Factors influencing primary care physicians to prescribe antibiotics in Delhi India

Tackling antibiotic resistance in India

Infectious diseases are major causes of mortality in India. This is aggravated by the increasing prevalence of antimicrobial resistance (AMR) both in the community and in hospitals. Due to the emergence of resistance to all effective antibiotics in nosocomial pathogens, the situation calls for emergency measures to tackle AMR in India. India has huge challenges in tackling AMR, ranging from lack of surveillance mechanisms for monitoring AMR and use; effective hospital control policies; sanitation and non-human use of antimicrobial. The Ministry of Health and Family Welfare of Govt. of India has taken initiatives to tackle AMR. Extensive guidelines have been drafted and a model worksheet has been developed as a roadmap to tackle AMR.

Understanding antimicrobial use and prescribing behaviours by pig veterinary surgeons and farmers: a qualitative study

Increasing awareness of bacterial antimicrobial resistance in human beings and veterinary medicine has raised concerns over the issue of overprescribing and the indiscriminate use of antimicrobials. Their use in food-producing animals is under scrutiny due to the perceived risk from the zoonotic transfer of resistant pathogens from animals to human beings. This study used focus groups to explore the drivers and motivators behind antimicrobial use and prescribing by veterinary surgeons and farmers in the pig industry in the UK. Studies of two veterinary and four farmer focus groups were undertaken, each with between three and six participants, in three geographically distinct regions of low, moderate and high pig density in England. Thematic analysis of the focus group transcriptions revealed convergent themes, both within and across, the veterinary and farmer focus groups. Veterinary opinion was such that 'external pressures', such as pressure from clients, legislation and public perception, were considered to strongly influence prescribing behaviour, whereas, farmers considered issues surrounding farming systems and management to be greater drivers towards antimicrobial use. Acquiring such in-depth insight into the antimicrobial prescribing behaviours in veterinary medicine provides more detailed understanding of prescribing practice and will aid the development of interventions to promote the responsible use of antimicrobials.

Association between point-of-care CRP testing and antibiotic prescribing in respiratory tract infections: a systematic review and meta-analysis of primary care studies

BACKGROUND

Most patients with respiratory tract infections (RTIs) are prescribed antibiotics in general practice. However, there is little evidence that antibiotics bring any value to the treatment of most RTIs. Point-of-care C-reactive protein testing may reduce antibiotic prescribing.

AIM

To systematically review studies that have examined the association between point-of-care (POC) C-reactive protein testing and antibiotic prescribing for RTIs in general practice.

DESIGN AND SETTING

Systematic review and meta-analysis of randomised controlled trials and observational studies.

METHOD

MEDLINE(®) and Embase were systematically searched to identify relevant publications. All studies that examined the association between POC C-reactive protein testing and antibiotic prescribing for patients with RTIs were included. Two authors independently screened the search results and extracted data from eligible studies. Dichotomous measures of outcomes were combined using risk ratios (RRs) with 95% confidence intervals (CIs) either by fixed or random-effect models.

RESULTS

Thirteen studies containing 10 005 patients met the inclusion criteria. POC C-reactive protein testing was associated with a significant reduction in antibiotic prescribing at the index consultation (RR 0.75, 95% CI = 0.67 to 0.83), but was not associated with antibiotic prescribing at any time during the 28-day follow-up period (RR 0.85, 95% CI = 0.70 to 1.01) or with patient satisfaction (RR 1.07, 95% CI = 0.98 to 1.17).

CONCLUSION

POC C-reactive protein testing significantly reduced antibiotic prescribing at the index consultation for patients with RTIs. Further studies are needed to analyse the confounders that lead to the heterogeneity.

Understanding and changing human behaviour--antibiotic mainstreaming as an approach to facilitate modification of provider and consumer behaviour

This paper addresses: 1) Situations where human behaviour is involved in relation to antibiotics, focusing on providers and consumers; 2) Theories about human behaviour and factors influencing behaviour in relation to antibiotics; 3) How behaviour in relation to antibiotics can change; and, 4) Antibiotic mainstreaming as an approach to facilitate changes in human behaviour as regards antibiotics. Influencing human behaviour in relation to antibiotics is a complex process which includes factors like knowledge, attitudes, social norms, socio-economic conditions, peer pressure, experiences, and bio-physical and socio-behavioural environment. Further, key concepts are often perceived in different ways by different individuals. While designing and implementing projects or programmes for behavioural change with respect to antibiotics for professionals or consumers it is helpful to consider theories or models of behaviour change, e.g. the 'stages of change model', including pre-contemplation, contemplation, preparation, action, and maintenance. People in different stages of change are susceptible to different behaviour modification strategies. Application of marketing principles to 'global good', so-called 'social marketing', to improve 'welfare of the individual and society' is gaining increased attention in public health. In conclusion, just providing correct knowledge is not sufficient although it is a pre-requisite for behaviour modification in the desired direction. We can never change the behaviour of any other human, but we can facilitate for others to change their own behaviour. One possibility is to implement 'antibiotic mainstreaming' as a potentially effective way for behaviour modification, i.e. to address consequences for maintaining effective antibiotics in all activities and decisions in society.

Assessment of antibiotic prescribing at different hospitals and primary health care facilities

In this study, it was aimed to investigate the utilization of antibiotics at various health care facilities. Photocopies of 1250 prescriptions which were containing antibiotics and written out in primary health care facilities (PHCFs), public hospitals (PHs), private hospitals and university hospitals in 10 provinces across Turkey, were evaluated by some drug use indicators. The number of drugs per prescription was 3.23 ± 0.92 and it was highest in PHCFs (3.34 ± 0.84), (p < 0.05). The cost per prescription was 33.3 $, being highest in PHs while being lowest in PHCFs (38.6 $ and 28.2 $ respectively). Antibiotic cost per prescription was 16.7 $ and it was also highest and lowest in PHs and PHCFs respectively (p < 0.05). The most commonly prescribed group of antibiotics was "beta-lactam antibacterials, penicillins" (29.2%) while amoxicillin/clavulanic acid was the most commonly prescribed antibiotic (18.1%). Sixty-one percent of the antibiotics prescribed for acute infections was generics; among facilities being highest in PHCFs (66.5%) and among diagnosis being highest in acute pharyngitis. In general, the duration of antibiotic therapy was approximately 7 days for acute infections. Although much more drugs were prescribed in PHCFs than others, it was found to be in an inverse proportion with both the total cost of prescriptions and the cost of antibiotics. Broad-spectrum antibiotics, beta-lactamase combinations in particular, were considered to be more preferable in all health care facilities is also notable. These results do serve as a guide to achieve the rational use of antibiotics on the basis of health care facilities and indications.

Understanding physician antibiotic prescribing behaviour: a systematic review of qualitative studies

Inappropriate prescription has been associated with mounting rates of antibiotic resistance worldwide, demanding more detailed studies into physicians' decision-making process. Accordingly, this study sought to explore physicians' perceptions of factors influencing antibiotic prescribing. A systematic search was performed for qualitative studies focused on understanding physicians' perceptions of the factors, attitudes and knowledge influencing antibiotic prescription. Of the total of 35 papers selected for review purposes, 18 solely included physicians and the remaining 17 also included patients and/or other healthcare providers. Data collection was based mainly on interviews, followed by questionnaires and focus groups, and the methodologies mainly used for data analysis were grounded theory and thematic analysis. Factors cited by physicians as having an impact on antibiotic prescribing were grouped into those that were intrinsic (group 1) and those that were extrinsic (group 2) to the healthcare professional. Among the former, physicians' attitudes, such as complacency or fear, were rated as being most influential on antibiotic prescribing, whilst patient-related factors (e.g. signs and symptoms) or healthcare system-related factors (e.g. time pressure and policies/guidelines implemented) were the most commonly reported extrinsic factors. These findings revealed that: (i) antibiotic prescribing is a complex process influenced by factors affecting all the actors involved, including physicians, other healthcare providers, healthcare system, patients and the general public; and (ii) such factors are mutually dependent. Hence, by shedding new light on the process, these findings will hopefully contribute to generating new and more effective strategies for improving antibiotic prescribing and allaying global concern about antibiotic resistance.

Attitudes of primary care physicians to the prescribing of antibiotics and antimicrobial resistance: a qualitative study from Spain

BACKGROUND AND OBJECTIVE

Resistance to antibiotics is a public health threat. A number of studies confirm the relationship between antibiotic use and the resistance rate. As a whole, physicians represent a large proportion of the health professionals involved in the use of this therapeutic group. Our study therefore sought to ascertain the opinions and attitudes of GPs in Spain with respect to antibiotics and resistance.

METHODS

We used the focus group (FG) method, with each group comprising 4-12 primary care physicians and a moderator. Based on a previous systematic review, we drew up an agenda to be followed during the holding of the sessions. Group proceedings were recorded and the transcriptions then analysed separately by two researchers.

RESULTS

Five FGs were formed, including a total of 33 physicians. The factors/attitudes that influenced the prescribing of antibiotics by GPs were fear, complacency, insufficient knowledge and external responsibility of the pharmaceutical industry, patients and over-the-counter antibiotics. The groups felt that antibiotic resistance was not a problem at a community level.

CONCLUSIONS

Identification of attitudes/knowledge related with inappropriate antibiotic prescribing will enable specific interventions to be designed, with the aim of targeting these shortcomings to improve antibiotic use and help reduce resistance.

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.

Antibiotic-prescribing practices of primary care prescribers for acute diarrhea in New Delhi, India

OBJECTIVE

To obtain information on the current prescribing rates of antibiotics in acute diarrhea in the community.

METHODS

Antibiotic use in acute diarrhea in the community (December 2007-November 2008) was surveyed by using patients' exit interviews at public and private facilities from four residential localities. Data were collected from 10 public sector facilities and 20 private clinics over 1 year. The percentage of patients receiving antibiotics and the prescribing pattern of antibiotics were analyzed by using the anatomical therapeutic chemical classification and the defined daily dose.

RESULTS

At public facilities 43% (171 of 398) and at private facilities 69% (76 of 110) of the patients with acute diarrhea were prescribed at least one antibiotic. Diarrhea increased during peak humid summer months, but doctors were fairly consistent in their antibiotic prescribing throughout the year. The main antibiotic class that was prescribed in both public and private sector facilities was fluoroquinolones, J01MA (91.5% and 96%, respectively). Pediatricians working in the private sector prescribed antibiotics to 51.5% (17 of 33) of children with diarrhea, whereas pediatricians working in the public sector prescribed antibiotics to 23% of children with acute diarrhea. At public facilities, the most commonly prescribed fluoroquinolone was norfloxacin, followed by ofloxacin and ciprofloxacin. At private clinics, it was ofloxacin followed by ciprofloxacin.

CONCLUSIONS

This study clearly showed the irrational use of antibiotics for the treatment of acute diarrhea in children and adults that warrants interventional strategies.