Quality assessment of diagnosis and antibiotic treatment of infectious diseases in primary care: a systematic review of quality indicators

Figures & data

Figure 1. Flow diagram summary of selection process.

Table 1. Overview of quality indicators.

Type of infection	Quality indicators concerning the diagnostic process (n = 7, 6%)	Quality indicators concerning the decision to prescribe antibiotics (n = 29, 22%)	Quality indicators concerning the choice of antibiotics (n = 94, 72%)	In total (n = 130, 100%)
Respiratory tract infection	0	23	45	68
Urogenital infection	7	3	5	15
Skin infection	0	0	3	3
Eye infection	0	0	2	2
Unspecific	0	3	39	42

Respiratory tract infection: sore throat/tonsillitis, otitis externa, acute otitis media, acute rhinosinusitis, acute cough, bronchitis, pneumonia, chronic obstructive pulmonary disease exacerbation. Urogenital infection: urinary tract infections, sexually transmitted disease.

Table 2. Quality indicators focusing on the decision to prescribe antibiotics.

Type of infection	Target for quality assessment: decision to prescribe antibiotics
Acute tonsillitis/pharyngitis	Proportion treated with antibiotics [36] Proportion with a positive Strep A test treated with antibiotics [36] Proportion >1 year treated with antibiotics [35]
Acute otitis media	Proportion treated with antibiotics [36] Proportion <2 years treated with antibiotics [36] Proportion >2 years treated with antibiotics [35] Proportion >2 years with less than three days of symptoms treated with antibiotics [36]
Acute/chronic rhinosinusitis	Proportion treated with antibiotics [36] Proportion >18 years treated with antibiotics [35]
Acute bronchitis/bronchiolitis	Proportion treated with antibiotics [36] Proportion aged between 18–75 years treated with antibiotics [35]
Pneumonia	Proportion aged between 18–65 years treated with antibiotics [35]
Acute exacerbation of COPD	Proportion treated with antibiotics [36] Proportion not fulfilling all the Anthonisen criteria treated with antibiotics [36]
Acute respiratory tract infection	Proportion treated with antibiotics [36]
Acute upper respiratory tract infection	Proportion >1 year treated with antibiotics [35]
Acute lower respiratory tract infection	Proportion treated with antibiotics [36] Proportion with a C-reactive protein <20 mg/l treated with antibiotics [36]
Acute urinary tract infection	Proportion of female patients >18 years treated with antibiotics [35]
Unspecific	Consumption of antibiotics expressed in DID [23] Seasonal variation of the total antibiotic consumption [23]

Anthonisen criteria: increased dyspnoea, increased and purulent expectorate.

COPD: chronic obstructive pulmonary disease; Strep A: streptococcus A antigen; DID: defined daily doses (DDD) per 1000 inhabitants per day. Seasonal variation: consumption in the winter quarters (October, December, January, March) compared with the summer quarters (July, September, April, June) of a 1-year period starting in July and ending the next calendar year in June, expressed as percentage: [DDD (winter quarters)/DDD (summer quarters) − 1] × 100.

Table 3. Quality indicators focusing on the choice of antibiotics.

Type of infection	Target for quality assessment: the choice of antibiotics
Acute tonsillitis/pharyngitis	Proportion treated with a specific antibiotic (narrow-spectrum penicillin, macrolides, cephalosporins, broad-spectrum penicillin ± clavulanic acid) [36] Proportion >1 year treated with a specific antibiotic (beta-lactamase sensitive penicillins, quinolones) [35]
Acute otitis media	Proportion treated with a specific antibiotic (narrow-spectrum penicillin, broad-spectrum penicillin ± clavulanic acid, macrolides, cephalosporins, quinolones) [36] Proportion >2 years treated with a specific antibiotic (beta-lactamase sensitive penicillins, penicillins with extended spectrum, quinolones) [35]
Acute/chronic rhinosinusitis	Proportion treated with a specific antibiotic (narrow-spectrum penicillin, broad-spectrum penicillin ± clavulanic acid, macrolides, cephalosporins, quinolones) [36] Proportion >18 years treated with a specific antibiotic (beta-lactamase sensitive penicillins, penicillins with extended spectrum, quinolones) [35]
Acute bronchitis/bronchiolitis	Proportion aged between 18–75 years treated with a specific antibiotic (penicillins with extended spectrum, tetracyclines, quinolones) [35]
Pneumonia	Proportion treated with a specific antibiotic (narrow-spectrum penicillin, broad-spectrum penicillin ± clavulanic acid, macrolides, cephalosporins, quinolones) [36] Proportion aged between 18–65 years treated with a specific antibiotic (penicillins with extended spectrum, tetracyclines, quinolones) [35]
Acute exacerbation of COPD	Proportion treated with a specific antibiotic (broad-spectrum penicillin ± clavulanic acid, macrolides, cephalosporins) [36]
Acute RTI	Proportion with no history of penicillin allergy treated with a specific antibiotic (macrolides) [36]
Acute upper RTI	Proportion >1 year treated with a specific antibiotic (beta-lactamase sensitive penicillins, quinolones) [35]
Acute lower RTI	Proportion treated with a specific antibiotic (narrow-spectrum penicillin, broad-spectrum penicillin ± clavulanic acid, macrolides, cephalosporins, quinolones) [36]
Urinary tract infection	Proportion of female patients >18 years treated with a specific antibiotic (nitrofuran derivatives, trimethoprim and derivatives, quinolones, other antibiotics) [35]
Unspecific	Consumption of a specific antibiotic (macrolides, lincosamides, streptogramins, penicillins, cephalosporins, quinolones) expressed in DID [23]

DID: defined daily doses (DDD) per 1000 inhabitants per day.

Table 4. Methods for development.

Consensus methods	Author, year	Evidence base	Expert panel	Specification	Application
Modified Delphi technique
	Campbell, 2000 [29]	Previous studies	Pharmaceutical/medical advisers (n = 305, 1. round) Lead prescribing advisers (n = 99, 2. round)	Drug-specific QIs	National (UK)
	Asch, 2002 [21]	Literature study, national guidelines	Primary care practitioners, STD practitioners, medical directors (n = 9)	Disease-specific QIs	National (US)
	Coenen, 2007 [23]	Literature guidelines	Members of EuroDURG, GRIN/ESPRIT, ESAC, WHO, BAPCOC (n = 22)	Drug-specific QIs	International
	Hansen, 2010 [36]	Literature study, national guideliende	GPs, clinical microbiologists, clinical pharmacologists from 13 countries (n = 27)	Disease-specific QIs	International
	Adriaenssens, 2011 [35]	National guidelines	GPs, specialists in infectious diseases, microbiology, pharmacy, pharmaco-epidemiology, quality indicator development and drug utilization (n = 62)	Disease-specific QIs	International
Non-Delphi specified
	Bateman, 1996 [30]	National guidelines	GPs (n = 8)	Drug-specific QIs	National (ES)
	Robertson, 2002 [28]	Prescribing data	GPs, specialist physicians, clinical pharmacologists, pharmacists, drug utilisation experts (n=not available)	Drug-specific QIs	National (AU)
	Giesen, 2007 [42]	National guidelines	GPs (n = 6, 1. round) (n = 7, 2. round) (n = 4, 3. round)	Disease-specific QIs	National (NL)
Non-Delphi unspecified^a
	Van Roosmalen, 2007 [43]	National guidelines	Data not available	Disease-specific QIs	National (NL)
	Fernandez, 2008 [27]	National guidelines	GPs, specialists, primary care pharmacists, hospital pharmacists (n = not available)	Drug-specific QIs	National (ES)
	Pulcini, 2013 [26]	Literature study, international guidelines	Infectious disease specialist, public health specialist, economist (n = 3)	Drug-specific QIs	National (F)

^a The consensus method is not specified.

QIs: Quality indicators; GPs: general practitioners; STD: sexually transmitted diseases; BNF: British national formulary; GRIN: General Practice Respiratory Infections Network; EuroDURG: European Drug Utilisation Research Group; ESPRIT: Study Group on Primary Care Topics; BAPCOC: Belgian Antibiotic Policy Coordination Committee; ESAC: European Surveillance of Antimicrobial Consumption.

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