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New Norwegian national guidelines for antibiotic use in primary care Presentation 14.5.09, Nordisk kongress, København Morten Lindbæk professor in general practice, UiO leader Antibiotic Centre for primary care. Background. 1999: National plan to stop antibiotic resistance

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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

Background primary care

  • 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

Goals primary care

  • 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”.

Important trends in antibiotic use norway 1999 2006
Important trends in antibiotic use Norway 1999-2006 primary care

  • 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%)


Relation between antibiotic consumption and proportion resistant pneumococci

In some European countries(Goossens et al, Lancet 2005; 365:579-587 )


Prevalence of av erythromycin resistance in pneumococci in blood culturs in Norway 2000-2006

NORM 2006

Joint edition between the directorate of health and asp
Joint edition between the Directorate of health and ASP blood culturs in Norway 2000-2006

  • 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”

E s eu
EØS/EU blood culturs in Norway 2000-2006

  • 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

Plan for the work
Plan for the work blood culturs in Norway 2000-2006

  • 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

Grading of evidence
Grading of evidence blood culturs in Norway 2000-2006

Implementation blood culturs in Norway 2000-2006

  • Written guidelines in book

  • Electronic format on CD and on the web, at


  • 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

Implementation blood culturs in Norway 2000-2006

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

What s new general chapters
What’s new? General chapters blood culturs in Norway 2000-2006

  • 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

Some important highlights in respiratory tract infections
Some important highlights in respiratory tract infections blood culturs in Norway 2000-2006

  • Acute otitis media

  • Acute sinusitis

  • Acute tonsillitis

  • Acute bronchitis Pneumonia

  • Exacerbations of COLD

  • (Acute conjunctivitis)

General considerations
General considerations blood culturs in Norway 2000-2006

  • 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)

Dosage of penicillin v
Dosage of penicillin V blood culturs in Norway 2000-2006

  • 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 1+1+2 (mill.IE) is obsolete. Swedish tradition has been 2x2 mill IE, Denmark? Finland?

  • Best er 1+1+1+1, alternatively 1+1+1.

  • 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…

Otitis media
Otitis media blood culturs in Norway 2000-2006

  • Children with fever + deteriorated general condition

  • Children under 1 year

  • ”Ear children” (recurrent infections)

  • perforation > 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

Acute sinusitis
Acute sinusitis blood culturs in Norway 2000-2006

  • Generalised infection and deteriorated general condition

  • Symptom duration > 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.

Acute tonsillitis
Acute tonsillitis blood culturs in Norway 2000-2006

  • 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 G&C – same clinical course

  • Children: No benefit from pencillin (Zwart BMJ)

  • Potential of delayed prescription?

Acute bronchitis pneumonia
Acute bronchitis - pneumonia blood culturs in Norway 2000-2006

  • 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.

Cold exacerbation change in guideline
COLD-exacerbation blood culturs in Norway 2000-2006change 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.

Conjunctivitis and kinder garten
Conjunctivitis and kinder garten blood culturs in Norway 2000-2006

  • 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

Controversies not covered here
Controversies not covered here blood culturs in Norway 2000-2006

  • Skin infections

  • Empiric treatment of urethritis

  • Bacterial vaginosis in pregnancy

  • Screening for symptomatic bacteriuria in pregnancy


Thanks for your attention blood culturs in Norway 2000-2006