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Press releases Saturday 28 July 2007

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(1) Prescribing of antibiotics to children still at a level to cause drug resistance, warn experts

(2) Proactive chlamydia screening is not good value for money

(3) Fluctuating weight between pregnancies carries health risks for an unborn baby

(3) New guide will help preserve patients' dignity



(1) Prescribing of antibiotics to children still at a level to cause drug resistance, warn experts
(Effect of antibiotic prescribing on antibiotic resistance in individual children in primary care: prospective cohort study)
 BMJ Online First

Regular prescribing of antibiotics to children in the community is sufficient to sustain a high level of antibiotic resistance in the population, warn experts in a study published on bmj.com today.

UK general practitioners are strongly encouraged to reduce antibiotic prescribing to minimise the risk of drug resistance, yet prescribing antibiotics to children remains common practice, write David Mant and colleagues at the University of Oxford.

A paper published in 1999 reported that over half (55%) of children aged 0-5 years in the UK (the group of patients who receive most antibiotics in the community) receive an average of 2.2 prescriptions for a ß-lactam antibiotic like amoxicillin from their general practitioner each year.

Although a reduction in prescribing (and the strategy of recommending a 24-48 hour delay before filling antibiotic prescriptions) has probably resulted in about a 40% fall in consumption since then, unpublished data suggest that community antibiotic prescribing is again rising, they say. This week's BMJ also reports on a study showing that UK GPs are still prescribing antibiotics for a large proportion of patients with minor infections, despite national guidance.

So they set out to assess the effect of antibiotic prescribing on antibiotic resistance in individual children in primary care.

They identified 119 children attending general practices in Oxfordshire with acute respiratory tract infection, of whom 71 received a ß-lactam antibiotic (amoxicillin) and 48 received no antibiotic. Background medical information was recorded and throat swabs were taken at the start of the study and again at two and 12 weeks to measure whether resistant bacteria were present.

Resistant bacteria were identified by the presence of a gene which codes for antibiotic resistance.

In children who did not receive an antibiotic, there was no increase in the proportion carrying resistant bacteria in the throat from the initial level at 2 or 12 weeks.

However, in children who received an antibiotic, the number carrying resistant bacteria more than doubled at the two week follow-up, but fell back close to the initial level by 12 weeks.

These results show that prescribing amoxicillin to a child in general practice doubles the risk of recovering a ß-lactam resistance element from that child’s throat two weeks later, say the authors. Although this effect is temporary in the individual child, it may be sufficient to sustain a high level of antibiotic resistance in the population, they warn.

Cutting resistance rates will require substantial and sustained changes in antibiotic prescribing in the community, they say. Options include shorter courses of treatment or only prescribing antibiotics in well defined and exceptional circumstances.

Contacts:
Contact: David Mant, Professor of General Practice, Department of Primary Health Care, University of Oxford, Oxford, UK
Email: david.mant{at}dphpc.ox.ac.uk  




(2) Proactive chlamydia screening is not good value for money
(Cost effectiveness of home based population screening for Chlamydia trachomatis in the UK: economic evaluation of Chlamydia screening studies (ClaSS) project)
BMJ Online First

Proactive chlamydia screening for young adults is an expensive intervention that probably does not represent good value for money, concludes a study published on bmj.com today.

There are two types of screening - proactive and opportunistic. Proactive screening uses population registers to invite people to be screened regularly, while opportunistic screening targets people attending health services for unrelated reasons.

In England, chlamydia screening is mainly opportunistic, but in some areas general practices registers are being used to send proactive invitations to potentially eligible people to remind them to be re-screened.

Most studies have suggested that chlamydia screening is cost-effective, but there are now questions surrounding the validity of these results. So researchers set out to compare the cost effectiveness of proactive screening with a policy of no organised screening.

Using a mathematical model, screening was offered proactively to a hypothetical population of 50,000 men and women aged 16-24 years. A dynamic model was used to give the closest possible approximation to the real sexual behaviour of this population.

Previous studies have used static models that are inappropriate for evaluating an infectious disease.

The cost-effectiveness of screening was based on major outcomes averted, defined as pelvic inflammatory disease, ectopic pregnancy, infertility, or neonatal complications.

For screening men and women, the incremental cost effectiveness ratio per major outcome averted after eight years was approximately £28,900 compared with no organised screening. It was less costly to screen women only but also less effective, and the incremental cost effectiveness ratio per major outcome averted was approximately £22,300.

Pelvic inflammatory disease was the most frequently avoided outcome.

When the incidence of major complications and uptake of screening were increased (but to values unlikely to be seen in real life), the cost effectiveness ratio fell to £6,200 per major outcome averted for screening women only.

The authors conclude: "Our evaluation of proactive population chlamydia screening, using a dynamic model incorporating realistic estimates of partner notification, the uptake of screening, and the incidence of severe complications, has shown it to be an expensive intervention that probably does not represent good value for money."

The recent economic evaluation of the National Chlamydia Screening Programme in England shows that opportunistic screening, which is currently being rolled out across England, is also unlikely to be cost-effective. This paper was first published in May 2007, ahead of print, in the journal Sexually Transmitted Infections and will appear in print on 30 July.

Contacts:
Tracy Roberts, Senior Lecturer in Health Economics, Health Economics Facility, HSMC, University of Birmingham, UK
Mobile +44 (0)774 987 9630

Nicola Low, Reader in Epidemiology and Public Health, Department of Social and Preventive Medicine, University of Berne, Switzerland
Email: low{at}ispm.unibe.ch 



(3) Fluctuating weight between pregnancies carries health risks for an unborn baby
(Editorial: Weight and pregnancy)
http://www.bmj.com/cgi/content/short/335/7612/169

Gaining or losing weight in between pregnancies can have major health implications for an unborn baby, warn two senior obstetricians in today’s BMJ.

While weight and obesity have long concerned women in relation to body image and lifestyle issues, few are aware of the possible risks that fluctuating weight could have on their unborn child, write Dr Jennifer Walsh and Professor Deirdre Murphy.

They point to two studies. The first, from Sweden, which found that weight gain between pregnancies was strongly associated with major complications for the woman and baby in the months preceding, during and just after childbirth. This was independent of whether a woman was, by definition, overweight.

The researchers studied 207,534 women from the beginning of their first pregnancy to the beginning of their second. They found increased rates of pre-eclampsia, diabetes in the expectant mother, pregnancy induced high blood pressure and high birth weight if a woman’s body mass index (BMI) increased by just one to two units. A rise of more than three BMI units significantly increased the rate of stillbirths.

The key message, say the authors, is that women of normal weight should avoid gaining weight between pregnancies, while overweight and obese women are likely to benefit from weight loss before becoming pregnant.

The second study looked at whether a change in the mother’s nutritional balance increased the risk of a premature birth. They found that women whose BMI fell by five or more units between pregnancies had a higher risk of giving birth prematurely than women whose weight remained stable or increased. The risk was significantly higher for women who had already had a premature birth (80% versus 28%).

"Although apparently conflicting, these studies show how important it is to attain and maintain a normal healthy weight before, during, and after pregnancy," say the authors.

Most women want to achieve the best start in life for their babies, they add. This could be a powerful motivational factor in helping them change the way they eat.

Contact:
eirdre Murphy, Professor of Obstetrics, Academic Department of Obstetrics and Gynaecology, Trinity College, University of Dublin and Coombe Women’s Hospital, Dublin, Republic of Ireland
Email: deirdre.j.murphy{at}tcd.ie 



(4) New guide will help preserve patients’ dignity
(Dignity and the essence of medicine: the A, B, C, and D of dignity conserving care)
http://www.bmj.com/cgi/content/short/335/7612/184

(Editorial: Rediscovering dignity at the bedside)
http://www.bmj.com/cgi/content/short/335/7612/167

Clinicians are being offered a new guide to help them maintain patients’ dignity, according to this week’s BMJ.

Doctors too often dismiss dignity in care because of a lack of time or because they feel a lack of expertise, says the article, which outlines the A, B, C, and D of dignity conserving care guide.

This guide or framework has its origins in palliative care, but can be applied across all medicine, says the author Dr Harvey Max Chochinov, one of Canada's leading palliative care experts and professor at the Department of Psychiatry, University of Manitoba.

Based on empirical evidence, the guide explains how kindness, humanity and respect are core values of medicine, but which are often thought of as the "niceties of care" only offered to patients if time and circumstances allow.

This area of care is referred to as spiritual care, whole person care, psychosocial care or dignity-conserving care, says the article.

Doctors and other health professionals have a profound influence on how patients experience illness and their sense of dignity, argues Dr Chochinov.

The importance of the four parts of the guide "A for attitude, B for behaviour, C for compassion and D for dialogue" is underlined, says the report, by the fact that loss of dignity is one of most common reasons patients seek out physician hastened death. The guide contains several check points under each part for health professionals to look at and to make sure they are following.

Dr Chochinov says the guide can be applied to teaching, clinical practice and standards, both at undergraduate and postgraduate levels, and across all medical specialties, multi-disciplinary teams, and allied health professionals.

Perhaps changing attitudes needs to pervade all medical school teaching, add Irene Higginson and Sue Hall, a palliative care doctor and psychologist at King’s College London in an accompanying editorial. They suggest that "Chochinov's ABCD should be the first mnemonic we teach all professionals entering health and social care, even before airway, breathing, and circulation."

Contacts:
Harvey Max Chochinov, Director, Manitoba Palliative Care Research Unit, CancerCare Manitoba, Canada
Email: harvey.chochinov{at}cancercare.mb.ca 

Irene Higginson, Professor of Palliative Care, Department of Palliative Care, Policy and Rehabilitation, King’s College London, UK
Email: palliativecare{at}kcl.ac.uk 

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