Delayed prescribing of antibiotics for acute respiratory infections by GP registrars: a qualitative study

Diagnosis and management of acute infections during telehealth consultations in Australian general practice: a qualitative study

BACKGROUND

The use of telehealth has increased dramatically since the beginning of the COVID-19 pandemic. Little is known about how GPs manage acute infections during telehealth, and the potential impact on antimicrobial stewardship.

AIM

To explore the experiences and perceptions of GP trainees' and supervisors' use of telehealth, and how it influences their management of acute infections.

DESIGN & SETTING

Australian GP registrars (trainees) and supervisors were recruited via email through their training organisations. Semi-structured interviews with 18 participants were conducted between July and August 2022.

METHOD

Interviews were transcribed verbatim and analysed using a reflexive thematic approach.

RESULTS

We identified six overall themes. 1. Participants experienced impaired diagnostic capacity during telehealth consultations. 2. Attempts to improve diagnostic acuity included various methods, such as having patients self-examine. 3. The management of clinical uncertainty frequently entailed referring patients for in-person assessment, overinvestigating, or overtreating. 4. Antibiotic prescribing decisions during telehealth were informed by less information than were in-person consults, with varying impact. 5. Participants believed that other GPs improperly prescribed antibiotics during telehealth. 6. Supervisors believed that registrars hadn't developed the knowledge or skills to determine when conditions could be managed appropriately via telehealth.

CONCLUSION

Telehealth has potential for reducing transmission of acute infections and increasing access to healthcare. However, the implications of GPs, especially less experienced GPs, making diagnoses with less certainty, and consequently compromising antimicrobial stewardship, are a concern. Patient self-assessment tools may improve outcomes of telehealth consultations for acute infections.

Perceptions and attitudes regarding delayed antibiotic prescription for respiratory tract infections: a qualitative study

BACKGROUND

Antibiotics are overprescribed for respiratory tract infections (RTIs). However, the decision to prescribe is often complex. Delayed antibiotic prescription (DAP), a strategy designed to promote more rational antibiotic use, is still not widely used. The aim of this study was to explore perceptions and attitudes in primary care professionals, regarding antibiotic use and different DAP strategies for uncomplicated RTIs.

METHODS

We conducted a qualitative study, using an inductive thematic approach to generate themes, based on focus group discussions and semi-structured interviews with professionals, recruited from 6 primary care centres (Barcelona metropolitan area, Spain).

RESULTS

26 professionals (25 family physicians and one nurse) were included in four focus group discussions and three semi-structured interviews. Participants commented that RTIs were a main reason for consultation, motivated often by patient anxiety and fear of possible complications, and this was associated with the patients' poor health-related education. Acknowledging inappropriate antibiotic use in the health system, participants attributed this, mainly to defensive medicine strategies. DAP was used when in doubt about the aetiology, and considering factors related to patient-physician interactions. The main perceived advantage of DAP was that it could reduce the need for additional visits, while the main disadvantage was uncertainty regarding proper use by the patient.

CONCLUSIONS

DAP was used by participants in cases of doubt, in specific situations, and for specific patient profiles. Weak points were detected in our primary care system and its users that affect the proper use of both antibiotics and DAP, namely, time pressure on professionals, poor patient health-related education, and the lack of a patient-physician relationship in some scenarios.

Factors Influencing the Implementation of Antimicrobial Stewardship in Primary Care: A Narrative Review

Antimicrobial resistance (AMR) is directly driven by inappropriate use of antibiotics. Although the majority of antibiotics (an estimated 80%) are consumed in primary care settings, antimicrobial stewardship (AMS) activities in primary care remain underdeveloped and factors influencing their implementation are poorly understood. This can result in promising stewardship activities having little-to-no real-world impact. With this narrative review, we aim to identify and summarize peer-reviewed literature reporting on (1) the nature and impact of AMS interventions in primary care and (2) the individual and contextual factors influencing their implementation. Reported activities included AMS at different contextual levels (individual, collective and policy). AMS activities being often combined, it is difficult to evaluate them as stand-alone interventions. While some important individual and contextual factors were reported (difficulty to reach physicians leading to a low uptake of interventions, tight workflow of physicians requiring implementation of flexible and brief interventions and AMS as a unique opportunity to strengthen physician-patients relationship), this review identified a paucity of information in the literature about the factors that support or hinder implementation of AMS in primary care settings. In conclusion, identifying multilevel barriers and facilitators for AMS uptake is an essential step to explore before implementing primary care AMS interventions.

General Practitioners’, Pharmacists’ and Parents’ Views on Antibiotic Use and Resistance in Malta: An Exploratory Qualitative Study

Background: Antibiotic resistance (ABR) remains a global health threat that requires urgent action. Antibiotic use is a key driver of ABR and is particularly problematic in the outpatient setting. General practitioners (GPs), the public, and pharmacists therefore play an important role in safeguarding antibiotics. In this study, we aimed to gain a better understanding of the antibiotic prescribing-use-dispensation dynamic in Malta from the perspective of GPs, pharmacists, and parents; Methods: we conducted 8 focus groups with 8 GPs, 24 pharmacists, and 18 parents between 2014 and 2016. Data were analysed using inductive and deductive content analysis; Results: Awareness on antibiotic overuse and ABR was generally high among interviewees although antibiotic use was thought to be improving. Despite this, some believed that antibiotic demand, non-compliance, and over-the-counter dispensing are still a problem. Nevertheless, interviewees believed that the public is more accepting of alternative strategies, such as delayed antibiotic prescription. Both GPs and pharmacists were enthusiastic about their roles as patient educators in raising knowledge and awareness in this context; Conclusions: While antibiotic use and misuse, and knowledge and awareness, were perceived to have improved in Malta, our study suggests that even though stakeholders indicated willingness to drive change, there is still much room for improvement.

Immediate and delayed antibiotic prescribing strategies used by Australian early-career general practitioners

Background

Antibiotics are overused for non-pneumonia acute respiratory tract infections (ARTIs).

Aim

To establish prevalence and explore associations of delayed and immediate antibiotic prescribing strategies of Australian early-career GPs (specialist GP vocational trainees, also known as GP registrars) for non-pneumonia ARTIs.

Design and setting

Cross-sectional analysis of data collected between September 2016 and December 2017 from the Registrar Clinical Encounters in Training cohort (ReCEnT) study, an ongoing cohort study of GP registrars’ in-practice clinical experiences in four Australian states and territories.

Method

Multinomial logistic regression with outcome antibiotic prescribing (no prescribing, immediate prescribing, and delayed prescribing).

Results

Of 7156 new ARTI diagnoses, no antibiotics were prescribed for 4892 (68%); antibiotics were prescribed for immediate use for 1614 diagnoses (23%) and delayed antibiotics were used for 650 diagnoses (9%). Delayed prescribing was used in 22% of otitis media, 16% of sinusitis, 13% of sore throat, 11% of acute bronchitis/bronchiolitis, and 5% of upper respiratory tract infection (URTI) diagnoses. Delayed prescribing was used for 29% of all prescriptions written. Delayed prescribing and immediate prescribing were associated with markers of clinical concern. Delayed prescribing was associated with longer duration of consultation and with fewer diagnoses/problems dealt with in the consultation.

Conclusion

Australian early-career GPs use no prescribing for ARTIs substantially more than established GPs; however, except where URTIs are concerned, they still prescribe antibiotics in excess of validated benchmarks. Australian early-career GPs may use delayed prescribing more often than European established GPs, and may use it to manage diagnostic uncertainty and, possibly, conflicting influences on prescribing behaviour. The use of delayed prescribing may enable a transition to an environment of more-rational antibiotic prescribing for ARTIs.

Autonomy, power dynamics and antibiotic use in primary healthcare: A qualitative study

Antibiotic resistance is a global health concern. Although numerous strategies have tried to reduce inadequate antibiotic prescribing, antibiotics are still prescribed in 60% of acute lower respiratory tract infections (ALRTIs) cases in Catalonia (Spain). This study aims to explore service users' experiences of ALRTIs, the quality and access to healthcare services, and health education. Selective purposive sampling was carried out, based on a prior definition of participant characteristics. These were sex, age, ethnicity, date of the last ALRTI, number of ALRTIs in the last year, and treatments received. Participants with a previous diagnosis of ALRTIs were recruited from three primary health care centres in Barcelona and one in Tarragona. Twenty-nine interviews were conducted between April and June 2019. A content thematic analysis was performed. Three themes were identified: 1) risk perceptions and help-seeking; 2) treatment preferences and antibiotic use; and 3) relationship dynamics and communication with healthcare professionals. Accounts of service users' sense of autonomy towards their health and power dynamics within the healthcare system were apparent. Supporting service users to become reliable, subjective and agentic experts of their health and bodies could help them to voice their healthcare agendas. Power structures embedded within healthcare, political and economic institutions should be challenged so that healthcare services can be co-developed (with service users) and based on service users' autonomy and horizontal relationships. Special consideration should be paid to the intersection of social vulnerabilities. A concordance approach to prescribing could be key to improve the responsible use of antibiotics and to contribute to the prevention of AMR in primary healthcare. The marketisation of health, and the increased demands of private healthcare in Spain due to the financial pressures on public healthcare as a consequence of the financial crisis of 2008 and the COVID-19 pandemic, are a risk for promoting adequate antibiotic prescribing and use. Trial registration The ISAAC-CAT study has been registered in the NCT registry, ID: NCT03931577.

Antimicrobial Resistance: Physicians' and Pharmacists' Perspective

Aims: The aim of this study was to evaluate pharmacists' and physicians' attitudes and knowledge about antimicrobial treatment and resistance and based on the results to identify possible gaps and suggest opportunities for collaboration between the two professions. Methods: The physician's questionnaire consisted of 47 items and the pharmacists' questionnaire consisted of 50 items. Participants were asked to identify situations in which they were more likely to prescribe/dispense an antimicrobial without a firm indication, to identify the greatest contributors to antimicrobial resistance (AMR) among health care workers, to rate statements related to AMR, how frequently they used different sources of information and to rate the possible causes of AMR. Furthermore, preparedness for specific actions in practice was self-rated and knowledge was evaluated. The questionnaires were anonymous and participation in the study was voluntary. Results: This research included 180 community pharmacists and 181 physicians. As many as 76 (42.0%) physicians stated they would prescribe an antimicrobial when unsure whether the infection was of viral or bacterial etiology. More than half of the participants considered family medicine doctors the greatest contributors to AMR (N = 216, 59.8%), followed by patients (N = 175, 48.5%). In questions focusing on knowledge, physicians scored significantly higher compared with pharmacists (4.06 ± 1.01 vs. 3.71 ± 1.08, p = 0.001). Conclusion: This research revealed practices among pharmacists and physicians that should be improved and it highlighted gaps in knowledge by both professions. More attention should be given to patient consultation when dispensing and prescribing an antimicrobial as this may reduce their contribution to AMR.