Published: 31st May, 2024
Contents
Our 100th Issue!
Today we celebrate a significant milestone: the publication of the 100th issue of Best Practice Bulletin. The COVID-19 Bulletin, as it was first known, was devised as a way of providing rapid news and clinical updates to our audience during the early stages of the pandemic. This was a challenging and unprecedented time for primary healthcare professionals, who had to navigate policy changes and evolving clinical recommendations on a regular basis, all while trying to provide the best possible standard of care and reassurance to their patients.
Upon returning to our physical workplaces after the first COVID-19 lockdown, we broadened the approach to the Bulletin, delivering a wider range of health-related news and other clinically focused items. The first issue of Best Practice Bulletin was published on 28th May, 2020. Since then, we have reported on more than 800 items and analysed the findings of over 100 “Paper of the Weeks”. The Bulletin is also how we update readers on our latest clinical education publications, B-QuiCK topics, CME and multimedia resources. Other regular features include medicine supply news, safety alerts, vaccine and disease trends, latest guideline reviews, upcoming webinars and conferences and much more. We then package this content into emails sent to approximately 12,000 subscribers each fortnight, and make the content available online to our website viewers. The introduction of over 900 Keywords linked to individual items has meant that readers can easily search our back catalogue of issues to find information on any given topic. FYI, the keyword with the most linked items is (unsurprisingly) COVID-19.
We hope you find the content of our bulletins to be relevant and useful, and that you enjoy reading them as much as we enjoy putting them together. Read on to discover three new publications this month from bpacnz, as well as your usual array of news and updates.
Thank you, Ngā mihi nui, from the Publications Team at bpacnz: here’s to the next 100!
If you have anything you would like included in a future issue of Best Practice Bulletin, email: [email protected]
New from bpacnz: Community-acquired pneumonia
Pneumonia is a significant cause of mortality in children and older people, particularly among Māori and Pacific peoples. In New Zealand, Māori males are six times more likely to die from pneumonia than non-Māori males. Prompt identification and treatment will enable patients with initially less severe community-acquired pneumonia to be managed at home, reducing hospitalisation and mortality. As vaccination provides some protection against community-acquired pneumonia, ensure that patients are up to date with vaccinations they are eligible for, including seasonal influenza, COVID-19, pneumococcal and childhood immunisations. This article covers the clinical diagnosis and management of community-acquired pneumonia in children and adults.
Read the full article here. A B-QuiCK summary is also available here.
Persistent fever is one of the characteristic signs of pneumonia in children. However, it can be difficult in young children to distinguish whether the cause of their fever is a life-threatening bacterial infection or a self-limiting viral illness that can be managed in the community. This resource, now updated based on 2024 guidelines, describes the symptoms and signs for assessing the risk of serious illness in children aged under five years presenting with fever. Read the full article here.
Bookmark this page for a quick reference guide to assessing fever in young children in a general practice setting
Also new from bpacnz: HIV pre- and post-exposure prophylaxis: a guide for primary care
Human immunodeficiency virus (HIV) pre-exposure prophylaxis (PrEP) is an oral combination tablet, taken either daily or around a planned potential HIV exposure event, that can greatly reduce the risk of new HIV infection as part of a prevention strategy. The same medicine can also be used for post-exposure prophylaxis (PEP) to reduce the chances of developing HIV following an unplanned high-risk exposure. Both PrEP and PEP are available fully funded with Special Authority approval for people at high risk of HIV infection and can be prescribed by general practitioners and nurse practitioners in primary care (except for PEP in occupational HIV exposures). Guidance on the use of PrEP has changed since it was first funded in 2018, and new national guidelines have now been published, so we encourage all primary care clinicians to familiarise themselves with this latest update.
Ensure that your key patient populations for PrEP know that this is available for them: non-judgmental communication is critical to facilitate open discussion and improve sexual health outcomes, particularly for men who have sex with men (MSM).
Click here to read the full article. B-QuiCK summaries on PrEP and PEP are also available.
A reminder that the Burnett Foundation Aotearoa and the New Zealand Sexual Health Society have been running a series of free HIV PrEP and PEP education sessions for non-specialist prescribers around the country and online (covered in Bulletin 98); click here for remaining dates and locations.
Pertussis cases on the rise
Reported pertussis (whooping cough) case numbers are increasing across some regions of New Zealand. According to data from ESR, there have been 125 cases of pertussis reported (confirmed, probable and suspected) in 2024 (data up to 25th May). In comparison, this time last year there were a total of 26 cases. The total number of cases so far in 2024 almost matches the total number of cases reported for the whole of 2023 (141).
Vaccination (with diphtheria, tetanus and pertussis vaccine, Boostrix) is recommended and funded for pregnant women during every pregnancy and for all children. As reported in Bulletin 88, it is also recommended but not funded for close family contacts of young infants and in some cases for those at higher risk of complications, e.g. people with COPD. The exact duration of protection is unknown, but many groups (e.g. lead maternity carers, primary care clinicians, early childhood workers) are recommended to have a booster dose at least every ten years: see the Immunisation Handbook for further information.
This is a timely reminder to opportunistically check whether patients (particularly children) have completed their course of Boostrix and to offer vaccination where appropriate. Some children may have missed out on their scheduled Boostrix vaccine(s) during the last four years due to the COVID-19 pandemic and lockdowns.
All suspected cases of pertussis must be notified to the local Medical Officer of Health. Do not wait for laboratory confirmation before isolating, treating and notifying.
IMAC is hosting an upcoming webinar for healthcare professionals on pertussis on Tuesday 11th June, at 12:15 – 12:45 pm. Click here to register.
Paediatric and infant Comirnaty XBB.1.5 vaccine update
IMAC recently hosted a webinar to educate the sector about the updated paediatric and infant Comirnaty XBB.1.5 COVID-19 vaccines. The Comirnaty XBB.1.5 10 microgram vaccine (blue cap) is now available for children aged 5 – 11 years. A single dose is sufficient for a primary course (unless the child is immunocompromised, in which case, a three dose primary course is required). This vaccine is a single dose vial that does not require dilution.
The Comirnaty XBB.1.5 3 microgram vaccine (maroon cap) is for children aged six months to four years with severe immunocompromise or a medical condition that increases their risk of severe illness from COVID-19. It was previously expected to be available at the same time as the blue cap vaccine, however, it is now reported that stock is not yet available in New Zealand but will arrive soon. The small number of providers who stock vaccine for this age group will be contacted directly about ordering.
Children in both of these age groups will also be eligible for a single additional dose of the Comirnaty XBB.1.5 vaccine (10 microgram or 3 microgram) if they have severe immunocompromise or a medical condition that increases their risk of severe COVID-19. It is recommended that the additional dose is given at least six months after a previous COVID-19 vaccine dose or COVID-19 infection (as with adults and older children).
Updated resources are available from IMAC, here. Watch the full webinar recording here.
Medicine news: pseudoephedrine, continuous glucose monitors
The following news relating to medicine supply, of particular interest to primary care, has recently been announced. Medicine supply information is also available in the New Zealand Formulary at the top of the individual monograph for any affected medicine and summarised here.
Medicines containing pseudoephedrine now available
Cold and flu products containing pseudoephedrine are now available for purchase in some pharmacies on the recommendation of a pharmacist. In April, 2024, Medsafe approved 11 cold and flu medicines containing pseudoephedrine, and since 20th May, some of these medicines have been available for purchase in pharmacies who wish to stock them. Pseudoephedrine was recently reclassified from a Class B to Class C controlled drug, and it is now a restricted medicine; products containing pseudoephedrine can be sold in a pharmacy by a registered pharmacist without a prescription.
Continuous glucose monitor funding update
Pharmac has provided an update on its proposal to fund continuous glucose monitors, insulin pumps and consumables (as reported in Bulletin 96). It is reported that in response to feedback received, further consideration and advice about some aspects of the proposal is needed, and therefore, the proposed funding date for continuous glucose monitors will be delayed. An information session is being held online via Microsoft Teams at 12 – 12:45 pm on Thursday, 6th June, 2024, where Pharmac will provide an update on the situation. An associated news release can be found here.
GP CME Conference Rotorua next week
If you are attending the GP CME conference in Rotorua at the end of next week (6th – 9th June), be sure to talk to our colleagues at the South Link Education Trust stand (75 – 77). The South Link Education Trust is the Diamond Sponsor of the GP CME conferences, and is home to South Link Health, BPAC Clinical Solutions, InPractice, bpacnz Publications and the New Zealand Formulary.
The BPAC CS team will be presenting the latest release from Smartcare GP: Inbox Manager. They would love to have a chat and show you how it works, along with the other products in the range.
While you are at the stand, grab yourself a free copy of the bpacnz special conference edition handbook - Navigating the last days of life: a general practice perspective. We look forward to hearing your feedback about our resources.
Latest Global Burden of Disease findings released
The Global Burden of Disease is the most comprehensive observational worldwide epidemiological study. Data is updated annually from more than 150 countries, including New Zealand, with the aim of quantifying health outcomes and risk factors, so that health systems can be improved and disparities eliminated over time. Findings from the 2021 Global Burden of Disease study have now been published (publication was delayed due to the COVID-19 pandemic).
For the first time since 1970/1971, a decline in global life expectancy of 1.6 years was observed (between 2019 and 2021). However, in 2020 and 2021, New Zealand was one of the few countries who had negative excess mortality, meaning fewer deaths occurred during that period than was expected. Globally, the leading causes of death in 2021 were ischaemic heart disease, COVID-19, stroke and COPD. The global disability-adjusted life years (DALYs)* increased in 2021 (mostly due to population growth and ageing); the leading causes of disease burden were COVID-19, ischaemic heart disease, neonatal disorders and stroke.
* DALYs are calculated by adding the estimated years lived with disability and years of life lost due to premature mortality
Key findings in New Zealand
- Top ten causes of death per 100,000 people: ischaemic heart disease, stroke, Alzheimer’s disease, COPD, lung cancer, colorectal cancer, chronic kidney disease, prostate cancer, lower respiratory tract infections and breast cancer
- Deaths due to ischaemic heart disease, stroke and breast cancer have reduced since 2011, whereas deaths due to Alzheimer’s disease, COPD, lung cancer, colorectal cancer, chronic kidney disease, prostate cancer and lower respiratory tract infections have increased
- Top ten causes of disease burden (DALYs): ischaemic heart disease, low back pain, falls, anxiety disorders, stroke, lung cancer, Alzheimer’s disease, diabetes, COPD and depressive disorders
- Top ten risk factors contributing to disease burden (DALYs) per 100,000 people: high body mass index, tobacco, high fasting plasma glucose, high blood pressure, poor diet, high alcohol use, occupational risks, high LDL, kidney dysfunction, low bone mineral density
Click here for additional New Zealand data. A media release from Manatū Hauora, Ministry of Health, is available here.
Headstrong app for mental wellbeing
Pink Shirt Day, an annual event to stop bullying by celebrating diversity and promoting kindness, was held recently on the 17th May. Bullying can have a significant impact on mental health, particularly for young people. Headstrong is a free New Zealand-based app that rangatahi (young people) can be encouraged to access; it is supported by Health New Zealand, Te Whatu Ora, and the University of Auckland. The app hosts a range of short courses/activities to support wellbeing in young people, including the foundations of mental wellbeing, stress and anxiety, Māori holistic health, substance misuse and addictive behaviours and exercise. The courses, which are designed to be in a “chat bot” format, are evidence-based and use a range of established methods such as cognitive behavioural therapy. Resources, including downloadable patient brochures and referral cards, are available here.
Student scholarships to boost rural healthcare professional recruitment
Rural Women New Zealand (RWNZ) has announced that it is offering scholarships and study grants, with support from Health New Zealand, Te Whatu Ora, to students from rural or regional communities who are enrolled in medicine, dental, midwifery, nursing or allied health studies. Particular consideration is being given to applicants from the most remote rural communities and under-represented populations in the rural workforce, e.g. Māori and Pacific peoples. The grants are intended to help with expanding the rural health workforce. Further information, including an application form, is available from the RWNZ, here. Applications close Monday, 1st July, 2024.
Paper of the Week: Managing recurrent urinary tract infections in primary care
A recurrent urinary tract infection (UTI) is defined as two episodes of a symptomatic uncomplicated UTI within six months or three episodes within 12 months. Infection typically results from bacterial flora from the skin migrating to the urethra and bladder. Organisms commonly associated with recurrent UTIs are similar to those that cause acute UTIs, e.g. Escherichia coli (most common), Klebsiella pneumonia, Staphylococcus saprophyticus, Enterococcus faecalis. Up to 50% of females will experience a UTI at some point in their lifetime, with one-quarter going on to develop recurrent UTIs.
Recurrent UTIs can be extremely frustrating for patients and challenging for clinicians to manage, and often result in secondary care referral. A review in the Australian Journal of General Practice aims to provide primary care clinicians with an overview of treatment options for a patient with recurrent UTIs that can be trialled before referring to urologist or while awaiting urological assessment. Management includes conventional behaviour modifications, non-antibacterial options, and as a last resort, antibiotic prophylaxis. Novel treatments and surgical interventions that may be appropriate for some patients are also discussed.
What is your usual strategy for managing patients with recurrent UTIs? How often can you identify a modifiable cause? Do you prescribe prophylactic antibiotic treatment? What non-antibiotic treatments have you found to be beneficial?
Read more
Risk factors for recurrent UTI are similar to those for any UTI, e.g. advancing age, residential care, reduced immune function due to co-morbidities, presence of structural or functional urinary tract abnormalities. Oestrogen-related changes in older females make them more susceptible to UTI, and sexual intercourse-related factors can contribute to UTI in all females. Prostatitis and benign prostatic hypertrophy can be factors in males with recurrent UTI.
Patients presenting with recurrent UTI with “red flags”, should be referred promptly for urological review (or other appropriate specialist); other patients can be initially managed in primary care using behavioural modifications, non-antibiotic treatments and in some cases, antibiotic prophylaxis.
Red flags for urology referral in a patient with recurrent UTI include:
- Males
- Pregnant females
- Functional or anatomical variation present
- Standard treatments have been unsuccessful in preventing recurrent infections
- Additional reason for concern, e.g. due to surgical or medical history
For patients appropriate for management in primary care, behavioural modifications are first-line:
- Identify and address any modifiable risk factors
- Optimise continence and bowel symptoms, e.g. fibre intake for constipation
- Advise on adequate fluid intake, e.g. at least 1.5 L/day
- Discuss good hygiene practices, e.g. wiping front to back after defecation, urinating after sexual intercourse
There is some evidence supporting the use of non-antibiotic treatments for reducing or preventing recurrent UTIs in certain patient populations:
- Topical vaginal oestrogen (Ovestin; funded) has been shown to reduce recurrent UTIs in postmenopausal females
- Methenamine hippurate (Hiprex; funded) is considered non-inferior to daily continuous low-dose antibiotic prophylaxis and resistance is not expected
- Cranberry products and D-mannose can be considered, however, the most effective dose, formulation and duration of treatment for these products is unknown
- Lactobacillus probiotics do not currently have enough evidence to support their use
Prophylactic antibiotics, e.g. trimethoprim, cefalexin or nitrofurantoin, may be considered as a last resort for patients with recurrent UTIs in whom behaviour modifications and non-antibiotic treatments/prophylaxis have been unsuccessful:
- Medicine choice is based on urine cultures and local susceptibility data
- Prescribe a dose less than typically recommended for management of an acute UTI; click here for dosing information
- Treat for at least six months (review patient after three months)
- Patients who develop a UTI after prophylaxis ends may require treatment indefinitely; discuss with a urologist
- If a factor in recurrent infections, consider prescribing post-coital prophylaxis, i.e. a single dose of antibiotic within two hours of sexual intercourse
- Rotate the prescribed antibiotic every six weeks (for a treatment duration of six months)
- Consider switching patients to a high-dose cranberry product (to be taken following sexual intercourse) if they do not develop a UTI after six-months
- Self-directed prophylaxis may be appropriate in patients who can recognise their symptoms. Prescribe a standard empiric antibiotic course that is initiated at the onset of UTI symptoms.
- Patients should still provide a urine sample to monitor for antibiotic resistance
Intravesical and novel treatments have limited availability in New Zealand and would generally only be offered by a specialist urology clinic:
- Intravesical glycosaminoglycan therapy replaces the non-stick coating of the bladder mucosa and available evidence shows promising results
- Immunomodulators and vaccines are potentially more effective than placebo although the current evidence base is small
Surgery may be required to address reversible causes of recurrent UTIs, e.g. pelvic organ prolapse, urinary tract obstruction or malignancy.
Wynn J, Homewood D, Tse V, et al. What to do about recurrent urinary tract infections: a review of evidence behind emerging therapies. Aust J Gen Pract 2024;53:265–73. https://doi.org/10.31128/AJGP-10-23-7004.
For further information on managing recurrent UTIs in primary care, see: https://bpac.org.nz/2021/uti.aspx#6
This Bulletin is supported by the South Link Education Trust
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