IMS
ABT Prescriptions in European coutries (2001)
5
Review of main guidelines in France
7
Common cold
Bacterial complication as acute otitis media, sinusitis
Risk factors for bacterial complication
Non-complicated common cold
Non-complicated common cold and risk factors
Common cold with bacterial complication
Inform parents/patients of clinical signs indicative of bacterial complication*
Symptomatic treatment
Symptomatic treatment and follow up
ABT treatment of the bacterial complication
In case of secondary bacterial complication
Investigate for
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Purulent AOM
OM with effusionRedness of tympanic membrane
No ABT No ABT
> 2 Years, mild symptoms
No ABT treatment
< 2 years,
> 2 years, marked symptoms
ABT treatment
Symptomatic treatment
Follow up 48-72 h
Amoxicillin clavulanic acid or cefuroxime-axetil or cefpodoxime-
proxetyl
Contra-indication for betalactam : erythromycin-sulfafurazole
pristinamycin
11
Clinical signs of pharyngitis
Rapid Antigen TestPositive Negative
ABT*
Symptomatic treatment
*Amoxicillin,
Penicillin allergy : 2nd, 3rd G cephalosporin
Contra-indication for betalactams : pristinamycin (> 6 y), macrolide, telithromycin
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Clinical signs of pharyngitis
Rapid Antigen TestPositive Negative
ABT* Yes NoAcute rheumatic fever risk factors
Symptomatic treatmentCulturePositive Negative
*Amoxicillin,
Penicillin allergy : 2nd, 3rd G cephalosporin
Contra-indication for betalactams : pristinamycin (> 6 y), macrolide, telithromycin
16
CAP : Healthy Adult
Pneumococcal or atypical ?
Pneumococcal
(acute onset)
Atypical (epidemic context, progressive
onset)
Oral amoxicillin 3g/d
Failure
Oral amoxicillin 3g/d
Or telithromycin,
or pristinamycin
Macrolide, Telithromycin, Pristinamycin,
Respiratory quinolone
Failure
Oral macrolide
Failure
Oral amoxicillin, Telithromycin, Pristinamycin,
Respiratory quinolone
Hospital if severity symptoms,
Complication, or failure of 2nd line ABT
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CAP : Adult with Risk Factors
Failure
Hospital
Parenteral 3rd G cephalosporin,
Amoxicillin clavulanic acid,
Respiratory quinolone
Severity symptoms Complication
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Classification of COPD
Stage I, II, III : FEV1/FVC < 70%,
Inconsistent chronic symptoms (cough, sputum production)
Dyspnea at restStage III : severe COPDFEV1 < 30% predictedor FEV1 < 50% + hypoxemia < 60 mmHg
Dyspnea of effortStage II : Moderate COPD
50% ≤ FEV1 < 80% predicted
No dyspnea of effortStage I : Mild COPD
FEV1 ≥ 80%
chronic symptoms : cough, sputum production
No dyspnea of effortStage 0 : FEV1/FVC > 70% predicted
Associated Clinical signsSeverity upon spirometry
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COPD : at risk patients*
One of the following characteristics
• FEV1 < 30% at baseline
• Hypoxemia at baseline (< 60 mmHg [8 Kpa])
• Frequent exacerbations (≥ 4/Year)
• Long term steroid treatment
• Comorbidity, underlying illness
• CAP history
* Risk of : – Severe respiratory failure, – Underlying illness decompensation, – GNB infection (H. influenzae excluded)
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Antibiotic management of AECOPD
One risk factor* at least
Yes
*Dyspnea (or FEV1 < 35%), hypoxemia, systemic steroid treatment, > 4 AECB / y, comorbidity, CAP history
Yes
Amoxicillin clavulanic acid, 2nd G oral cephalosporin (cefuroxim)
3rd G cephalosporin (cefpodoxime, cefotiam, ceftriaxone)
Respiratory quinolone
Failure :Sputum culture : Pseudomonas ?
X-ray
No
AmoxicillinMacrolide
PristinamycinTelithromycin
No
Follow upNo antibiotic
Clinical worseningor
Purulence of sputum
Acute Exacerbation of COPD stage I, II, III
Increased purulence of sputum + dyspnea and/or increased volume of sputum
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Controlling ABT prescriptions in France
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Controlling ABT prescriptions in France :History
• 1993 : « RMO » : French references • 1996 : Antibiotics and resistance in hospital (Andem)• 1998 : Observatory on use of ABT• 1999 : Fight against bacterial resistance (InVS)• 1999-02 : Official French Guidelines (Afssaps)• 2001 : National Antibiotic Plan (B Kouchner, Health Minister)• 2002 : Consensus conference : How to improve quality of
ABT prescriptions ? (French Society for Infectious Diseases)• 2002 : Ministerial circular : ABT referent doctors• 2002 : French social insurance campaign
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French 1993 references « RMO »
• « Experts » from the French Social Security
• Focus on useless or dangerous prescriptions
• “It is not indicated to prescribe….”
– Aminopenicillin and betalactamase inhibitor, 2nd or 3rd G
cephalosporin
– For no risk patients
– Suffering of seasonal respiratory infections, pharyngitis, or CAP
– Excluded : AOM, sinusitis, epiglottitis, bronchiolitis
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French 1993 references « RMO » : Results
Angine
Bronchite
IPPM/IMS France
Indication targeted by the « RMO » Indication not targeted by the « RMO »
0
10
20
30
40
50
60
70
80
P93 A93 P94 A94 P95 A95 P96 A96 P97 A97
Acute Otitis
Acute sinusitis
RMO + 12 months RMO + 4 yearsRMO
0
10
20
30
40
50
60
70
80
P93 A93 P94 A94 P95 A95 P96 A96 P97 A97
Pharyngitis
Bronchitis
% ABTRMO + 4 yearsRMO + 12 monthsRMO
% ABT
27
Prescription : impact of RMO and Drug Promotion
0
5
10
15
20
25
30
35
40
85 87 89 91 93 95 97 99 '01
'03
Aminopenicillin
R.M.O
Amoxicillin price
0
5
10
15
20
25
30
35
40
85 87 89 91 93 95 97 99 '01
'03
Cephalosporins
R.M.O
0
5
10
15
20
25
30
35
40
85 87 89 91 93 95 97 99 '01
'03
Macrolides
R.M.O
Prescriptions Drug promotion Launching new drugSources : CAM, Dorema
Generic Drug
28
Prescription : Impact of RMO andDrug Promotion
0
5
10
15
20
25
87 89 91 93 95 97 99 '01
'03
BL Inhibitors
R.M.O
0
5
10
15
20
25
87 89 91 93 95 97 99 '01
'03
C2G / C3G
R.M.O
0
5
10
15
20
25
87 89 91 93 95 97 99 '01
'03
Quinolones
R.M.O
Prescriptions Drug promotion Launching new drug
Sources : CAM, Dorema
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French National ABT Campaign
• General Public… – Television vidéo clips, radio, newspapers, magazines
• Medical Doctors…– Rapid Antigen Test for pharyngitis, formation– Therapeutic forms – Individual medical interview– Transmission of consumption information
• Childhood professionals, parents…– Information, education, meetings
• Patients…– Documentations, information ABT risks, resistance…
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ABT prescriptions since 1980 in France
Source : EPPM
100
110
120
130
140
150
160
170
180
190
200
210
220
1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002
BASE 100 = 1980
(#)
(#)
(#)
(#)
(#)
(#)
(#)
(RMO)
(#)
(#) = Epidemy
(#)
(#)
Plan CNAMTS
(#)
32
First Results : drop in prescriptions
Mean drop : -10,2 %
4,1 millions of prescriptions
-5,4 %1,9 millions ofprescriptions
En
mil
lio
ns
de
pre
sc
rip
tio
ns
D. Guillemot, CERBEP, Institut Pasteur - CNAMTS
34,7
40,7 M
38,8 M
36,6 M
30
32
34
36
38
40
42
2000-2001 2001-2002 2002-2003 2003-2004
33
ABT consumption by age
Since 2002,
23,1% < 15 years
20,6% 0- 5 years
D. Guillemot, CERBEP, Institut Pasteur - CNAMTS
0
0,5
1
1,5
2
2,5
3
1 2 3 4 5 6-10 11-15
16-20
21-25
26-30
31-35
36-40
41-45
46-50
51-55
56-60
61-65
66-70
71-75
76-80
81-85
86-90
90et +
Age (years)
Con
sum
ptio
n by
6 m
onth
s/in
habi
tant
winter 2001-2002 winter 2002-2003 winter 2003-2004
-0,5
-0,6
-0,3
34
ABT prescriptions in respiratory infections1995-2004
Sinusite CIM 10
OtiteBronchite
Prescriptions/100 visits
Pharyngite
Source : EPPM
15
25
35
45
55
65
75
85
95
105
1995(été)
1996 1997 1998 1999 2000 2001 2002 2003 2004
Tonsillitis
Rhinopharyngitis
Bronchitis
Acute Otitis
Sinusitis CIM 9
Sinusitis CIM 10
Pharyngitis
36
ABT treatment prescribed by GPs for CAP 2
No risk factors
Risk factors
total‡
In agreement with guidelines 22 (47%) 16 (34%) 38 (40)
Not in agreement with guidelines 25 (53%) 31 (66%) 56 (60%)
Total, N° 47 47 94
Pts without risk factor = amoxicillin or macrolide
Pts with risk factors = amoxicillin clavulanate, or oral cephalosporin ± macrolide or quinolone
Fantin B Chest 2001;120:185-192‡ p < 0.5
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Conclusion“Now, HERE, you see, it takes all the running
YOU can do, to keep in the same place”
Alice’s adventures trough the looking glass. L. Caroll