Prescription of antibiotics and prescribers' characteristics. A study into prescription of antibiotics in upper respiratory tract infections in general practice

Early-career general practitioners' antibiotic prescribing for acute infections: a systematic review

BACKGROUND

Antimicrobial resistance is a worldwide threat, exacerbated by inappropriate prescribing. Most antibiotic prescribing occurs in primary care. Early-career GPs are important for the future of antibiotic prescribing and curbing antimicrobial resistance.

OBJECTIVES

To determine antibiotic prescribing patterns by early-career GPs for common acute infections.

METHODS

A systematic literature search was conducted using PubMed, Embase and Scopus. Two authors independently screened abstracts and full texts for inclusion. Primary outcomes were antibiotic prescribing rates for common acute infections by GPs with experience of 10 years or less. Secondary outcomes were any associations between working experience and antibiotic prescribing.

RESULTS

Of 1483 records retrieved, we identified 41 relevant studies. Early-career GPs were less likely to prescribe antibiotics compared with their more experienced colleagues (OR range 0.23-0.67). Their antibiotic prescribing rates for 'any respiratory condition' ranged from 14.6% to 52%, and for upper respiratory tract infections from 13.5% to 33%. Prescribing for acute bronchitis varied by country, from 15.9% in Sweden to 26% in the USA and 63%-73% in Australia. Condition-specific data for all other included acute infections, such as sinusitis and acute otitis media, were limited to the Australian context.

CONCLUSIONS

Early-career GPs prescribe fewer antibiotics than later-career GPs. However, there are still significant improvements to be made for common acute conditions, as their prescribing is higher than recommended benchmarks. Addressing antimicrobial resistance requires an ongoing worldwide effort and early-career GPs should be the target for long-term change.

Prescribing style and variation in antibiotic prescriptions for sore throat: cross-sectional study across six countries

Background

Variation in prescription of antibiotics in primary care can indicate poor clinical practice that contributes to the increase of resistant strains. General Practitioners (GPs), as a professional group, are expected to have a fairly homogeneous prescribing style. In this paper, we describe variation in prescribing style within and across groups of GPs from six countries.

Methods

Cross-sectional study with the inclusion of 457 GPs and 6394 sore throat patients. We describe variation in prescribing antibiotics for sore throat patients across six countries and assess whether variation in “prescribing style” – understood as a subjective tendency to prescribe – has an important effect on variation in prescription of antibiotics by using the concept of prescribing style as a latent variable in a multivariable model. We report variation as a Median Odds Ratio (MOR) which is the transformation of the random effect variance onto an odds ratio; Thus, MOR = 1 means similar odds or strict homogeneity between GPs’ prescribing style, while a MOR higher than 1 denotes heterogeneity in prescribing style.

Results

In all countries some GPs always prescribed antibiotics to all their patients, while other GPs never did. After adjusting for patient and GP characteristics, prescribing style in the group of GPs from Russia was about three times more heterogeneous than the prescribing style in the group of GPs from Denmark – Median Odds Ratio (6.8, 95% CI 3.1;8.8) and (2.6, 95% CI 2.2;4.4) respectively.

Conclusion

Prescribing style is an important source of variation in prescription of antibiotics within and across countries, even after adjusting for patient and GP characteristics. Interventions aimed at influencing the prescribing style of GPs must encompass context-specific actions at the policy-making level alongside GP-targeted interventions to enable GPs to react more objectively to the external demands that are in place when making the decision of prescribing antibiotics or not.

Seasonality and Physician-related Factors Associated with Antibiotic Prescribing: A Cross-sectional Study in Isfahan, Iran

Background:

Irrational antibiotic prescribing as a global health problem has a major influence on medical care quality and healthcare expenditure. This study was aimed to determine the pattern of antibiotic use and to assess the seasonality and physician-related factors associated with variability in antibiotic prescribing in Isfahan province of Iran.

Methods:

This cross-sectional survey was conducted on all prescriptions issued by general physicians from rural and urban areas in 2011. Associations between season of prescribing and physician-related variables including gender, practice location and time since graduation with antibiotic prescriptions and also the pattern of antibiotic prescribing were assessed using Chi-square tests and multiple logistic regression models.

Results:

Of the 7439709 prescriptions issued by 3772 general practitioners, 51% contained at least one antibiotic. Penicillins were the most frequently prescribed antibiotics, followed by cephalosporins and macrolides. Over-prescription of penicillins was associated with female gender (odds ratio [OR], 2.61; 95% confidence interval [CI] 2.13–3.19) and with moderate duration of time in practice (10–20 years) (OR, 1.42; 95% CI 1.14–1.76). Higher rates of cephalosporins prescription were observed in urban areas than rural areas and by male physicians. Seasonal peak was detected for penicillins and cephalosporins prescriptions in autumn.

Conclusions:

These findings showed the widespread use of antibiotics by general practitioners that was associated with the physicians’ gender, time since graduation and practice location and also season of prescribing. More researches are needed on other factors related to the overprescribing of antibiotics and they could be used to project educational programs for improvement of antibiotic prescribing quality in our country.

Misprescription of antibiotics in primary care: a critical systematic review of its determinants

BACKGROUND

Antibiotic resistance is one of the principal public health problems worldwide. Currently, inappropriate use of antibiotics is regarded as the principal determinant of resistance, with most of these drugs being prescribed outside a hospital setting. This systematic review sought to identify the factors, attitudes and knowledge linked to misprescription of antibiotics.

METHODS

A systematic review was conducted using the MEDLINE-PubMed and EMBASE databases. The selection criteria required that papers: (1) be published in English or Spanish; (2) designate their objective as that of addressing attitudes/knowledge or other factors related with the prescribing of antibiotics; and (3) use quality and/or quantity indicators to define misprescription. The following were excluded: any paper that used qualitative methodology and any paper that included descriptive analysis only.

RESULTS

A total of 46 papers that met the inclusion criteria were included in the review. They were very heterogeneous and displayed major methodological limitations. Doctors' socio-demographic and personal factors did not appear to exert much influence. Complacency (fulfilling what professionals perceived as being patients'/parents' expectations) and, to a lesser extent, fear (fear of possible complications in the patient) were the attitudes associated with misprescription of antibiotics.

CONCLUSIONS

Before designing interventions aimed at improving the prescription and use of antibiotics, studies are needed to identify precisely which factors influence prescribing.

Factors affecting the prescribing patterns of antibiotics and injections

There are serious problems concerning the inadequate prescription of antibiotics and overuse of injections in primary care. However, the determinants of prescription patterns in Korea are not well-documented. To examine the area characteristics affecting the prescription of antibiotics and injections in primary care practices in the treatment of respiratory tract infections (RTIs), a nationwide cross-sectional study was performed in all 250 administrative districts of Korea. The outcome was modeled as a binary variable: over-prescription or not compared with the nation-wide average. Over-prescription of antibiotics was associated with the ratio of specialists to general physicians and over-prescription in previous years in the area (adjusted odds ratio [aOR], 4.8; 95% confidence interval [CI] 1.5-14.8; and aOR, 12.0; 95% CI 5.5-25.9, respectively). Over-use of injections was associated with younger population, urban living and the number of hospital beds in the area (aOR, 0.2; 95% CI 0.1-0.4; aOR, 0.3; 95% CI 0.1-0.8; and aOR, 0.4, 95% CI 0.2-0.9; respectively). There were differences in the prescribing patterns in different districts; prescription patterns were affected more by supply factors than by demand factors. Highly competitive medical environment associated with supply factors is a significant determinant of prescription patterns in Korea.

Do general practitioners' consultation rates influence their prescribing patterns of antibiotics for acute respiratory tract infections?

OBJECTIVES

To examine general practitioners' (GPs') antibiotic prescribing patterns for acute respiratory tract infections (ARTIs) as compared with national guidelines. We also wanted to explore possible predictors of antibiotic prescription patterns.

METHODS

Observational study based on prescription data from 440 Norwegian GPs in December 2004 through to November 2005. Outcome measures were the type and frequency of antibiotic prescriptions for various ARTI diagnoses, with patients' and GPs' characteristics as explanatory variables.

RESULTS

In the study period, the 440 GPs treated a total of 142 900 ARTI episodes. In 33.5% [95% confidence interval (CI): 31.9%-35.1%] of these episodes an antibiotic was issued, of which penicillin V (pcV) accounted for 41.2% (95% CI: 37.4%-44.9%). GPs with a high number of total annual encounters had higher antibiotic prescription rates for ARTIs and used more non-pcV antibiotics compared with GPs with fewer annual patient encounters. GPs in the highest quintile with respect to the total annual encounter rate had 1.6 times the odds of prescribing antibiotics compared with GPs in the lowest quintile. Correspondingly, the odds of choosing a non-pcV antibiotic were 2.8 times higher in the top quintile of GPs compared with GPs in the bottom quintile with respect to antibiotic prescription rates.

CONCLUSIONS

ARTIs are frequently treated with antibiotics and often with broader spectrum agents than pcV, which is the recommended first-line antibiotic in the Norwegian guidelines. GPs with a high practice activity are, in general, more liberal with respect to the prescription of antibiotics for ARTIs, and the higher the antibiotic prescription rate, the larger the share of non-pcV agents.

Antimicrobial treatment of upper respiratory tract infections from the Dutch perspective

The worldwide problem of multiple resistant strains should be attacked by a more adequate, rational prescription behaviour of antibiotics. As most upper respiratory tract infections (URTIs) have a viral cause and are selflimiting, antibiotics should be used for certain indications only. The development of evidence based guidelines, based on outcome studies in the field of URTIs carried out in general practice populations is recommended. The general practitioners (GPs) with defined practice populations are in a key position for research and a restrictive antibiotic policy. Several RCTs are carried out in general practice indicating that antibiotic prescriptions can be reduced. This will contribute to the decrease of resistant strains.

Which practices are high antibiotic prescribers? A cross-sectional analysis

BACKGROUND

Substantial variation in antibiotic prescribing rates between general practices persists, but remains unexplained at national level.

AIM

To establish the degree of variation in antibiotic prescribing between practices in England and identify the characteristics of practices that prescribe higher volumes of antibiotics.

DESIGN OF STUDY

Cross-sectional study.

SETTING

8057 general practices in England.

METHOD

A dataset was constructed containing data on standardised antibiotic prescribing volumes, practice characteristics, patient morbidity, ethnicity, social deprivation, and Quality and Outcomes Framework achievement (2004-2005). Data were analysed using multiple regression modelling.

RESULTS

There was a twofold difference in standardised antibiotic prescribing volumes between practices in the 10th and 90th centiles of the sample (0.48 versus 0.95 antibiotic prescriptions per antibiotic STAR-PU [Specific Therapeutic group Age-sex weightings-Related Prescribing Unit]). A regression model containing nine variables explained 17.2% of the variance in antibiotic prescribing. Practice location in the north of England was the strongest predictor of high antibiotic prescribing. Practices serving populations with greater morbidity and a higher proportion of white patients prescribed more antibiotics, as did practices with shorter appointments, non-training practices, and practices with higher proportions of GPs who were male, >45 years of age, and qualified outside the UK.

CONCLUSION

Practice and practice population characteristics explained about one-sixth of the variation in antibiotic prescribing nationally. Consultation-level and qualitative studies are needed to help further explain these findings and improve our understanding of this variation.

Parental experiences and attitudes regarding the management of acute otitis media--a comparative questionnaire between Finland and The Netherlands

BACKGROUND

Both treatment guidelines and the amount of antibiotics used for acute otitis media (AOM) vary across western countries. Parental expectations and their awareness of antimicrobial use and resistance, which may also be influenced by the guidelines, are not yet completely known.

OBJECTIVE

To compare parental experiences and opinions regarding the management of AOM in children with AOM in Finland and The Netherlands.

METHODS

We sent the questionnaires via public day care in Turku, Finland, and Utrecht, The Netherlands. We asked about family background, child's history of AOM and parental experiences and attitudes about AOM treatment and antimicrobial resistance.

RESULTS

Of 1151 participants, 83% in Finland and 49% in The Netherlands had had at least one episode of AOM. Antibiotics were used more frequently in Finland than in The Netherlands, 99% versus 78%, respectively. More Finnish parents reported to believe that antibiotics are necessary in the treatment of AOM as compared to Dutch parents. Use of analgesics for AOM was similar (80% in Finland and 86% in The Netherlands). One-third of the parents had discussed resistance with their doctor. According to parental experiences, antimicrobial resistance had caused more problems in Finland than in The Netherlands (20% versus 2%). Finally, 88% of parents in Finland and 65% in The Netherlands were worried that bacteria could become resistant to antibiotics.

CONCLUSIONS

Treatment practices and parental expectations seem to interact with each other. Therefore, if we aim to change AOM treatment practices, we have to modify both guidelines and parental expectations.

GPs' antibiotic prescription patterns for respiratory tract infections--still room for improvement

OBJECTIVE

Inappropriate use of antibiotics is associated with increased antibiotic resistance in the community. About 90% of all antibiotic prescriptions in Norway are issued by general practitioners and in 60% issued for respiratory tract infections. The article describes and analyses antibiotic prescription patterns by general practitioners in Vestfold, Norway.

DESIGN

Prospective cohort study.

SUBJECTS

A total of 145 list-holding general practitioners in Vestfold, Norway in February to March 2003.

METHODS

Merging of two electronic administrative data sets: antibiotic prescriptions dispensed in pharmacies and general practitioners' electronic bills from the National Insurance Agency.

MAIN OUTCOME MEASURES

Proportion and type of antibiotic prescribed for different respiratory tract infectious diagnoses.

RESULTS

We found large variations among general practitioners' antibiotic prescription habits. In 27% of consultations with RTI diagnoses, an antibiotic was prescribed; 37% were for Penicillin V and 28% for a macrolide. Quinolones and cephalosporins were only rarely prescribed. In a logistic regression analysis the following factors were independently associated with antibiotic prescription rate: type of infection, type of contact, being a general practitioner specialist, and years since medical exam. In another logistic regression analysis the following factors were independently associated with broad-spectrum antibiotic prescription: type of infection, age of patient, type of contact, being a specialist, length of list, and being a high prescriber of antibiotics.

CONCLUSION

The variation in proportion of total antibiotic prescribing and broad-spectrum prescription for respiratory tract infections is high, and reveals potentials to change general practitioners' prescription behaviour, in order to maintain the positive situation in Norway as to antibiotic resistance.

Family Practitioners' Diagnostic Decision-Making Processes Regarding Patients with Respiratory Tract Infections: An Observational Study

Background. The influence of patient characteristics on family practitioners' (FPs') diagnostic decision making has mainly been investigated using indirect methods such as vignettes or questionnaires. Direct observation— borrowed from social and cultural anthropology— may be an alternative method for describing FPs' real-life behavior and may help in gaining insight into how FPs diagnose respiratory tract infections, which are frequent in primary care. Objective. To clarify FPs' diagnostic processes when treating patients suffering from symptoms of respiratory tract infection. Methods. This direct observation study was performed in 30 family practices using a checklist for patient complaints, history taking, physical examination, and diagnoses. The influence of patients' symptoms and complaints on the FPs' physical examination and diagnosis was calculated by logistic regression analyses. Dummy variables based on combinations of symptoms and complaints were constructed and tested against saturated (full) and backward regression models. Results. In total, 273 patients (median age 37 years, 51% women) were included. The median number of symptoms described was 4 per patient, and most information was provided at the patients' own initiative. Multiple logistic regression analysis showed a strong association between patients' complaints and the physical examination. Frequent diagnoses were upper respiratory tract infection (URTI)/common cold (43%), bronchitis (26%), sinusitis (12%), and tonsillitis (11%). There were no significant statistical differences between ``simple heuristic'' models and saturated regression models in the diagnoses of bronchitis, sinusitis, and tonsillitis, indicating that simple heuristics are probably used by the FPs, whereas ``URTI/common cold'' was better explained by the full model. Conclusion. FPs tended to make their diagnosis based on a few patient symptoms and a limited physical examination. Simple heuristic models were almost as powerful in explaining most diagnoses as saturated models. Direct observation allowed for the study of decision making under real conditions, yielding both quantitative data and ``qualitative'' information about the FPs' performance. It is important for investigators to be aware of the specific disadvantages of the method (e.g., a possible observer effect).

Characteristics of children consulting for cough, sore throat, or earache

BACKGROUND

GPs are often consulted for respiratory tract symptoms in children.

AIM

To explore characteristics of children, their parents, and their GPs that are correlated with consulting a GP for cough, sore throat, or earache.

DESIGN OF STUDY

Second Dutch National Survey of General Practice (DNSGP-2) with a health interview and an additional questionnaire.

SETTING

Children aged 0-17 years registered with 122 GPs in Dutch general practice.

METHOD

Characteristics of patients and their GPs were derived from the DNSGP-2 health interview and a questionnaire, respectively. Characteristics of the illness symptoms and GP consultation were acquired by means of an additional questionnaire. Data were analysed using multivariate logistic regression.

RESULTS

Of all children who completed the questionnaire, 550 reported cough, sore throat, or earache in the 2 weeks preceding the interview with 147 of them consulting their GP. Young children more frequently consulted the GP for respiratory symptoms, as did children with fever, longer duration of symptoms, those reporting their health to be 'poor to good', and living in an urban area. When parents were worried, and when a child or their parents were cued by someone else, the GP was also consulted more often. GP-related determinants were not associated with GP consultation by children.

CONCLUSION

This study emphasises the importance of establishing the reasons behind children with respiratory tract symptoms consulting their GP. When GPs are aware of possible determinants of the decision to consult a GP, more appropriate advice and reassurance can be given regarding these respiratory symptoms, which are generally self-limiting.

Diagnostic labelling as determinant of antibiotic prescribing for acute respiratory tract episodes in general practice

Background

Next to other GP characteristics, diagnostic labelling (the proportion of acute respiratory tract (RT) episodes to be labelled as infections) probably contributes to a higher volume of antibiotic prescriptions for acute RT episodes. However, it is unknown whether there is an independent association between diagnostic labelling and the volume of prescribed antibiotics, or whether diagnostic labelling is associated with the number of presented acute RT episodes and consequently with the number of antibiotics prescribed per patient per year.

Methods

Data were used from the Second Dutch National Survey of General Practice (DNSGP-2) with 163 GPs from 85 Dutch practices, serving a population of 359,625 patients. Data over a 12 month period were analysed by means of multiple linear regression analysis. Main outcome measure was the volume of antibiotic prescriptions for acute RT episodes per 1,000 patients.

Results

The incidence was 236.9 acute RT episodes/1,000 patients. GPs labelled about 70% of acute RT episodes as infections, and antibiotics were prescribed in 41% of all acute RT episodes. A higher incidence of acute RT episodes (beta 0.67), a stronger inclination to label episodes as infections (beta 0.24), a stronger endorsement of the need of antibiotics in case of white spots in the throat (beta 0.11) and being male (beta 0.11) were independent determinants of the prescribed volume of antibiotics for acute RT episodes, whereas diagnostic labelling was not correlated with the incidence of acute RT episodes.

Conclusion

Diagnostic labelling is a relevant factor in GPs' antibiotic prescribing independent from the incidence of acute RT episodes. Therefore, quality assurance programs and postgraduate courses should emphasise to use evidence based prognostic criteria (e.g. chronic respiratory co-morbidity and old age) as an indication to prescribe antibiotics in stead of single inflammation signs or diagnostic labels.

General and URTI-specific antibiotic prescription rates in a Malaysian primary care setting

Antibiotic prescribing by primary care doctors has received renewed interest due to the continuing emergence of antibiotic resistance and the attendant cost to healthcare. We examined the antibiotic prescribing rate in relation to selected socio-demographic characteristics of the prescribers at the Seremban Health Clinic, a large public primary care clinic, designated for teaching, in the state of Negeri Sembilan, Malaysia. Data were obtained from: (1) retrospective review of prescriptions for the month of June 2002 and (2) a questionnaire survey of prescribers. A total of 10667 prescriptions were reviewed. The overall antibiotic prescribing rate was 15%; the rate (16%) was higher for the general Outpatient Department (OPD) than the 3% for the Maternal & Child Health Clinic (MCH). The antibiotic prescription rates for upper respiratory tract infection (URTI) were 26% and 16%, respectively, for the OPD and MCH. Half of all the antibiotic prescriptions were for URTI making prescribing for URTI an appropriate target for educational intervention. The URTI-specific antibiotic prescription rate did not correlate with the prescribers' intention to specialise, patient load, perceived patient's expectation for an antibiotic, or the score for knowledge of streptococcal tonsillitis. Prescribing behaviours and record-keeping practices requiring correction were identified.

Antibiotic prescribing patterns for sore throat infections in a university-based primary care clinic

BACKGROUND

Recent studies reveal that a high percentage (over 50%) of episodes for upper respiratory tract infections (URTIs) are treated with antibiotics, regardless of appropriateness or the necessity for prescription. We identified antibiotic prescriptions in a primary health care centre (PHC) and evaluated their suitability for sore throat infections. We also explored whether symptoms, signs, diagnosis and antibiotics prescribed differed by gender.

PATIENTS AND METHODS

We collected data on all patients visiting the centre over a period of 12 weeks with a main complaint of sore throat who were prescribed antibiotics after taking a blood count and throat culture. Patients older than 16 years of age were included in the study irrespective of sex, nationality, marital status, occupation or location of residence. The chi square (chi2) statistical test was used in comparing categorical variables. A P value of < 0.05 was considered significant.

RESULTS

During the period of study, 579 patients with URTIs presented to the health centre, from which 339 patients with a sore throat were enrolled. Of the study group, 48.7% (165) were male and 51.3% (174) female, with the majority of patients being under 30 years old (54.3%). Throat cultures were positive in 56 patients (16.5%). Most of patients were diagnosed as having pharyngitis (22.7%), and the most frequently prescribed medicine was an oral penicillin (39.1%). Two hundred eight-six patients (84.4%) had 2 or fewer Centor criteria.

CONCLUSIONS

Throat cultures were positive in only 16.5% of the patients prescribed antibiotics. This indicates that physicians in the health centre of the university are prescribing antibiotics inappropriately and inconsistently. This also highlights the need for more prescriber education, especially as the range of medications available to the general practitioner for prescribing increases.

Intrauterine contraception: the role of general practitioners in four Dutch general practices

The intrauterine device (IUD) use in the Netherlands and the United States is limited to a small group of women, though the risk of infection and pregnancy is small. Therefore, it was of interest to investigate the characteristics of women who choose an IUD as contraceptive method and the influence of general practitioners concerning IUD insertion. The aim of this retrospective cohort study was to assess differences between general practices and to investigate the characteristics of IUD users. Also, we wished to study changes in IUD use with time. Patients were selected from four academic general practices belonging to the continuous morbidity registration project in Nijmegen, the Netherlands. The population under study included 461 women registered in the academic practices with a code for insertion of a new IUD in the period from 1981 to 2001. More than half of the women were between 25 and 34 years old at the time of insertion. Almost one quarter were nulliparous, one quarter unmarried and the distribution of socioeconomic status was the same as the entire practice population. General practitioners have clear preferences for certain types of IUD and, in particular, for not inserting an IUD in nulliparous women. In conclusion, married or cohabiting women, around 30 years of age, with children, are in the majority in receiving an IUD as contraception. General practitioners clearly follow their own opinions about inserting IUD in nulliparous women. Currently, general practitioners are prescribing more Multiload Cu 375 IUDs and levonorgestrel-releasing IUDs.

Antibiotics for coughing in general practice: a questionnaire study to quantify and condense the reasons for prescribing

BACKGROUND

Antibiotics are being overprescribed in ambulant care, especially for respiratory tract infections (RTIs). Gaining insight into the actual reasons for prescribing remains important for the design of effective strategies to optimise antibiotic prescribing. We aimed to determine items of importance for the antibiotic prescribing decision and to make them operational for an intervention trial.

METHODS

A postal questionnaire based upon focus group findings was sent to 316 Flemish general practitioners (GPs). On a verbal rating scale the GPs scored to what extent they consider the questionnaire items in decision making in case of suspected RTI in a coughing patient and how strongly the items support or counter antibiotic treatment. Factor analysis was used to condense the data. The relative importance of the yielded operational factors was assessed using Wilcoxon Matched Pairs test.

RESULTS

59.5% completed the study. Response group characteristics (mean age: 42.8 years; 65.9% men) approximated that of all Flemish GPs. Participants considered all the items included in the questionnaire: always the operational factor 'lung auscultation', often 'whether or not there is something unusual happening' - both medical reasons - and to a lesser extent 'non-medical reasons' (P < 0.001). Non-medical as well as medical reasons support antibiotic treatment, but non-medical reasons to a lesser extent (P < 0.001).

CONCLUSION

This study quantified, condensed and confirmed the findings of previous focus group research. Practice guidelines and interventions to optimise antibiotic prescribing have to take non-medical reasons into account.

Does clinical error contribute to unnecessary antibiotic use?

Patient expectations and physician attitudes are often cited as factors in the overuse of antibiotics. This study examined whether clinical error might also be important. In treating 517 patients with sore throat, family physicians estimated the probability that group A streptococcus infection was present. Two thirds of antibiotics prescribed were to culture-negative patients and therefore considered unnecessary. Physicians overestimated the probability that a group A streptococcal infection was present by an average 33.2% in these cases, compared with 6.9% otherwise (p < 0.001). The rate of unnecessary prescribing was 5.1% when the physician estimate differed from the true probability of a group A streptococcal infection by <10%, 16.0% for an error of 10-29%, 35.6% for an error of 30-49%, and 78.3% when the chance of the infection was overestimated by 50% or more. Clinical error in estimating the likelihood of group A streptococcal infection probably contributes to unnecessary antibiotic use in patients with sore throat.

Reasons for non-guideline-based antibiotic prescriptions for acute otitis media in The Netherlands

BACKGROUND

Appropriate use of antibiotics is a major issue in today's medicine. The increasing worldwide bacterial resistance to antimicrobial agents is forcing us to prescribe antibiotics more rationally. It is known that overuse of antibiotics for upper respiratory tract infections exists. Little is known about the reasons for actual prescribing of antibiotics. In order to be able to implement strategies to restrict inappropriate antibiotic prescriptions, insight into the reasons for the actual prescribing could be important.

OBJECTIVE

We aimed to explore the reasons, other than those stated in the guidelines of the Dutch College of GPs, for prescribing antibiotics for acute otitis media.

METHOD

Seventy antibiotic prescriptions for acute otitis media, prescribed by 22 Dutch GPs, were evaluated to see whether they followed the guidelines on acute otitis media of the Dutch College of General Practitioners. Non-guideline-based antibiotic prescriptions were discussed in stimulated recall interviews with the prescribing GPs regarding their prescribing behaviour of antibiotics for acute otitis media.

RESULTS

In total, 77% of the antibiotic prescriptions did not follow the guidelines of the Dutch College of General Practitioners. Medical reasons for prescribing antibiotics were mentioned most often for non-guideline-based antibiotic prescriptions; however, in a substantial number of cases doctors gave non-medical reasons as well.

CONCLUSIONS

Appropriate use of antibiotics might not be reached by focusing only on the efficacy of these drugs. The impact of doctors' awareness of their non-medical motives for prescribing antibiotics on more rational antibiotic prescribing should be investigated further.

Understanding the culture of prescribing: qualitative study of general practitioners' and patients' perceptions of antibiotics for sore throats

OBJECTIVES

To better understand reasons for antibiotics being prescribed for sore throats despite well known evidence that they are generally of little help.

DESIGN

Qualitative study with semi-structured interviews.

SETTING

General practices in South Wales.

SUBJECTS

21 general practitioners and 17 of their patients who had recently consulted for a sore throat or upper respiratory tract infection.

MAIN OUTCOME MEASURES

Subjects' experience of management of the illness, patients' expectations, beliefs about antibiotic treatment for sore throats, and ideas for reducing prescribing.

RESULTS

Doctors knew of the evidence for marginal effectiveness yet often prescribed for good relationships with patients. Possible patient benefit outweighed theoretical community risk from resistant bacteria. Most doctors found prescribing "against the evidence" uncomfortable and realised this probably increased workload. Explanations of the distinction between virus and bacterium often led to perceived confusion. Clinicians were divided on the value of leaflets and national campaigns, but several favoured patient empowerment for self care by other members of the primary care team. Patient expectations were seldom made explicit, and many were not met. A third of patients had a clear expectation for antibiotics, and mothers were more likely to accept non-antibiotic treatment for their children than for themselves. Satisfaction was not necessarily related to receiving antibiotics, with many seeking reassurance, further information, and pain relief.

CONCLUSIONS

This prescribing decision is greatly influenced by considerations of the doctor-patient relationship. Consulting strategies that make patient expectations explicit without damaging relationships might reduce unwanted antibiotics. Repeating evidence for lack of effectiveness is unlikely to change doctors' prescribing, but information about risk to individual patients might. Emphasising positive aspects of non-antibiotic treatment and lack of efficacy in general might be helpful.

Quantitative systematic review of randomised controlled trials comparing antibiotic with placebo for acute cough in adults

OBJECTIVES

To assess whether antibiotic treatment for acute cough is effective and to measure the side effects of such treatment.

DESIGN

Quantitative systematic review of randomised placebo controlled trials.

DATA SOURCES

Nine trials (8 published, 1 unpublished) retrieved from a systematic search (electronic databases, contact with authors, contact with drug manufacturers, reference lists); no restriction on language.

MAIN OUTCOME MEASURES

Proportion of subjects with productive cough at follow up (7-11 days after consultation with general practitioner); proportion of subjects who had not improved clinically at follow up; proportion of subjects who reported side effects from taking antibiotic or placebo.

RESULTS

Eight trials contributed to the meta-analysis. Resolution of cough was not affected by antibiotic treatment (relative risk 0.85 (95% confidence interval 0.73 to 1.00)), neither was clinical improvement at re-examination (relative risk 0.62 (0.36 to 1.09)). The side effects of antibiotic were more common in the antibiotic group when compared to placebo (relative risk 1.51 (0.86 to 2.64)).

CONCLUSIONS

Treatment with antibiotic does not affect the resolution of cough or alter the course of illness. The benefits of antibiotic treatment are marginal for most patients with acute cough and may be outweighed by the side effects of treatment.

Rational prescribing and interpractitioner variation. A multilevel approach

There are marked geographical variations in rates of medical and surgical intervention at every level of aggregation and in every aspect of medical practice. These data raise a range of important theoretical, methodological, and policy issues. Much the same pattern of variation characterizes the prescription and consumption of therapeutic drugs. Data from a survey of general practice in New Zealand confirm the existence of extensive variability in prescribing. Multilevel techniques are deployed to isolate the specific interpractitioner element in this variability. Controlling for patient, diagnostic, and practitioner variables improves the predictive power of the model but does not reduce the extent of interpractitioner variability in prescribing rates. The existence of such variability raises questions about the role of clinical uncertainty and professional autonomy in the promotion of rational therapeutics in medical practice.