COMMON INFECTIONS IN FINNISH PRIMARY HEALTH CARE The discovery of antibiotics in 1940s led to a dramatic change in health care. Besides saving seriously ill patients to life, antibiotics also largely made modern vaccine production and surgery possible. Undoubtedly antibiotics belong to the most remarkable discoveries of medical history. With the increasing use of antibiotics the emerging bacterial resistance to these drugs has become a problem. During the past ten years it has also become obvious that new antimicrobials with a totally new mode of action are not in sight in the near future. Therefore, it has become more important than ever to preserve the effect of the existing antimicrobials for as long as possible. Most antibiotics are prescribed in outpatient care. To be able to supervise rational antibiotic use and to focus it on those, who benefit the most from it, it is necessary to know which infections antibiotics are used for in outpatient care. This thesis has examined how common infections were diagnosed and treated in Finnish primary health care centres, how in line the practises were with treatment guidelines, and whether they could be directed closer towards recommendations by means of educational intervention at the work site. The study revealed that although diagnostic and treatment practices were, in some aspects, well in line with the guidelines, there was quite a lot of room for improvement in other aspects. Medical education at the work site proved problematic as half of the doctors changed during the five study years. The data-collection method was first tested in the 20 health centres in the region of Pirkanmaa in a one-week survey in November 1994. The GPs fill in a case-report form during a one week period for each patient consultation related to an infection. In all, 4150 consultations were recorded during the study week. Later, national data was collected in 30 MIKSTRA study health centres around the country during the one week (week 46) in November annually from 1998 to 2002 and in 20 control health centres (in 2002 only). In this five-year national study, 29 043 consultations for an infection were recorded in the study health centres and 4881 consultations in the control health centres National evidence-based treatment guidelines were drawn-up in co-operation with the Current Care Programme of the Finnish Medical Association Duodecim in 1999-­2000 on the six most common infections in primary care (otitis media, sinusitis, tonsillitis, acute bronchitis, urinary tract infections and bacterial skin infections). The guidelines were implemented in the study health centres by means of an interactive education at the work site, facilitated by a trained, local trainer and supported by feedback on previous data collections and patient and population information. Respiratory tract infections comprised three quarters of all infections with common cold, otitis media and sinusitis as the most common diagnoses. Almost two thirds of patients were prescribed antibiotics in Pirkanmaa in 1994, while little less than half received them according to the national study in 1998-2002. Sales of antibiotics had decreased with 13% also in the national sales data from 1993 to 1998, i.e. before the MIKSTRA study began. Patients with a common cold were rather seldom prescribed antibiotics (9-­15%), while most patients with otitis media, sinusitis and urinary tract infections (82-­95%) received them. Antibiotics were also prescribed to a substantial proportion of patients with acute bronchitis (59-­83%), although scientific evidence does not support its benefit in that disease. About half of the antibiotic treatments that were prescribed for respiratory tract infections, were totally or almost in line with the recommendations. Prescribing in line with the recommendations in all aspects (i.e. first-line antibiotic or justified second-line antibiotic for a recommended period for otitis media, sinusitis or tonsillitis) increased from 21% in 1998 to 27% in 2001 (p<0.001). One fifth of antibiotics were prescribed for infections for which they are not recommended, mainly for acute bronchitis, both before and after the intervention. In a quarter of cases, other than a first-line drug was selected without any justification being given. In the rest of the cases infection and antibiotic choice were correct but the duration of treatment was longer than recommended. The proportion of use of the recommended first-line antibiotics increased significantly in sinusitis, acute bronchitis and urinary tract infections during the intervention. Macrolide antibiotics, which are recommended only as the second or third line drug for common respiratory tract infections, were however commonly used as first-line drugs for upper respiratory tract infections and acute bronchitis. The proportion of antibiotic treatments with a recommended, shorter duration of treatment also increased significantly in otitis media, sinusitis and urinary tract infections during the intervention. However, in half of the cases the treatment regimen for otitis media was still longer than five days at the end of the study. In respiratory tract infections, to assess whether there is an infection for which antibiotic is worthwhile or not, is problematic and some diagnostic tools are often needed. A sinus ultrasound device was widely available and adequately used in diagnosing sinusitis (74%), but throat swab was underused in throat infections (culture 37% vs. 42%, antigen detection 24% vs. 30% before and after intervention, respectively). Tympanometry was recommended for use in diagnosing otitis media, but the device was available in only a third of the study health centres and, even if it was present, it was very seldom used (1%). No change was seen over the years, either in the number of tympanometries or in the frequency of its use. In acute bronchitis, the scant use of recommended C-reactive protein test (8%) increased slightly (to 11 %). The obtained, detailed information on the diagnostic and treatment practises make it possible to give precise advice on how to further improve the performance. The means are ­ in theory ­ rather simple: use of appropriate diagnostic tools, shorter courses of antibiotics, the use of second-line drugs only when a special justification exists, and a watchful waiting in milder cases. But to change accustomed habits needs time, education, and the motivating of professionals and patients as well as further follow-up and feedback.