Throat swabs and antibiotic use for GAS sore throat. Sandy Dawson

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1 Throat swabs and antibiotic use for GAS sore throat Sandy Dawson

2 Background Acute rheumatic fever (ARF) and consequent rheumatic heart disease (RHD) remain a significant cause of morbidity and premature death in New Zealand. Almost all cases and deaths are considered preventable using a combination of public health and personal health approaches 1.

3 Porirua Union Community Health Services (PUCHS) has recently implemented a nurse-led sore throat protocol developed collaboratively as part of a DHB project. This audit was designed to provide baseline pre-intervention data, and an early assessment of effectiveness.

4 AIM To assess: the uptake of throat swabs in children age 3-14 enrolled with PUCHS, the quality of antibiotic prescribing for those who were GAS positive, and the proportion for whom antibiotics were actually dispensed.

5 Methods Number of enrolled children age 3-14: The PHO enrolment database 1 April 2010 Throat swab uptake: The Medtech query builder was used to extract the population of confirmed enrolled children age from 1-15 years of age from 1 April 2009 to 30 June 2011 with a record in the inbox that contained Throat swab in the subject field. GAS positive cases: The Medtech query output included the comments entered by the GP or nurse: If these were blank or unclear then the patient s medical record was individually checked to establish if GAS had been reported. Only individuals aged between 3 and 14 at the time of the swab result were included. Prescribed antibiotics: The Medtech data query was expanded to include all antibiotics in the New Zealand Guidelines for Rheumatic Fever which had been prescribed to the individuals who had a record of a throat swab from 5 days prior to the swab being reported to 7 days afterwards. Dispensed antibiotics: National Pharmaceutical database NHI linkage to establish if and when - guideline antibiotics had been dispensed by a community pharmacy for all individuals with GAS positive throat swabs for the two years period from 1 April 2009 to 30 March 2011 were included.

6 PUCHS Enrolled Age 3-14 at 1 Apr

7 Annual Throat Swab Rate 19.2% 20.0% 18.0% 16.0% 14.0% 12.0% 10.0% 10.9% 6.2% 7.3% 7.8% 8.0% 6.0% 4.0% 2.0% 0.0%

8 Swabs THROAT SWABS by MONTH GAS No GAS

9 Number of swabs THROAT SWABS by Ethnicity No GAS GAS % +ve % 17% 13% 28% 19% 0 Maori [47] Pacific [143] European [16] All Others [40] TOTAL [246] % GAS +ve : No significant difference overall p = 0.40

10 Number of swabs THROAT SWABS by Gender No GAS GAS Female Male Grand Total % GAS +ve : Females 24% Males 14% p = 0.03

11 Swabs THROAT SWABS by AGE GAS +ve No GAS Age at time of test

12 Prescribing Quality GAS +ve swabs Appropriate Antibiotic Rx by PUCHS Appropriate Antibiotic Rx One child has prescription from elsewhere Full Ten Day Rx Total number of Rx lapses Concordance in %

13 Dispensed Antibiotics 1 Apr Mar 2011 Throat swabs GAS +ve swabs Appropriate antibiotic Rx Appropriate antibiotic dispensed by pharmacy (19.5%) 36 (92%) 30 (77%) Note: It is possible that some antibiotic in this period was dispensed from the practice s MPS stores.

14 How long before success 27 Months Per year Number of swabs Number GAS +ve ARF attack rate 0.3% Expected ARF (UNTREATED) 100 yrs 6.3 Effectiveness of Antibiotics 73% Expected ARF (TREATED) 100 yrs 1.7 ARF cases avoided in 100 years CASE PREVENTED EVERY ~ 20 YEARS

15 And in that 20 years Number of throat swabs 2,200 Number started on antibiotics 2,200? Ten Day course dispensed Number of antibiotic daily doses to prevent ONE case of ARF 22,000? Amoxycillin? Or Penicillin?

16 Conclusions Throat swabs rates have increased following the rheumatic fever project which is encouraging However increasing swab rates are not resulting in increasing GAS +ve detection. This should be monitored carefully Swabs rates seem equitable by ethnicity, but girls may not be accessing them as effectively as boys. Campaign media and messages should be reviewed In general prescribing concordance is now very good, and dispensing may be a greater problem. This finding supports dispensing at the point of care As with so many prevention projects this takes a long time to deliver the desired outcomes, and this primary care component needs to be part of a broader strategy

17 Impact PUCHS for CME DHB Rheumatic Fever Project Might publish if others are interested in contributing data Discussion with Aotea Pathology about monitoring swab positive rates and using regional data linkages to shortcut Medtech data problems

18 PRIMEX Summary