Decision making, evidence, audit, and education: case study of antibiotic prescribing in general practice

Antibiotic prescribing practices in primary and secondary health care facilities in Uttar Pradesh, India

BACKGROUND

Emerging antibiotic resistance in common pathogens is a worldwide problem known to be related to inappropriate overuse of antibiotics. Wide variability in antibiotic use throughout the world is because of various factors, including socio-cultural differences.

OBJECTIVE

To study the rate of antibiotic prescribing for common outpatient illnesses and the various disease, patient, physician and health facility characteristics, which influence this in primary and secondary healthcare settings in Uttar Pradesh.

METHODS

After sampling of health facilities - both private and government, rural and urban, a cross-sectional survey of prescriptions for patients presenting with runny or blocked nose, cough, sore throat, diarrhoea or fever without localizing symptoms was conducted. Information on disease, patient, physician and facility characteristics was collected. Outcome factors: antibiotic prescription and group of antibiotic prescribed. No intervention was made.

RESULTS

Overall antibiotic prescription rate was 81.8%. It was significantly higher in urban private than in government settings, and higher in rural than in urban settings. Presence of fever prompted antibiotic use across all strata. Lower age of patients and higher socioeconomic status were associated with higher antibiotic use. Patient requests for antibiotics were very rare. Specialist practices with staff with higher qualifications and better opportunities for updating knowledge were associated with lower antibiotic prescribing. Government health-facilities with larger staff complement and better infrastructure was associated with lower prescribing rates. The most common antimicrobial agents used were the penicillin, sulfonamides and fluoroquinolones. Injection use paralleled antibiotic use.

CONCLUSIONS

These data on overprescribing of antibiotics can be used to design educational programs for physicians working in these settings.

Medication use for pediatric upper respiratory tract infections

The present study monitored medication prescribing patterns to patients treated for upper respiratory tract infections (URTIs) in the pediatric outpatient department (OPD) at Central Referral Hospital (CRH), Gangtok, Sikkim. A total of 562 URTI prescriptions of children, aged 0-12 years attending pediatric OPD at CRH, Sikkim were collected by a random once-weekly survey between May 2002 and April 2003. Males numbered 284 (50.5%), and females 278 (49.5%). Most of the patients in our study were aged 2-5 years (preschool children) (44.8%). The average number of medications prescribed per encounter was 2.37; 59.2% (789) of medicines were fixed-dose combination (FDC) products and two-thirds of FDCs were respiratory medicines (521). The most commonly prescribed medicines were respiratory medicines (47% of the total medicines prescribed). Others were antimicrobials (30.7%) and analgesic-antipyretics (18.8%). Among respiratory medicines, cough and cold preparations (prescribed in 13 different FDC products in 25 brand names) were prescribed most frequently (62%) followed by nasal preparations (21%) and beta(2) adrenergic agonist inhalers (9.2%). Ninety-eight percent of nasal preparations were isotonic saline drops (129). Antihistaminics (41.8%), non-opioid antitussives (13.5%), alpha agonist oral decongestants (42.3%), expectorants (32.2%), mucolytics (18.7%), paracetamol (14.7%), and beta(2) agonists (17.2%) were common ingredients of respiratory medicine combinations. Antihistamines (2.5%) and beta(2) agonists (9.2%) were used alone. The most commonly prescribed antimicrobial was amoxicillin with clavulanate (28.4%) followed by cefadroxil (20%), cotrimoxazole (9.5%) and amoxicillin alone (9.3%). Average number of antimicrobials prescribed was 0.7 (409/562). The most commonly prescribed analgesic-antipyretic was paracetamol (81.3%) followed by combination of ibuprofen and paracetamol (12.4%) and nimesulide (5.6%). Medication selection was rational in few cases. Various anomalies were observed in various aspects of drug use in children for URTI's. The main aim of the initiative is the need for more rational medicine use in URTIs in children for improvement of clinical effectiveness, cost effectiveness and reduction of potential useless risk of side effects.

Increased treatment failure after 3-days' courses of nitrofurantoin and trimethoprim for urinary tract infections in women: a population-based retrospective cohort study using the PHARMO database

AIM

To assess determinants of treatment failure after antimicrobial therapy of urinary tract infections in women.

METHODS

In primary care 16 703 Dutch women who received a first course (3, 5 or 7 days) of trimethoprim, nitrofurantoin or norfloxacin between 1 January 1992 through 31 December 1997 and who were between 15 and 65 years old at the day of first use were selected. Failure of the initial treatment was defined as a further prescription for one of these three antibiotics or for cotrimoxazole, amoxicillin, ciprofloxacin or ofloxacin, within 31 days after the end of the initial therapy.

RESULTS

Treatment failure rate was 14.4% in patients treated with trimethoprim and nitrofurantoin and 9.6% in patients treated with norfloxacin. A multivariate analysis showed that 5 days'[RR(NIT) 0.67, 95% confidence interval (CI) 0.57, 0.82, RR(TRI) 0.82, 95% CI 0.73, 0.91] and 7 days' (RR(NIT) 0.64, 95% CI 0.53, 0.77, RR(TRI) 0.85, 95% CI 0.71, 1.02) trimethoprim and nitrofurantoin treatment appeared to be more effective than a 3-day treatment (reference category). Other factors increasing treatment failure rates were the age of the patient, the year of therapy and previous hospitalization.

CONCLUSIONS

It may be concluded that 3-day courses of nitrofurantoin and trimethoprim are less effective than 5- and 7-day courses in the treatment of uncomplicated urinary tract infections in women.

Scope and nature of prescribing decisions made by general practitioners

BACKGROUND

This study describes cognitive processes of doctors who are deciding on the treatment for a patient. This helps to uncover how prescribing decisions could benefit from (computerised) support.

METHODS

While thinking aloud, 61 general practitioners made prescribing decisions for five patients with urinary tract infections or stomach complaints. The resulting 305 transcripts were analysed to determine the scope and nature of the decision processes. Differences in the process were related to case or doctor characteristics, and to differences in the quality of prescribing behaviour.

RESULTS

The decision processes were not extensive, particularly for patients with a urinary tract infection. The doctors did not actively consider all possible relevant information. Considerations referring to core aspects of the treatment were made in 159 cases (52%) and to contextual aspects in 111 cases (36%). Habitual behaviour, defined as making a treatment decision without any specific contemplation, was observed in 118 cases (40%) and resulted in prescribing first choice as well as second choice drugs. For stomach complaints, second choice drugs were often prescribed after considering other treatments or in view of specific circumstances. Experience of the doctor was not related to the type of decision process.

CONCLUSIONS

The processes observed deviate from the decision theoretic norm of thoroughly evaluating all possible options, but these deviations do not always result in suboptimal prescribing. Decision support is useful for bringing pertinent information and first choice treatments to the prescriber's attention. In particular, information about relevant contraindications, interactions, and costs could improve the quality of prescribing.

Is it possible to decrease antibiotic prescribing in primary care? An analysis of outcomes in the management of patients with sore throats

OBJECTIVES

The aim of this study was to assess whether it was possible to change clinical practice through the introduction of an evidence-based protocol for the management of sore throats. The impact of the changed clinical practice on patients was also assessed.

METHOD

An observational study was carried out comparing management of patients with sore throats in a semi-rural general practice (14 000 patients), before and after the introduction of an evidence-based protocol, using a multidisciplinary approach. All patients over the age of 2 years presenting with sore throats as their chief presenting complaint were included in the study which ran for two 6-month periods: February-July 1997 (n = 435) and February-July 1998 (n = 350). Antibiotic prescribing rates, consultation and reconsultation rates, duration of sore throat, analgesia requirements and satisfaction were assessed.

RESULTS

Antibiotic prescribing was significantly reduced in period 2 (56% compared with 19%). Consultation rates decreased by 19% in period 2. Median number of days to recovery of sore throats was the same in both groups. Reconsultation rates and dissatisfaction rates were the same in both groups.

CONCLUSION

Using a multidisciplinary approach, it is possible to reduce antibiotic prescribing for sore throats significantly without adversely affecting outcome.