Report #9 - Landstinget Blekingeltblekinge.se/globalassets/forskning-och-utveckling/blekinge-kompe... · Strama is organised at two levels: a network of independent local multidis

ImPrim Report #9

B. Counteracting bacterial resistance in the BSR

eu.baltic.net

Part-financed by the European Union

(European Regional Development Fund and European Neighbourhood and

Partnership Instrument)

1

ImPrim Work Package 5

PHC as one pillar of regional development: Strategies to increase regional competitiveness

Report #9

Counteracting bacterial resistance within PHC in the BSR - Towards prudent prescribing of antibiotics

Editor Ingvar Ovhed3

Authors

Rolanda Valinteliene1, Ilona Bumbliene2, Kristina Leuketiene2, Ruta Radzeviciene2, E-L Strandberg3, Ingvar Ovhed3

1Institute of Hygiene, Vilnius Lithuania

2Department of Public Health, Faculty of health sciences, Klaipeda University, Lithuania

3Blekinge Centre of Competence, Karlskrona Sweden

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Content

ABSTRACT .............................................................................................................................................. 5

ABBREVIATIONS .................................................................................................................................... 6

1. INTRODUCTION .................................................................................................................................. 7

2. ACHIEVEMENT – FACING ANTIMICROBIAL RESISTANCE ......................................................... 14

3. FEASIBILITY STUDY IN KLAIPEDA, LITHUANIA ........................................................................... 15

4. IMPLEMENTATION OF A REGIONAL MODEL ON CONTAINMENT OF ANTIMICROBIAL

RESISTANCE (AMR MODEL) IN KLAIPEDA ...................................................................................... 27

5. A CLINICAL AUDIT ON URINE TRACT INFECTIONS (UTI), KLAIPEDA REGION LITHUANIA .. 30

6. RESEARCH STUDY AND HAPPY AUDIT 2 ..................................................................................... 39

7. DISCUSSION AND CONCLUSIONS ................................................................................................ 41

8. REFERENCES ................................................................................................................................... 44

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Abstract

The overall objective of ImPrim flagship project is to improve public health (especially in the

eastern part of the BSR). Within this wide field, the project will focus on the role of primary

health care and its benefits for the public health system as well as the regional competitiveness.

The specific objective of this PHC project piloted in the ImPrim frame work is Communicable

diseases and how to counteract the development of bacterial resistance from a primary health

care perspective. Focus for the ImPrim deliverable in the field of communicable disease was

changed.

Initially the focus was TBC and HIV,but this is not an arena where PHC will be a significant

actor. In stead was the increasing problem of bacterial resistance as a threat to future

development of health care considered to be more relevant for activities in PHC. During those

two years of the ImPrim project time when the changed focus was present, significant series of

projects have been piloted in the ImPrim frame work.

Existing professional networks like BARN (Baltic Antibiotic Resistance collaboration Networks)

have supported the implementation of highly relevant and important new policies and

organizations in the Klaipeda region in Lithuania. In clinical practice among professionals as well

as on the regional administration level have new tools and new structures been implemented.

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Abbreviations

APO Audit Project Odense

BSR Baltic Sea Region

BARN Baltic Antibiotic Resistance Collaboration Networks

BCC Blekinge Centre of Competence

GP General Practitioner

IoH Institute of Hygiene

MRSA Multiple Resistant Stafylococcus Aureus

NDPHS Northern Dimension Partnership in Public Health and Social Well-

being

NDPHS EG Expert Group of the Northern Dimension Partnership in Public Health and Social Well-being

NHS The National Health Service

PC Primary Care

PHC Primary Health Care

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1. Introduction

Excessive and inappropriate use of antibiotics is considered to be the most important reason for

development of bacterial resistance to antibiotics. It has been clearly documented that the

prevalence of resistant strains is correlated with the consumption of antibiotics, and studies

comparing bacterial resistance in various European countries have shown striking differences in

the consumption of antibiotics. As antibiotic resistance may spread across borders, countries with

a high prevalence of resistant strains may serve as a source of bacterial resistance for countries

with a low prevalence.

The ImPrim subprojects to counteract communicable diseases will focus on the role of Primary

Health care (PHC) in this field. A change from TBC and HIV/Aids to Respiratory Tract (RTI)

and Urinary Tract infections (UTI) has been carried out during 2011. The development of

bacterial resistance is now recognized as one of the main threats for further progress of health

care. PHC doctors play a dominating role in prescribing antibiotics for RTI as well as UTI.

ImPrim project partners have since long played an active role working for prudent prescribing of

antibiotics. Three projects partners in one of the latest transnational EU-project; “Happy Audit -

Medical Audits for Prudent Use of Antimicrobial Agents in European Primary Health Care” are

also partners of ImPrim. (2-4)

The first workshop in the BARN (Baltic Antibiotic Resistance Networks collaboration) project

was carried out in Riga during spring 2011. One out of three subprojects were dedicated to PHC

and Lithuania. This Lithuanian subproject was integrated with the ImPrim subprojects in this

field as both Blekinge Centre of Competence, Sweden (LP in ImPrim project), Institute of

Hygiene, Vilnius (PP4) and Dept of Public Health Klaipeda univ (PP14) were all active partners

in BARN networks.

A project group was formed by participants from these three ImPrim partners and their initial

idea was a project titled “Strama in Lithuania” aiming to introduce the idea of Strama in

Klaipeda region. The project idea was supported by the BARN steering committee and the

project started as a subproject of Imprim. Today two more projects are carried out under the

ImPrim umbrella and a third research project has started up coordinated from Lunds university

and funded by Sida Baltic Sea Unit to study the project process in Lithuania.

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BARN

A network of professionals in the BSR coordinated through Swedish Smittskyddsinstitutet.

Mission: BARN will bring together professionals with visions on how to counteract development

and spread of antimicrobial resistance. BARN aims to inform about old and new projects in the

Baltic Sea region, to facilitate exchange of ideas and experience. BARN will create possibilities for

informal collaboration between experts and promote projects with hands-on implications in

everyday practice. BARN will assist to identify funding opportunities. BARN is an extension of

activities initiated in the networks of BALTICCARE (The Baltic Network for Infection Control

and Containment of Antibiotic Resistance), Strama and Happy Audit.

BARN invites professionals from all fields to join to find project ideas, contribute with expertise

or just seek information.

STRAMA

In order to reduce inappropriate use of antibiotics and to counteract the increase in antimicrobial

resistance in community-acquired and nosocomial infections, a national project was initiated in

Sweden in 1994. The overall aim of Strama (The Swedish Strategic Programme Against

Antibiotic Resistance) is to preserve the effectiveness of antibiotics in humans and animals.

Strama is organised at two levels: a network of independent local multidis ciplinary groups in

each county that provide prescribers with feedback on antibiotic use and resistance and

implement guidelines; and a national executive working group funded by the government. To

gain an insight into antibiotic use, Strama has conducted several large diagnosis prescribing

surveys in primary care, in the hospital settings and in nursing homes. National antibiotic

susceptibility data for Sweden and mandatory notification show that in recent years the

proportion of Streptococcus pneumoniae with decreased sensitivity to penicillin V has stabilised

(around 6 %), but the number of notified cases of meticillin-resistant Staphylococcus aureus

(MRSA) has increased and ESBL-producing Enterobacteraceae have turned into an endemic

situation. Still, Sweden is among the countries with the lowest rates of MRSA (<1 %), S.

pneumoniae can still be treated with penicillin V and the rate of Escherichia coli-

producingESBLs is below 5 %. Strama's activities have contributed to a steady decrease in

antibiotic use from the mid 1990s until 2004(when total use slowly started to increase again)

without measurable negative consequences. Regular collaboration with national and regional

news media has been one of the key strategies.

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Large diagnosis-prescribing surveys have been undertaken, and the concept of basic hygiene

precautions was introduced, together with extensive programs for early case finding. However,

surveillance has been hampered by inadequate IT systems and some difficulties in collecting

relevant data on antibiotic sales at the national level. Also, a decentralized system with 21

counties and regions has resulted in divergence of action plans and rules. The containment of

antibiotic resistance thus far may be explained by the early response in human and veterinary

medicine and close multisectorial collaboration, supported by the government, before problems

got out of hand.

On-going national projects (http://en.strama.se/dyn//,84,2,70.html )

• The Strama Point Prevelence Study 2003 and 2004 on hospital antibiotic use

• A study of hygienic routines and infections in child day care

• The Strama diagnosis-antibiotic prescribing survey 2002

• ICU-Strama Link to interactive database

• Survey of activities at the county level, 2003

• Swedish antibiotic nursing home trial (SANT)

• Self-medication with antibiotics in a Swedish general population

Weekly antibiotic prescribing and influenza activity in Sweden; a study throughout five influenza

seasons

Sweden sets national target for antibiotic use in outpatient care In December 2010 the Swedish Government announced a 500 million SEK commitment to

improving patient safety in health care during 2011 out of which 100 million SEK will be

allocated to the work with improving rational use of antibiotics. In 2010 the average use of

antibiotics in outpatient care* in Sweden was 390 prescriptions per 1000 inhabitants. There are

however, great regional differences.

The 100 million SEK to be shared between the 21 county councils in Sweden are conditional in

the way that for county councils to receive any funding they are firstly required to form a Strama

group with a clear mandate to coordinate local activities. Secondly, prescribers must increase the

adherence to treatment recommendations aiming at no more than 250 prescriptions per 1000

inhabitants per year by 2014, a national target set by the Swedish government. The funding will

be allocated yearly in relation to potential step-wise fulfillment of the mentioned criteria.

http://soapimg.icecube.snowfall.se/strama/Swedres%20PPS%202004.doc

http://soapimg.icecube.snowfall.se/strama/A_Study_of_Hygienic_in_Child_Day_Care.doc

http://soapimg.icecube.snowfall.se/strama/The_STRAMA_diagnosis_2002.doc

http://soapimg.icecube.snowfall.se/strama/ICU-STRAMA.doc

http://www4.smittskyddsinstitutet.se/IvaStrama/index.jsp

http://soapimg.icecube.snowfall.se/strama/Survey_of_Activities_at_the_County_Level.doc

http://soapimg.icecube.snowfall.se/strama/Swedish_Antibiotic_Nursing_home_Trial.doc

http://soapimg.icecube.snowfall.se/strama/Self-medication.doc

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* Outpatient care refers to antibiotics prescribed in primary care and open specialist surgeries.

New organisation of Strama

From July 1st 2010, Strama (the Swedish Strategic Programme against Antibiotic Resistance) is an

advisory body with the remit to assist the Swedish Institute for Infectious Disease Control in:

1) matters regarding antibiotic use and containment of antibiotic resistance

2) facilitating an interdisciplinary and locally approved working model, ensuring involvement by

concerned authorities, counties, municipalities and non-profit organizations.

HAPPY AUDIT in Lithuania

In the transnational EU-project Happy Audit a clinical APO-audit on RTI and antibiotic

prescribing in PHC was carried out in seven countries during 2008 and 2009. In 2008, 618 GPs in

Spain, Denmark, Sweden, Lithuania, Kaliningrad region and Argentine took part and in 2009 511

GPs. They registered in all 33273 consultations in 2008 and 29390 in 2009. The goal was to lower

the prescribing of Antibiotics per se but also to change the policy towards more narrow

antibiotics. Moreover the doctors in Lithuania, Spain, Argentine and Kaliningrad region got

access to use new Point of Care (POC) tests: StrepA and C-Reactive Protein (CRP). Between the

two registration periods the participants were offered an intervention program including training

courses on appropriate use of antibiotics for RTIs, clinical recommendations for diagnosis and

treatment of RTIs, posters for waiting rooms and brochures and hand out to patients about

prudent use of antibiotics and training in use and interpretation of POC tests.

The main results was a relative reduction of 25% in the doctors’ total prescribing of antibiotics.

In Argentine the relative reduction of total antibiotic prescribing was 20%, in Denmark 9% and

in Sweden 10%. In Lithuania the antibiotic prescribing was nealy halved, while in the same time

the fraction of penicillin V markedly increased. In Kaliningrad the prescribing of antibiotics more

than halved and in Spain the doctors’ prescribing of antibiotics was reduced by approx. 1/3.

Most impressive changes of doctors prescribing were seen in Klaipeda region in Lithuania (1-4).

As shown in fig. 1, For Lithuanian doctors the use of the narrow penicillin, PcV had increased

from 13,8% to more than 50% between 2008 to 2009. This means that the Lithuanian group

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changed their prescribing of antibiotics from a Middle European broad spectrum profile to the

Scandinavian

Fig. HA1. Proportions of prescribed antibiotics, Lithuanian group Happy Audit 2008 and 2009

Figure 2 shows the dramatic diminishing of prescriptions of antibiotics among the Lithuanian

participants in the two Happy Audit registrations in 2008 and 2009.

Only those doctors who took part in the 2009 registration are included in the 2008 results.

Only those doctors who took part in the 2009 registration are included in the 2008 results.

13,8

37,8

21,3

12,7

0,8 1,7

10,1

1,3

52,9

20,3

4,5

14,8

0,0 1,7 3,0 2,8

0,0

10,0

20,0

30,0

40,0

50,0

60,0

PcV Amoxi/piva Amoxi/clav Macrolid Chinolon Tetracycline Cephalosp Others

%

Proportion of prescribed antibiotics, Lithuania 2008 and 2009

2008

2009

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Figure HA2. Total prescription of antibiotics, Lithuanian group Happy Audit

In figures this meant that in 2008 the doctors did not prescribe antibiotics at 1395 out of total

2409 consultations. But, in 2009 the same doctors did not prescribe antibiotics in 1491 out of a

total of 1976 consultations for acute respiratory infections.

The BARN projects and ImPrim

The BARN projects carried out in connection with the ImPrim project: To create a Strama-like

group in Lithuania and carrying out first clinical audit on UTI.

The first workshop in the BARN project was carried out in Riga during spring 2011. One out of

three subprojects were dedicated to PHC and Lithuania. A project group was formed by

participants from Institute of Hygiene, Vilnius, Department of Public Health, Klaipeda university

and Blekinge Centre of Competence – all three ImPrim partners, PP4, PP14 and LP. This group

presented a project titled “Strama in Lithuania” later on “planning a regional antimicrobial

management group”aiming to introduce the idea of Strama in Klaipeda region. The project idea

was supported and the project started as a subproject of Imprim. Today two parallel projects are

carried out under the ImPrim umbrella and a third research project has started up coordinated

from Lunds university to study the PHC process in Lithuania.

2008 2009

None AB 57,9 75,5

Any AB 41,5 23,7

0

10

20

30

40

50

60

70

80

%

No or any antibiotics prescribed, Happy Audit 2008 and 2009, GPs Lithuania

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Professionals from Institute of Hygiene (IoH), Vilnius have taken active part in the BARN

meetings in Riga and Vilnius during 2011. Inspired by these workshops IoH (Imprim PP4) has

started up two ImPrim subprojects on regional strategy on antibacterial resistance and

implementation of a prudent prescribing of antibiotics together with Department of Public

Health, Klaipeda university (ImPrim PP14) and Blekinge Centre of Competence (BCC ImPrim

LP).

First subproject has been a feasibility study in Klaipeda region – implemented during 2011.

An analysis of regional governmental and municipal resources of institutions as well human

resources was carried out. Moreover available data on antibiotic use as well as bacterial resistance

in Klaipeda region has been described. The following functions were described; Funding, Data

monitoring, Dissemination of information, Training of medical staff, Public education, Desicion

making. Responsible institutions would be Primary Care Centres, Municipality of the Klaipeda

District, Klaipeda City Municipality, Public health bureau and Klaipeda university, Responsible

for reporting on microbiological as well as consumption data would be Klaiepda territorial Sick

Fund, Centre of Public Health and microbiological laboratories.

A steering group of 14 persons, mostly doctors, was formed and has started to work. Their first

task will be to carry out a clinical audit on UTI in PHC as well as hospital care. An audit report

will be produced after the registration phase. The follow up meetings will give opportunity to

invite doctors in PHC as well as on hospital to educational activities. These activities will take

place mostly during year 2012, but are planned to continue in the future. This group of 14 people

will be the basis for the future Lithuanian “Strama” or antimicrobial management group. This

work will be described in detail in the following pages by Dr Rolanda Valintiene, IoH.

In Klaipeda region the project is coordinated from the Department of Public Health at the

Klaipeda university. Regional coordinators are dr Ruta Radzeviciene-Jurgute and dr Ilona

Bumbliene. When the group of professionals was formed their first project was to carry out a

clinical audit on UTI. Both doctors in PHC and in hospital care will be engaged. The first step in

an audit process will be to get consensus on the variables. UTI – Urine Tract Infections, are not

as common as respiratory tract infections in PHC. However, these infections are of significant

importance up to the issue of bacterial resistance. Patients are many times old and those patients

have a tendency to develop pyelonephritis risking sepsis or bacteriemia. These complicating

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infections are life threatening not least if they are caused by resistant bacterias. It is well known

that PHC doctors have a tendency to use broad spectrum antibiotics for the more simple UTIs.

Prescribing must be strict prudent to meet the dangerous increasing bacterial resistance. The

audit project per se will involve starting up an audit centre at the department of Public Health at

Klaipeda university, described in the ImPrim report no 3: “Quality improvement from a bottom-

up perspective - the clinical audit tool”

2. Achievement – facing antimicrobial resistance

Implementation of regional model on containment of antimicrobial resistance

Objective: To prepare and pilot regional strategy on containment of antimicrobial resistance and

implementation of rational antibiotic use.

Location: Klaipeda region, Lithuania

Time: July 2011 – December 2012

Responsible participants:

Institute of Hygiene – Project leader

Klaipeda University – Project partner

Plan of implementation:

Feasibility study in Klaipeda region – to identify main partners and investigate priority activities

(2011 July – November )

Preparation of regional strategy on containment of AMR (2011 December – 2012 February

Implementation of regional model on containment of antimicrobial resistance (AMR model) in

Klaipeda region (2012 March – December)

Expected outcomes:

Outcomes Indicators of activities

Regional strategy on containment of AMR

Presentation of the strategy to national experts

Formation of regional antimicrobial management group

Plan of activities and regular meetings

Creation of monitoring system of antibiotics prescribing

Accessibility of data

Training of regional antimicrobial management group members and other health care workers

Number of participants

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Overview of activities

3. Feasibility study in Klaipeda, Lithuania

Feasibility study in Klaipeda region – To identify main partners and investigate priority activities

– Period: July – November 2011. The study consisted of three parts:

1. Analysis of health care providers in Klaipeda region.

2. Analysis of functions of health care related institutions

3. Analysis of perceptions and expectations related to AMR control of different

stakeholders

The first inventory study was performed to investigate the network of health care providers in

Klaipeda region.

Hospital care

There are nine hospitals in Klaipeda city and region – Klaipeda Republican Hospital, Klaipeda

Seamen‘s Hospital, Klaipeda University Hospital, Klaipeda Medical Nursing Hospital, Children‘s

Hospital of Klaipeda, Klaipeda district Gargzdai Hospital, Klaipeda tuberculosis hospital, Silute

Hospital, Kretinga Hospital.

Microbiological investigations and determination of sensitivity to antibiotics of isolated bacteria

are performed in three hospital laboratories – the Klaipeda Republican Hospital, Klaipeda

Seamen‘s Hospital and Klaipeda University Hospital.

Primary health

There are 47 primary health care centers in Klaipeda city and district. Microbiological

investigations are performed in different laboratories based on bilateral agreements between

Center and laboratory selected on the basis of best economical conditions.

Preparation of regional strategy on containment of AMR

Preparation of regional strategy on containment of AMR (2011 December – 2012 February

The aim of this second study was to analyze functions, regulations, human resources of

governmental and municipal health and high education institutions, to determine their current

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responsibilities in AMR control and their possibilities to coordinate work of regional

antimicrobial management group (futher -Group), based on Sweden STRAMA model, in

Klaipeda region.

All public health, health care and related institutions including municipality, state health insurance

fund and Klaipeda University were selected for analysis. Regulations, functions and objectives of

institutions were analyzed through their official websites and during the meetings with specialists

from these institutions. One of the objectives of the analysis was to identify potential members of

AMR group in Klaipeda region and to identify main institution which could coordinate the group

work. Functions related with public health surveillance, health promotion, health programs,

prescription drugs, microbiological diagnosis, population health status, communicable diseases

were collected.

Main functions were collected from official institutions regulations and to identify institutions

relevant for the project following keywords were used: antimicrobial resistance management,

antimicrobial resistance, antibiotic consumption, antibiotic usage, prudent use of antibiotics,

public health surveillance, health promotion, health programs, prescription drugs, microbiological

diagnosis, population health status, communicable diseases.

None of the institutions had antimicrobial resistance management, antimicrobial resistance,

antibiotic consumption, antibiotic usage, prudent use of antibiotics mentioned in their regulations

so for further detailed analysis were selected seven institutions with other Project keywords in

their regulations:

Klaipeda Territorial Health Insurance Fund

Klaipeda City Municipality

Klaipeda District Municipality

Klaipeda Public Health Bureau

Klaipeda District Municipality Public Health Bureau

Klaipeda Public Health Centre

Klaipeda University

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Klaipeda Territorial Health Insurance Fund (THIF) is a state institution, whose objective is to

guarantee the insured person‘s health care delivery and reimbursement of medicines and costs for

services and medicines issued payment.

THIF functions related with Project keywords:

Fund local health programs;

Analyze and evaluate data on the county‘s municipal population health status and demographic

structure of population trends;

Control personal health care services and medicines cost, quantity and quality.


Klaipeda City Municipality objectives related with public health are to solve city problems in

organizing programs, adoption of legal documents, coordinating activities of other responsible

institutions. Klaipeda City Municipality functions related with Project keywords (elected of

responsibilities and roles of institution specialists) are:

Prepare decisions and other regulations related with health care organization, management,

execution and control.

Organize preparation of municipality sponsored decisions and programs.

Prepare decisions and other regulations related to the primary health care.

Initiate and supervise the Lithuanian health program, implementation of public health programs

at the local level.

Prepare and/ or initiate municipal complex and targeted health programs implementation to

ensure organization of services, service performance monitoring.

Coordinate public health education issues.

Participate in the preparation of city plans for the prevention of communicable diseases, anti-

epidemic tools acts and organizes their implementation of controls.

Organize implementation of public health and long-term continuous health programs

Control implementation of communicable disease prevention measures in city plan and other

legal anti-epidemic measures

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Klaipeda District Municipality

Klaipeda District Municipality objectives related with population health are to solve city

problems in organizing programs, adoption of legal documents, coordinating activities of other

responsible institutions. There is Health and Social Welfare Committee in Municipality of

Klaipeda District. Function of this Committee related with Project keywords are:

Consider and submit proposals to the protection of the health issues and control their

implementation

In addition, in 2011 one of the health priorities for action is:

Communicable diseases (tuberculosis, rabies, sexually transmitted diseases) prevention


The main objectives of the Bureau activities – to improve health of the population, reduce

morbidity and mortality. Klaipeda Public Health Bureau conducts public health surveillance in

the city and Among the activities of the Bureau – organization and presentation of non-

specialized public health services to population main fo which is health promotion.

Klaipeda Public Health Bureau functions related with Project keywords are:

Develop and implement public health promotion and disease prevention programs

Carry out health education, spread knowledge about healthy lifestyles and propagate it,

Provide information about health measures and events for population

Implement mandatory health education


The main objectives of the Bureau activities – to improve health of the population, reduce

morbidity and mortality. Klaipeda District Municipality Public Health Bureau conducts public

health surveillance in the district. Klaipeda District Municipality Public Health Bureau functions

related with Project keywords are:

Development and implementation public health strengthening measures

Organization of health training for population, dissemination of knowledge about healthy

lifestyles, propagation of healthy lifestyles, to provide information about health measures and

events

Implementation of Lithuanian health program, the Government of the Republic of

Lithuania resolutions adopted by public health programs and health measures in the municipality

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Implementation of measures of municipality special program for public health support and

other local health programs

Develop of community health improvement programs, to participate in projects

Klaipeda Public Health Centre

Klaipeda Public Health Centre is institution, which have three directions of action – public health

safety, public health safety control and communicable disease prevention and control.

Klaipeda Public Health Centre functions related with Project keywords:

According to Lithuanian Republic of communicable disease prevention and control

statutory powers implement communicable disease prevention and control

Implement epidemiological surveillance of communicable diseases

Carry out epidemiological investigation of diseases and their outbreaks,

management of cases and liquidation of outbreaks

Having regard to the epidemiological situation prepares / participates in the

development of targeted communicable diseases prevention and control programs for

municipalities, submit these programs proposals to the municipal administrations, submit

proposals for communicable diseases prevention plans, participate in formation of municipality

communicable diseases management plans

Klaipeda University

Klaipeda University Faculty of Health Sciences one of the main areas of research:

Complex biomedical and social research for sustainable society development by modeling aspect

Health promotion and disease prevention methodologies and health care efficiency research

Klaipeda department of National Public Health Surveillance Laboratory

One of the main functions of Laboratory is to conduct laboratory tests required for

communicable diseases diagnosis and prevention. However Klaipeda branch of laboratory not

perform this function.

After analysis of official websites, all functions of the analyzed institutions have been divided into

the following categories: control, funding, data monitoring, dissemination of information,

training of medical staff, public education, making decisions, organization, data reporting

(microbiological, consumption) (1 table). The aim was to determine which institution could be as

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the main and coordinating regional AMR management group. Some functions of institutions

overlaped, but there is no institution, which is responsible for antimicrobial resistance

management in the region.

1. Control Klaipeda Territorial Health Insurance Fund

Centre of Public Health

2. Funding Klaipeda Territorial Health Insurance Fund

Municipality of the Klaipeda District


3. Data monitoring Klaipeda Territorial Health Insurance Fund

Public health bureau


Microbiology laboratories (of hospitals etc)

4. Dissemination of information


Klaipeda university


5. Training of medical staff Klaipeda university

Primary care centre

6. Public education Public health bureau

Primary care centre

7. Making decisions Klaipeda Territorial Health Insurance Fund

Municipality of the Klaipeda District


8. Organization Municipality of the Klaipeda District



Klaipeda university

Primary care centre

9. Data reporting (microbiological, consumption)



Microbiology laboratories (of hospitals etc)

Primary care centre

1 table. Functions of health care related institutions in Klaipeda region

The third study was performed to learn perceptions and expectations related to AMR control of

primary care doctors, local health care administrators and public health officials.

The third study was performed to learn perceptions and expectations related to AMR control of

primary care doctors, local health care administrators and public health officials. Objectives of

interviews with primary care doctors, local health care administrators and public health officials

was to determine awareness about antimicrobial resistance problem and expectations about

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necessary measures and actions to solve antimicrobial resistance problem. Face to face interviews

were performed. There were representatives of these institutions interviewed:

Public Health Centre



Klaipeda Republican Hospital

Primary health care center



Interview with Head of Communicable Disease Division and Deputy director

Main current related activities: Public Health Centre collects information from all laboratories

and health care institutions about isolated recordable pathogens. MRSA, VRE, resistant

salmonella are among them but detailed analysis and feedback is not performed.

Possible future activities after creation of regional AMR group: Public Health Centre could

perform preventive measures (disseminate information to the public), cooperate and exchange

information with primary health care centers.

Identified problems: treatment algorithms for doctors are missing, they could be developed

during the project.


Interview with Director of Bureau and health promotion specialist

Main current related activities: Klaipeda District Municipality Public Health Bureau implements

preventive measures, which must be coordinated with municipality.

Possible future activities after creation of regional AMR group: Bureau could disseminate

information to the public, coordinate AMR group meetings.

Identified problems: what‘s missing for AMR problem solution in bureau: more knowledge on

AMR topics. Possible problems of participation in project: doubts about Klaipeda city and

Klaipeda district work compatibility, institution doesn‘t feel that could influence primary health

care specialists.


Interview with Deputy director

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Main current related activities: Public health bureau of Klaipeda city implements preventive

measures. Antimicrobial resistance management is one of bureau priority activities.

Possible future activities after creation of regional AMR group: Bureau could disseminate

information to the public and health care professionals.

Identified problems: what‘s missing in Bureau: more knowledge on AMR topics.

Klaipeda Republican Hospital

Interview with infection control specialist, microbiologist

Main current related activities: Klaipeda Republican Hospital collects antimicrobial resistance

data in the hospital, however data base non-computerized, data for only two years.

Possible future activities after creation of regional AMR group : Klaipeda Republican Hospital

could share experiences and hospital data.

Identified problems: what‘s missing for AMR problem solution in the hospital: computerized

program for collection and analysis of antimicrobial resistance data

Problems of participation in project implementation: too little cooperation between hospitals in

Klaipeda region, few microbiological samples from primary health care centers.

Primary health care center

Interview with Director and general practitioner

Main current related activities: Primary health care center coordinated and participated in Happy

audit study

Possible future activities after creation of regional AMR group: Center could be responsible for

clinical audit and lead the related subgroup.

Identified problems: what‘s missing for AMR problem solution in primary health care: treatment

recommendations, system where general practitioners could compare each other by prescribing

antibiotics, trainings on antimicrobial resistance and antibiotic prescribing topics.

Additional activities performed:

Visit to Sweden (4 persons) to learn about Strama work at national and local levels

Representatives from main Project partners (Institute of Hygiene, Klaipeda University) have

visited meeting in Hoor (Sweden) January 2012. During discussions with participation of the

meeting the Project implementation was reviewed and Swedish experience was learned. The

importance to involve health care administrators and policy makers was stressed out. There were

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methods how to measure the effect of the program and effectiveness of STRAMA-like group

discussed.

The goal of the second phase of the Project was to prepare the regional’s strategy on

containment of antimicrobial resistance. Preparation of the proposal of strategy was implemented

in November 2011, February 2012.

Activities


Preparation of working plan of regional antimicrobial management group


Previous phase of the Project have identified potential stakeholders and suggested main areas of

activities for local antimicrobial management group. Meeting with STRAMA people in Sweden

have helped to set priorities and structure the proposals of AMR group composition and their

plan of action prepared by the specialist from the Institute of Hygiene.

The second phase started from Joint meeting of representatives from identified regional

stakeholders.

The main tasks for the meeting were to nominate AMR group members, set their priority

activities and discuss the working forms.

The regional meeting was organized in November 2011 inviting representatives from stakeholder

institutions: Health Sciences Faculty of Klaipeda University, JSC "My family doctor" (Primary

health center), Klaipeda Territorial Health Insurance Fund, Public Health Center, Public Health

Bureaus, doctors of Klaipeda municipality and Klaipeda district municipality and doctors

(epidemiologists, infection control specialists, microbiologists) form Klaipeda hospitals.

Participants - potential members of regional AMR management group were chosen from

institutions – stakeholders identified during the first phase of the Project whose functions were

partly related to management of antibiotic use and antimicrobial resistance. It was decided during

the meeting that in addition the regional AMR group should include different specialists from all

biggest Klaipeda region hospitals – one specialist per hospital (clinician, microbiologist or

infection control specialist). The call was sent out to all Klaipeda hospital to nominate persons.

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The specialists in the group were chosen by the areas of competence to perform the functions of

the group. The functions are: microorganisms resistant monitoring; public education; family

doctor; monitoring of antibacterial drug prescribing; funding; senior epidemiologist; public health

promotion and training;

Final composition of regional antimicrobial management group:

1. Janina Asadauskienė (Municipality doctor)

2. Ilona Bumblienė (Epidemiologist)

3. Alfridas Bumblys (Health Insurance Fund)

4. Rasa Girdžiūnienė (Infectious diseases doctor)

5. Arnoldas Jurgutis (Klaipeda University)

6. Laima Kaveckienė (Municipality doctor)

7. Rūta Markevičė (Institute of Hygiene)

8. Ineta Pačiauskaitė (Public health bureau)

9. Rūta Radzevičienė –Jurgutė (Primary health care physician)

10. Ona Sokolova (Public health centre)

11. Daiva Sriebalienė (Epidemiologist)

12. Jūratė Šuliauskaitė (Pediatrician)

13. Neringa Tarvydienė (Public health bureau)

14. Rita Vėlavičienė (Microbiologist)

There were short presentations done by representatives of some institutions to get better

understanding about currently available data, performed activities, experiences.

Main positive points :

- previous experience of Klaipeda University and family doctors in auditing antibiotic prescribing

during Happy audit project,

- some data on resistance of reportable pathogens available in Public Health Centre;

- data on consumption of reimbursed antibiotics (more relevant for children population) available

in regional health insurance fund with the availability to stratify data by doctor, clinic, patient.

Main problematic points:

- Most of the hospitals do not have computerized system in the microbiology laboratory;

- There are no tradition of collaboration between hospitals;

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- Different institutions serve for the different population (e.g. – regional health insurance fund and

Public health centre – for Klaipeda region (several municipalities), public health bureau – for one

municipality, hospitals – differently)

After discussions the prioritization of activities was done and main areas of activities for Regional

AMR management group suggested were:

- Monitoring of resistance of infectious agents and creation of a data register;

- Creation of a data register of antibiotic use;

- Initiation of preparation of treatment guidelines;

- The feedback of data about antibiotic prescribing (from health insurance fund) to primary care

institutions;

Preparation of working plan of regional antimicrobial management group

The preparation of the working plan have started during the same Joint meeting. There were

short presentations done by representatives of some institutions to get better understanding

about currently available data, performed activities, experiences.

Main positive points identified :

- previous experience of Klaipeda University and family doctors in auditing antibiotic prescribing

during Happy audit project,

- some data on resistance of reportable pathogens available in Public Health Centre;

- data on consumption of reimbursed antibiotics (more relevant for children population) available

in regional health insurance fund with the availability to stratify data by doctor, clinic, patient.

Main problematic points identified:

- Most of the hospitals do not have computerized system in the microbiology laboratory;

- There are no tradition of collaboration between hospitals;

- Different institutions serve for the different population (e.g. – regional health insurance fund and

Public health centre – for Klaipeda region (several municipalities), public health bureau – for one

municipality, hospitals – differently)

After discussions the prioritization of activities was done and main areas of activities for Regional

AMR management group suggested were:

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- Monitoring of resistance of infectious agents and creation of a data register;

- Creation of a data register of antibiotic use;

- Initiation of preparation of treatment guidelines;

- The feedback of data about antibiotic prescribing (from health insurance fund) to primary care

institutions;

The final AMR management group action plan for 2012 have been finalized via electronic

communication and it includes key activities:

Coordination

- Training about antimicrobial resistant and antibiotic consumption for AMR management group

and others health care professionals (25 persons). (4. x 8 hrs. x 4 experts)

- Working group meetings (for 4 meetings per 2012)

- Working group meeting with a national group of AMR

Monitoring of antimicrobial resistance

- Creation of AMR monitoring database

- Determination of resistance of selected microorganisms (UTI study)

Monitoring of antimicrobial drugs consumption

- creation of audit system

- continuous surveillance of antibiotic consumption using regional health insurance fund data

- self medication study in Klaipeda city and district

Promotion and implementation of proper use of antibacterial agents

- dissemination of information to public

- a “simple” audit (sending information from regional health insurance fund on antibiotic

prescribing to family medicine centers)

- final conference.

The second meeting of the regional AMR group have been organized to approve the action plan

and approve the activity regulations rules.

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The main functionsof the Group have been set as follow:

- disscuss and tackle arising antimicrobial resistance and antibiotic usage problems in the

Klaipeda region;

- participate in the monitoring of antimicrobial resistance and antibiotic consumption in Klaipeda

region;

- make suggestions and recommendations to local authorities, institutions and national experts to

prevent the spread of antimicrobial-resistant microorganisms and promote rational use of

antibiotics.

The group carrying out its functions is entitled to:

- get information for the Group's activities from the institutions whose representatives

participate in group activities;

- consult with other specialist (experts) not involved in the Group,

- prepare and offer the proposals and the necessary management decisions to solve the problems

of antimicrobial resistance.

4. Implementation of a regional model on containment of antimicrobial resistance (AMR model) in Klaipeda

Implementation of regional model on containment of antimicrobial resistance (AMR model) in

Klaipeda region (2012 March – December)

The implementation of key activities of AMR management group action plan for 2012:

Training on antimicrobial resistant and antibiotic consumption for regional AMR management

group and others health care professionals.

Inequalities in knowledge on AMR and related issues among representatives of all stakeholders

have been identified as one of the problems during the first Joint meeting was. So it was essential

to start the activities from the training of Group specialists.

The main topics of the training of Group were rational use of antibiotics and development,

control of resistance. The training was conducted in two session of two days (four days in total).

The target group of training was local antimicrobial resistance management group members,

general practitioners, microbiologists and other health professionals.

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National lecturers – recognized specialists in clinical microbiology and pharmacology have been

invited as lectors. The main topics were: „Antibiotics: Why is it important today to talk about

their rationale use? “, „Antimicrobial resistance: the situation in Europe and Lithuania“,

„Bacterial resistance to antimicrobials: mechanisms of resistance, detection methods and use of

results in clinical practice“, „Infection diagnosis and treatment challenges associated with multiple

resistance: ESBL-producing bacteria“, “The importance of clinical microbiology in diagnostic of

infectious diseases“, „Susceptibility to antimicrobial agents in: methods of antibiotic selection and

interpretation of the results“, “Proper use of antibiotics: appropriate principles of antimicrobial

drug use“.

The practical part of the training was spent to review and discuss in detail the activities from the

Group action plan.

Working group meetings (4 meetings per 2012)

Two group meetings were organized till July. First was organized to discuss about the analysis

and dissemination of antibiotic prescribing data from Klaipeda Territorial Health Insurance Fund

(feedback to Primary health care centers). Organization of study to evaluate the extent of self-

medication with antibiotics and knowledge about antibacterial medicines in Klaipeda region was

discussed during the second meeting.

The third meeting will take place in September to discuss the preparation of leaflets and other

information material to public informing them about the problem of antimicrobial resistance and

importance of proper use of antibiotics. The list of events dedicated to European antibiotic

awareness day (November 18) will be disussed and approved.

The fourth meeting will take place in the end of the year to review activities of 2012 and set the

palnt for 2013.

Monitoring of antimicrobial resistance

Creation of AMR monitoring database

As none of the laboratories have AMR monitoring database, the possibility to use WHONET

program in hospitals was discussed with all the laboratories ant decided to translate WHONET

program into Lithuanian language. The training to use of WHONET to specialists from

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microbiology laboratories will be carried in September 2012 followed by installation of the

program in hospitals.

Determination of resistance of selected microorganisms (UTI study)

In addition to ongoing resistance surveillance (mentioned in section 1.2.) pathogens of urinary

tract infections were selected for active antimicrobial resistance surveillance. The determination

of resistance of urinary tract infections agents is planning on October 2012, during the second

phase of UTI audit. It is planed to stimulate primary health doctors to take samples in all case of

UTI, determination of resistance of isolated bacteria will per carried out in one selected

laboratory.

Monitoring of antimicrobial drugs consumption

Creation of audit system

See - UTI audit study.

Continuous surveillance of antibiotic consumption using Klaipeda health insurance fund data.

It was decided to set the indicators and feedback to primary health centers information on

antibiotic prescribing. All the information will be treated confidentially. Health insurance fund

data have been selected as most easily accessed and well represented data source. Unfortunatelly

only information on reimbursed medicines is collected and due to national reimbursement system

(antibiotics are reimbursed for children (all diseases) and in few cases to adults (selected diseases

e.g. pneumonia) antibiotic prescribing for children (0-18 years) was selected for monitoring. The

list of indicators to monitor antibiotic consumption (prescribing) was set up during Group

meetings and training sessions. The main indicators for antibiotic monitoring have been

identified as follows:

- number of antibiotic prescriptions / 1000 children (0-18 years) in separate municipalities

of Klaipeda region 2011;

- number of antibiotic prescriptions to children / 1000 children (0-18 years) in separate

primary care centers of Klaipeda region 2011;

- percentage of phenoxymethylpenicillin prescriptions to children among all penicillin group

prescriptions to children in separate primary care centers of Klaipeda region 2011.

-

The first feedback to Primary Care Centers was send on June 2012 including data from 2011.

Another feedback is planning on September 2012, to present data of the half-year of 2012.

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Self medication study in Klaipeda city and district

This study aims to evaluate extent of self-medication with antibiotics and knowledge about

antibacterial medicines among citizens of Klaipeda region. The ongoing survey which includes

interviews with 300 residents. The survey is carried out by Klaipeda city and district public health

bureau. Results of the study will be used to plan activities to rice public awareness about

resistance and prepare material for different public groups.

Promotion and implementation of proper use of antibacterial agents

A “simple” audit (sending information from regional health insurance fund on antibiotic

prescribing to primary care centers)

The first feedback to Primary Care Centers was send on June 2012 including data from 2011. All

the information is kept confidentially (not showing the names of other centers). Another

feedback is planning on September 2012, to present data of the half-year of 2012.

The report of the data was send to 41 primary care centers in all 7 municipalities of Klaipeda

region.

There were huge antibiotics prescribing differences (69 times) found between separate primary

health care centers when analyzing 2011 data. Low proportion (4,4 %) of narrow spectrum

antibiotics was discovered in most Primary care centers.

Dissemination of information to public

The main activities to dissemination project results and experience will start in the autumn of

2012: There are planed: meeting with doctors in Klaipeda hospitals, publishing of guidelines of

urinary tract infections diagnosis and treatment and final conference (November 2012). Activities

to public will be carried out as European antibiotic awareness day activities, their final list will be

approved in September.

5. A clinical audit on Urine Tract Infections (UTI), Klaipeda region Lithuania

As a part of the ImPrim project on Communicable diseases on how to counteract antibiotic

resistance an auditproject was carried out on UTI. The Audit was executed in two levels: in two

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Klaipeda hospitals and four PHC centers. Variables in hospitals and variables in primary care are

somewhat different also up numbers. Doctors in PC registered 61 variables for each patient and

in hospitals the doctors registered several more or a total of 120 variables for each patient. There

are of course both differences and similarities between patients in PHC and at hospital with UTI.

In hospital a patient with a pyelonephritis can be very severe case, while most UTI n PHC are

quite simple to handle. However, if a pyelonephritis has got a sepsis caused by a multi resistant

bacteria and the first therapy alternative will be inappropriate the outcome might be a

catastrophe.

Most patients with a pyelonephritis have had earlier more simple UTI. If they at those episodes

have got broad spectrum antibiotics the risk for coming resistant infections will be bigger. Still

there will all the time be less severe pyelonephritis who easily will be treated adequately and

effectively in PHC. So, this field has since long been complex and difficult.

Variables in the PHC UTI audit

Gender

Age

Symptoms and signs

Fever

Chills

Dysuria

Frequent urination

Suprapubic pain

Side (back) pain

General ailment

Genital symptoms

None of the listed

Duration in days

History

Urinary Tract Infection within 6 past

months

Antibiotics within 6 past months

Pregnancy

Investigations

Urine test with automatic analyzer

Urine strip test

Microscopy

CRP

Complete blood test

Urine culture

None of the listed

Urine test

Leukocytes rate < 100

Leukocytes rate 100 -250

Leukocytes rate 250 – 500

Erythrocytes rate < 10

Erythrocytes rate 10 – 20

Erythrocytes rate 20 – 30

Erythrocytes rate > 30

Nitrate positive

Nitrate negative

Urine culture

Not done

Done - no growth of bacteria

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Growth of bacteria

E Coli

Other

Sensitivity

Amoxicillin

Amoxicillin with clavulanic r.

First generation cephalosporins:

cephalothin

Second generation cephalosporins:

cefuroxime

Third generation cephalosporins:

cefotaxime / ceftazidime

Trimethoprim / trimethoprim +

sulfamethoxazole

Nitrofurantoin

Ciprofloxacin

Norfloxacin

Doctor’s diagnosis

Cystitis

Pyelonephritis

Asymptomatic bacteriuria

Urinary tract infection for pregnant

women

Other urinary tract infection

Other information

The patient insisted on antibiotic

Referred to consultation of specialist /

hospitalized

None of the listed

Treatment

Waiting for culture results

Amoxicillin

Amoxicillin + clavulanic acid

Ciprofloxacin

Norfloxacin

Trimethoprim / sulfamethoxazole

Nitrofurantoin

Furadonin

First generation cephalosporins:

cephalothin

Second generation cephalosporins:

cefuroxime

Third generation cephalosporins:

cefotaxime / ceftazidime

No antibiotics prescribed

Herbal antiseptics

Duration of treatment (days)

Results

The first three figures show one obvious difference between PHC and hospital up to UTI

patients age and gender. We have a higher proportion of men in hospital mostly due to the older

patients with hypertrophic prostate. In lower ages girls and adult women are the most common

patients, mostly treated in PHC for a simple cystitis.

Figure UTI:1

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Figure UTI:2

Figure UTI:3

Men Women

PHC 18,92% 79,73%

Hospital 38,18% 61,82%

0,00%

10,00%

20,00%

30,00%

40,00%

50,00%

60,00%

70,00%

80,00%

90,00%

Pe

r ce

nt

Urine Tract Infections in PHC and hospital, genders Klaipeda 2012

≤6ys 7-18ys 19-65ys ≥66ys

PHC 6,1% 6,8% 67,6% 19,6%

Hospital 0,0% 1,8% 34,5% 63,6%

0,0%

10,0%

20,0%

30,0%

40,0%

50,0%

60,0%

70,0%

80,0%

Pe

r ce

nt

Urine Tract Infections, PHC and hospital, Age groups Klaipeda 2012

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Comment figure UTI.3: Interesting is that asymptomatic bacteriauria was as common on hospital as

in PHC. But also important will be that most severe infections, the pyelonephritis are as common

in PHC as the cases with asymptomatic bacteriauria.

Asymptom bact.uria

Cystitits Pyelonephritis Other

PHC 18,0% 43,0% 18,0% 32,0%

Hospital 18,0% 13,0% 55,0% 22,0%

0,0%

10,0%

20,0%

30,0%

40,0%

50,0%

60,0%

Diagnosis Urine Tract infections, Klaipeda 2012

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Figure UTI:4

Comment figure UTI.4: Most common antibiotic used in PHC is Nitrofurantoin and Ciprofloxacin

is almost only used to pyelonephritis. The herbal antiseptic may be important as the doctors by

that get an alternative to offer their patients.

First presentation of the outcomes from this clinical audit project was done at the 2nd European

confernce on Antibiotic resistance and prevention of infections October 4-5 d. in Vilnius,

Lithuania. The abstract from this event follows:

0 5 10 15 20 25 30 35

Waiting culture

Amoxi

Amoxi+clav

Ciproflox

Norflox

Trim.Sulfa

Nitrofurant

Others

No antibiotics

Herbal antisept

Numbers

Treatment Urine Tract Infections, Klaipeda 2012

Asymptom bact.uri Cystitis Pyelonephritis Others

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Abstract to present at at the 2nd European confernce on Antibiotic resistance and prevention of

infections October 4-5 d. in Vilnius, Lithuania.

Application of Apo Audit method for improvement of management of UTI in primary

health care and hospital care in Klaipeda

Bumbliene I.1,3, Strandberg E.L2,4, Radzeviciene R.1,5, Ovhed I.4, Jurgutis A.1, Salyga J.3,

Jukneviciute V.1.

1 Klaipedos University, 2 Lund University, 3 Klaipesda Seamens Hospital, 4 Blekinge Centre of

Competence, 5 JCC “Mano seimos gydytojas”

Clinical evidences show that inappropriate, irrational use of antibiotics is closely related to

bacterial resistance. Urine track infections are one of the most common diseases in primary

health care, as well as in inpatient care. Successful treatment of urine track infections highly

depends on identification of the microorganism that caused urine track infection, on the

prescription of appropriate antibiotic, it`s dose and the duration of treatment.

After the diagnosis of urine track infection physician usually starts the empirical antibacterial

treatment based only on the assumption about possible pathogen. However, choice of treatment

strategy depends on health care institution that the patient addresses. If the patient is treated in

inpatient care institution possibilities to identify the urine track infection agent and resistance to

antibiotics are higher. After the identification of urine track infection agent and resistance to

antimicrobial medicines, treatment with antibiotics becomes more rational.

In the end of year 2011 Klaipeda University Health Science Faculty Public Health Department

initiated urine track infections diagnostics and treatment study. The objective of the study was to

ascertain how family physicians and inpatient physicians diagnose and treat the patients with

urine track infections, applying internal quality control method (APO). The audit was

implemented in 3 levels: general practice level, outpatient care and inpatient care institutions. 23

family physicians, 17 doctors consultants of outpatient and inpatient departments’ participated in

the audit. According to the results of the study and learning objectives proposed by the doctors,

the training workshops were organised. Moreover, more appropriate conditions for diagnostic

were facilitated, and urine track infections protocols were prepared. Doctors’ participation on

voluntary bases creates more appropriate attitude towards rational use of antibiotics.

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First follow-up meeting on UTI audit, Klaipeda region September 2012

The following report is direct notes from the first clinical audit on UTI registered parallel on two

both PHC and hospital level. The intense clinical discussion is demonstrated. It is the common

outcome from such a registration. The participants have a very concrete basis of data from their

own practice.

Initial group work

During the follow up meeting results of the first urinary tract infections (UTI) registration were

discussed by participating family doctors (FD) and specialist doctors (nephrologists, urologists,

rheabilitologists) in 5 small groups. Groups of 24 physicians discussed the results of the audit

approx. 50 min.

Meeting experts

After groups discussions some emerging issues were written on the sticky notes which were

placed on the flip chart board (separately GPs and specialists issues). All the doctors participated

in general discussion on the raised questions. Two experts - Jolanta Miciulevičienė - Laboratory

Medicine physician of Vilnius City Hospital Laboratory and Inga Skarupskienė – associated

professor from Kaunas Medical University Hospital Nephrology Clinic helped to answer unclear

questions. Issues that have been discussed:

• To prevent a recurrence of UTI, how much time a / b should be taken?

• Is there a need to treat asymptomatic bacteriuria ?

• Complete blood count test - is it informative for diagnostics?

• What was meant by "other urinary tract infection" when physicians marked it in the registration

chart?

• What should be duration of treatment with antibiotics?

When there are 25-75 leukocytes detected in automatic urine test - should the treatment for UTI

be given?

• Does it make sense for treatment with herbal antiseptics? How effective are they?

• How important is to perform the urinary red blood cell count?

• Where the primary health care doctors can perform a urine microscopy?

• Erythrocyte results – what do they tell?

• Is there a need for treatment with amoxicillin and clavulanic acid, why is not enough

amoxicillin?

• Microscopic or automatic analyzer urine test are better? Are they equivalent?

• Why do GPs cannot perform urine culture?

• Do re-visit means that the patient is not sufficiently cured?

• How much reasonable is to continue treatment with nitrofurantoin about 3 months 100mg

once per day?

How long in the hospital does it take to receive results of antibioticogram?

• Why in the hospital after receiving results of antibioticogram most often is given ceftriaxon?

Maybe it is according to some algorithm?

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Comments and discussions

• Primary care doctors: the diagnosis of "another UTI infection" – is marked when the doctor is

not sure what diagnosis should be put, when it is not clear either it is cystitis or pyelonephritis.

Finally it was agreed that if there is fever and pain - more likely will be to diagnose pyelonephritis.

Asymptomatic bacteriuria is quite often diagnosed in primary care, but it is somehow confusing,

because there is no possibility to perform urine culture for GPs, and asymptomatic bacteriuria

can be diagnosed when 2 cultures in a row for women and one culture for men is positive. GPs

stated that they diagnosed asymptomatic bacteriuria when the patient had no symptoms, and

urine test not culture was positive.

Diagnosis of UTI depends a lot on collection of urine samples. Once again common rules and

mistakes for collecting urine sample were discussed by the participants.

Different policies

It became obvious that primary health care center and hospital opportunities to perform urine

tests vary. In the hospitals urine microscopy is always performed whenever the culture is sent. In

primary health care centers it is more difficult, because it is difficult to perform microscopy and

culture. It is not forbidden, but the state is not paying for this test, it costs 30-70 litas depending

on antibioticogram, only if the patient agrees to pay by himself, it can be performed. Suggestion

by the experts was that at least microscopic test in the laboratory should be done, if GPs find

leucocytes after performing automatic analysis of urine.

If acute severe illness is suspected GPs should do CRP, it is more valuable then to perform total

blood test, but in the case of pyelonephritis it should have some value.

Urea – is the least effective investigation to assess kidney function, although it is payed by the

state, but in acute UTI it is not valuable and is not worth doing.

Uncomplicated UTI (for young, premenopausal, non-pregnant women) is best treated without

antibiotics at all, but if necessary: first choice medication is nitrofurantoin (Nitrofurantoin

monohydrate) or sulfamethaxozol/trimetoprim (Biseptol,Septrin), second choice - quinolones,

however it is better not to start treatment with these medications.

Herbal antiseptics can be used in prevention, not treatment. There is some scientific evidence

that cranberries are effective for UTI prevention. But it should not be the one which is

prescribed for the acute infection.

The long-term nitrofurantoin treatment is accepted if UTI are happening more than 2 episodes

per half-year, or 3 - within one year. Pyelonephritis is more rare in primary care than the lower

UTI like cystitis. Nitrofurantoin is not suitable for treatment of pyelonephritis.

Gentamicin is not recommended for treatment of UTI in primary care also.

In the hospital antibioticogram results are got within few days, but in spite of other possibilities

of treatment most often was chosen ceftriaxon, because it is most cheap for the hospital to

buy!!!!!

Conclusions

Recommendations for treatment of any infection varies between countries, much depends on the

antibiotics market. Lithuania is too small a country to have its own guidelines, and must adapt to

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other guidelines. However, what concerns the treatment at least American experience and

guidance should be avoided, because there is most worst situation with antibiotic resistance.

As a result of this project guidelines for primary care management of UTI should be published

with the guidance of Hygiene Institute.

The second registration will be carried out during autumn 2012. If urine culture in PHC will be

possible during that registration this project will produce totally new scientific knowledge.

6. Research study and Happy audit 2

Research study

The whole process on communicable diseases in ImPrim started up in 2011 and will be closed in

2012. However, the activities will continue far ahead. The topic is of crucial importance for

clinicians as well as for public health. Because of that, Swedish Sida now gives financial support

for a research study, aiming to evaluate scientifically the two projects – the regional “Strama” in

Lithuania and the clinical audit on UTI as well as the initiation of an audit centre in Klaipeda

region.

This research study is coordinated from Family medicine unit, Department of clinical sciences,

Malmö, Lunds university. A network of researchers from Lithuania and Sweden has been

formed. Two workshops have been carried out , in Klaipeda in sep 2011 and in Höör, Sweden

Jan 2012. During the last meeting professor Sigvard Mölstad described the strategy for the

Swedish Strama work like this: The overall objective is: “To preserve effective antibacterial

therapy for current and future generations” and Strama intend to;

Create a cross-sectorial national forum to

- share information

- formulate national strategies

- support and initiate research activities

- collaborate with media

Happy Audit 2

The two projects recommended from the BARN platform; “Strama in Lithuania” and “Klaipeda

Auditcentre” are carried out through financing from the EUS-BSR project ImPrim. During the

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last BARN meeting in Vilnius was proposed that next step at the PHC level would be a clinical

audit among family doctors in Latvia, Lithuania, Poland, Sweden and Kaliningrad oblast. This

work, called “Happy Audit 2” has now started. Focus will be doctors’ diagnosis of RTI and their

prescribing of antibiotics. First registration period will be three weeks during October –

November 2012. That means a mapping of about 2000-3000 consultations from each country or

about 12-15 000 in total.

The following variables will be measured

Variables Happy Audit 2

Code doctor:

Date (day) for registration):

Patients age:

Patients gender:

1. Duration: days with symptoms

Symptoms

2. Fever (temp>38,5)

3. Cough and/or rhinorrhoea

4. Ear pain

5. Painful swalling

6. Tonsill exudat

7. Tender cerv gland

8. Dyspnoe or tachypnoe

9. Increased sputum

10. Purulent sputum

11. None

Investigation

12. StrepA positive

13. StrepA negative

14. CRP (mg/l)

15. X-ray positive

16. x-ray negative

17. None

Ethiology

18. Probably viral infection

19. Probably bacterial infection

Your diagnosis

20. Common cold

21. Acute media otitis

22. Acute sinusitis

23. Acute pharyngitis

24. Acute tonsillitis

26. Pneumonia

27. Exacerbation of COPD or chronic

bronchit

28. Influenza

29. Other acute RTI

Prescription of antibiotic

30. Penicillin V

31. Amoxi/pivampicillin

32. Amoxicillin + clavulan acid

33. macrolid

34. Chinolon

35. Tetracyclin

36. Cephalosporin

37. Other antibiotic

38. No antibiotic prescribed

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Other activities/ decisions

39. Delayed prescription

40. Pc allergy

41. If possible I would have chosen PcV

tablets in this case.

42. Patient demands antibiotic therapy

43. Patient denies antibiotic therapy

43. Follow up own clinic

44. Referral to other spec/hospital

45. Neither

7. Discussion and conclusions

Several important steps have been taken during 2011 and 2012 to develop these projects on how

to counteract the development of antibiotic resistance. Even for the heavy fields Tuberculosis

and HIV- Aids have problems with increasing resistance developed. However, that will seldom

or perhaps almost never be a main problem in PHC research and therapy. Therefore the

permission to change focus for the ImPrim activities in the field communicable diseases became

very important. In stead of TBc/HIV focus was changed to antibiotic resistance among bacteria

which cause ordinary RTIs and UTIs. These infections are frequent in PHC and ordinary hospital

care. Doctors in PHC are prescribing more than 90% of all antibiotics.

Also of great importance has been the parallel establishing of the network BARN. Three out of

the ImPrim project partners took part in BARN from the beginning. Because of that, the

subprojects in ImPrim got support from authoritative specialists all around the BSR. Moreover

the project partners had thorough experiences from the earlier transnational EU project Happy

Audit. All together these prerequisites made it possible to start a series of important and

integrated parallel subprojects. The regional management group will be the start of a Strama like

national intervention in Lithuania. Register data for continuous control of resistance pattern and

antibiotic use will be of basic importance. The audit centre established at the department of

Public Health at Klaipeda university has already started up and delivered data from a clinical audit

on diagnosis and treatment of UTI in both PHC and hospital care. The follow up activities will

be an important intervention initiating clinical discussions and lectures based on the participants

own results.

The ImPrim subprojects on communicable diseases have been developed from a basis of

Evidence based medicine (EBM) in the field of Infectious diseases and antibiotic prescribing.

Transnational professional networks are important sources of inspiration. The projects illustrate

how the bottom-up perspective can be used as a support for the health care planning on the

national as well as the regional level. By this way of working, essential changes in health care may

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42

be most easy to initiate. Moreover, these projects, which have taken place inside the ImPrim

framework will continue in future network constellations like BARN. By that the ImPrim project

will initiate further research and development (R&D) projects in a crucial field.

STRATEGIES TO FOLLOW

According to the ambitious subprojects carried out in the ImPrim framework in this field the

strategy for a future work in PHC is quite clear. An important part in this work has been the

close collaboration with the high-level professional network; Baltic Antibiotic Resistance

collaboration Networks (BARN). Already has the ImPrim project in this field implied formation

of a regional group with a wide competence and area of responsibility. This group has started

eduction as well as carried out important clinical audit projects among doctors in both PHC and

hospital care. Moreover, has the sick fund published register data on antibiotic prescribing to

children.

Today is widely recognized that the increasing microbial resistance will be a future threat to a

continuing favourable development of public health.

The following conclusions may be drawn on what strategies to follow:

A regional and national strategy for containment of antimicrobial resistance must be formulated

Regional groups active in this field must be established, responsible for publishing guidelines as

well as continuous education activities supporting clinical audit projects in in prudent prescribing

of antibiotics.

Working with public health issues via media and direct to the population, especially families with

preschool children.

Working with more stringent demands for a optimal hygiene in hospitals

increasing public knowledge about hygiene and preventive care of different infectious diseases

Develop microbiological registers with continuous follow up of the national microbial resistance

pattern and feed-back to regional, national and international authorities.

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Develop register on the continuous antibiotic consumption available for all patients.

Develop register on the continuous antibiotic consumption in veterinary medicine.

Develop a transnational strategy for collaboration in the field of antimicrobial resistance

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8. References

1. Håkansson A, Ovhed I, Jurgutis A, Kalda R, Ticmane G. Family medicine in the Baltic

countries. Scand J Prim Health Care. 2008;26(2):67-9.

2. Bjerrum L, Munck A, Gahrn-Hansen B, Hansen MP, Jarbol DE, Cordoba G, Llor C, Cots JM,

Hernández S, López-Valcárcel BG, Pérez A, Caballero L, von der Heyde W, Radzeviciene R,

Jurgutis A, Reutskiy A, Egorova E, Strandberg EL, Ovhed I, Mölstad S, Stichele RV, Benko R,

Vlahovic-Palcevski V, Lionis C, Rønning M.

Health Alliance for prudent antibiotic prescribing in patients with respiratory tract infections

(HAPPY AUDIT) -impact of a non-randomised multifaceted intervention programme. BMC

Fam Pract. 2011;12:52.

3. Strandberg EL. Developing General Practice: The Role of the APO-method. Thesis Lunds

university 2008.

4. Butler CC, Hood K, Kelly MJ, Goossens H, Verheij T, Little P, Melbye H, Torres A, Mölstad

S, Godycki-Cwirko M, Almirall J, Blasi F, Schaberg T, Edwards P, Rautakorpi UM, Hupkova H,

Wood J, Nuttall J, Coenen S. Treatment of acute cough/lower respiratory tract infection by

antibiotic class and associated outcomes: a 13 European country observational study in primary

care. J Antimicrob Chemother. 2010;65:2472-8. Epub 2010 Sep 18.

5. Strandberg EL, Ovhed I, Troein M, Håkansson A. Influence of self-registration on audit

participants and their non-participating colleagues. A retrospective study of medical records

concerning prescription patterns. Scand J Prim Health Care. 2005;23:42-6.

http://www.ncbi.nlm.nih.gov/pubmed/18570002










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