Antibiotics, children and quality

Too busy to read the journals? Let Dr Honor Merriman guide you through the latest research.

Br J Gen Pract 2007; 57: 569-73

Over the past decade there has been an overall decrease in the number of antibiotic prescriptions in primary care. There has also been a decrease in the number of skin infections. This study looked at the number of prescriptions issued for skin infections in adults (flucloxacillin)and found that these were actually similar each year between 1999 and 2003, with a peak for prescribing each autumn. This shows that GPs are treating skin infections more vigorously, in contrast to antibiotic prescriptions for URTIs, which have decreased steadily year on year.

GPs may need to review their reasons for using flucloxacillin, because it seems strange to be using it in similar amounts when there are fewer skin infections. Just as we accept that natural immunity will cure sore throats, would it not do the same for mildly inflamed skin lesions?

BMJ doi:10.1136/bmj.39238.890810.BE

Since the introduction of the quality framework there have been necessary changes to the way GPs and practice nurses work. The use of templates to record clinical data has been the most obvious change in what we do from day to day. Other activities have needed recall of patients for review and changes in the computer coding of the different clinical conditions.

Have these changes to our activity affected professional attitudes?

Most GPs have remained positive about their clinical activity and have not felt professionally compromised but nurses expressed concern about changes to their clinical practice. To balance this, nurses appreciated being given responsibility for delivering on targets in particular disease areas. The study looked at 2004 clinical targets and it was of interest that most GPs did not question the validity of the targets themselves.

I wonder if this would be the response if the same question were asked now.

Br J Gen Pract 2007; 57: 538-46

One of the major challenges in primary care is to ensure that children who are showing the early signs of a serious illness are assessed accurately, so they can receive the specialist care needed as soon as possible. Guidance is needed because many children are seen in primary care with acute illness, but only a few will need care beyond what their GP can offer.

The Belgian doctors carrying out this study found that classical textbook signs of illness such as meningeal irritation and poor peripheral circulation were of high specificity. Decision trees were used for other clinical signs and were found helpful. The absence of signs in 'ruling out' a serious diagnosis was found to be more useful than signs 'ruling in' a diagnosis.

The most useful factor in each decision tree was a physician's statement 'something is wrong'.

CMAJ 2007; 176: 1,711-4

Previous studies have shown that children living in single-parent or step-parent households are more likely than children in households with two biological parents to be prescribed methylphenidate.

This national study (1994 to 2000) showed the medication was used in 3.3 per cent of those whose parents remained married and 6.1 per cent of those whose parents divorced. It is not clear whether marital discord prior to divorce affected the children's behaviour or whether the stress of living with children with difficult behaviour affected the marriages.

The author concludes the risk of divorce was not notably higher among parents whose children were taking methylphenidate in 1994, which corresponds with previous studies showing that parents of disabled or mentally ill children are not at greater risk of divorce.

Dr Merriman is a GP in Oxford and a member of our team who regularly reviews the journals

Flucloxacillin prescribing for skin infections in adults is increasing, while incidence of skin infections is decreasing.

The quality framework has not resulted in GPs feeling professionally compromised and most have remained positive.

Significant illness in children is better diagnosed with the use of decision tree guidance.

Divorce is not more likely among the parents of mentally ill children.

Leg ulcers and surgery

Does surgery for superficial venous reflux improve with compression treatment for recurrent leg ulcers in the longer term?

Conventional treatment with compression hosiery is successful but ulcers tend to recur where there is reflux from deep veins in the legs (varicose veins).Compression hosiery tends to be unpopular with patients since the stockings are difficult to put on and are uncomfortable.

There appears to be benefit in ulcer healing and in prevention of ulcer recurrence if surgery is combined with the use of compression hosiery.

In particular the time spent ulcer free was markedly greater in patients after vein surgery.

The lesson seems to be clear, patients who have venous ulcers and are well enough for surgery should be referred for a surgical opinion.

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