Ključne poruke za liječnike u primarnoj zdravstvenoj zaštiti

informativni materijal ključne poruke materijal iz kompleta

Sve veća rezistencija na antibiotike predstavlja sadašnju i buduću prijetnju za djelotvornost antibiotika

Rezistencija na antibiotike predstavlja sve veći problem u javnome zdravstvu u Europi [1, 2].

Iako se broj infekcija uslijed bakterija rezistentnih na antibiotike povećava, spektar novih raspoloživih antibiotika nije obećavajući, te stoga predstavlja slabe izglede za dostupnost djelotvornog liječenja antibioticima u budućnosti [3, 4].

Rastući trend bakterija rezistentnih na antibiotike mogao bi se promijeniti, ukoliko se potakne ograničena i odgovarajuća primjena antibiotika u bolesnika u primarnoj zdravstvenoj skrbi.

Izlaganje antibioticima povezano je s pojavom rezistencije na antibiotike [5–8]. Na rezistenciju utječu cjelokupna potrošnja antibiotika u populaciji, kao i način primjene antibiotika [9, 10].

Iskustva iz pojedinih europskih država pokazuju da je smanjenje u propisivanju antibiotika za bolesnike na izvanbolničkom liječenju rezultiralo istovremenim smanjenje u rezistenciji na antibiotike [10–12].

Otprilike 80% do 90% svih propisanih recepata za antibiotike je u primarnoj zdravstvenoj zaštiti, i to uglavnom za infekcije dišnih putova [9, 14, 15].

Postoje dokazi koji potvrđuju da antibiotici nisu potrebni u mnogim slučajevima infekcija dišnih putova [16–18], te da je imunosni sustav bolesnika sposoban boriti se protiv jednostavne infekcije.

U slučaju bolesnika s određenim faktorima rizika, poput primjerice, ozbiljnim eksacerbacijama kronične opstruktivne plućne bolesti (COPD) s povećanom proizvodnjom sputuma, potrebno je propisivanje antibiotika [19, 20].

Nepotrebno propisivanje antibiotika u primarnoj zdravstvenoj zaštiti složeni je fenomen, no uglavnom je povezan s faktorima, poput pogrešnog tumačenja simptoma, dijagnostičke nesigurnosti i opaženih očekivanja bolesnika [14, 21]. 

Ključ je komunikacija s bolesnicima

Ispitivanja su pokazala da zadovoljstvo bolesnika u okruženju primarne zdravstvene zaštite više ovisi o učinkovitijoj komunikaciji, nego o dobivanju recepta za antibiotik [22–24] te da propisivanje antibiotika za infekcije gornjih dišnih putova ne smanjuje stopu narednih posjeta bolesnika liječniku [25].

Profesionalan liječnički savjet utječe na percepciju i stav bolesnika prema njihovoj bolesti i prepoznatoj potrebi za primjenom antibiotika, posebice prilikom savjetovanja o tome što mogu očekivati tijekom bolesti, uključujući i realno vrijeme oporavka i strategije za samoupravljanje [26].

Nije potrebno da liječnici u primarnoj zdravstvenoj zaštiti izdvajaju više svog vremena za konzultacije koje uključuju savjetovanje o alternativama propisivanju antibiotika. Ispitivanja su pokazala da se takvo savjetovanje može pružiti unutar prosječnog vremena potrebnog za konzultacije, te da se pritom može zadržati visoki stupanj zadovoljstva bolesnika [14, 27, 28].

Literatura:

[1] - European Antimicrobial Resistance Surveillance System. EARSS Annual Report 2007. Bilthoven, Netherlands: National Institute for Public Health and the Environment, 2008.
[2] - Cars O, Högberg LD, Murray M, Nordberg O, Sivaraman S, Lundborg CS, So AD, Tomson G. Meeting the challenge of antibiotic resistance. BMJ 2008;337:a1438. doi: 10.1136/bmj.a1438.
[3] - Finch R. Innovation - drugs and diagnostics. J Antimicrob Chemother 2007;60(Suppl 1):i79-82.
[4] - Boucher HW, Talbot GH, Bradley JS, Edwards JE, Gilbert D, Rice LB, Scheld M, Spellberg B, Bartlett J. Bad bugs, no drugs: no ESKAPE! An update from the Infectious Diseases Society of America. Clin Infect Dis 2009;48(1):1-12.
[5] - Malhotra-Kumar S, Lammens C, Coenen S, Van Herck K, Goossens H. Effect of azithromycin and clarithromycin therapy on pharyngeal carriage of macrolide-resistant streptococci in healthy volunteers: a randomised, double-blind, placebo-controlled study. Lancet 2007;369(9560):482-90.
[6] - Donnan PT, Wei L, Steinke DT, Phillips G, Clarke R, Noone A, Sullivan FM, MacDonald TM, Davey PG. Presence of bacteriuria caused by trimethoprim resistant bacteria in patients prescribed antibiotics: multilevel model with practice and individual patient data. BMJ 2004;328(7451):1297-301.  
[7] - Hillier S, Roberts Z, Dunstan F, Butler C, Howard A, Palmer S. Prior antibiotics and risk of antibiotic-resistant community-acquired urinary tract infection: a case-control study. J Antimicrob Chemother 2007;60(1):92-9.
[8] - London N, Nijsten R, Mertens P, v d Bogaard A, Stobberingh E. Effect of antibiotic therapy on the antibiotic resistance of faecal Escherichia coli in patients attending general practitioners. J Antimicrob Chemother 1994;34(2):239-46.
[9] - Goossens H, Ferech M, Vander Stichele R, Elseviers M; ESAC Project Group. Outpatient antibiotic use in Europe and association with resistance: a cross-national database study. Lancet 2005;365(9459):579-87.
[10] - Guillemot D, Carbon C, Balkau B, Geslin P, Lecoeur H, Vauzelle-Kervroëdan F, Bouvenot G, Eschwége E. Low dosage and long treatment duration of beta-lactam: risk factors for carriage of penicillin-resistant Streptococcus pneumoniae. JAMA 1998;279(5):365-70.
[11] - Butler CC, Dunstan F, Heginbothom M, Mason B, Roberts Z, Hillier S, Howe R, Palmer S, Howard A. Containing antibiotic resistance: decreased antibiotic-resistant coliform urinary tract infections with reduction in antibiotic prescribing by general practices. Br J Gen Pract 2007;57(543):785-92.
[12] - Goossens H, Coenen S, Costers M, De Corte S, De Sutter A, Gordts B, Laurier L, Struelens MJ. Achievements of the Belgian Antibiotic Policy Coordination Committee (BAPCOC). Euro Surveill 2008;13(46):pii=19036.
[13] - Sabuncu E, David J, Bernède-Bauduin C, Pépin S, Leroy M, Boëlle PY, Watier L, Guillemot D. Significant reduction of antibiotic use in the community after a nationwide campaign in France, 2002-2007. PLoS Med 2009;6(6):e1000084.
[14] - Cals JWL, Butler CC, Hopstaken RM, Hood K, Dinant GJ. Effect of point of care testing for C reactive protein and training in communication skills on antibiotic use in lower respiratory tract infections: cluster randomised trial.BMJ 2009 May 5;338:b1374. doi: 10.1136/bmj.b1374.
[15] - Wise R, Hart T, Cars O, Streulens M, Helmuth R, Huovinen P, Sprenger M., Antimicrobial resistance. Is a major threat to public health. BMJ 1998;317(7159):609-10.
[16] - Butler CC, Hood K, Verheij T, Little P, Melbye H, Nuttall J, Kelly MJ, Mölstad S, Godycki-Cwirko M, Almirall J, Torres A, Gillespie D, Rautakorpi U, Coenen S, Goossens H. Variation in antibiotic prescribing and its impact on recovery in patients with acute cough in primary care: prospective study in 13 countries. BMJ 2009;338:b2242.
[17] - Smucny J, Fahey T, Becker L, Glazier R. Antibiotics for acute bronchitis. Cochrane Database Syst Rev 2004;(4):CD000245.
[18] - Spurling GK, Del Mar CB, Dooley L, Foxlee R. Delayed antibiotics for respiratory infections. Cochrane Database Syst Rev 2007;(3):CD004417.
[19] - Puhan MA, Vollenweider D, Latshang T, Steurer J, Steurer-Stey C. Exacerbations of chronic obstructive pulmonary disease: when are antibiotics indicated? A systematic review. Respir Res 2007 Apr 4;8:30.
[20] - Puhan MA, Vollenweider D, Steurer J, Bossuyt PM, Ter Riet G. Where is the supporting evidence for treating mild to moderate chronic obstructive pulmonary disease exacerbations with antibiotics? A systematic review. BMC Med. 2008 Oct 10;6:28.
[21] - Akkerman AE, Kuyvenhoven MM, Wouden JC van der, Verheij TJM. Determinants of antibiotic overprescribing in respiratory tract infections in general practice. J Antimicrob Chemother 2005;56(5):930-6.
[22] - Butler CC, Rollnick S, Pill R, Maggs-Rapport F, Stott N. Understanding the culture of prescribing: qualitative study of general practitioners' and patients' perceptions of antibiotics for sore throats. BMJ 1998;317(7159):637-42.
[23] - Kallestrup P, Bro F. Parents' beliefs and expectations when presenting with a febrile child at an out-of-hours general practice clinic. Br J Gen Pract 2003;53(486):43-4.
[24] - Macfarlane J, Holmes W, Macfarlane R, Britten N. Influence of patients’ expectations on antibiotic management of acute lower respiratory tract illness in general practice: questionnaire study. BMJ 1997;315(7117):1211-4.
[25] - Li J, De A, Ketchum K, Fagnan LJ, Haxby DG, Thomas A. Antimicrobial prescribing for upper respiratory infections and its effect on return visits. Fam Med 2009;41(3):182-7.
[26] - Rutten G, Van Eijk J, Beek M, Van der Velden H. Patient education about cough: effect on the consulting behaviour of general practice patients. Br J Gen Pract 1991; 41(348):289-92.
[27] - Cals JWL, Scheppers NAM, Hopstaken RM, Hood K, Dinant GJ, Goettsch H, Butler CC. Evidence based management of acute bronchitis; sustained competence of enhanced communication skills acquisition in general practice. Patient Educ Couns 2007;68(3):270-8.
[28] - Welschen I, Kuyvenhoven MM, Hoes AW, Verheij TJM. Effectiveness of a multiple intervention to reduce antibiotic prescribing for respiratory tract symptoms in primary care: randomised controlled trial. BMJ 2004; 329(7463):431-3.