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

Knowledge and Awareness of Physicians About Rational Antibiotic Use and Antimicrobial Resistance Before and After Graduation: A Cross-Sectional Study Conducted in Malatya Province in Turkey

BACKGROUND

We aimed to evaluate the level of theoretical knowledge of rational antibiotic use and awareness about emergence of multidrug resistance (MDR) among the senior students at a medical school and the actively-working family physicians.

METHODS

This cross-sectional research was carried out between 1 February and 30 April 2019 in Malatya province. Two-hundred twenty-five senior students in the Inonu University Medical School (Group 1) and 230 actively-working family physicians in Malatya primary health care services who were found to be eligible (Group 2) were included in this study. Power analysiscalculated the minimum of 240 participants with a proportion difference of 0.18 between the groups, a type I error of 0.05 and a type II error of 0.20. A questionnaire including seven sections and 28 questions was applied to the participants.

RESULTS

Doctors were more hesitant in pre-graduation and more self-confident in the post-graduation period for the decision to start antibiotic treatment. In addition, doctors forget their theoretical knowledge of antibiotics over time and are unable to follow current developments after graduation. The most important concern in the pre-graduation period was the choice of antibiotics from the wrong group, while in the post-graduation period it is the fear of the presence of unproven infection.

CONCLUSION

Physicians' antibiotic prescribing habits, attitudes and behaviors vary before and after graduation. Sustainable education for antibiotic use for physicians after graduation can contribute positively to reduce of antimicrobial resistance rates and to increase awareness about the use of rational antibiotics.

Worldwide comparison of treatment guidelines for sore throat

Introduction

Sore throat (acute pharyngitis) is globally one of the most frequent reasons for seeking healthcare. Its etiology is mostly viral. In 15%‐30% of cases, group A streptococci (GAS) are detected, which may cause acute rheumatic fever. We have done a worldwide systematic review to compare diagnostic and therapeutic guidelines across countries and regions. Previous reviews of sore throat guidelines were limited to specific regions and/or language; this is the first global review.

Materials and Methods

Searches were performed in MEDLINE, EMBASE and COCHRANE (key words: sore throat, pharyngitis, tonsillitis or pharyngotonsillitis, and management, guidance, guideline or recommendation) and on the web sites of major health authorities and associated institutions from Africa, Asia, Europe, Middle East, North America, Oceania and South America.

Results

Thirty‐six guidelines were identified from 26 countries. Most common are recommendations relying on the symptom‐ and age‐based Centor or McIsaac scores. However, antibiotic treatment may be based on other symptomatic criteria; in the most extreme approach just sore throat in children. The recommendation of GAS‐specific diagnostic tests is mainly limited to countries where such tests are readily available, although some countries choose not to use them. Penicillins are consistently recommended as first‐line antibiotics. By contrast, guidance for symptomatic treatment is variable and mostly sparse or missing. African countries without sore throat guidelines and Asian countries bypassing them are afflicted by rising antibiotic resistance.

Conclusion

The availability of sore throat guidelines varies considerably by region and country. Moreover, important divergence is found among the guidelines regarding diagnostic and treatment criteria. This may be explained by the historical background or adoption of external guidelines, rather than local incidences of GAS infections or acute rheumatic fever. Absence of recommendations on symptomatic treatment in many guidelines is concerning, and raises issues about antimicrobial stewardship, as this should be the mainstay of sore throat management, rather than antibiotics.

Factors affecting physicians' perception of the overuse of antibiotics

OBJECTIVE

We aimed to determine the reasons for irrational antibiotic use, to evaluate knowledge, attitudes, and behaviors of physicians regarding such use, to find factors affecting knowledge of physicians, and to explore precautions that need to be taken to stop irrational antibiotic use.

MATERIAL AND METHODS

We performed the study between January 2014 and June 2014. We included 202 physicians who answered a questionnaire with 22 multiple-choice questions about knowledge (eight questions), behavior and attitudes of physicians (nine questions), and recommendations for reducing antibiotic consumption (five questions). Answers to all questions were assessed according to the physician's age, educational status, metropolitan areas, and healthcare facilities.

RESULTS

The effects of parents' expectations and satisfaction (7.4%-40.0%) (P<0.0001) and socioeconomical status of families (33%-62%) (P=0.007) increased as the participants' age decreased. Participants working at public hospitals (42.6%) considered expectations and satisfaction of parents more important than other participants (10.5%-26.9%; P=0.002). Rapid recovery of patients was not an essential determinant for administering antibiotics for pediatricians (25.7%) and pediatric assistants (26.9%). However, it was important for emergency physicians (55.6%) and family physicians (60%, P=0.016). Physicians working at university hospitals did not consider this determinant as important as physicians working in other healthcare facilities (P=0.001).

CONCLUSION

To determine the obstacles associated with promoting rational antibiotic usage, every country should assess the attitudes, behavior, and knowledge of physicians related to such use. The present study is one of the few in Turkey to address the problems associated with irrational antibiotic use.

Over prescription of antibiotics for adult pharyngitis is prevalent in developing countries but can be reduced using McIsaac modification of Centor scores: a cross-sectional study

BACKGROUND

Although Group A beta hemolytic streptococcus (GABHS) can cause bacterial pharyngitis, the most common etiology is viral; despite this viral etiology, antibiotics are commonly prescribed for this infection in industrialized countries. We investigated the prevalence of GABHS in adult pharyngitis patients from lower socioeconomic settings in Karachi, Pakistan, how often antibiotics are prescribed for pharyngitis and if appropriate agents were used in a developing world setting. Finally, we wanted to see the usefulness of modified McIsaac scores in predicting positive cultures.

METHODS

Adult patients were recruited from three local hospital outpatient dispensaries (OPDs). All patients aged 14-65 years who were suspected of having bacterial pharyngitis had throat swabs taken. Laboratory results for GABHS pharyngitis were then compared with their prescriptions. Appropriateness (using the World Health Organization's definition) and type of antibiotic prescribed were assessed.

RESULTS

Of 137 patients, 30 patients each were studied for scores of 0, 1, 2 and 3; 17 patients were studied for score 4. Although 6 (4.4%) patients were GABHS+, for a prevalence of 43.8 per 1000 population, antibiotics were prescribed to 135 patients (98.5%). Of these, only 11.1% received appropriate antibiotics while 88.9% received inappropriate antibiotics. Penicillins were prescribed most (34.1%), especially amoxicillin/clavulanate; followed by macrolides (31.1%), especially the second-generation agents, and fluoroquinolones (14.8%). McIsaac scores were found to be 100% sensitive and 68.7% specific, giving a positive predictive value (PPV) of 12.7% and a negative predictive value (NPV) of 100%.

CONCLUSIONS

Antibiotics were prescribed irrationally to adult pharyngitis patients, as most cultures were negative for bacterial infection. McIsaac modification of Centor scores related directly to culture results. We would therefore highly recommend its use to help family physicians make treatment decisions for adult pharyngitis patients.

In primary health care, never prescribe antibiotics to patients suspected of having an uncomplicated sore throat caused by group A beta-haemolytic streptococci without first confirming the presence of this bacterium

BACKGROUND

There are several consensus-describing decision rules for patients in primary health care with a sore throat. The objective of this study was to estimate the number of unnecessary antibiotic prescriptions in primary health care given to patients with a sore throat, due to these different decision rules. A further aim was to suggest revised rules for decision-making in primary health care, when a sore throat caused by group A beta-haemolytic streptococci (GAS) is suspected.

METHODS

The design was a reanalysis of previously published articles describing the prevalence of GAS and physician behaviour when treating patients with a sore throat. The risk of unnecessary antibiotic prescribing in different situations was estimated and applied to the Swedish population.

RESULTS

Introducing the rule of never prescribing antibiotics without first confirming the presence of GAS would result in an annual reduction in Sweden of 20,360-25,192 unnecessary antibiotic prescriptions in children and 65,311-98,160 in adults.

CONCLUSIONS

The single most important rule in primary health care to minimize the risk of unnecessary antibiotic prescription to patients with an uncomplicated sore throat, and where an infection with GAS is suspected, is to never prescribe antibiotics at the first visit without first confirming the presence of this bacterium. Adding more decision rules may to some extent further reduce the number of unnecessary antibiotic prescriptions.

Validity and reliability of instruments designed to measure factors influencing the overuse of antibiotics

BACKGROUND

Antibiotic overuse is a global public health issue that is influenced by several factors. The degree and prevalence of antibiotic overuse is difficult to measure directly. A more practical approach, such as the use of a psycho-social measurement instrument, might allow for the observation and assessment of patterns of antibiotic use.

STUDY OBJECTIVE

The aim of this paper is to review the nature, validity, and reliability of measurement scales designed to measure factors associated with antibiotic misuse/overuse.

DESIGN

This study is descriptive and includes a systematic integration of the measurement scales used in the literature to measure factors associated with antibiotic misuse/overuse. The review included 70 international scientific publications from 1992 to 2010.

MAIN RESULTS

Studies have presented scales to measure antibiotic misuse. However, the workup of these instruments is often not mentioned, or the scales are used with only early-phase validation, such as content or face validity. Other studies have discussed the reliability of these scales. However, the full validation process has not been discussed in any of the reviewed measurement scales.

CONCLUSION

A reliable, fully validated measurement scale must be developed to assess the factors associated with the overuse of antibiotics. Identifying these factors will help to minimize the misuse of antibiotics.

Medicaid/State Children's Health Insurance Program patients and infectious diseases treated in emergency departments: U.S., 2003

OBJECTIVE

Emergency departments (EDs) are a critical source of medical care in the U.S. Information is sparse concerning infectious disease visits among Medicaid entitlement enrollees nationwide. The objective of this study was to describe infectious diseases in terms of Medicaid/State Children's Health Insurance Program (SCHIP) as an expected source of payment.

METHODS

Data for 2003 from the National Hospital Ambulatory Medical Care Survey (NHAMCS) were analyzed for infectious disease visits. NHAMCS is a national probability sample survey of visits to hospital EDs and outpatient departments of nonfederal, short-stay, and general hospitals in the U.S. Data are collected annually and are weighted to generate national estimates.

RESULTS

Nationally in 2003, an estimated 21.6 million visits were made to hospital EDs for infectious diseases (rate = 76 visits/1,000 people). Medicaid/SCHIP was the expected source of payment for an estimated 6.7 million infectious disease-related visits (rate = 200 visits/1,000 people covered by Medicaid). Children aged < 15 years made 39% of visits nationwide (nationwide rate = 139 visits/1,000 people). Of Medicaid visits, 63% were made by children < 15 years of age (Medicaid enrollees rate = 255 visits/1,000 people). The rate of visits for Medicaid enrollees was comparable for females and males (198 visits vs. 201/1,000 people). The rate of visits for black Medicaid enrollees was 33% higher than for white Medicaid enrollees (255 vs. 192 visits/1,000 people). Upper respiratory tract infection (URTI) is the most frequent infectious condition recorded at ED visits. An estimated 47% of ED visits with an expected pay source of Medicaid relate to URTIs (93 visits/1,000 people), compared with 38% of ED visits in general (29 visits/1,000 people).

CONCLUSION

Medicaid enrollee-specific ED visit rates for infectious diseases were higher by age group, gender, race, and region, compared with national rates. Because approximately half of visits relate to URTIs for a Medicaid payment group, URTIs should form the basis for development of appropriate control strategies.