Morten Lindbæk

• Christiansen, Cathrine S; Høye, Sigurd; Lindbæk, Morten; Halvorsen, Jon Anders & Emilsson, Louise (2025). Acne management in Norway: GP and dermatologist prescriptions (2012–2019): a nationwide overview. British Journal of General Practice Open. 9(3). doi: 10.3399/bjgpo.2024.0211. Fulltekst i vitenarkiv Vis sammendrag

  Background Acne is common and associated with negative psychosocial health and risk of permanent skin alterations. GPs prescribe the main portion of antibiotics used for acne. Increased isotretinoin prescription by GPs can potentially reduce overall antibiotic use, but prescription practice and trends are unknown. Aim To examine acne treatment in Norway and quantify prescription and initiation of isotretinoin and tetracyclines. Design & setting An observational study linking data from health registries. Data were collected from the Norwegian Prescription Database (NorPD), the national GP claims register (KUHR database), and the Regular General Practitioner (RGP) registry. Method All patients aged 12–39 years who received an acne diagnosis or were prescribed acne medication in Norway 2012–2019 were included. Linear regression was used to explore time trends. Results In total, 316 075 patients were included (63% female). Yearly prevalence of systemic treatment increased from 1.9 in 2012 to 2.4% in 2019; isotretinoin increased by +123%, tetracyclines by +4% as measured in defined daily doses (DDDs). Topical treatment increased by +13% as measured by number of prescriptions. GP prescription of tetracyclines decreased 11%; however, courses had a mean duration of 160 days, which is longer than the recommended 90 days, and only 26% had a co-occurring topical treatment prescription. GPs initiated 5% of isotretinoin courses in 2012, versus 10% in 2019, and 19% ( n = 1339) of GPs initiated isotretinoin at least once during the study period. Conclusion GPs reduced their prescription of tetracyclines, but our data still show potential for further improvements in prescribing practice. Increased isotretinoin prescription by GPs may lead to reduced antibiotic use and better treatment regimens for moderate-to-severe acne.

• Xu, Alice X. T; Brown, Kevin; Schwartz, Kevin L; Aghlmandi, Soheila; Alderson, Sarah & Brehaut, Jamie C [Vis alle 36 forfattere av denne artikkelen] (2025). Audit and Feedback Interventions for Antibiotic Prescribing in Primary Care: A Systematic Review and Meta-analysis. Clinical Infectious Diseases. ISSN 1058-4838. 80(2), s. 253–262. doi: 10.1093/cid/ciae604. Fulltekst i vitenarkiv Vis sammendrag

  Background This systematic review evaluates the effect of audit and feedback (A&F) interventions targeting antibiotic prescribing in primary care and examines factors that may explain the variation in effectiveness. Methods Randomized controlled trials (RCTs) involving A&F interventions targeting antibiotic prescribing in primary care were included in the systematic review. Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, and ClinicalTrials.gov were searched up to May 2024. Trial, participant, and intervention characteristics were extracted independently by 2 researchers. Random effects meta-analyses of trials that compared interventions with and without A&F were conducted for 4 outcomes: (1) total antibiotic prescribing volume; (2) unnecessary antibiotic initiation; (3) excessive prescription duration, and (4) broad-spectrum antibiotic selection. A stratified analysis was also performed based on study characteristics and A&F intervention design features for total antibiotic volume. Results A total of 56 RCTs fit the eligibility criteria and were included in the meta-analysis. A&F was associated with an 11% relative reduction in antibiotic prescribing volume (N = 21 studies, rate ratio [RR] = 0.89; 95% confidence interval [CI]: .84, .95; I2 = 97); 23% relative reduction in unnecessary antibiotic initiation (N = 16 studies, RR = 0.77; 95% CI: .68, .87; I2 = 72); 13% relative reduction in prolonged duration of antibiotic course (N = 4 studies, RR = 0.87 95% CI: .81, .94; I2 = 86); and 17% relative reduction in broad-spectrum antibiotic selection (N = 17 studies, RR = 0.83 95% CI: .75, .93; I2 = 96). Conclusions A&F interventions reduce antibiotic prescribing in primary care. However, heterogeneity was substantial, outcome definitions were not standardized across the trials, and intervention fidelity was not consistently assessed.

• Heltveit-Olsen, Silje Rebekka; Arnljots, Egill Snaebjörnsson; Sundvall, Pär-Daniel; Gunnarsson, Ronny; Kowalczyk, Anna & Godycki-Cwirko, Maciej [Vis alle 16 forfattere av denne artikkelen] (2025). Methenamine hippurate as prophylaxis for recurrent urinary tract infections in older women - a triple-blind, randomised, placebo-controlled, phase IV trial (ImpresU). Clinical Microbiology and Infection (CMI). ISSN 1198-743X. 31(11), s. 1873–1879. doi: 10.1016/j.cmi.2025.07.006. Fulltekst i vitenarkiv Vis sammendrag

  Objectives This study aims to investigate the preventive effect of the antiseptic methenamine hippurate on recurrent urinary tract infections (rUTIs) in older women. Methods Triple-blind, randomised, placebo-controlled phase IV trial with a 6-month treatment period and a 6-month follow-up. Women ≥70 years with rUTIs were recruited from general practice in Norway, Sweden, Poland, and The Netherlands. Recruitment started in December 2019, with follow-up completed at the end of June 2023. Participants were randomly assigned to methenamine hippurate 1g × 2 or placebo 1 tablet × 2 for 6 months. The primary outcome was the number of antibiotic treatments for urinary tract infections (UTIs) during the treatment period. Secondary outcomes included the number of antibiotic treatments for UTIs during the follow-up period, UTI symptom severity and episode duration. Differences in complications were measured as safety outcomes. Results Of 289 recruited women, 281 (97%) were included in the main analysis (140 in the methenamine hippurate group, 141 in the placebo group). During the treatment period, the methenamine hippurate group had a lower incidence of antibiotic treatments for UTIs than the placebo group, with an incidence rate ratio of 0.75 (95% CI: 0.57–1.0, p 0.049). In the follow-up period, the ratio was reversed: the methenamine hippurate group had a higher incidence of antibiotic treatments for UTIs than the placebo group, with an incidence rate ratio of 1.7 (95% CI:1.3–2.3, p<0.001). There were no important differences in UTI symptom severity/duration or complications between the groups. Discussion Methenamine hippurate reduces the frequency of rUTIs in older women with a point estimate of a 25% reduction, suggesting advantages over low-dose antibiotic prophylaxis because of its low potential for selection for antimicrobial resistance and mild side effects. However, discontinuation after 6-month treatment duration seems to increase the risk of UTI relapses, and physicians should be aware of this risk when initiating or discontinuing treatment.

• Abrahamsen, Cathrine; Wangen, Knut Reidar; Lindbæk, Morten & Werner, Erik Lønnmark (2024). Predictors of treatment outcomes for patients with persistent physical symptoms in primary care: findings from a cluster randomised controlled trial. British Journal of General Practice Open. 8(4), s. 1–8. doi: 10.3399/BJGPO.2024.0004. Fulltekst i vitenarkiv Vis sammendrag

  Background Persistent physical symptoms (PPS) are consistently prevalent among primary care patients. PPS can negatively affect quality of life, healthcare costs, and work participation. In a previous study, we found substantially improved outcomes and reduced sick leave for patients treated by a work-focused communication tool, known as the Individual Challenge Inventory Tool (ICIT), compared with a control group. Aim To examine predictors of treatment outcome in patients who received treatment by ICIT, delivered by the patient’s GP. Design & setting This study is based on the findings of our previous cluster randomised controlled trial undertaken in Norway. Method Regression analyses of the intervention group were used to identify predictors (all measured at baseline) of improvements in Patient Global Impression of Change (PGIC) and sick leave after 11 weeks follow-up. Results Living alone predicted improvement in the adjusted model (odds ratio [OR] 4.03, 95% confidence interval [CI] = 1.33 to 12.25, P = 0.014). Receiving long-term benefits predicted improved PGIC in both the unadjusted (OR 2.30, 95% CI = 1.21 to 4.39, P = 0.011) and adjusted models (OR 2.46, 95% CI = 1.04 to 5.83, P = 0.040). In addition, living alone predicted reduced sick leave in the adjusted model (OR 3.23, 95%CI = 1.11 to 9.42, P = 0.032). Conclusion In general, there were few factors to predict the outcome of the work-focused communication tool. We therefore suggest that this work-focused communication tool is applicable to most patients with PPS. GPs may consider using the ICIT for all primary care patients who exhibit ineffective coping strategies in their daily lives and work, especially those who live alone.

• Hartman, Esther; Groen, Wim; Heltveit-Olsen, Silje Rebekka; Lindbæk, Morten; Høye, Sigurd & Lithén, Sara Sofia [Vis alle 17 forfattere av denne artikkelen] (2024). Implementation of a tailored multifaceted antibiotic stewardship intervention to improve antibiotic prescribing for urinary tract infections in frail older adults (ImpresU) in four European countries: a process evaluation alongside a pragmatic cluster randomized controlled trial. Trials. 25(1). doi: 10.1186/s13063-024-08545-4. Fulltekst i vitenarkiv Vis sammendrag

  Background We previously performed a pragmatic cluster randomized controlled trial (RCT) in general practices and older adult care organizations in Poland, the Netherlands, Norway, and Sweden. We found that a multifaceted antibiotic stewardship intervention (ASI) substantially reduced antibiotic use for suspected urinary tract infections (UTIs) in frail older adults compared with usual care. We aimed to evaluate the implementation process of the ASI to provide recommendations for clinical practice. Methods We conducted a process evaluation alongside the cluster RCT. The ASI consisted of a decision-tool and a toolbox, which were implemented using a participatory-action-research (PAR) approach with sessions for education and evaluation. We documented the implementation process of the intervention and administered a questionnaire to health care professionals (HCPs) from participating organizations in the intervention and usual care clusters. We evaluated the multiple components of the intervention and its implementation following a structured framework. Results The questionnaire was completed by 254 HCPs from the 38 participating clusters. All components were largely delivered according to plan and evaluated as useful. The decision-tool and toolbox materials were reported to facilitate decision-making on UTIs. Regarding the PAR approach, educational sessions focusing on the distinction between UTIs and asymptomatic bacteriuria were held in all 19 intervention clusters. In 17 out of these 19 clusters, evaluation sessions took place, which were reported to help remind HCPs to implement the ASI. During both sessions, HCPs valued the reflection that took place and the resulting awareness of their behavior. It allowed them to explore implementation barriers and to tailor their local implementation process to overcome these. For example, HCPs organized extra educational sessions or revised local policies to incorporate the use of the decision-tool. Various HCPs took key roles in implementation. Staff changes and the COVID-19 pandemic were important contextual barriers. Conclusions We found each component of the multifaceted ASI and its implementation to have added value in the process to improve antibiotic prescribing for suspected UTIs in a heterogeneous older adult care setting. We recommend using a multifaceted, multidisciplinary approach that enables HCPs to reflect on their current practice and accordingly tailor local implementation. Trial registration ClinicalTrials.gov NCT03970356. Registered on May 31, 2019.

• Harbin, Nicolay Jonassen; Haug, Jon Birger; Lindbæk, Morten; Akselsen, Per Espen & Romøren, Maria (2023). A Multifaceted Intervention and Its Effects on Antibiotic Usage in Norwegian Nursing Homes. Antibiotics. 12(9), s. 1–16. doi: 10.3390/antibiotics12091372. Fulltekst i vitenarkiv
• Hartman, Esther; Pol, Alma C. Van De; Heltveit-Olsen, Silje Rebekka; Lindbæk, Morten; Høye, Sigurd & Lithén, Sara Sofia [Vis alle 18 forfattere av denne artikkelen] (2023). Effect of a multifaceted antibiotic stewardship intervention to improve antibiotic prescribing for suspected urinary tract infections in frail older adults (ImpresU): pragmatic cluster randomised controlled trial in four European countries. The BMJ. doi: 10.1136/bmj-2022-072319. Fulltekst i vitenarkiv Vis sammendrag

  Objective To evaluate whether antibiotic prescribing for suspected urinary tract infections in frail older adults can be reduced through a multifaceted antibiotic stewardship intervention. Design Pragmatic, parallel, cluster randomised controlled trial, with a five month baseline period and a seven month follow-up period. Setting 38 clusters consisting of one or more general practices (n=43) and older adult care organisations (n=43) in Poland, the Netherlands, Norway, and Sweden, from September 2019 to June 2021. Participants 1041 frail older adults aged 70 or older (Poland 325, the Netherlands 233, Norway 276, Sweden 207), contributing 411 person years to the follow-up period. Intervention Healthcare professionals received a multifaceted antibiotic stewardship intervention consisting of a decision tool for appropriate antibiotic use, supported by a toolbox with educational materials. A participatory-action-research approach was used for implementation, with sessions for education, evaluation, and local tailoring of the intervention. The control group provided care as usual. Main outcome measures The primary outcome was the number of antibiotic prescriptions for suspected urinary tract infections per person year. Secondary outcomes included the incidence of complications, all cause hospital referrals, all cause hospital admissions, all cause mortality within 21 days after suspected urinary tract infections, and all cause mortality. Results The numbers of antibiotic prescriptions for suspected urinary tract infections in the follow-up period were 54 prescriptions in 202 person years (0.27 per person year) in the intervention group and 121 prescriptions in 209 person years (0.58 per person year) in the usual care group. Participants in the intervention group had a lower rate of receiving an antibiotic prescription for a suspected urinary tract infection compared with participants in the usual care group, with a rate ratio of 0.42 (95% confidence interval 0.26 to 0.68). No differences between intervention and control group were observed in the incidence of complications (<0.01 v 0.05 per person year), hospital referrals (<0.01 v 0.05), admissions to hospital (0.01 v 0.05), and mortality (0 v 0.01) within 21 days after suspected urinary tract infections, nor in all cause mortality (0.26 v 0.26). Conclusions Implementation of a multifaceted antibiotic stewardship intervention safely reduced antibiotic prescribing for suspected urinary tract infections in frail older adults.

• Abrahamsen, Cathrine; Reme, Silje Endresen; Wangen, Knut Reidar; Lindbæk, Morten & Werner, Erik Lønnmark (2023). The effects of a structured communication tool in patients with medically unexplained physical symptoms: a cluster randomized trial. EClinicalMedicine. doi: 10.1016/j.eclinm.2023.102262. Fulltekst i vitenarkiv Vis sammendrag

  Background Medically Unexplained Physical Symptoms (MUPS) are prevalent among primary care patients and frequently lead to diminished quality of life, increased healthcare costs, and decreased work participation. We aimed to examine the effects of a work-focused structured communication tool based on cognitive-behavioral therapy in patients with MUPS. Methods In a Norwegian two-arm cluster randomized trial, the effectiveness of the structured communication tool Individual Challenge Inventory Tool (ICIT) was compared to usual care for patients with MUPS using a two-arm cluster randomized design. Enrollment period was between March 7 and April 1, 2022. Ten groups (clusters) of 103 General Practitioners (GPs) were randomized to provide the ICIT or usual care for 11 weeks. Patients received two or more sessions with their GP, and outcomes were assessed individually. Primary outcome was patient-reported change in function, symptoms, and quality of life measured by the Patient Global Impression of Change (PGIC). Secondary outcomes included sick leave, work-related self-efficacy (RTW-SE), health-related quality of life (RAND-36), and patient experiences with consultants (PEQ). The trial was registered on ClinicalTrials.gov (NCT05128019). Findings A total of 541 patients with MUPS were enrolled in the study. In the intervention group 76% (n = 223) showed a significant overall improvement in function, symptoms, and quality of life as measured by the PGIC, compared to 38% (n = 236) in the usual care group (mean difference −0.8 ([95% CI −1.0 to −0.6]; p < 0.0001). At 11 weeks, the intervention group had a 27-percentage point decrease in sick leave (from 52.0 to 25.2), compared to 4-percentage point decrease (from 49.7 to 45.7) in the usual care group. Furthermore, compared to usual care, the intervention group reported significant improvements in work-related self-efficacy, health-related quality of life, and greater satisfaction with the communication during the consultations. No adverse events were reported. Interpretation The implementation of the structured communication tool ICIT in primary care significantly improved patient outcomes and reduced sick leave among patients with MUPS.

• Schwartz, Kevin L.; Xu, Alice X. T.; Alderson, Sarah; Bjerrum, Lars; Brehaut, Jamie & Brown, Benjamin C. [Vis alle 24 forfattere av denne artikkelen] (2023). Best practice guidance for antibiotic audit and feedback interventions in primary care: a modified Delphi study from the Joint Programming Initiative on Antimicrobial resistance: Primary Care Antibiotic Audit and Feedback Network (JPIAMR-PAAN). Antimicrobial Resistance & Infection Control. 12(1). doi: 10.1186/s13756-023-01279-z. Fulltekst i vitenarkiv Vis sammendrag

  Background Primary care is a critical partner for antimicrobial stewardship efforts given its high human antibiotic usage. Peer comparison audit and feedback (A&F) is often used to reduce inappropriate antibiotic prescribing. The design and implementation of A&F may impact its effectiveness. There are no best practice guidelines for peer comparison A&F in antibiotic prescribing in primary care. Objective To develop best practice guidelines for peer comparison A&F for antibiotic prescribing in primary care in high income countries by leveraging international expertise via the Joint Programming Initiative on Antimicrobial Resistance—Primary Care Antibiotic Audit and Feedback Network. Methods We used a modified Delphi process to achieve convergence of expert opinions on best practice statements for peer comparison A&F based on existing evidence and theory. Three rounds were performed, each with online surveys and virtual meetings to enable discussion and rating of each best practice statement. A five-point Likert scale was used to rate consensus with a median threshold score of 4 to indicate a consensus statement. Results The final set of guidelines include 13 best practice statements in four categories: general considerations (n = 3), selecting feedback recipients (n = 1), data and indicator selection (n = 4), and feedback delivery (n = 5). Conclusion We report an expert-derived best practice recommendations for designing and evaluating peer comparison A&F for antibiotic prescribing in primary care. These 13 statements can be used by A&F designers to optimize the impact of their quality improvement interventions, and improve antibiotic prescribing in primary care.

• Gunnarsson, Ronny K.; Ebell, Mark; Centor, Robert; Little, Paul; Verheij, Theo & Lindbæk, Morten [Vis alle 7 forfattere av denne artikkelen] (2023). Best management of patients with an acute sore throat–a critical analysis of current evidence and a consensus of experts from different countries and traditions. Infectious Diseases. ISSN 2374-4235. 55(6), s. 384–395. doi: 10.1080/23744235.2023.2191714. Fulltekst i vitenarkiv
• Michalsen, Benedikte Olsen; Xu, Alice X. T; Alderson, Sarah L.; Bjerrum, Lars; Brehaut, Jamie & Bucher, Heiner C. [Vis alle 22 forfattere av denne artikkelen] (2023). Regional and national antimicrobial stewardship activities: a survey from the Joint Programming Initiative on Antimicrobial Resistance - Primary Care Antibiotic Audit and Feedback Network (JPIAMR-PAAN). JAC-Antimicrobial Resistance (JAC-AMR). 5(2). doi: 10.1093/jacamr/dlad048. Fulltekst i vitenarkiv
• Takada, Toshihiko; Hoogland, Jeroen; Hansen, Jens G.; Lindbæk, Morten; Autio, Timo & Alho, Olli-Pekka [Vis alle 9 forfattere av denne artikkelen] (2022). Diagnostic prediction models for CT-confirmed and bacterial rhinosinusitis in primary care: Individual participant data meta-analysis. British Journal of General Practice. ISSN 0960-1643. 72(721), s. E601–E608. doi: 10.3399/BJGP.2021.0585. Fulltekst i vitenarkiv
• Harbin, Nicolay Jonassen; Lindbæk, Morten & Romøren, Maria (2022). Barriers and facilitators of appropriate antibiotic use in primary care institutions after an antibiotic quality improvement program – a nested qualitative study. BMC Geriatrics. 22(1). doi: 10.1186/s12877-022-03161-w. Fulltekst i vitenarkiv Vis sammendrag

  Background Antibiotic prescribing by physicians in primary care institutions is common and affected by several factors. Diagnosis and treatment of infections in a nursing home (NH) resident is challenging, with the risk of both under- and overtreatment. Identifying barriers and facilitators of appropriate antibiotic prescribing in NHs and municipal acute care units (MACUs) is essential to ensure the most adequate antibiotic treatment possible and develop future antibiotic stewardship programs. Methods After implementing a one-year antibiotic quality improvement program, we conducted six semi-structured focus group interviews with physicians (n = 11) and nurses (n = 14) in 10 NHs and 3 MACUs located in the county of Østfold, Norway. We used a semi-structured interview guide covering multiple areas influencing antibiotic use to identify persistent barriers and facilitators of appropriate antibiotic prescribing after the intervention. The interviews were audio-recorded and transcribed verbatim. The content analysis was performed following the six phases of thematic analysis developed by Braun and Clarke. Results We identified thirteen themes containing barriers and facilitators of the appropriateness of antibiotic use in primary care institutions. The themes were grouped into four main levels: Barriers and facilitators 1) at the clinical level, 2) at the resident level, 3) at the next of kin level, and 4) at the organisational level. Unclear clinical presentation of symptoms and lack of diagnostic possibilities were described as essential barriers to appropriate antibiotic use. At the same time, increased availability of the permanent nursing home physician and early and frequent dialogue with the residents’ next of kin were emphasized as facilitators of appropriate antibiotic use. The influence of nurses in the decision-making process regarding infection diagnostics and treatment was by both professions described as profound. Conclusions Our qualitative study identified four main levels containing several barriers and facilitators of appropriate antibiotic prescribing in Norwegian NHs and MACUs. Diagnostic uncertainty, frequent dialogue with next of kin and organisational factors should be targeted in future antibiotic stewardship programs in primary care institutions. In addition, for such programs to be as effective as possible, nurses should be included on equal terms with physicians.

• Rui, Linda; Lindbæk, Morten & Gjelstad, Svein (2022). Preventive effect of methenamine in women with recurrent urinary tract infections–a case–control study. Scandinavian Journal of Primary Health Care. ISSN 0281-3432. doi: 10.1080/02813432.2022.2139363. Fulltekst i vitenarkiv
• Heltveit-Olsen, Silje Rebekka; Sundvall, Pär-Daniel; Gunnarsson, Ronny; Arnljots, Egill Snaebjörnsson; Kowalzcyk, Anna & Godycki-Cwirko, Maciek [Vis alle 15 forfattere av denne artikkelen] (2022). Methenamine hippurate to prevent recurrent urinary tract infections in older women: protocol for a randomised, placebo-controlled trial (ImpresU). BMJ Open. 12:e065217(11), s. 1–11. doi: 10.1136/bmjopen-2022-065217. Fulltekst i vitenarkiv Vis sammendrag

  Introduction Methenamine hippurate is a urinary antiseptic used as preventive treatment for recurrent urinary tract infections (UTIs) in some Scandinavian countries. However, the scientific evidence for the preventive effect and safety for longer-term use is limited. The aim of this study is to assess whether methenamine hippurate can reduce the incidence of UTIs in older women with recurrent UTIs. Methods and analysis The ImpresU consortium is a collaboration between Norway, Sweden, Poland and the Netherlands. The study is a randomised, controlled, triple-blind phase IV clinical trial. Women ≥70 years with recurrent UTIs are screened for eligibility in a general practice setting. We aim to include 400 women in total, with 100 recruited from each collaborating country. The participants are randomised to treatment with methenamine hippurate 1 g or placebo tablets two times per day for a treatment period of 6 months, followed by a drug-free follow-up period of 6 months. The primary outcome is number of antibiotic treatments for UTIs during the treatment period. The secondary outcomes include number of antibiotic treatments for UTIs during the follow-up period and self-reported symptom of severity and duration of UTI episodes. Differences in complications between the treatment groups are measured as safety outcomes. We also aim to investigate whether strain characteristics or phylogenetic subgroups of Escherichia coli present in the urine culture at inclusion have a modifying effect on the outcomes. Ethics and dissemination Ethical approvals are obtained in all participating countries. The results will be communicated in peer-reviewed journals and at scientific conferences.

• Hartman, Esther; Groen, Wim; Heltveit-Olsen, Silje Rebekka; Lindbæk, Morten; Høye, Sigurd & Skoglund, Ingmarie [Vis alle 16 forfattere av denne artikkelen] (2022). Decisions on antibiotic prescribing for suspected urinary tract infections in frail older adults: A qualitative study in four European countries. Age and Ageing. ISSN 0002-0729. 51(6). doi: 10.1093/ageing/afac134. Fulltekst i vitenarkiv Vis sammendrag

  Abstract Background a suspected urinary tract infection (UTI) is the most common reason to prescribe antibiotics in a frail older patient. Frequently, antibiotics are prescribed unnecessarily. To increase appropriate antibiotic use for UTIs through antibiotic stewardship interventions, we need to thoroughly understand the factors that contribute to these prescribing decisions. Objectives (1) to obtain insight into factors contributing to antibiotic prescribing for suspected UTIs in frail older adults. (2) To develop an overarching model integrating these factors to guide the development of antibiotic stewardship interventions for UTIs in frail older adults. Methods we conducted an exploratory qualitative study with 61 semi-structured interviews in older adult care settings in Poland, the Netherlands, Norway and Sweden. We interviewed physicians, nursing staff, patients and informal caregivers. Results participants described a chain of decisions by patients, caregivers and/or nursing staff preceding the ultimate decision to prescribe antibiotics by the physician. We identified five themes of influence: (1) the clinical situation and its complexity within the frail older patient, (2) diagnostic factors, such as asymptomatic bacteriuria, (3) knowledge (gaps) and attitude, (4) communication: interprofessional, and with patients and relatives and (5) context and organisation of care, including factors such as availability of antibiotics (over the counter), antibiotic stewardship efforts and factors concerning out-of-hours care. Conclusions decision-making on suspected UTIs in frail older adults is a complex, multifactorial process. Due to the diverse international setting and stakeholder variety, we were able to provide a comprehensive overview of factors to guide the development of antibiotic stewardship interventions.

• Abrahamsen, Cathrine; Lindbæk, Morten & Werner, Erik Lønnmark (2022). Experiences with a structured conversation tool: a qualitative study on feasibility in general practice in Norway. Scandinavian Journal of Primary Health Care. ISSN 0281-3432. 40(2). doi: 10.1080/02813432.2022.2076396. Fulltekst i vitenarkiv
• Li, Xiao; Bilcke, Joke; Velden, Alike W. van der; Bruyndonckx, Robin; Coenen, Samuel & Bongard, Emily [Vis alle 31 forfattere av denne artikkelen] (2022). Cost-effectiveness of adding oseltamivir to primary care for influenza-like-illness: economic evaluation alongside the randomised controlled ALIC⁴E trial in 15 European countries. European Journal of Health Economics. ISSN 1618-7598. doi: 10.1007/s10198-022-01521-2. Fulltekst i vitenarkiv Vis sammendrag

  Abstract Background Oseltamivir is usually not often prescribed (or reimbursed) for non-high-risk patients consulting for influenza-like-illness (ILI) in primary care in Europe. We aimed to evaluate the cost-effectiveness of adding oseltamivir to usual primary care in adults/adolescents (13 years +) and children with ILI during seasonal influenza epidemics, using data collected in an open-label, multi-season, randomised controlled trial of oseltamivir in 15 European countries. Methods Direct and indirect cost estimates were based on patient reported resource use and official country-specific unit costs. Health-Related Quality of Life was assessed by EQ-5D questionnaires. Costs and quality adjusted life-years (QALY) were bootstrapped ( N  = 10,000) to estimate incremental cost-effectiveness ratios (ICER), from both the healthcare payers’ and the societal perspectives, with uncertainty expressed through probabilistic sensitivity analysis and expected value for perfect information (EVPI) analysis. Additionally, scenario (self-reported spending), comorbidities subgroup and country-specific analyses were performed. Results The healthcare payers’ expected ICERs of oseltamivir were €22,459 per QALY gained in adults/adolescents and €13,001 in children. From the societal perspective, oseltamivir was cost-saving in adults/adolescents, but the ICER is €8,344 in children. Large uncertainties were observed in subgroups with comorbidities, especially for children. The expected ICERs and extent of decision uncertainty varied between countries (EVPI ranged €1–€35 per patient). Conclusion Adding oseltamivir to primary usual care in Europe is likely to be cost-effective for treating adults/adolescents and children with ILI from the healthcare payers’ perspective (if willingness-to-pay per QALY gained &gt; €22,459) and cost-saving in adults/adolescents from a societal perspective.

• Kaußner, Yvonne; Röver, Christian; Heinz, Judith; Hummers, Eva; Debray, Thomas P.A. & Hay, Alastair D. [Vis alle 18 forfattere av denne artikkelen] (2022). Reducing antibiotic use in uncomplicated urinary tract infections in adult women: a systematic review and individual participant data meta-analysis. Clinical Microbiology and Infection (CMI). ISSN 1198-743X. doi: 10.1016/j.cmi.2022.06.017. Fulltekst i vitenarkiv
• Hansen, Bjørn Åsheim; Grude, Nils; Lindbæk, Morten & Stenstad, Tore (2022). The efficacy of pivmecillinam in oral step-down treatment in hospitalised patients with E. coli bacteremic urinary tract infection; a single-arm, uncontrolled treatment study. BMC Infectious Diseases. 22(1). doi: 10.1186/s12879-022-07463-7. Fulltekst i vitenarkiv Vis sammendrag

  Background The role of oral beta-lactam antibiotics in treating febrile urinary tract infections (UTI) is not yet definite. Today, fluoroquinolones together with trimethoprim–sulfamethoxazole (TMP–MTX) are considered standard of care and often the only available evidence-based oral treatment for febrile UTI. This study clarifies the efficacy and safety of pivmecillinam (PIV) used as step-down therapy for bacteremic urinary tract infection (UTI). Methods A single-arm, uncontrolled treatment trial was conducted in the period September 2017–March 2020. Candidates for inclusion were men and women suffering from E. coli bacteremia due to UTI and were consecutively included in a Norwegian hospital. Exclusion criteria were among others: other ongoing bacterial infection, septic shock, pyonephrosis/abscess and pregnancy. After 3 days of parenteral antibiotic, the treatment was converted to the study drug; oral PIV 400 mg QID for 1 week. Primary endpoint was a combination of three elements; afebrility, no need for retreatment and improvement in self-reported health status. Test Of Cure (TOC) was 1 week post-treatment. Secondary endpoints included among others microbiological efficacy and CRP value < 30 mg/L. Results Of 476 screened subjects, 53 patients were included. Median age was 67 years, 28 (56%) were women. 50 patients were evaluated for per-protocol analysis. 44 of 50 patients (88%) (95% CI [75.7–95.5]) reached the primary endpoint on TOC. 14 of 48 patients (29.2%) had significant growth (> 103 CFU/mL) of E.coli on TOC. CRP-level was strongly associated to treatment outcome, (OR 0.006 [95% CI 0.00–0.11], p < 0.001). Conclusions This trial documents that PIV 400 mg QID given for 1 week following 3 days of parenteral antibiotics, is a suitable treatment option in patients suffering from bacteremic UTI due to E. coli. Randomised clinical trials studying the efficacy of PIV vs standard of care of febrile UTI are warranted.

• Harbin, Nicolay Jonassen; Rystedt, Karin; Lindbæk, Morten; Jurgute, Ruta Radzeviciene; Johan, Westin & Gunnarsson, Ronny [Vis alle 10 forfattere av denne artikkelen] (2021). Does C-reactive protein predict time to recovery and benefit from oseltamivir treatment in primary care patients with influenza-like illness? A randomized controlled trial secondary analysis. Scandinavian Journal of Primary Health Care. ISSN 0281-3432. doi: 10.1080/02813432.2021.2006482. Fulltekst i vitenarkiv Vis sammendrag

  Objective Recovery time and treatment effect of oseltamivir in influenza-like illness (ILI) differs between patient groups. A point-of-care test to better predict ILI duration and identify patients who are most likely to benefit from oseltamivir treatment would aid prescribing decisions in primary care. This study aimed to investigate whether a C-reactive protein (CRP) concentration of ≥30 mg/L can predict (1) ILI disease duration, and (2) which patients are most likely to benefit from oseltamivir treatment. Design Secondary analysis of randomized controlled trial data. Setting Primary care in Lithuania, Sweden and Norway during three consecutive influenza seasons 2016–2018. Subjects A total of 277 ILI patients aged one year or older and symptom duration of ≤72 h. Main outcome measures Capillary blood CRP concentration at baseline, and ILI recovery time defined as having ‘returned to usual daily activity’ with residual symptoms minimally interfering. Results At baseline, 20% (55/277) had CRP concentrations ≥30mg/L (range 0–210). CRP concentration ≥30 mg/L was not associated with recovery time (adjusted hazards ratio (HR) 0.80: 95% CI 0.50–1.3; p = 0.33). Interaction analysis of CRP concentration ≥30 mg/L and oseltamivir treatment did not identify which patients benefit more from oseltamivir treatment (adjusted HR 0.69: 95% CI 0.37–1.3; p = 0.23).

• Eliassen, Knut Eirik Ringheim; Ocias, Lukas; Krogfelt, Karen; Wilhelmsson, Peter; Dudman, Susanne & Andreassen, Åshild Kristine [Vis alle 8 forfattere av denne artikkelen] (2021). Tick-transmitted co-infections among erythema migrans patients in a general practice setting in Norway: a clinical and laboratory follow-up study. BMC Infectious Diseases. 21. doi: 10.1186/s12879-021-06755-8. Fulltekst i vitenarkiv Vis sammendrag

  Background Erythema migrans (EM) is the most common manifestation of Lyme borreliosis. Here, we examined EM patients in Norwegian general practice to find the proportion exposed to tick-transmitted microorganisms other than Borrelia, and the impact of co-infection on the clinical manifestations and disease duration. Methods Skin biopsies from 139/188 EM patients were analyzed using PCR for Neoehrlichia mikurensis, Rickettsia spp., Anaplasma phagocytophilum and Babesia spp. Follow-up sera from 135/188 patients were analyzed for spotted fever group (SFG) Rickettsia, A. phagocytophilum and Babesia microti antibodies, and tested with PCR if positive. Day 0 sera from patients with fever (8/188) or EM duration of ≥ 21 days (69/188) were analyzed, using PCR, for A. phagocytophilum, Rickettsia spp., Babesia spp. and N. mikurensis. Day 14 sera were tested for TBEV IgG. Results We detected no microorganisms in the skin biopsies nor in the sera of patients with fever or prolonged EM duration. Serological signs of exposure against SFG Rickettsia and A. phagocytophilum were detected in 11/135 and 8/135, respectively. Three patients exhibited both SFG Rickettsia and A. phagocytophilum antibodies, albeit negative PCR. No antibodies were detected against B. microti. 2/187 had TBEV antibodies without prior immunization. There was no significant increase in clinical symptoms or disease duration in patients with possible co-infection. Conclusions Co-infection with N. mikurensis, A. phagocytophilum, SFG Rickettsia, Babesia spp. and TBEV is uncommon in Norwegian EM patients. Despite detecting antibodies against SFG Rickettsia and A. phagocytophilum in some patients, no clinical implications could be demonstrated.

• Ouchi, Dan; Garcia-Sangenis, Ana; Moragas, Ana; Velden, Alike van der; Verheij, Theo J. M. & Butler, Christopher C. [Vis alle 28 forfattere av denne artikkelen] (2021). Clinical prediction of laboratory-confirmed influenza in adults with influenza-like illness in primary care. A randomized controlled trial secondary analysis in 15 European countries. Family Practice. ISSN 0263-2136. 39(3), s. 398–405. doi: 10.1093/fampra/cmab122. Fulltekst i vitenarkiv
• Høye, Sigurd & Lindbæk, Morten (2021). Riktigere bruk av antibiotika i primærhelsetjenesten. Michael quarterly. Supplement. ISSN 1893-0808. 18(28), s. 134–140. Fulltekst i vitenarkiv Vis sammendrag

  Antibiotika er en begrenset ressurs, og fornuftig bruk av antibiotika i primærhelsetjenesten er nødvendig for å redusere utbredelsen av antibiotikaresistens. Infeksjonstilstander og antibiotikabruk i primærhelsetjenesten er blant de viktigste forskningsområdene ved Avdeling for allmennmedisin. Forskningen er knyttet til Antibiotikasenteret for primærmedisin, et nasjonalt kompetansesenter som skal fremme rasjonell og begrenset bruk av antibiotika i primærhelsetjenesten. Resultatene fra forskningen har fått direkte innvirkning på pasientbehandlingen i primærhelsetjenesten.

• Hartman, Esther; Groen, Wim; Heltveit-Olsen, Silje Rebekka; Lindbæk, Morten; Høye, Sigurd & Sundvall, Pär-Daniel [Vis alle 17 forfattere av denne artikkelen] (2021). Multifaceted antibiotic stewardship intervention using a participatory-action-research approach to improve antibiotic prescribing for urinary tract infections in frail elderly (ImpresU): study protocol for a European qualitative study followed by a pragmatic cluster randomised controlled trial. BMJ Open. 11(10), s. 1–8. doi: 10.1136/bmjopen-2021-052552. Fulltekst i vitenarkiv Vis sammendrag

  Introduction Almost 60% of antibiotics in frail elderly are prescribed for alleged urinary tract infections (UTIs). A substantial part of this comprises prescriptions in case of non-specific symptoms or asymptomatic bacteriuria, for which the latest guidelines promote restrictiveness with antibiotics. We aim to reduce inappropriate antibiotic use for UTIs through an antibiotic stewardship intervention (ASI) that encourages to prescribe according to these guidelines. To develop an effective ASI, we first need a better understanding of the complex decision-making process concerning suspected UTIs in frail elderly. Moreover, the implementation approach requires tailoring to the heterogeneous elderly care setting. Methods and analysis First, we conduct a qualitative study to explore factors contributing to antibiotic prescribing for UTIs in frail elderly, using semi-structured interviews with general practitioners, nursing staff, patients and informal caregivers. Next, we perform a pragmatic cluster randomised controlled trial in elderly care organisations. A multifaceted ASI is implemented in the intervention group; the control group receives care as usual. The ASI is centred around a decision tool that promotes restrictive antibiotic use, supported by a toolbox with educational materials. For the implementation, we use a modified participatory-action-research approach, guided by the results of the qualitative study. The primary outcome is the number of antibiotic prescriptions for suspected UTIs. We aim to recruit 34 clusters with in total 680 frail elderly residents ≥70 years. Data collection takes place during a 5-month baseline period and a 7-month follow-up period. Finally, we perform a process evaluation. The study has been delayed for 6 months due to COVID-19 and is expected to end in July 2021. Ethics and dissemination Ethical approvals and/or waivers were obtained from the ethical committees in Poland, the Netherlands, Norway and Sweden. The results will be disseminated through publication in peer-reviewed journals and conference presentations.

• Verheij, Theo; Cianci, Daniela; Velden, Alike van der; Butler, Christopher C.; Bongard, Emily & Coenen, Samuel [Vis alle 29 forfattere av denne artikkelen] (2021). Clinical presentation and disease course in patients with flu-like illness: does microbiological aetiology matter? British Journal of General Practice. ISSN 0960-1643. doi: 10.3399/BJGP.2021.0344. Fulltekst i vitenarkiv
• Kållberg, Cecilia Birgit Maria; Hudson, Jemma; Blix, Hege Salvesen; Årdal, Christine Oline; Klein, E & Lindbæk, Morten [Vis alle 9 forfattere av denne artikkelen] (2021). The effect of generic market entry on antibiotic prescriptions in the United States. Nature Communications. 12(1), s. 1–9. doi: 10.1038/s41467-021-23049-4. Fulltekst i vitenarkiv Vis sammendrag

  When patented, brand-name antibiotics lose market exclusivity, generics typically enter the market at lower prices, which may increase consumption of the drug. To examine the effect of generic market entry on antibiotic consumption in the United States, we conducted an interrupted time series analysis of the change in the number of prescriptions per month for antibiotics for which at least one generic entered the US market between 2000 and 2012. Data were acquired from the IQVIA Xponent database. Thirteen antibiotics were analyzed. Here, we show that one year after generic entry, the number of prescriptions increased for five antibiotics (5 to 406%)—aztreonam, cefpodoxime, ciprofloxacin, levofloxacin, ofloxacin —and decreased for one drug: cefdinir. These changes were sustained two years after. Cefprozil, cefuroxime axetil and clarithromycin had significant increases in trend, but no significant level changes. No consistent pattern for antibiotic use following generic entry in the United States was observed.

• Butler, Christopher C.; Velden, Alike van der; Bongard, Emily; Saville, Benjamin R; Holmes, Jane & Coenen, Samuel [Vis alle 35 forfattere av denne artikkelen] (2020). Oseltamivir plus usual care versus usual care for influenza-like illness in primary care: an open-label, pragmatic, randomised controlled trial. The Lancet. ISSN 0140-6736. 395(10217), s. 42–52. doi: 10.1016/S0140-6736(19)32982-4. Fulltekst i vitenarkiv
• Rystedt, Karin; Harbin, Nicolay Jonassen; Lindbæk, Morten; Radzeviciene, Ruta; Gunnarsson, Ronny & Eggertsen, Robert [Vis alle 10 forfattere av denne artikkelen] (2020). Is C-reactive protein associated with influenza A or B in primary care patients with influenza-like illness? A cross-sectional study. Scandinavian Journal of Primary Health Care. ISSN 0281-3432. s. 1–7. doi: 10.1080/02813432.2020.1843942. Fulltekst i vitenarkiv Vis sammendrag

  Objective Identifying influenza A or B as cause of influenza-like illness (ILI) is a challenge due to non-specific symptoms. An accurate, cheap and easy to use biomarker might enhance targeting influenza-specific management in primary care. The aim of this study was to investigate if C-reactive protein (CRP) is associated with influenza A or B, confirmed with PCR testing, in patients presenting with ILI. Design Cross-sectional study. Setting Primary care in Lithuania, Norway and Sweden. Subjects A total of 277 patients at least 1 year of age consulting primary care with ILI during seasonal influenza epidemics. Main outcome measures Capillary blood CRP analysed as a point-of-care test and detection of influenza A or B on nasopharyngeal swabs in adults, and nasal and pharyngeal swabs in children using PCR. Results The prevalence of positive tests for influenza A among patients was 44% (121/277) and the prevalence of influenza B was 21% (58/277). Patients with influenza A infection could not be identified based on CRP concentration. However, increasing CRP concentration in steps of 10 mg/L was associated with a significantly lower risk for influenza B with an adjusted odds ratio of 0.42 (0.25–0.70; p<.001). Signs of more severe symptoms like shortness of breath, sweats or chills and dizziness were associated with higher CRP. Conclusions There was no association between CRP and influenza A. Increased concentration of CRP was associated with a lower risk for having influenza B, a finding that lacks clinical usefulness. Hence, CRP testing should be avoided in ILI, unless bacterial pneumonia is suspected.

• Heinz, Judith; Röver, Christian; Furaijat, Ghefar; Kaußner, Yvonne; Hummers, Eva & Debray, Thomas [Vis alle 19 forfattere av denne artikkelen] (2020). Strategies to reduce antibiotic use in women with uncomplicated urinary tract infection in primary care: protocol of a systematic review and meta-analysis including individual patient data. BMJ Open. 10(10), s. 1–8. doi: 10.1136/bmjopen-2019-035883. Fulltekst i vitenarkiv
• Eig, Ruth Davey; Harbin, Nicolay Jonassen; Gjelstad, Svein; Høye, Sigurd; Jensen, Siri & Lindbæk, Morten [Vis alle 7 forfattere av denne artikkelen] (2020). RASK – Promoting appropriate use of antibiotics in municipal healthcare institutions. I Simonsen, Gunnar Skov; Blix, Hege Salvesen; Grave, Kari & Urdahl, Anne Margrete (Red.), NORM/NORM-vet 2019. Usage of Antimicrobial Agents and Occurrence of Antimicrobial Resistance in Norway. NORM/NORM-VET. s. 42–43. Fulltekst i vitenarkiv
• Høye, Sigurd; Lindbæk, Morten & Blix, Hege Salvesen (2020). RAK – Promoting appropriate use of antibiotics among general practitioners. I Simonsen, Gunnar Skov; Blix, Hege Salvesen; Grave, Kari & Urdahl, Anne Margrete (Red.), NORM/NORM-vet 2019. Usage of Antimicrobial Agents and Occurrence of Antimicrobial Resistance in Norway. NORM/NORM-VET. s. 40–41. Fulltekst i vitenarkiv
• Vik, Ingvild; Mdala, Ibrahimu; Bollestad, Marianne; Cordoba, Gloria; Bjerrum, Lars & Neumark, Thomas [Vis alle 10 forfattere av denne artikkelen] (2020). Predicting the use of antibiotics after initial symptomatic treatment of an uncomplicated urinary tract infection: Analyses performed after a randomised controlled trial. BMJ Open. 10:e035074(8), s. 1–8. doi: 10.1136/bmjopen-2019-035074. Fulltekst i vitenarkiv Vis sammendrag

  Objective To predict antibiotic use after initial treatment with ibuprofen using data from a randomised controlled trial comparing ibuprofen to pivmecillinam in the treatment of women with symptoms of an uncomplicated urinary tract infection (UTI). Setting 16 sites in a primary care setting in Norway, Sweden and Denmark. Participants Data from 181 non-pregnant women aged 18–60 presenting with symptoms of uncomplicated UTI, initially treated with ibuprofen. Methods Using the least absolute shrinkage and selection operator logistic regression model, we conducted analyses to see if baseline information could help us predict which women could be treated with ibuprofen without risking treatment failure and which women should be recommended antibiotics. Results Of the 143 women included in the final analysis, 77 (53.8%) recovered without antibiotics and 66 (46.2 %) were subsequently prescribed antibiotics. In the unadjusted binary logistic regression, the number of days with symptoms before inclusion (<3 days) and feeling moderately unwell or worse (≥4 on a scale of 0–6) were significant predictors for subsequent antibiotic use. In the adjusted model, no predictors were significantly associated with subsequent antibiotic use. The area under the curve of the final model was 0.66 (95% CI: 0.57 to 0.74). Conclusion We did not find any baseline information that significantly predicted the use of antibiotic treatment. Identifying women who need antibiotic treatment to manage their uncomplicated UTI is still challenging. Larger data sets are needed to develop models that are more accurate

• Venekamp, Roderick; Hansen, Jens Georg; Reitsma, Johannes B.; Ebell, Mark H & Lindbæk, Morten (2020). Accuracy of signs, symptoms and blood tests for diagnosing acute bacterial rhinosinusitis and CT-confirmed acute rhinosinusitis in adults: protocol of an individual patient data meta-analysis. BMJ Open. 10(11), s. 1–7. doi: 10.1136/bmjopen-2020-040988. Fulltekst i vitenarkiv
• Harbin, Nicolay Jonassen; Haug, Jon Birger; Romøren, Maria & Lindbæk, Morten (2020). Oral and parenteral antibiotic use in Norwegian nursing homes: are primary care institutions becoming our new local hospitals? JAC-Antimicrobial Resistance (JAC-AMR). 2(4), s. 1–8. doi: 10.1093/jacamr/dlaa093. Fulltekst i vitenarkiv Vis sammendrag

  Abstract Background Norwegian nursing homes (NHs) have over the last 10 years increasingly applied the use of parenteral treatment, which in turn allows more broad-spectrum use of antibiotics. Previous studies from Norwegian NHs have for the most part not described parenteral formulations. Objectives To describe systemic antibiotic use in Norwegian NHs. Methods Thirty-seven NHs in the county of Østfold, Norway, were invited to participate in this retrospective cross-sectional study. Associated pharmacies provided sales data for systemic antibiotic use for the participating NHs for 1 year (October 2015 to October 2016). General institutional characteristics were collected through a questionnaire. Results Thirty-four NHs participated in the study. Mean use of antibiotics was 10.0 DDD/100 bed days (range 0.6–30.9 DDD/100 bed days). Oral antibiotics accounted for 83% and parenteral antibiotics for 17% of the total antibiotic use. Of parenteral antibiotics, ampicillin was most used (31.1%) followed by cefotaxime (17.7%) and penicillin G (16.6%). The proportion of antibiotics compliant with guideline recommendations was 60%. Being a short-term NH was associated with increased antibiotic use, with an unstandardized coefficient of 13.1 (95% CI 4.2–21.9; P = 0.005). Conclusions We found a high level of total and parenteral antibiotic use compared with previous studies from Norwegian NHs. Data showed wide variations in total antibiotic use and that only a moderate proportion of the antibiotic use was considered guideline compliant. This highlights the necessity of further implementation strategies regarding the national guidelines for antibiotic use in NHs.

• Buul, Laura W Van; Monnier, Annelie A; Sundvall, Par-Daniel; Ulleryd, Peter; Godycki-Cwirko, Maciek & Kowalczyk, Anna [Vis alle 8 forfattere av denne artikkelen] (2019). Antibiotic Stewardship in European Nursing Homes: Experiences From the Netherlands, Norway, Poland, and Sweden. Journal of the American Medical Directors Association. ISSN 1525-8610. 21(1), s. 34–40.e1. doi: 10.1016/j.jamda.2019.10.005. Fulltekst i vitenarkiv
• Holmedal, Øystein; Olaussen, Morten; Mdala, Ibrahimu; Natvig, Bård & Lindbæk, Morten (2019). Predictors for outcome in acute lateral epicondylitis. BMC Musculoskeletal Disorders. 20(1). doi: 10.1186/s12891-019-2758-y. Fulltekst i vitenarkiv Vis sammendrag

  Background Lateral epicondylitis or tennis elbow is a frequent condition with long-lasting symptoms. In order to identify predictors for treatment success and pain in lateral epicondylitis, we used data from a randomized controlled trial. This trial investigated the efficacy of physiotherapy alone or combined with corticosteroid injection for acute lateral epicondylitis in general practice. Methods The outcomes treatment success and pain score on VAS were assessed at 6, 12, 26 and 52 weeks. We ran a univariate binary logistic regression with generalized estimating equations (GEE) and subsequently an adjusted multilevel logistic regression to analyze the association between potential prognostic indicators and the outcome success/ no success. To assess the changes in pain score we used a two-level multilevel linear regression (MLR) followed by an adjusted MLR model with random effects. Results The most consistent predictor for reduced treatment success at all time points was a high Pain Free Function Index score signifying more pain on everyday activities. Being on paid sick-leave and having a recurring complaint increased short term treatment success but gave decreased long-term treatment success. The patients reporting symptoms after engaging in probable overuse in an unusual activity, tended towards increased treatment success at all time-points, but significant only at 12 weeks. The most consistent predictor of increased pain at all time points was a higher overall complaints score at baseline. Conclusions: Our results suggest that in treating acute lateral epicondylitis, a consideration of baseline pain, a registration of the patient’s overall complaint on a VAS scale and an assessment of the patient’s perceived performance in everyday activities with the Pain Free Function Index can be useful in identifying patients that will have a more protracted and serious condition. Trial registration ClinicalTrials.gov Identifier: NCT00826462 . Date of registration January 22, 2009. The Trial was prospectively registrated.

• Jansåker, Filip; Bollestad, Marianne; Vik, Ingvild; Lindbæk, Morten; Bjerrum, Lars & Frimodt-Møller, Niels [Vis alle 7 forfattere av denne artikkelen] (2019). Pivmecillinam for uncomplicated lower urinary tract infections caused by staphylococcus saprophyticus - cumulative observational data from four recent clinical studies. Antibiotics. 8(2). doi: 10.3390/antibiotics8020057. Fulltekst i vitenarkiv
• Fossum, Guro Haugen; Gjelstad, Svein; Kvaerner, Kari Jorunn & Lindbæk, Morten (2018). Prescribing antibiotics when the stakes are higher — do GPs prescribe less when patients are pregnant? A retrospective observational study. British Journal of General Practice Open. 2(2), s. 1–12. doi: 10.3399/bjgpopen18X101505. Fulltekst i vitenarkiv Vis sammendrag

  Background Most oral antibiotics are prescribed by GPs, and they are therefore the most important influencers with regard to improving antibiotic prescription patterns. Although GPs’ prescription patterns in general are well-studied, little is known about antibiotic prescription patterns in pregnancy. Aim To study GPs’ antibiotic prescriptions in respiratory tract infections (RTIs) during pregnancy, and assess differences, if any, between pregnant and non-pregnant patients. Design & setting Retrospective observational study combining prescription data from the Norwegian Peer Academic Detailing (Rx-PAD) study database, pregnancy data from the Norwegian birth registry, and pharmacy dispension data from the Norwegian Prescription Database (NorPD). Method Records of patient contacts with 458 GPs, between December 2004 and February 2007, were screened for RTI episodes. Similar diagnoses were grouped together, as were similar antibiotics. Episodes were categorised according to whether the patient was pregnant or not, and included women aged 16–46 years. Logistic regression models were used to assess odds ratios (ORs), and calculated relative risks (cRRs) were produced. The authors also adjusted for clustering at various levels. Results Overall prescription rate for RTI episodes was 30.8% (n = 96 830). The cohort was reduced to include only episodes with women pregnant in the study period (n = 18 890). The antibiotic prescription rate in pregnancy was 25.9% versus 34.2% in the time before and after pregnancy (cRR = 0.66 [95% confidence intervals {CI} = 0.68 to 0.81]). During pregnancy, 83.0% of the antibiotic prescriptions were picked up at a pharmacy, compared to an 86.6% filling rate in non-pregnant patients. The difference was not significant when adjusting for clustering at the patient level. Conclusion Norwegian GPs prescribe fewer antibiotics overall when patients are pregnant and, when they do prescribe, choose more narrow spectrum antibiotics for RTIs. This indicates a possible lower target rate for GP prescriptions to females. A low antibiotic dispension rate during pregnancy may represent a discussion topic in the consultation setting, to address possible reasons and avoid under-treatment.

• Fossum, Guro Haugen; Lindbæk, Morten; Gjelstad, Svein & Kvaerner, Kari Jorunn (2018). Relationship between Maternal and First Year of Life Dispensations of Antibiotics and Antiasthmatics. Antibiotics. 7(3). doi: 10.3390/antibiotics7030084. Fulltekst i vitenarkiv Vis sammendrag

  Antibiotics are the most frequent prescription drugs used by pregnant women. Our objective was to investigate if the dispensation of antibiotics and antiasthmatics in children less than 1 year of age is associated with prenatal antibiotic exposure. A secondary aim was to explore the incidence of dispensed antibiotics in pregnancy and dispensed antibiotics and antiasthmatics in children. We conducted an observational study using the Peer Academic Detailing study database to select patients eligible for match in the Medical Birth Registry of Norway, a total of 7747 mother-and-child pairs. Details on antibiotic and antiasthmatic pharmacy dispensations were obtained from the Norwegian Prescription Database. One quarter (1948 of 7747) of the mothers in the study had been dispensed antibiotics during pregnancy. In their first year of life, 17% (1289) of the children had had an antibiotic dispensation, 23% (1747) an antiasthmatic dispensation, and 8% (619) of the children had had both. We found a significant association between dispensed antibiotics in pregnancy and dispensed antibiotics to the child during their first year of life; OR = 1.16 (95% CI: 1.002–1.351). The association was stronger when the mothers were dispensed antibiotics at all, independent of the pregnancy period; OR = 1.60 (95% CI: 1.32–1.94). We conclude that the probability for dispensation of antibiotics was increased in children when mothers were dispensed antibiotics, independent of pregnancy. Diagnostic challenges in the very young and parental doctor-seeking behavior may, at least in part, contribute to the association between dispensations in mothers and children below the age of one year.

• Bollestad, Marianne; Vik, Ingvild; Grude, Nils & Lindbæk, Morten (2018). Predictors of Symptom Duration and Bacteriuria in Uncomplicated Urinary Tract Infection. Scandinavian Journal of Primary Health Care. ISSN 0281-3432. doi: 10.1080/02813432.2018.1499602. Fulltekst i vitenarkiv
• Eliassen, Knut Eirik Ringheim; Reiso, Harald; Berild, Dag & Lindbæk, Morten (2018). Comparison of phenoxymethylpenicillin, amoxicillin, and doxycycline for erythema migrans in general practice. A randomized controlled trial with a 1-year follow-up. Clinical Microbiology and Infection (CMI). ISSN 1198-743X. 24(12), s. 1290–1296. doi: 10.1016/j.cmi.2018.02.028. Fulltekst i vitenarkiv
• Bollestad, Marianne; Grude, Nils; Solhaug, Sigrid; Raffelsberger, Niclas Peter; Handal, Nina & Nilsen, Hans-Johnny [Vis alle 16 forfattere av denne artikkelen] (2018). Clinical and bacteriological efficacy of pivmecillinam treatment for uncomplicated urinary tract infections caused by ESBL-producing Escherichia coli: a prospective, multicentre, observational cohort study. Journal of Antimicrobial Chemotherapy. ISSN 0305-7453. 73(9), s. 2503–2509. doi: 10.1093/jac/dky230. Fulltekst i vitenarkiv
• Vik, Ingvild; Bollestad, Marianne; Grude, Nils; Baerheim, Anders; Damsgaard, Eivind & Neumark, Thomas [Vis alle 10 forfattere av denne artikkelen] (2018). Ibuprofen versus pivmecillinam for uncomplicated urinary tract infection in women-A double-blind, randomized non-inferiority trial. PLoS Medicine. ISSN 1549-1277. 15(5), s. 1–21. doi: 10.1371/journal.pmed.1002569. Fulltekst i vitenarkiv
• Lindbæk, Morten (2018). Antibiotic prescribing does not decrease complications in adult patients with lower respiratory tract infections. Evidence-Based Medicine. ISSN 1356-5524. doi: 10.1136/bmjebm-2017-110794. Fulltekst i vitenarkiv
• Kållberg, Cecilia Birgit Maria; Årdal, Christine Oline; Blix, Hege Salvesen; Klein, Eili; Martinez, Elena M & Lindbæk, Morten [Vis alle 9 forfattere av denne artikkelen] (2018). Introduction and geographic availability of new antibiotics approved between 1999 and 2014. PLOS ONE. 13(10). doi: 10.1371/journal.pone.0205166. Fulltekst i vitenarkiv Vis sammendrag

  Background Despite the urgent need for new, effective antibiotics, few antibiotics of value have entered the market during the past decades. Therefore, incentives have been developed to stimulate antibiotic R&D. For these incentives to be effective, geographic availability for recently approved antibiotics needs to be better understood. In this study, we analyze geographic availability and market introduction of antibiotics approved between 1999 and 2014. Material and method We identified antibiotics, considered new chemical entities (NCEs) for systemic use approved globally between 1999 and 2014, from national medicine agencies’ lists of approved drugs, and data from the WHO Collaborating Center for Drug Statistics. Geographic availability was mapped using sales data from IQVIA, and analyzed with regards to class, indication, safety, and origin. Results Of the 25 identified NCEs, only 12 had registered sales in more than 10 countries. NCEs with the widest geographic availability had registered sales in more than 70 countries within a ten-year timeframe and 30 countries within a three-year timeframe, spreading across five different geographic regions and three country income classes. Half (52%) of the NCEs had an indication for infections caused by antibiotic- resistant bacteria, little diversity was seen regarding target pathogen and indication. Antibiotics originated from and/or marketed by companies from the US or Europe had greater geographic availability compared to Japanese antibiotics, which seldom reached outside of Asia. For 20 NCEs developers chose to fully or partially sublicense marketing rights to a number of companies of different sizes. Conclusion Our findings show great variation in geographic availability of antibiotics, indicating that availability in multiple regions and country income classes is possible, but rarely seen within a few years of market authorization. Sublicensing agreements between multiple companies was common practice. Moreover, differences were seen between countries regarding benefit/risk evaluations and company behavior. These findings could be a potential source of uncertainties, and create barriers to assure that working antibiotics are developed and made available according to public health needs.

• Lindbæk, Morten (2018). Broad-spectrum antibiotics gave no clinical benefit and more adverse effects than narrow-spectrum antibiotics in treating acute respiratory tract infections in US children. BMJ Evidence Based Medicine. doi: 10.1136/bmjebm-2018-110938. Fulltekst i vitenarkiv
• Eliassen, Knut Eirik; Berild, Dag; Reiso, Harald; Grude, Nils; Christophersen, Karen Sofie & Finckenhagen, Cecilie [Vis alle 7 forfattere av denne artikkelen] (2017). Incidence and antibiotic treatment of erythema migrans in Norway 2005–2009. Ticks and Tick-borne Diseases. ISSN 1877-959X. 8(1), s. 1–8. doi: 10.1016/j.ttbdis.2016.06.006. Fulltekst i vitenarkiv
• Eliassen, Knut Eirik; Hjetland, Reidar; Reiso, Harald; Lindbæk, Morten & Tschudi-Madsen, Hedda (2017). Symptom load and general function among patients with erythema migrans: a prospective study with a 1-year follow-up after antibiotic treatment in Norwegian general practice. Scandinavian Journal of Primary Health Care. ISSN 0281-3432. 35(1), s. 75–83. doi: 10.1080/02813432.2017.1288812. Fulltekst i vitenarkiv
• Romøren, Maria; Gjelstad, Svein & Lindbæk, Morten (2017). A structured training program for health workers in intravenous treatment with fluids and antibiotics in nursing homes: A modified stepped-wedge cluster-randomised trial to reduce hospital admissions. PLOS ONE. 12(9). doi: 10.1371/journal.pone.0182619. Fulltekst i vitenarkiv Vis sammendrag

  Objectives Hospitalization is potentially detrimental to nursing home patients and resource demanding for the specialist health care. This study assessed if a brief training program in administrating intravenous fluids and antibiotics in nursing homes could reduce hospital transfers and ensure high quality care locally. Design A pragmatic and modified cluster randomized stepped-wedge trial with randomization on nursing home level. Participants 330 cases in 296 nursing home residents from 30 nursing homes were included. Cases were patients provided intravenous antibiotics or intravenous fluids, in nursing home or hospital. Primary outcome was localization of treatment, secondary outcomes were number of days treated, days of hospitalization among admitted patients, type of antibiotics used and 30-day mortality. Intervention The nursing homes sequentially received a one-day educational program for the health workers including theory and practical training in intravenous treatment of dehydration and infection, run by two skilled nurses. After completing the training program, the nursing homes had competence to provide intravenous treatment locally. Results The intervention had a highly significant effect on treatment in nursing homes (OR 8.35, 2.08 to 33.6; P<0.01, or RR 2.23, 1.48 to 2.56). The number treated in nursing homes was stable over time; the number treated in hospital gradually decreased (chi square for trend P< 0.001). Among patients receiving intravenous antibiotics in the nursing homes, 50 (46%) died within 30 days, compared to 30 (36%) treated in the hospital (P = 0.19). Among patients receiving intravenous fluids locally, 21 (19%) died within 30 days, compared to 2 (8%) in the hospital group (P = 0.34). Mortality was associated with reduced consciousness and elevated c-reactive protein. Conclusions A brief educational program delivered to nursing home personnel was feasible and effective in reducing acute hospital admissions from nursing homes for treatment of dehydration and infections.

• Alberg, Torunn; Holen, Øyunn; Blix, Hege Salvesen; Lindbæk, Morten; Bentele, Horst & Eriksen, Hanne-Merete (2017). Antibiotikabruk og infeksjoner i sykehjem. Tidsskrift for Den norske legeforening (Tidsskriftet). ISSN 0029-2001. 137(5), s. 357–361. doi: 10.4045/tidsskr.16.0621. Fulltekst i vitenarkiv
• Bollestad, Marianne; Vik, Ingvild; Grude, Nils; Blix, Hege Salvesen; Brekke, Hanne & Lindbæk, Morten (2017). Bacteriology in uncomplicated urinary tract infections in Norwegian general practice from 2001–2015. British Journal of General Practice Open. 1(4). doi: 10.3399/bjgpopen17X101145. Fulltekst i vitenarkiv Vis sammendrag

  Background: Uncomplicated urinary tract infections in women are common, and urine samples from these patients are not routinely cultured. Empirical treatment is based on knowledge of resistance patterns for common uropathogens. Aim: To evaluate the bacteriological findings and resistance patterns in urine samples from women with uncomplicated urinary tract infections, and to assess the relationship between antimicrobial use and resistance patterns from 2000–2015 in Norway. Method: Bacteriology and resistance patterns were compared in 184 urine cultures from 2001, 406 urine cultures from 2010–2011 and 259 urine cultures from 2013–2015. Antibiotic use data from 2000–2015 were obtained from national databases. Results: Escherichia coli (E. coli) was the main bacterial agent in 80% of the cultures. Staphylococcus saprophyticus (Staph. saprophyticus) represented 6–17%. For E. coli, resistance to mecillinam showed some variation but remained below 9%. There was negligible resistance to nitrofurantoin. Resistance to trimethoprim seemed to stabilise over the last 5 years at around 20%. Amoxicillin resistance had some variations, but remained stable around 30%. There was a steady rise in total consumption of selected antibiotics commonly used to treat urinary tract infections for the period 2000–2015. Conclusion: Mecillinam and nitrofurantoin are both excellent first choices for empirical treatment of uncomplicated urinary tract infections. This study suggests that increasing resistance to trimethoprim challenges the rationale for its use as a first-line agent.

• Berg, Are Stuwitz; Inchley, Christopher; Fjærli, Hans Olav; Leegaard, Truls Michael; Lindbæk, Morten & Nakstad, Britt (2017). Clinical features and inflammatory markers in pediatric pneumonia: a prospective study. European Journal of Pediatrics. ISSN 0340-6199. 176(5), s. 629–638. doi: 10.1007/s00431-017-2887-y. Fulltekst i vitenarkiv Vis sammendrag

  Abstract In this prospective, observational study on previously healthy children <18 years, we aimed to study the diagnostic ability of clinical features and inflammatory markers to (i) predict pathologic chest radiography in suspected pneumonia and (ii) differentiate etiology in radiological proven pneumonia. In 394 cases of suspected pneumonia, 265 (67%) had radiographs consistent with pneumonia; 34/265 had proof of bacterial etiology. Of the cases, 86.5% had received pneumococcal conjugate vaccine. In suspected pneumonia, positive chest radiography was significantly associated with increasing C-reactive protein (CRP) values, higher age, and SpO2 ≤92% in multivariate logistic regression, OR 1.06 (95% CI 1.03 to 1.09), OR 1.09 (95% CI 1.00 to1.18), and OR 2.71 (95% CI 1.42 to 5.18), respectively. In proven pneumonia, bacterial pneumonia was significantly differentiated from viral/atypical pneumonia by increasing CRP values and SpO2 >92% in multivariate logistic regression, OR 1.09 (95% CI 1.05 to 1.14) and OR 0.23 (95% CI 0.06 to 0.82), respectively. Combining high CRP values (>80 mg/L) and elevated white blood cell (WBC) count provided specificity >85%, positive likelihood ratios >3, but sensitivity <46% for both radiographic proven and bacterial pneumonia. Conclusion: With relatively high specificity and likelihood ratio CRP, WBC count and hypoxemia may be beneficial in ruling in a positive chest radiograph in suspected pneumonia and bacterial etiology in proven pneumonia, but with low sensitivity, the clinical utility is limited.

• Gran, Sarah Frandsen; Brænd, Anja Maria; Lindbæk, Morten & Frich, Jan C (2016). General practitioners’ and students’ experiences with feedback during a six-week clerkship in general practice: A qualitative study. Scandinavian Journal of Primary Health Care. ISSN 0281-3432. 34(2), s. 172–179. doi: 10.3109/02813432.2016.1160633. Fulltekst i vitenarkiv Vis sammendrag

  Objective: Feedback may be scarce and unsystematic during students' clerkship periods. We wanted to explore general practitioners' (GPs) and medical students' experiences with giving and receiving supervision and feedback during a clerkship in general practice, with a focus on their experiences with using a structured tool (StudentPEP) to facilitate feedback and supervision. Design: Qualitative study. Setting: Teachers and students from a six-week clerkship in general practice for fifth year medical students were interviewed in two student and two teacher focus groups. Subjects: 21 GPs and nine medical students. Results: We found that GPs first supported students' development in the familiarization phase by exploring the students' expectations and competency level. When mutual trust had been established through the familiarization phase GPs encouraged students to conduct their own consultations while being available for supervision and feedback. Both students and GPs emphasized that good feedback promoting students' professional development was timely, constructive, supportive, and focused on ways to improve. Among the challenges GPs mentioned were giving feedback on behavioral issues such as body language and insensitive use of electronic devices during consultations or if the student was very insecure, passive, and reluctant to take action or lacked social or language skills. While some GPs experienced StudentPEP as time-consuming and unnecessary, others argued that the tool promoted feedback and learning through mandatory observations and structured questions. Conclusion: Mutual trust builds a learning environment in which supervision and feedback may be given during students' clerkship in general practice. Structured tools may promote feedback, reflection and learning.

• Ulstad, Charlotte Rosenberg; Solheim, Margrete; Berg, Sophie; Lindbæk, Morten; Dahle, Ulf R & Wester, Astrid Lousie (2016). Carriage of ESBL/AmpC-producing or ciprofloxacin non-susceptible Escherichia coli and Klebsiella spp. in healthy people in Norway. Antimicrobial Resistance & Infection Control. 5. doi: 10.1186/s13756-016-0156-x. Fulltekst i vitenarkiv Vis sammendrag

  Background Asymptomatic carriage has been recognised as an important risk factor for infection caused by antibiotic resistant bacteria. A 14% global prevalence of Extended-Spectrum Beta-lactamase (ESBL) carriage was recently reported, but large intra-and interregional variations were observed. We investigated the faecal carriage rates of ESBL-, AmpC-producing and ciprofloxacin non-susceptible Escherichia coli and Klebsiella spp. in healthy Norwegians. Methods Rectal samples were obtained from 284 volunteers, together with demographic data and information on recent travel history. The rectal samples were screened by selective plating and E. coli and Klebsiella spp. identified using MALDI-TOF. Phenotypic and molecular characterization of resistant isolates was also performed. Results ESBL- or AmpC-producing E. coli and Klebsiella spp. were isolated from 4.9% and 3.2% of the study population, respectively. Carriage of ciprofloxacin non-susceptible isolates was detected in 9.9% of the volunteers. Molecular typing of ESBL/plasmid-mediated AmpC (pAmpC)-producing isolates suggested an allodemic situation rather than the dissemination of a specific clone in the Norwegian community. In concurrence with previous findings, travel to South-East Asia was associated with increased risk of carrying resistant E. coli or Klebsiella spp., highlighting the contribution of factors such as increased global mobility in erasing the boundaries between healthcare and community settings when it comes to spread of resistant bacteria. Conclusions Overall, our study recognised Norway as a low-incidence country for faecal carriage of resistant bacteria among healthy individuals. Furthermore, our work denoted the importance of healthy humans as a reservoir for transmission of antibiotic resistant E. coli and Klebsiella spp.

• Dyrkorn, Roar; Gjelstad, Svein; Espnes, Ketil Arne & Lindbæk, Morten (2016). Peer academic detailing on use of antibiotics in acute respiratory tract infections. A controlled study in an urban Norwegian out-of-hours service. Scandinavian Journal of Primary Health Care. ISSN 0281-3432. 34(2), s. 180–185. doi: 10.3109/02813432.2016.1163035. Fulltekst i vitenarkiv
• Bollestad, Marianne; Grude, Nils & Lindbæk, Morten (2015). A randomized controlled trial of a diagnostic algorithm for symptoms of uncomplicated cystitis at an out-of-hours service. Scandinavian Journal of Primary Health Care. ISSN 0281-3432. 33(2), s. 57–64. doi: 10.3109/02813432.2015.1041827. Fulltekst i vitenarkiv
• Olaussen, Morten; Holmedal, Øystein; Mdala, Ibrahimu; Brage, Søren Karl & Lindbæk, Morten (2015). Corticosteroid or placebo injection combined with deep transverse friction massage, Mills manipulation, stretching and eccentric exercise for acute lateral epicondylitis: a randomised, controlled trial. BMC Musculoskeletal Disorders. 16. doi: 10.1186/s12891-015-0582-6. Fulltekst i vitenarkiv Vis sammendrag

  Background Lateral epicondylitis of the elbow is a frequent condition with long-lasting symptoms. Corticosteroid injection is increasingly discouraged and there is little knowledge on the combined effect of corticosteroid injection and physiotherapy for acute conditions. We wanted to investigate the efficacy of physiotherapy alone and combined with corticosteroid injection for acute lateral epicondylitis. Methods A randomized, controlled study with one-year follow-up was conducted in a general practice setting in Sarpsborg, Norway. We included 177 men and women aged 18 to 70 with clinically diagnosed lateral epicondylitis of recent onset (2 weeks to 3 months). They were randomly assigned to one of three treatments: physiotherapy with two corticosteroid injections, physiotherapy with two placebo injections or wait-and-see (control). Physiotherapy consisted of deep transverse friction massage, Mills manipulation, stretching, and eccentric exercises. We used double blind injection of corticosteroid and single blind assessments. The main outcome measure was treatment success defined as patients rating themselves completely recovered or much better on a six-point scale. Results One hundred fifty-seven patients (89 %) completed the trial. Placebo injection with physiotherapy showed no significant difference compared to control or to corticosteroid injection with physiotherapy at any follow-up. Corticosteroid injection with physiotherapy had a 10.6 times larger odds for success at six weeks (odds ratio 10.60, p < 0.01) compared to control (NNT = 3, 99 % CI 1.5 to 4.2). At 12 weeks there was no significant difference between these groups, but at 26 weeks the odds for success were 91 % lower (OR 0.09, p < 0.01) compared to control, showing a large negative effect (NNT = 5, 99 % CI 2.1 to 67.4). At 52 weeks there was no significant difference. Both control and placebo injection with physiotherapy showed a gradual increase in success. Conclusions Acute lateral epicondylitis is a self-limiting condition where 3/4 of patients recover within 52 weeks. Physiotherapy with deep transverse friction massage, Mills manipulation, stretching, and eccentric exercises showed no clear benefit, and corticosteroid injection gave no added effect. Corticosteroid injections combined with physiotherapy might be considered for patients needing a quick improvement, but intermediate (12 to 26 weeks) worsening of symptoms makes the treatment difficult to recommend. Trial registration ClinicalTrials.gov Identifier: NCT00826462

• Touboule-Lundgren, Pia; Jensen, Siri; Drai, Johan & Lindbæk, Morten (2015). Identification of cultural determinants of antibiotic use cited in primary care in Europe: A mixed research synthesis study of integrated design "culture is all around us" Health behavior, health promotion and society. BMC Public Health. 15:908. doi: 10.1186/s12889-015-2254-8. Fulltekst i vitenarkiv Vis sammendrag

  BACKGROUND: Inappropriate antibiotic prescribing, particularly for respiratory tract infections (RTI) in ambulatory care, has become a worldwide public health threat due to resulting antibiotic resistance. In spite of various interventions and campaigns, wide variations in antibiotic use persist between European countries. Cultural determinants are often referred to as a potential cause, but are rarely defined. To our knowledge, so far no systematic literature review has focused on cultural determinants of antibiotic use. The aim of this study was to identify cultural determinants, on a country-specific level in ambulatory care in Europe, and to describe the influence of culture on antibiotic use, using a framework of cultural dimensions. METHOD: A computer-based systematic literature review was conducted by two research teams, in France and in Norway. Eligible publications included studies exploring antibiotic use in primary care in at least two European countries based on primary study results, featuring a description of cultural determinants, and published between 1997 and 2015. Quality assessment was conducted independently by two researchers, one in each team, using appropriate checklists according to study design. Each included paper was characterized according to method, countries involved, sampling and main results, and cultural determinants mentioned in each selected paper were extracted, described and categorized. Finally, the influence of Hofstede's cultural dimensions associated with antibiotic consumption within a primary care setting was described. RESULTS: Among 24 eligible papers, 11 were rejected according to exclusion criteria. Overall, 13 papers meeting the quality assessment criteria were included, of which 11 used quantitative methods and two qualitative or mixed methods. The study participants were patients (nine studies) and general practitioners (two studies). This literature review identified various cultural determinants either patient-related (illness perception/behaviour, health-seeking behaviour, previous experience, antibiotic awareness, drug perception, diagnosis labelling, work ethos, perception of practitioner) or practitioner-related (RTI management, initial training, antibiotic awareness, legal issues, practice context) or both (antibiotic awareness). DISCUSSION AND CONCLUSION: Cultural factors should be considered as exerting an ubiquitous influence on all the consecutive stages of the disease process and seem closely linked to education. Interactions between determinant categories, cultural dimensions and antibiotic use in primary care are multiple, complex and require further investigation within overlapping disciplines. The context of European projects seems particularly

• Foshaug, Mats; Vandbakk-Rüther, Maria; Skaare, Dagfinn; Grude, Nils & Lindbæk, Morten (2015). Mycoplasma pneumoniae detection causes excess antibiotic use in Norwegian general practice: a retrospective case–control study. British Journal of General Practice. ISSN 0960-1643. 65(631), s. e82–e88. doi: 10.3399/bjgp15X683509. Fulltekst i vitenarkiv
• Fagan, Mark Stephan; Lindbæk, Morten; Grude, Nils; Reiso, Harald; Romøren, Maria & Skaare, Dagfinn [Vis alle 7 forfattere av denne artikkelen] (2015). Antibiotic resistance patterns of bacteria causing urinary tract infections in the elderly living in nursing homes versus the elderly living at home: an observational study. BMC Geriatrics. 15. doi: 10.1186/s12877-015-0097-x. Fulltekst i vitenarkiv Vis sammendrag

  Background Antibiotic resistance is a problem in nursing homes. Presumed urinary tract infections (UTI) are the most common infection. This study examines urine culture results from elderly patients to see if specific guidelines based on gender or whether the patient resides in a nursing home (NH) are warranted. Methods This is a cross sectional observation study comparing urine cultures from NH patients with urine cultures from patients in the same age group living in the community. Results There were 232 positive urine cultures in the NH group and 3554 in the community group. Escherichia coli was isolated in 145 urines in the NH group (64 %) and 2275 (64 %) in the community group. There were no clinically significant differences in resistance. Combined, there were 3016 positive urine cultures from females and 770 from males. Escherichia coli was significantly more common in females 2120 (70 %) than in males 303 (39 %)(p < 0.05). Enterococcus faecalis was significantly less common in females 223(7 %) than males 137 (18 %) (p < 0.05). For females, there were lower resistance rates to ciprofloxacin among Escherichia coli (7 % vs 12 %; p < 0.05) and to mecillinam among Proteus mirabilis (3 % vs 12 %; p < 0.05). Conclusions Differences in resistance rates for patients in the nursing home do not warrant separate recommendations for empiric antibiotic therapy, but recommendations based on gender seem warranted.

• Vik, Ingvild; Bollestad, Marianne; Grude, Nils; Baerheim, Anders; Mölstad, Sigvard & Bjerrum, Lars [Vis alle 7 forfattere av denne artikkelen] (2014). Ibuprofen versus mecillinam for uncomplicated cystitis - a randomized controlled trial study protocol. BMC Infectious Diseases. 14:693. doi: 10.1186/s12879-014-0693-y. Fulltekst i vitenarkiv Vis sammendrag

  Background: Although uncomplicated cystitis is often self-limiting, most such patients will be prescribed antibiotic treatment. We are investigating whether treatment of cystitis with an NSAID is as effective as an antibiotic in achieving symptomatic resolution. Methods/Design: This is a randomized, controlled, double blind trial following the principles of Good Clinical Practice. Women between the ages of 18 to 60 presenting with symptoms of uncomplicated cystitis are screened for eligibility. 500 women from four sites in Norway, Sweden and Denmark are allocated to treatment with 600 mg ibuprofen three times a day or 200 mg mecillinam three times a day for three days. Allocation is conducted using block randomization. The primary outcome is the number of patients who feel cured by day four as recorded in a diary. Adverse events will be handled and reported in accordance with Good Clinical Practice. Discussion: If treatment of uncomplicated cystitis with ibuprofen is as effective as mecillinam for symptom relief, we can potentially reduce the use of antibiotics on a global scale.

• Lindbæk, Morten (2014). Delayed prescribing for respiratory tract infections in primary care results in lower antibiotic use. Evidence-Based Medicine. ISSN 1356-5524. 19(5), s. 197–197. doi: 10.1136/eb-2014-110012. Fulltekst i vitenarkiv
• Earnshaw, S; Lindbæk, Morten & Col, European Antibiotic Awareness Day (2014). European Antibiotic Awareness Day: a five-year perspective of Europe-wide actions to promote prudent use of antibiotics. Eurosurveillance. ISSN 1025-496X. 19(41). Fulltekst i vitenarkiv
• Fagan, Mark Stephan; Lindbæk, Morten; Reiso, Harald & Berild, Dag (2014). A simple intervention to reduce inappropriate ciprofloxacin prescribing in the emergency department. Scandinavian Journal of Infectious Diseases. ISSN 0036-5548. 46(7), s. 481–485. doi: 10.3109/00365548.2014.880187. Fulltekst i vitenarkiv
• Gjelstad, Svein; Høye, Sigurd; Straand, Jørund; Brekke, Mette; Dalen, Ingvild & Lindbæk, Morten (2013). Improving antibiotic prescribing in acute respiratory tract infections: cluster randomised trial from Norwegian general practice (prescription peer academic detailing (Rx-PAD) study). BMJ. British Medical Journal. ISSN 0959-8146. 347. doi: 10.1136/bmj.f4403. Fulltekst i vitenarkiv
• Fossum, Guro Haugen; Lindbæk, Morten; Gjelstad, Svein; Dalen, Ingvild & Kvaerner, Kari Jorunn (2013). Are children carrying the burden of broad-spectrum antibiotics in general practice? Prescription pattern for paediatric outpatients with respiratory tract infections in Norway. BMJ Open. 3(1). doi: 10.1136/bmjopen-2012-002285. Fulltekst i vitenarkiv
• Høye, Sigurd; Gjelstad, Svein & Lindbæk, Morten (2013). Effects on antibiotic dispensing rates of interventions to promote delayed prescribing for respiratory tract infections in primary care. British Journal of General Practice. ISSN 0960-1643. 63(616), s. E777–E786. doi: 10.3399/bjgp13X674468. Fulltekst i vitenarkiv
• Skeie, Ivar; Brekke, Mette; Clausen, Thomas; Gossop, Michael; Lindbæk, Morten & Reinertsen, Even [Vis alle 8 forfattere av denne artikkelen] (2013). Increased Somatic Morbidity in the First Year after Leaving Opioid Maintenance Treatment: Results from a Norwegian Cohort Study. European Addiction Research. ISSN 1022-6877. 19(4), s. 194–201. doi: 10.1159/000345229. Fulltekst i vitenarkiv
• Olaussen, Morten; Holmedal, Øystein; Lindbæk, Morten; Brage, Søren Karl & Solvang, Hiroko Kato (2013). Treating lateral epicondylitis with corticosteroid injections or non-electrotherapeutical physiotherapy: a systematic review. BMJ Open. 3(10:e003564). doi: 10.1136/bmjopen-2013-003564. Fulltekst i vitenarkiv Vis sammendrag

  Objectives. To evaluate the current evidence for the efficacy of corticosteroid injection and non-electrotherapeutic physiotherapy compared with control for treating lateral epicondylitis. Design. Systematic review. Participants. We searched five databases in September 2012 for randomised controlled studies with a minimum quality rating. Of the 640 studies retrieved, 11 were included, representing 1161 patients of both sexes and all ages. Interventions. Corticosteroid injection and non-electrotherapeutic physiotherapy. Outcome measures. Relative risk (RR) or standardised mean difference (SMD) for overall improvement, pain and grip strength at 4–12, 26 and 52 weeks of follow-up. Results. Corticosteroid injection gave a short-term reduction in pain versus no intervention or non-steroidal anti-inflammatory drugs (SMD -1.43, 95% CI -1.64 to -1.23). At intermediate follow-up, we found an increase in pain (SMD 0.32, 95% CI 0.13 to 0.51), reduction in grip strength (SMD -0.48, 95% CI -0.73 to -0.24) and negative effect on the overall improvement effect (RR 0.66 (0.53 to 0.81)). For corticosteroid injection versus lidocaine injection, the evidence was conflicting. At long-term follow-up, there was no difference on overall improvement and grip strength, with conflicting evidence for pain. Manipulation and exercise versus no intervention showed beneficial effect at short-term follow-up (overall improvement RR 2.75, 95% CI 1.30 to 5.82), but no significant difference at intermediate or long-term follow-up. We found moderate evidence for short-term and long-term effects of eccentric exercise and stretching versus no intervention. For exercise versus no intervention and eccentric or concentric exercise and stretching versus stretching alone, we found moderate evidence of no short-term effect. Conclusions. Corticosteroid injections have a short-term beneficial effect on lateral epicondylitis, but a negative effect in the intermediate term. Evidence on the long-term effect is conflicting. Manipulation and exercise and exercise and stretching have a short-term effect, with the latter also having a long-term effect.

• Hjetland, Reidar; Eliassen, Knut Eirik; Lindbæk, Morten; Nilsen, Roy Miodini; Grude, Nils & Ulvestad, Elling (2013). Tick bites in healthy adults from western Norway: Occurrence, risk factors, and outcomes. Ticks and Tick-borne Diseases. ISSN 1877-959X. 4(4), s. 304–310. doi: 10.1016/j.ttbdis.2013.02.003. Fulltekst i vitenarkiv
• Waal, Helge; Brekke, Mette; Clausen, Thomas; Lindbæk, Morten; Rosta, Judith & Skeie, Ivar [Vis alle 7 forfattere av denne artikkelen] (2012). Fastlegers syn på legemiddelassistert rehabilitering. Tidsskrift for Den norske legeforening (Tidsskriftet). ISSN 0029-2001. 132(16), s. 1861–1866. doi: 10.4045/tidsskr.12.0124. Fulltekst i vitenarkiv
• Fagan, Mark Stephan; Mæhlen, Marthe Thoresen; Lindbæk, Morten & Berild, Dag (2012). Antibiotic prescribing in nursing homes in an area with low prevalence of antibiotic resistance: Compliance with national guidelines. Scandinavian Journal of Primary Health Care. ISSN 0281-3432. 30(1), s. 10–15. doi: 10.3109/02813432.2011.629156. Fulltekst i vitenarkiv Vis sammendrag

  Objective. To examine antibiotic prescribing in nursing homes and determine to what degree the prescribing was in accordance with the national guidelines for antibiotic prescribing. Design. Retrospective examination of patients’ records who were prescribed antibiotics in the period 1 March 2007 to 28 February 2008. Setting and patients. Patients residing in the nursing homes of Arendal, Norway. Main outcome measures. Choice of antibiotic in respect of the recommendations in the national guidelines for antibiotic prescribing. Results. A total of 714 antibiotic courses were prescribed to 327 patients yielding a prevalence of 6.6%. Compliant prescribing was 77% for urinary tract infections (UTI), 79% for respiratory tract infections (RTI), and 76% for skin and soft tissue infections (SSTI). Ciprofloxacin was responsible for 63% of non-compliant prescribing. On the respite wards there was a higher rate of total prescribing, non-compliant prescribing, and prescribing by physicians employed at the local hospital. Conclusion. Guidelines for antibiotic use must be implemented actively and efforts to improve antibiotic prescribing in nursing homes must be aimed at both nursing home and hospital physicians.

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• Lindbæk, Morten (2013). Nasjonale retningslinjer for antibiotikabruk i primærhelsetjenesten. Helsedirektoratet. ISBN 9788280812711. 330 s. Fulltekst i vitenarkiv
• Lindbæk, Morten (2012). Nasjonale faglige retningslinjer for antibiotikabruk i primærhelsetjenesten. 2 utgave (2012). Helsedirektoratet. ISBN 9788280812520. 238 s. Fulltekst i vitenarkiv

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• Knudsen, Caroline Vestby; Akselsen, Per Espen; Fostervold, Aasmund; Gammelsrud, Karianne Wiger; Haugan, Ingvild & Husby, Alexander [Vis alle 11 forfattere av denne artikkelen] (2025). Bruk-Spar-Reserve. Tidsskrift for Den norske legeforening (Tidsskriftet). ISSN 0029-2001. 145(7). doi: 10.4045/tidsskr.25.0062. Fulltekst i vitenarkiv
• Straand, Jørund; Gradmann, Christoph; Lindbæk, Morten & Simonsen, Gunnar Skov (2025). The history of antibiotic development and resistance (Third Edition). I Quah, Stella R. (Red.), International Encyclopedia of Public Health. Academic Press. ISSN 9780323972802. doi: 10.1016/B978-0-323-99967-0.00076-4. Fulltekst i vitenarkiv Vis sammendrag

  The identification and development of specific biological or chemical medicines to control bacteria and cure patients suffering from infectious disease was a major scientific innovation in medicine. But following widespread use of antimicrobials, bacterial resistance emerged and spread toward an increasing number of antibiotics. Worldwide antibiotic overuse and misuse are important for the selection of bacterial resistance which has become a substantial global threat against public health. Declining supplies of new antibiotics strengthens this concern. Strategies for counteracting the threatening inability of antibiotics to control infectious disease are based on the approach to “think globally while acting locally.”

• Straand, Jørund; Gradmann, Christoph; Lindbæk, Morten & Simonsen, Gunnar Skov (2024). Antibiotikaresistens – historien om da bakteriene slo tilbake. Michael. ISSN 1893-9651. 21(2), s. 184–201. doi: 10.5617/michael.11441. Fulltekst i vitenarkiv Vis sammendrag

  Bakterier er dynamiske organismer som gjennom sin plastisitet og kontinuerlige tilpasning til omgivelsene illustrerer evolusjon gjennom naturlig utvalg og «survival of the fittest». Økt forekomst av antibiotikaresistens er et naturlig og forventet svar på utstrakt bruk av antibiotika. Dette forklarer hvorfor historien om utvikling og utbredelse av antibiotika følges av en parallell historie: historien om antibiotikaresistens – her dels omtalt som sett fra et norsk ståsted. I løpet av rundt 90 år med utstrakt bruk av antimikrobielle legemidler er erkjennelsen om hvordan antibiotikabruk og resistens henger sammen gradvis blitt mer og mer tydelig, fra spredte enkelttilfeller på 1930-tallet til dagens globale pandemi av resistente og multiresistente mikrober. Mikrobene har bevist sin evne til å utvikle resistens mot så å si samtlige antimikrobielle midler som er utviklet siden 1930-tallet.

• Straand, Jørund; Gradmann, Christoph; Lindbæk, Morten & Simonsen, Gunnar Skov (2024). Antibiotika - oppdagelse og utvikling fra før bakteriologiens gjennombrudd til i dag. Michael. ISSN 1893-9651. 21(2), s. 165–183. doi: 10.5617/michael.11416. Fulltekst i vitenarkiv Vis sammendrag

  Oppdagelse og utvikling av antibakterielle legemidler er blant de største triumfene innen moderne medisin og i menneskehetens historie. Takket være antibiotika og kjemoterapeutika ble leger i stand til å behandle alvorlige infeksjonssykdommer og helbrede pasienter som ellers var levnet små sjanser til overlevelse. Ikke rart at antibakterielle midler ble opplevd som mirakelmedisiner da de ble tilgjengelige. Artikkelen gir en historisk framstilling av oppdagelse og utvikling av antibiotika, fra før bakteriologiens gjennombrudd mot slutten av 1800-tallet og fram til vår tid. Dagens situasjon kjennetegnes av økende antibiotika-resistens samtidig som tilgangen på nye og effektive antibiotika langt på vei har stoppetopp.

• Grønmo, Maria Mellemstrand; Møller-Stray, Janne; Akselsen, Per Espen; Lindemann, Paul Christoffer; Fostervold, Aasmund & Knudsen, Caroline Vestby [Vis alle 10 forfattere av denne artikkelen] (2024). Gentamicin bør fortsatt inngå i empirisk sepsisregime hos voksne. 144(3), s. 1–8. doi: 10.4045/tidsskr.23.0659. Fulltekst i vitenarkiv Vis sammendrag

  Kombinasjonen av et smalspektret betalaktamantibiotikum og aminoglykosid bør fortsatt være førstevalg i norske retningslinjer som empirisk antibiotikabehandling av de fleste alvorlige infeksjoner.

• Lindbæk, Morten & Sundsfjord, Arnfinn Ståle (2023). Improving antibiotic prescribing for uncomplicated UTIs. The BMJ. 383, s. p2456–p2456. doi: 10.1136/bmj.p2456. Fulltekst i vitenarkiv
• Gunnarsson, Ronny K.; Ebell, Mark; Centor, Robert; Little, Paul; Verheij, Theo & Lindbæk, Morten [Vis alle 7 forfattere av denne artikkelen] (2023). Best management of patients with an acute sore throat is still best management for these patients. Infectious Diseases. ISSN 2374-4235. doi: 10.1080/23744235.2023.2212054. Fulltekst i vitenarkiv
• Lindbæk, Morten; Austad, Bjarne & Siem, Geir (2023). Kapittel 3.4 Øret. I Hunskaar, Steinar (Red.), Allmennmedisin. Gyldendal Norsk Forlag A/S. ISSN 9788205579866. s. 326–348. Fulltekst i vitenarkiv
• Høye, Sigurd & Lindbæk, Morten (2021). Antibiotikasenteret for primærmedisin - kort vei fra forskning til forbedring av klinisk praksis. LVS-info. s. 5–9. Fulltekst i vitenarkiv
• Høye, Sigurd; Lindbæk, Morten & Blix, Hege Salvesen (2019). Effects of an easy-to-implement, sustainable antimicrobial stewardship intervention in primary care – the ENORM (Educational intervention in NORwegian Municipalities for antibiotic treatment in line with guidelines) study. Fulltekst i vitenarkiv
• Lindemann, Paul Christoffer; Gammelsrud, Karianne Wiger; Löhr, Iren Høyland; Akselsen, Per Espen; Lindbæk, Morten & Sundsfjord, Arnfinn (2019). Valg av antibiotika - viktig endring i prøvesvar fra mikrobiologen. 139(12). doi: 10.4045/tidsskr.19.0339. Fulltekst i vitenarkiv
• Lindbæk, Morten; Bjerrum, Lars & Llor, Carl (2019). Challenges in handling of Urinary tract infections in primary care. Fulltekst i vitenarkiv
• Dysthe, Bjørg Elise Tønnesen; Lødøen, Gjertrud; Romøren, Maria & Lindbæk, Morten (2018). Klamydiaepidemien som viste seg å være feilregistreringer. doi: 10.4045/tidsskr.17.0965. Fulltekst i vitenarkiv
• Bollestad, Marianne; Vik, Ingvild; Lindbæk, Morten; Grude, Nils; Brekke, Hanne & Blix, Hege Salvesen (2017). “Bacteriology in uncomplicated urinary tract infections in Norwegian general practice from 2001-2015.”. Fulltekst i vitenarkiv
• Bollestad, Marianne; Grude, Nils; Lindbæk, Morten & Simonsen, Gunnar Skov (2017). “Mecillinam treatment of UTI caused by ESBL producing E. coli”. Fulltekst i vitenarkiv
• Bjerrum, Lars & Lindbæk, Morten (2015). Which treatment strategy for women with symptoms of urinary tract infection. The BMJ. 351, s. 6888–6888. Fulltekst i vitenarkiv
• Bjerrum, Lars; Correa, GC Cordoba; Llor, Carl & Lindbæk, Morten (2013). Lower threshold for rapid antigen detection testing in patients with sore throats would reduce antibiotic use. BMJ. British Medical Journal. ISSN 0959-8146. 347. doi: 10.1136/bmj.f7055. Fulltekst i vitenarkiv
• Lindbæk, Morten; Jensen, Siri; Eliassen, Knut Eirik; Fetveit, Arne; Grude, Nils & Berild, Dag [Vis alle 7 forfattere av denne artikkelen] (2013). New guidelines for use of antibiotics in the primary health care service. Tidsskrift for Den norske legeforening (Tidsskriftet). ISSN 0029-2001. Fulltekst i vitenarkiv
• Gjelstad, Svein & Lindbæk, Morten (2013). Prognosis of respiratory tract infections in primary care. BMJ. British Medical Journal. ISSN 0959-8146. 347. doi: 10.1136/bmj.f7185. Fulltekst i vitenarkiv
• kallestrup, Per; Schriver, Michael; Lindbæk, Morten & Hjortdahl, Per (2013). "If you want to go fast, go alone. If you want to go far, go together": a call for a Nordic engagement in the development of family medicine in Africa. Scandinavian Journal of Primary Health Care. ISSN 0281-3432. 31(4), s. 183–184. doi: 10.3109/02813432.2013.838340. Fulltekst i vitenarkiv
• Skeie, Ivar; Brekke, Mette; Lindbæk, Morten & Waal, Helge (2013). Somatisk sykelighet blant opioidavhengige før, under og etter legemiddelassistert rehabilitering (LAR). Fulltekst i vitenarkiv
• Johansen, Inger; Lindbæk, Morten; Stanghelle, Johan K & Brekke, Mette (2013). Effekt av rehabilitering av eldre i to ulike modeller i primærhelsetjenesten - en åpen, prospektiv, sammenliknende observasjonsstudie. Fulltekst i vitenarkiv
• Harbin, Nicolay Jonassen; Romøren, Maria & Lindbæk, Morten (2025). Promoting prudent antibiotic use in nursing homes in the municipalities. Universitetet i Oslo. ISSN 9788234807169. Fulltekst i vitenarkiv Vis sammendrag

  To hamper further rise of antibiotic resistance, effective measures aiming to reduce unnecessary antibiotic use needs to be developed and implemented. Previous studies have concluded that there is potential for improved antibiotic use in nursing homes (NHs). This thesis explores antibiotic use and stewardship in Norwegian NHs through a multi-methods approach, including a descriptive baseline data analysis, a controlled multifaceted antibiotic improvement intervention, and a qualitative study of NH healthcare professionals’ perceptions on barriers and facilitators of prudent antibiotic use. The baseline analysis of 34 NHs showed wide variability in antibiotic use, with short-term NHs having significantly higher use. Penicillins were the most used antibiotic group while antibiotics used for urinary tract infections (UTIs) was the dominating indication group. Parenteral antibiotics accounted for 17% with a notable use of broad-spectrum agents. The intervention, which targeted both physicians and nurses and included academic detailing, audit and feedback, clinical guiding tools and targeted education, did not significantly lower overall antibiotic use compared to controls. However, it achieved a substantial 33% reduction in antibiotics for UTIs and a 19% decrease in methenamine use. Qualitative findings identified barriers and facilitators at multiple levels—organisational, clinical, resident, and next-of-kin, that influence prescribing behaviors. Increased professional knowledge and awareness, correct use of point-of-care tests and communication with next-of-kin were perceived as facilitators of prudent antibiotic use. The study confirmed the vital role of nurses in clinical decision-making, highlighting their integration into stewardship efforts. The findings of the thesis underscore the need for tailored implementation strategies, improved interprofessional collaboration, good dialogue with next-of-kin and better diagnostic resources to optimise antibiotic use in NHs.

• Berg, Sophie; Ulstad, Charlotte Rosenberg; Lindbæk, Morten; Wester, Astrid Louise & Dahle, Ulf R (2015). Rapport fra nettbasert spørreundersøkelse om antibiotikaresistens. Folkehelseinstituttet. ISSN 9788280826893. Fulltekst i vitenarkiv
• Steinbakk, Martin; Sunde, Marianne; Urdal, Anne Margrete; Barkbu, Kjersti Nilsen; Sørum, Henning & Lunestad, Bjørn Tore [Vis alle 10 forfattere av denne artikkelen] (2014). Antibiotikaresistens - kunnskapshull, utfordringer og aktuelle tiltak. Rapport fra tverrsektoriell ekspertgruppe. Folkehelseinstituttet. Fulltekst i vitenarkiv

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