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

Antimicrobial Prescription Behavior in Equine Asthma Cases: An International Survey

Equine asthma is considered a non-infectious respiratory disease characterized by inflammation and hypersensitivity. Given the importance of antimicrobial stewardship, an international survey was designed to investigate the use of antimicrobials in asthmatic horses and the factors influencing prescription behavior. An online survey was distributed in six languages by international mailing lists and social media from December 2020 to January 2022. Of the 434 responses recorded, 249 veterinarians working in 25 countries finished the survey. These included 79 ECEIM/ACVIM diplomats. A total of 204 respondents confirmed national regulations concerning antimicrobial use in their country. Knowledge of the asthma definitions as presented in the revised ACVIM consensus statement was greater in veterinarians treating over 95% of equine patients compared to veterinarians treating more species, based on 10 questions (answers consistent with the consensus statement in 7 (IQR 5-9) and 4 (IQR 3-6) questions, respectively, (p < 0.001)). A total of 131 respondents stated to use antimicrobials (at least 'sometimes') in at least one of the three presented cases consistent with equine asthma. Trimethoprim-Sulfa combinations, penicillin(s), and tetracyclines were prescribed most (by 105, 53 and 38 veterinarians, respectively). Aminoglycosides, cephalosporins and fluoroquinolones were also selected (22, 15, 9 veterinarians respectively). Tetracyclines and cephalosporins are prescribed more often by veterinarians working without national regulations (p 0.019 and p 0.035, respectively). The most selected factors influencing prescription behavior were: 'tracheal wash culture' (62% of 131 veterinarians using antimicrobials in these cases), 'whether other horses in the barn have similar complaints' (60%), and 'response to other forms of therapy' (53%). In conclusion, insight into prescription behavior is the first step towards minimizing and optimizing antimicrobial use.

Context and general practitioner decision-making - a scoping review of contextual influence on antibiotic prescribing

Background

How contextual factors may influence GP decisions in real life practice is poorly understood. The authors have undertaken a scoping review of antibiotic prescribing in primary care, with a focus on the interaction between context and GP decision-making, and what it means for the decisions made.

Method

The authors searched Medline, Embase and Cinahl databases for English language articles published between 1946 and 2019, focusing on general practitioner prescribing of antibiotics. Articles discussing decision-making, reasoning, judgement, or uncertainty in relation to antibiotic prescribing were assessed. As no universal definition of context has been agreed, any papers discussing terms synonymous with context were reviewed. Terms encountered included contextual factors, non-medical factors, and non-clinical factors.

Results

Three hundred seventy-seven full text articles were assessed for eligibility, resulting in the inclusion of 47. This article documented the experiences of general practitioners from over 18 countries, collected in 47 papers, over the course of 3 decades.

Contextual factors fell under 7 themes that emerged in the process of analysis. These were space and place, time, stress and emotion, patient characteristics, therapeutic relationship, negotiating decisions and practice style, managing uncertainty, and clinical experience. Contextual presence was in every part of the consultation process, was vital to management, and often resulted in prescribing.

Conclusion

Context is essential in real life decision-making, and yet it does not feature in current representations of clinical decision-making. With an incomplete picture of how doctors make decisions in real life practice, we risk missing important opportunities to improve decision-making, such as antibiotic prescribing.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-021-01574-x.

Understanding farmers' and veterinarians' behavior in relation to antimicrobial use and resistance in dairy cattle: A systematic review

To tackle antimicrobial resistance, it is vital that farmers' and veterinarians' antimicrobial use behaviors and attitudes toward resistance are understood so that we can identify how beliefs and motives influence practices. Current literature details qualitative and quantitative research that explores the knowledge, attitudes and perceptions of dairy farmers and veterinarians with respect to antimicrobial resistance and antimicrobial practices, and the reported findings are varied and conflicting. Our objective was to conduct a systematic review to assess the evidence and knowledge gaps in the published literature. We identified articles via database searches of Embase, Medline, PubMed, Scopus, and Web of Science; we limited findings to published articles available in English with no publication year restrictions. Article screening was conducted at 3 levels: title, abstract, and full text. Of the 349 articles identified, 35 were retained for systematic review. Transparency of reporting was assessed for each study using the Consolidated Criteria for Reporting Qualitative Research (COREQ) framework. Quality was assessed using the Critical Appraisal Skills Programme qualitative checklist. Findings relating to dairy farmers' and veterinarians' knowledge, attitudes, and perceptions on antimicrobial resistance and practices were thematically analyzed. The comprehensiveness of reporting was variable: studies reported 5 to 26 of the 32 COREQ checklist items. Five key themes emerged from the data: knowledge and awareness of antimicrobial resistance; factors influencing farmer and veterinarian decision-making; perceived barriers and facilitators to reduced antimicrobial use; perceived responsibility for antimicrobial resistance; and the role of the farmer and veterinarian relationship in reducing antimicrobial use. Awareness of prudent antimicrobial use was not uniform between studies. Many factors influence farmers' and veterinarians' decisions to use antimicrobials, including animal welfare and available resources. The farmer-veterinarian relationship is a potential barrier or facilitator of reduced antimicrobial use, depending on the perceived relationship dynamic. Encouraging collaboration between farmers and veterinarians could lead to shared responsibility for reducing antimicrobial use. This review provided a coherent picture of what is currently known and identified gaps in the current knowledge to inform future behavioral intervention research. Increased knowledge, skill development, resources, engagement, and further research to address the gaps we identified are the main recommendations to effectively overcome barriers, elicit appropriate behavior change, and achieve reduced antimicrobial use in dairy cattle.

Antimicrobial use practices, attitudes and responsibilities in UK farm animal veterinary surgeons

Increasing levels of antimicrobial resistance in human and veterinary medicine have raised concerns around 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 humans. This study aimed to explore UK veterinary surgeons antimicrobial prescribing behaviours, their attitudes to antimicrobial resistance and their perceptions of responsibility of antimicrobial use in pigs through a questionnaire study on a census sample of 261 veterinary surgeons in England, Wales and Scotland who had a clinical caseload which included commercial pigs. The questionnaire had a useable response rate of 34.1% (n = 61/179) in eligible veterinary surgeons. Overall, veterinary surgeons reported personal confidence that their prescribing decisions were responsible however, there was concern that the prescribing behaviours of other veterinary surgeons and physicians in human medicine may be less responsible; a sociological concept known as 'othering'. In parallel, veterinary surgeons seldom identified that treatment failure was a consequence of antimicrobial resistance in their own clinical caseload, however they considered it an issue for other veterinary surgeons and for human prescribers. Veterinary surgeons consulted a wide spectrum of resources on antimicrobial use in pigs which, on occasion, contained conflicting guidance on what was defined as responsible prescribing. The decision over whether or not to prescribe an antimicrobial was influenced by numerous factors relating to the veterinary surgeons' experience and the clinical situation presented, but maintaining pig welfare was a high priority. There was a shared desire to seek alternative methods to prevent disease to antimicrobial use, however the use of diagnostics to support prescribing decisions was an infrequently reported behaviour and could play a more significant role in prescriber decisions if more cost effective and rapid tests were available. Future interventions to optimise antimicrobial use in pigs needs to focus on the evolution of antimicrobial use practices in a changing political and scientific landscape whilst also considering individual motivations and justifications for use.

Treatments for subacute cough in primary care: systematic review and meta-analyses of randomised clinical trials

BACKGROUND

Subacute cough following a non-specific viral infection lasting 3-8 weeks is common. However, despite many treatment options there are no systematic reviews evaluating these.

AIM

To provide a systematic overview of treatment options and outcomes evaluated in randomised clinical trials (RCTs).

DESIGN AND SETTING

Systematic review and meta-analyses assessing the overall effects of any treatment for subacute cough.

METHOD

The authors systematically searched PubMed/MEDLINE and the Cochrane Central Register of Controlled Trials (last search March 2017) for RCTs in adult patients with subacute cough. The authors considered trials evaluating any outcome of any drug or non-drug treatments, apart from traditional Chinese and Asian medicines. They combined treatment effects on cough-related outcomes in random effects meta-analyses.

RESULTS

Six eligible RCTs including 724 patients were identified. These assessed montelukast, salbutamol plus ipratropium bromide, gelatine, fluticasone propionate, budesonide, and nociception opioid 1 receptor agonist and codeine. Five studies reported effects on various cough severity scores at various timepoints. No treatment option was associated with a clear benefit on cough recovery or other patient-relevant outcomes in any of the studies or in meta-analyses for cough outcomes at 14 days and 28 days. Reported adverse events were rather mild and reported for 14% of patients across all treatments.

CONCLUSION

Evidence on treatment options for subacute cough is weak. There is no treatment showing clear patient-relevant benefits in clinical trials.

General Practitioners' Views on the Acceptability and Applicability of Using Quality Indicators as an Intervention to Reduce Unnecessary Prescription of Antibiotics in Four South American Countries

As part of the quality improvement program &ldquo;Health Alliance for Prudent Prescribing, Yield And Use of anti-microbial Drugs In the Treatment of respiratory tract infections&rdquo; (HAPPY AUDIT) South America, we planned to implement an intervention based on the use of quality indicators as a means to influence General Practitioners&rsquo; (GPs) prescribing decision. Knowledge on the acceptability and applicability of an intervention is crucial to decide whether the intervention is suitable and will achieve the expected outcomes. This study explores GPs&rsquo; views about the acceptability and applicability of using quality indicators as an intervention to influence their prescribing decision in patients with suspected Respiratory Tract Infections (RTIs) across four countries in South-America. In March 2015, GPs that were participating in HAPPY AUDIT South America were invited to participate in focus groups. A discussion guide covering the domains acceptability and applicability was used. Data was analyzed through systematic text condensation with an inductive approach. 171 GPs were invited and 48% participated. Acceptability ranged from totally acceptable to slightly acceptable. This spectrum of GPs views on acceptability was influenced by themes concerning applicability. In conclusion, there is a positive attitude towards the use of quality indicators. Nonetheless, applicability challenges have to be taken into consideration and solved if we are to achieve a large effect with the implementation of this intervention.

"What they see is what you get": Prescribing antibiotics for respiratory tract infections in primary care: Do high prescribers diagnose differently? An analysis of German routine data

BACKGROUND

Characteristics of high and low prescribers of antibiotics in German primary care were analysed using population data. We aimed to evaluate differences in prescribing rates and factors being associated with high prescribing, and whether high prescribers made the diagnosis of perceived bacterial infections more often.

METHODS

Routine data were provided by the Bavarian Association of Statutory Health Insurance Physicians. Routine data are delivered by primary care practices on a quarterly basis. We analysed data from 2011 and 2012. Patients older than 15 years with respiratory tract infections consulting a primary care physician were selected (6.647 primary care practices). Patient and physician characteristics associated with high prescribing were identified using stepwise logistic regression.

RESULTS

Mean prescribing rate of antibiotics was 24.9%. Prescribing rate for high prescribers was 43.5% compared to 8.5% for low prescribers. High prescribers made the diagnosis of perceived bacterial infections more often (Mhigh = 64.5%, Mlow = 45.2%). In the adjusted regression model, perceived bacterial infections were strongly associated with high prescribing (OR = 13.9, 95% CI [10.2, 18.8]). Treating patients with comorbidities was associated with lower prescribing of antibiotics (OR = 0.6, 95% CI [0.4, 0.8]). High prescribers had a higher practice volume, a higher degree of prescribing dominance, and were situated more often in deprived areas and in rural settings.

INTERPRETATION

Compared to findings of studies in other European countries, prescribing rates were low. There was a considerable difference between prescribing rates of high and low prescribers. Diagnostic labelling was the best predictor for high prescribing. Current guidelines recommend considering antibiotic treatment for patients with co-morbidities. In our study, treating a large number of high-risk patients was not associated with high prescribing.

Antimicrobial Stewardship Initiatives Throughout Europe: Proven Value for Money

Antimicrobial stewardship is recognized as a key component to stop the current European spread of antimicrobial resistance. It has also become evident that antimicrobial resistance is a problem that cannot be tackled by single institutions or physicians. Prevention of antimicrobial resistance needs rigorous actions at ward level, institution level, national level and at supra-national levels. Countries can learn from each other and possibly transplant best practices across borders to prevent antimicrobial resistance. The aim of this study is to highlight some of the success stories of proven cost-effective interventions, and to describe the actions that have been taken, the outcomes that have been found, and the difficulties that have been met. In some cases we came across substantial scope for real-life cost savings. Although the best approach to effectively hinder the spread of antimicrobial resistance remains unclear and may vary significantly among settings, several EU-wide examples demonstrate that cost-effective antimicrobial stewardship is possible. Such examples can encourage others to implement (the most cost-effective) elements in their system.

Physicians' attitudes and knowledge concerning antibiotic prescription and resistance: questionnaire development and reliability

BACKGROUND

Understanding physicians' antibiotic-prescribing behaviour is fundamental when it comes to improving antibiotic use and tackling the growing rates of antimicrobial resistance. The aim of the study was to develop and validate--in terms of face validity, content validity and reliability--an instrument designed to assess the attitudes and knowledge underlying physician antibiotic prescribing.

METHODS

The questionnaire development and validation process comprised two different steps, namely: (1) content and face validation, which included a literature review and validation both by physicians and by Portuguese language and clinical psychology experts; and (2) reliability analysis, using the test-retest method, to assess the questionnaire's internal consistency (Cronbach's alpha) and reproducibility (intraclass correlation coefficient--ICC). The questionnaire includes 17 items assessing attitudes and knowledge about antibiotic prescribing and resistances and 9 items evaluating the importance of different sources of knowledge. The study was conducted in the catchment area covered by Portugal's Northern Regional Health Administration and used a convenience sample of 61 primary-care and 50 hospital-care physicians.

RESULTS

Response rate was 64% (49% to retest) for primary-care physicians and 66% (60% to retest) for hospital-care physicians. Content validity resulted in 9 changes to professional concepts. Face validity assessment resulted in 19 changes to linguistic and interpretative terms. In the case of the reliability analysis, the ICC values indicated a minimum of fair to good reproducibility (ICC > 0.4), and the Cronbach alpha values were satisfactory (α > 0.70).

CONCLUSIONS

The questionnaire developed is valid--in terms of face validity, content validity and reliability--for assessing physicians' attitudes to and knowledge of antibiotic prescribing and resistance, in both hospital and primary-care settings, and could be a very useful tool for characterising physicians' antibiotic-prescribing behaviour.

Primary care clinicians' perceptions about antibiotic prescribing for acute bronchitis: a qualitative study

Background

Clinicians prescribe antibiotics to over 65% of adults with acute bronchitis despite guidelines stating that antibiotics are not indicated.

Methods

To identify and understand primary care clinician perceptions about antibiotic prescribing for acute bronchitis, we conducted semi-structured interviews with 13 primary care clinicians in Boston, Massachusetts and used thematic content analysis.

Results

All the participants agreed with guidelines that antibiotics are not indicated for acute bronchitis and felt that clinicians other than themselves were responsible for overprescribing. Barriers to guideline adherence included 6 themes: (1) perceived patient demand, which was the main barrier, although some clinicians perceived a recent decrease; (2) lack of accountability for antibiotic prescribing; (3) saving time and money; (4) other clinicians’ misconceptions about acute bronchitis; (5) diagnostic uncertainty; and (6) clinician dissatisfaction in failing to meet patient expectations. Strategies to decrease inappropriate antibiotic prescribing included 5 themes: (1) patient educational materials; (2) quality reporting; (3) clinical decision support; (4) use of an over-the-counter prescription pad; and (5) pre-visit triage and education by nurses to prevent visits.

Conclusions

Clinicians continued to cite patient demand as the main reason for antibiotic prescribing for acute bronchitis, though some clinicians perceived a recent decrease. Clinicians felt that other clinicians were responsible for inappropriate antibiotic prescribing and that better pre-visit triage by nurses could prevent visits and change patients’ expectations.

Electronic supplementary material

The online version of this article (doi:10.1186/s12875-014-0194-5) contains supplementary material, which is available to authorized users.

Amoxicillin for acute lower respiratory tract infection in primary care: subgroup analysis of potential high-risk groups

BACKGROUND

Antibiotics are of limited overall clinical benefit for uncomplicated lower respiratory tract infection (LRTI) but there is uncertainty about their effectiveness for patients with features associated with higher levels of antibiotic prescribing.

AIM

To estimate the benefits and harms of antibiotics for acute LRTI among those producing coloured sputum, smokers, those with fever or prior comorbidities, and longer duration of prior illness.

DESIGN AND SETTING

Secondary analysis of a randomised controlled trial of antibiotic placebo for acute LRTI in primary care.

METHOD

Two thousand and sixty-one adults with acute LRTI, where pneumonia was not suspected clinically, were given amoxicillin or matching placebo. The duration of symptoms, rated moderately bad or worse (primary outcome), symptom severity on days 2-4 (0-6 scale), and the development of new or worsening symptoms were analysed in pre-specified subgroups of interest. Evidence of differential treatment effectiveness was assessed in prespecified subgroups by interaction terms.

RESULTS

No subgroups were identified that were significantly more likely to benefit from antibiotics in terms of symptom duration or the development of new or worsening symptoms. Those with a history of significant comorbidities experienced a significantly greater reduction in symptom severity between days 2 and 4 (interaction term -0.28, P = 0.003; estimated effect of antibiotics among those with a past history -0.28 [95% confidence interval = -0.44 to -0.11], P = 0.001), equivalent to three people in 10 rating symptoms as a slight rather than a moderately bad problem. For subgroups not specified in advance antibiotics provided a modest reduction in symptom severity for non-smokers and for those with short prior illness duration (<7 days), and a modest reduction in symptom duration for those with short prior illness duration.

CONCLUSION

There is no clear evidence of clinically meaningful benefit from antibiotics in the studied high-risk groups of patients presenting in general practice with uncomplicated LRTIs where prescribing is highest. Any possible benefit must be balanced against the side-effects and longer-term effects on antibiotic resistance.

Managing expectations of antibiotics for upper respiratory tract infections: a qualitative study

PURPOSE

Communication experts have suggested that it is good practice to ask patients' directly whether they expect to receive antibiotics as part of asking about the triad of ideas, concerns, and expectations for health care. Our aim was to explore the views and experiences of family physicians about using this strategy with their patients, focusing the interview on the problem of eliciting expectations of antibiotics as a possible treatment for upper respiratory tract infections.

METHODS

We conducted a qualitative study using semistructured interviews with 20 family physicians in South Wales, United Kingdom, and performing thematic analysis.

RESULTS

Family physicians assumed most patients or parents wanted antibiotics, as well as wanting to be "checked out" to make sure the illness was "nothing serious." Physicians said they did not ask direct questions about expectations, as that might lead to confrontation. They preferred to elicit expectations for antibiotics in an indirect manner, before performing a physical examination. The majority described reporting their findings of the examination as a "running commentary" so as to influence expectations and help avoid generating resistance to a soon-to-be-made-explicit plan not to prescribe antibiotics. The physicians used the running commentary to preserve and enhance the physician-patient relationship.

CONCLUSIONS

Real-world family physicians use indirect methods to explore expectations for treatment and, on the basis of their physical examination, build an argument for reassuring the patient or parent. In contrast to proposed models in the communication literature, interventions to promote appropriate antibiotic prescribing might include a focus on training in communication skills that (1) integrates these indirect methods as part of building collaborative physician-patient relationships and (2) uses the running commentary of examination findings to facilitate participation in clinical decisions.

Are patient views about antibiotics related to clinician perceptions, management and outcome? A multi-country study in outpatients with acute cough

BACKGROUND

Outpatients with acute cough who expect, hope for or ask for antibiotics may be more unwell, benefit more from antibiotic treatment, and be more satisfied with care when they are prescribed antibiotics. Clinicians may not accurately identify those patients.

OBJECTIVE

To explore whether patient views (expecting, hoping for or asking for antibiotics) are associated with illness presentation and resolution, whether patient views are accurately perceived by clinicians, and the association of all these factors with antibiotic prescribing and patient satisfaction with care.

METHODS

Prospective observational study of 3402 adult patients with acute cough presenting in 14 primary care networks. Correlations and associations tested with multilevel logistic regression and McNemar 's tests, and Cohen's Kappa, positive agreement (PA) and negative agreement (NA) calculated as appropriate.

RESULTS

1,213 (45.1%) patients expected, 1,093 (40.6%) hoped for, and 275 (10.2%) asked for antibiotics. Clinicians perceived 840 (31.3%) as wanting to be prescribed antibiotics (McNemar's test, p<0.05). Their perception agreed modestly with the three patient views (Kappa's = 0.29, 0.32 and 0.21, PA's = 0.56, 0.56 and 0.33, NA's = 0.72, 0.75 and 0.82, respectively). 1,464 (54.4%) patients were prescribed antibiotics. Illness presentation and resolution were similar for patients regardless their views. These associations were not modified by antibiotic treatment. Patient expectation and hope (OR:2.08, 95% CI:[1.48,2.93] and 2.48 [1.73,3.55], respectively), and clinician perception (12.18 [8.31,17.84]) were associated with antibiotic prescribing. 2,354 (92.6%) patients were satisfied. Only those hoping for antibiotics were less satisfied when antibiotics were not prescribed (0.39 [0.17,0.90]).

CONCLUSION

Patient views about antibiotic treatment were not useful for identifying those who will benefit from antibiotics. Clinician perceptions did not match with patient views, but particularly influenced antibiotic prescribing. Patients were generally satisfied with care, but those hoping for but not prescribed antibiotics were less satisfied. Clinicians need to more effectively elicit and address patient views about antibiotics.

Variation in family physicians' recording of auscultation abnormalities in patients with acute cough is not explained by case mix. A study from 12 European networks

BACKGROUND

Conflicting data on the diagnostic and prognostic value of auscultation abnormalities may be partly explained by inconsistent use of terminology.

OBJECTIVES

To describe general practitioners use of chest auscultation abnormality terms for patients presenting with acute cough across Europe, and to explore the influence of geographic location and case mix on use of these terms.

METHODS

Clinicians recorded whether 'diminished vesicular breathing', 'wheezes', 'crackles' and 'rhonchi' were present in an observational study of adults with acute cough in 13 networks in 12 European countries. We describe the use of these terms overall and by network, and used multilevel logistic regression to explore variation by network, controlling for patients' gender, age, comorbidities, smoking status and symptoms.

RESULTS

2345 patients were included. Wheeze was the auscultation abnormality most frequently recorded (20.6% overall) with wide variation by network (range: 8.3-30.8%). There was similar variation for other auscultation abnormalities. After controlling for patient characteristics, network was a significant predictor of auscultation abnormalities with odds ratios for location effects ranging from 0.37 to 4.46 for any recorded auscultation abnormality, and from 0.25 to 3.14 for rhonchi.

CONCLUSION

There is important variation in recording chest auscultation abnormalities by general practitioners across Europe, which cannot be explained by differences in patient characteristics. There is a need and opportunity for standardization in the detection and classification of lung sounds.

Acute cough: the use of antibiotics and health care services in an urban health centre in Israel

BACKGROUND

Acute cough, often caused by a viral respiratory infection, is a common symptom in primary care. Although clinical guidelines recommend symptomatic treatment for acute cough, antibiotics are frequently prescribed.

OBJECTIVE

To determine antibiotic prescribing for acute cough at the initial consultation and to follow subsequent medical consultations and use of medications.

METHODS

The study population included all adult patients with acute cough who visited general practitioners from one health centre (HC) during four months. Information was gathered from medical charts and telephone interviews conducted two weeks later.

RESULTS

Fifty six of three hundred and thirty eight participants (16.6%) received antibiotics at the initial visit. Eighty three participants made subsequent visits to the HC, 40 participants visited physicians outside the HC and nine participants visited both. During two weeks after the initial visit, 35 participants were prescribed antibiotics (eight in the HC, 27 outside the HC). Total antibiotic use rose to 27% (91/338) during the study period. At that time 98 (29%) of the participants reported they were still ill. Multivariate analysis showed that expectation to receive antibiotics was reported at a higher rate by the participants who received it, as compared to those who did not (32.2% versus 13.2%, OR: 2.3; 95% CI: 1.2-4.8). Receiving antibiotics was also associated with use of health services (20.3% versus 9.9%, OR: 2.7; 95% CI: 1.2-6.2).

CONCLUSIONS

Patient activism during the course of acute cough is associated with increased antibiotic use.

Influences on antimicrobial prescribing behaviour of veterinary practitioners in cattle practice in Ireland

Guidelines on prudent antimicrobial use in veterinary medicine have been developed to reduce inappropriate prescribing of antimicrobials. Such guidelines focus mainly on the clinical and pharmacological indications for prescribing. A questionnaire study of veterinary surgeons engaged in cattle practice was completed to determine if non-clinical issues influence the decision to prescribe antimicrobials, and to assess if pharmacological and non-pharmacological issues influence the choice of antimicrobial prescribed. Non-clinical issues, including issues related to professional stress, influenced the prescribing decision of the majority of respondents. However, the nature of the veterinarian-client relationship did not influence the prescribing behaviour of the majority of respondents. Pharmacological and non-pharmacological issues influenced the choice of antimicrobial prescribed. The veterinary surgeon's prior experience of a drug was considered 'often' or 'always' by 95.7 per cent of respondents when making this decision. The findings of this study have implications for the recognition and management of stress within the profession, and for the development of intervention strategies to reduce inappropriate antimicrobial prescribing.

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.

Clinical influences on antibiotic prescribing decisions for lower respiratory tract infection: a nine country qualitative study of variation in care

OBJECTIVES

There is variation in antibiotic prescribing for lower respiratory tract infections (LRTI) in primary care that does not benefit patients. This study aims to investigate clinicians' accounts of clinical influences on antibiotic prescribing decisions for LRTI to better understand variation and identify opportunities for improvement.

DESIGN

Multi country qualitative interview study. Semi-structured interviews using open-ended questions and a patient scenario. Data were subjected to five-stage analytic framework approach (familiarisation, developing a thematic framework from the interview questions and emerging themes, indexing, charting and mapping to search for interpretations), with interviewers commenting on preliminary reports.

SETTING

Primary care.

PARTICIPANTS

80 primary care clinicians randomly selected from primary care research networks based in nine European cities.

RESULTS

Clinicians reported four main individual clinical factors that guided their antibiotic prescribing decision: auscultation, fever, discoloured sputum and breathlessness. These were considered alongside a general impression of the patient derived from building a picture of the illness course, using intuition and familiarity with the patient. Comorbidity and older age were considered main risk factors for poor outcomes. Clinical factors were similar across networks, apart from C reactive protein near patient testing in Tromsø. Clinicians developed ways to handle diagnostic and management uncertainty through their own clinical routines.

CONCLUSIONS

Clinicians emphasised the importance of auscultation, fever, discoloured sputum and breathlessness, general impression of the illness course, familiarity with the patient, comorbidity, and age in informing their antibiotic prescribing decisions for LRTI. As some of these factors may be overemphasised given the evolving evidence base, greater standardisation of assessment and integration of findings may help reduce unhelpful variation in management. Non-clinical influences will also need to be addressed.

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 availability and the prevalence of pediatric pneumonia during a physicians' strike

BACKGROUND

Antibiotics are widely believed to be overpre-scribed for pediatric respiratory infections, yet there are few data available on the effect of a sudden decrease in antibiotic availability on pediatric infectious disease.

OBJECTIVE

To determine whether the prevalence of radiographically diagnosed pneumonia changed over a period of decreased physician access and decreased antibiotic availability.

DESIGN

A retrospective study was performed which reviewed the number of pediatric respiratory antibiotic prescriptions over a period which included a physicians' strike. The study examined whether antibiotic availability had been affected by the strike. Pediatric chest radiograph reports were reviewed for the same period to determine whether changes in antibiotic availability had affected the prevalence of radiographically diagnosable pneumonias among children presenting to a pediatric emergency room.

RESULTS

While prescriptions for antibiotics fell by a minimum estimate of 28% during the strike, there was no change in the frequency of radiographic diagnoses of pneumonia.

CONCLUSIONS

Respiratory antibiotics appear to be available in the community in excess of the amount required to control pneumonia. A 28% decrease in antibiotic availability did not result in a significant increase in respiratory disease.

Infectious disease management in primary care: perceptions of GPs

Background

It is important to keep the level of antibiotic prescribing low to contain the development of resistant bacteria. This study was conducted to reveal new knowledge about how GPs think in relation to the prescribing of antibiotics - knowledge that could be used in efforts toward rational treatment of infectious diseases in primary care. The aim was to explore and describe the variations in GPs' perceptions of infectious disease management, with special reference to antibiotic prescribing.

Methods

Twenty GPs working at primary care centres in a county in south-west Sweden were purposively selected based on the strategy of including GPs with different kinds of experience. The GPs were interviewed and perceptions among GPs were analysed by a phenomenographic approach.

Results

Five qualitatively different perceptions of infectious disease management were identified. They were: (A) the GP must help the patient to achieve health and well-being; (B) the management must meet the GP's perceived personal, professional and organisational demands; (C) restrictive antibiotic prescribing is time-consuming; (D) restrictive antibiotic prescribing can protect the effectiveness of antibiotics; and (E) patients benefit personally from restrictive antibiotic prescribing.

Conclusions

Restrictive antibiotic prescribing was considered important in two perceptions, was not an issue as such in two others, and was considered in one perception although the actual prescribing was greatly influenced by the interaction between patient and GP. Accordingly, to encourage restrictive antibiotic prescribing several aspects must be addressed. Furthermore, different GPs need various kinds of support. Infectious disease management in primary care is complex and time-consuming, which must be acknowledged in healthcare organisation and planning.

The determinants of the antibiotic resistance process

BACKGROUND

The use of antibiotic drugs triggers a complex interaction involving many biological, sociological, and psychological determinants. Resistance to antibiotics is a serious worldwide problem which is increasing and has implications for morbidity, mortality, and health care both in hospitals and in the community.

OBJECTIVES

To analyze current research on the determinants of antibiotic resistance and comprehensively review the main factors in the process of resistance in order to aid our understanding and assessment of this problem.

METHODS

We conducted a MedLine search using the key words "determinants", "antibiotic", and "antibiotic resistance" to identify publications between 1995 and 2007 on the determinants of antibiotic resistance. Publications that did not address the determinants of antibiotic resistance were excluded.

RESULTS

The process and determinants of antibiotic resistance are described, beginning with the development of antibiotics, resistance and the mechanisms of resistance, sociocultural determinants of resistance, the consequences of antibiotic resistance, and alternative measures proposed to combat antibiotic resistance.

CONCLUSIONS

Analysis of the published literature identified the main determinants of antibiotic resistance as irrational use of antibiotics in humans and animal species, insufficient patient education when antibiotics are prescribed, lack of guidelines for treatment and control of infections, lack of scientific information for physicians on the rational use of antibiotics, and lack of official government policy on the rational use of antibiotics in public and private hospitals.

Sputum colour for diagnosis of a bacterial infection in patients with acute cough

OBJECTIVE

Sputum colour plays an important role in the disease concepts for acute cough, both in the patients' and the doctors' view. However, it is unclear whether the sputum colour can be used for diagnosis of a bacterial infection.

DESIGN

Cross-sectional study.

SETTING

A total of 42 GP practices in Dusseldorf, Germany.

SUBJECTS

Sputum samples obtained from 241 patients suffering from an episode of acute cough seeing their doctor within a routine consultation.

MAIN OUTCOME MEASURES

Relation of sputum colour and microbiological proof of bacterial infection defined as positive culture and at least a moderate number of leucocytes per low magnification field.

RESULTS

In 28 samples (12%) a bacterial infection was proven. Yellowish or greenish colour of the sputum sample and bacterial infection showed a significant correlation (p = 0.014, Fisher's exact test). The sensitivity of yellowish or greenish sputum used as a test for a bacterial infection was 0.79 (95% CI 0.63-0.94); the specificity was 0.46 (95% CI 0.038-0.53). The positive likelihood-ratio (+LR) was 1.46 (95% CI 1.17-1.85).

CONCLUSIONS

The sputum colour of patients with acute cough and no underlying chronic lung disease does not imply therapeutic consequences such as prescription of antibiotics.

Reducing unnecessary prescriptions of antibiotics for acute cough: adaptation of a leaflet aimed at Turkish immigrants in Germany

Background

The reduction in the number of unnecessary prescriptions of antibiotics has become one of the most important objectives for primary health care. German GPs report that they are under "pressure to prescribe" antibiotics particularly in consultations with Turkish immigrants. And so a qualitative approach was used to learn more about the socio-medical context of Turkish patients in regard to acute coughs. A German leaflet designed to improve the doctor-patient communication has been positively tested and then adapted for Turkish patients.

Methods

The original leaflet was first translated into Turkish. Then 57 patients belonging to 8 different GPs were interviewed about the leaflet using a semi-standardised script. The material was audio recorded, fully transcribed, and analysed by three independent researchers. As a first step a comprehensive content analysis was performed. Secondly, elements crucial to any Turkish version of the leaflet were identified.

Results

The interviews showed that the leaflets' messages were clearly understood by all patients irrespective of age, gender, and educational background. We identified no major problems in the perception of the translated leaflet but identified several minor points which could be improved. We found that patients were starting to reconsider their attitudes after reading the leaflet.

Conclusion

The leaflet successfully imparted relevant and new information to the target patients. A qualitative approach is a feasible way to prove general acceptance and provides additional information for its adaptation to medico-cultural factors.

Evidence based management of acute bronchitis; sustained competence of enhanced communication skills acquisition in general practice

OBJECTIVE

To determine if a communication skills training program for general practitioners involving context-rich learning experiences and 'peer review' of consultation transcripts results in communication skills acquisition and maintenance, while preserving time-efficiency in consultations.

METHODS

A pre-test-post-test evaluation of training 20 general practitioners (GPs) in enhanced communication skills. Audio taped consultations with simulated patients in routine practice conducted before, within 2 weeks and again 6 months after communication skills training were analysed and consultation length measured. Transcripts were scored for specific skills to determine differences in short and longer-term competence of GPs for the communication skills.

RESULTS

There was good evidence that GPs acquired key communication skills after training and that these were maintained over 6 months. Consultations remained within normal consultation length in primary care.

CONCLUSION

Specific communication skills for acute bronchitis can be successfully acquired by GPs through context-rich communication training with peer review of transcripts with simulated patients, without making consultation length unfeasible.

PRACTICE IMPLICATIONS

This approach to skill acquisition is useful for enhancing communication skills competence in general medical practice.

Reducing antibiotic prescriptions for acute cough by motivating GPs to change their attitudes to communication and empowering patients: a cluster-randomized intervention study

OBJECTIVES

Assessing the efficacy of an educational intervention that aimed to reduce unnecessary antibiotic prescriptions in primary care by motivating GPs to change their attitudes to communication and by empowering patients.

METHODS

One hundred and four GPs in North-Rhine/Westphalia-Lippe, Germany were cluster-randomized into intervention and control. GPs randomized to receive the intervention were visited by peers. The intervention strategy was focused on the communication within the encounter, not on sharing knowledge about antibiotic prescribing. Leaflets and posters were provided that aimed at patient empowerment, thus enabling patients to raise the topic of antibiotic prescriptions themselves.

RESULTS

Eighty-six GPs (83%) remained in the study at 6 weeks and 61 GPs (59%) at 12 months. Antibiotic prescription rates within the control group were 54.7% at baseline and 36.4% within the intervention group at baseline. Generalized estimating equation models were applied. Baseline imbalances and confounding variables were controlled by adjustment. After the intervention, the ORs for the prescription of an antibiotic dropped to 0.58 [95% CI: (0.43;0.78), P < 0.001] after 6 weeks and were 0.72 [95% CI: (0.54;0.97), P = 0.028] after 12 months in the intervention group. In the control group, the ORs rose to 1.52 [95% CI: (1.19;1.95), P = 0.001] after 6 weeks and were 1.31 [95% CI: (1.01;1.71), P = 0.044] after 12 months; these ORs correspond to an approximately 60% relative reduction in antibiotic prescription rates at 6 weeks and a persistent 40% relative reduction at 12 months.

CONCLUSIONS

An interventional strategy that focused on doctor-patient communication and patient empowerment is an effective concept to reduce antibiotic prescriptions in primary care.

Improving management of patients with acute cough by C-reactive protein point of care testing and communication training (IMPAC3T): study protocol of a cluster randomised controlled trial

Background

Most antibiotic prescriptions for acute cough due to lower respiratory tract infections (LRTI) in primary care are not warranted. Diagnostic uncertainty and patient expectations and worries are major drivers of unnecessary antibiotic prescribing. A C-reactive protein (CRP) point of care test may help GPs to better guide antibiotic treatment by ruling out pneumonia in cases of low test results. Alternatively, enhanced communication skills training to help clinicians address patients' expectations and worries could lead to a decrease in antibiotic prescribing, without compromising clinical recovery, while enhancing patient enablement. The aim of this paper is to describe the design and methods of a study to assess two interventions for improving LRTI management in general practice.

Methods/Design

This cluster randomised controlled, factorial trial will introduce two interventions in general practice; point of care CRP testing and enhanced communication skills training for LRTI. Twenty general practices with two participating GPs per practice will recruit 400 patients with LRTI during two winter periods. Patients will be followed up for at least 28 days. The primary outcome measure is the antibiotic prescribing rate. Secondary outcomes are clinical recovery, cost-effectiveness, use of other diagnostic tests and medical services (including reconsultation), and patient enablement.

Discussion

This trial is the first cluster randomised trial to evaluate the influence of point of care CRP testing in the hands of the general practitioner and enhanced communication skills, on the management of LRTI in primary care. The pragmatic nature of the study, which leaves treatment decisions up to the responsible clinicians, will enhance the applicability and generalisability of findings. The factorial design will allow conclusion to be made about the value of CRP testing on its own, communication skills training on its own, and the two combined. Evaluating a biomedical and communication based intervention ('hard' and 'soft' technologies) together in this way makes this trial unique in its field.

Physician practice patterns: chest x-ray ordering for the evaluation of acute cough illness in adults

OBJECTIVES

The authors examine which clinical factors contribute to the clinician suspicion of pneumonia, as well as the relationship between clinical factors, clinician suspicion of pneumonia, and ordering chest X-rays (CXR).

METHODS

Three hundred consecutive adults presenting to the clinic with acute cough in the winter of 2003 were studied. Using standardized encounter forms, data were collected on sociodemographics, illness impact, symptoms, tobacco use, past medical history, vital signs, physical examination findings, chest X-ray result, and clinician diagnoses. Clinicians rated their suspicion of pneumonia on a 5-point Likert scale. Multivariable logistic regression analysis was used to determine independent predictors of clinician suspicion of pneumonia and of ordering of CXRs.

RESULTS

Clinician suspicion of pneumonia was low in the majority of patients presenting for evaluation of cough (63%). Higher clinician suspicion of pneumonia was predicted by advanced patient age (odds ratio [OR]: 4.6; 95% confidence interval [CI] [1.2-18.1]), shortness of breath (2.4; [1.0-6.0]), fever (5.5; [1.8-17.5]), tachycardia (3.8; [1.1-13.1]), rales (23.8; [5.7-98.7]), and rhonchi (14.6; [5.2-40.5]). CXRs were ordered in 19% of patients presenting with acute cough. Intermediate clinician suspicion of pneumonia (OR: 7.9; 95% CI: [2.8, 22.5]) (v. low suspicion), advanced patient age ([.greaterequal] 65 years) (9.2; [2.7, 31.6]) (v. ages 18-44 years), and decreased breath sounds on examination (5.1; [1.8, 14.3]) are independent predictors of ordering a CXR. Among patients with a clinical diagnosis of pneumonia (n = 31), CXRs were ordered in only 61%.

CONCLUSIONS

Advanced patient age and physical findings on chest examination influence clinician practice in obtaining CXRs, beyond their contribution to clinician suspicion of pneumonia. Physicians do not appear to endorse recommendations that the diagnosis of community-acquired pneumonia be based on or confirmed by CXR.

Do clinical findings in lower respiratory tract infection help general practitioners prescribe antibiotics appropriately? An observational cohort study in general practice

BACKGROUND

Antibiotics are over-prescribed for lower respiratory tract infection (LRTI). The influence of clinicians' history and examination findings on antibiotic prescribing for LRTI has not been directly assessed, and the extent to which these clinical findings predict appropriate antibiotic prescribing is unknown. A clearer understanding is crucial to achieving evidence-based prescribing.

OBJECTIVES

To directly assess the influence of general practitioners' history and examination findings on antibiotic prescribing for LRTI, and to explore the extent to which these clinical findings predict appropriate antibiotic prescribing.

METHODS

In this observational cohort study 25 GPs in The Netherlands were recruited during routine consultations and 247 adult patients with a clinical diagnosis of LRTI. The GPs recorded clinical information. Odds ratios (ORs) with 95% confidence intervals (CIs) for clinical variables predicting a prescription for an antibiotic were calculated. The relationship between antibiotic prescription and radiographic evidence of pneumonia was explored in order to gauge appropriateness of antibiotic prescribing.

RESULTS

Auscultation abnormalities (OR 11.5; 95% CI 5.4-24.7), and diarrhoea (OR>11) were strongly associated with antibiotic prescribing. An antibiotic was prescribed for 195 (79%) patients. Assuming that an antibiotic definitely needs to be prescribed only for patients with pneumonia, antibiotics may have been inappropriately prescribed for 166/193 (86%) of the patients. Antibiotics were not prescribed for 5 of the 32 (16%) patients with a radiographic diagnosis of pneumonia.

CONCLUSIONS

Abnormal findings on auscultation in patients with LRTI strongly predict antibiotic prescribing and this is probably inappropriate for most patients. These results should prompt GPs to consider the extent to which finding 'crackles/rhonchi on auscultation' influences their decisions to prescribe antibiotics for their patients with LRTI, and to consider the predictive value of individual clinical signs in reaching evidence-based prescribing decisions.

Antibiotic prescribing for acute cough: the effect of perceived patient demand

BACKGROUND

GPs decide whether or not to prescribe antibiotics for acute cough. Apart from clinical signs and symptoms, non-medical reasons influence this decision as well.

AIM

To obtain a valid estimate of the effect of perceived patient demand.

DESIGN OF STUDY

Secondary analysis of cluster randomised controlled trial data.

SETTING

Eighty-five Flemish GPs.

METHOD

GPs completed a preprinted form with medical as well as non-medical information and their prescription for 20 consecutive adult patients consulting with acute cough in the periods February to April 2000 and 2001. The effect of perceived patient demand on antibiotic prescribing was estimated by performing alternating logistic regression analysis. A hierarchical backwards elimination procedure, described by Kleinbaum, was used.

RESULTS

Seventy-two GPs participated, including 1448 patients eligible for analysis; 500 (34.5%) were prescribed an antibiotic and, according to the GP, 218 (15.1%) asked for an antibiotic. In cases of perceived patient demand antibiotics were prescribed significantly more often (odds ratio [OR] = 4.64, 95% confidence interval [CI] = 2.96 to 7.26). In the final model (n = 819; OR = 4.60, 2.59 to 8.17); Hosmer-Lemeshow goodness-of-fit P = 0.72), the effect of perceived patient demand for an antibiotic depended on the outcome of the lung auscultation. When patient demand was perceived, antibiotics were prescribed significantly more often only in the case of a normal lung auscultation or in the case of only one abnormal auscultatory finding (adjusted OR = 20.83, 95% CI = 8.86 to 48.99; adjusted OR = 4.79; 95% CI = 2.16 to 10.60, respectively).

CONCLUSIONS

Perceived patient demand has a significant, independent and clinically relevant effect on antibiotic prescribing for acute cough with negative findings on the lung auscultation. Practice guidelines and interventions to optimise antibiotic prescribing have to take this effect into account.

Determinants of antibiotic overprescribing in respiratory tract infections in general practice

OBJECTIVES

To assess determinants of antibiotic overprescribing in patients with sinusitis, tonsillitis and bronchitis in Dutch general practice.

PATIENTS AND METHODS

A total of 146 general practitioners (GPs) from The Netherlands included all patients with sinusitis, tonsillitis and bronchitis during a 4 week period in the winter of 2002/2003, and recorded patient characteristics, clinical presentation and management. Overprescribing of antibiotics was assessed using the recommendations of the Dutch national guidelines as a benchmark.

RESULTS

In almost 50% of all 1469 respiratory tract infection (RTI) consultations (694/1469), the antibiotic prescribing decisions were in accordance with the recommendations of the Dutch national guidelines. Overprescribing was highest in tonsillitis and bronchitis [71% (168/238) and 63% (415/656), respectively], while in sinusitis this was only 22% (128/575). Underprescribing was seen in 1% (3/238), 3% (17/656) and 8% (44/575), respectively. Patients who received an antibiotic prescription that was not in accordance with the guidelines had more inflammation signs such as fever (ORs 2.08, 2.18 and 3.04, for sinusitis, tonsillitis and bronchitis, respectively), were more severely ill according to their GP (ORs 2.37, 1.87 and 1.42, respectively), and their GP assumed more often that they expected an antibiotic (ORs 1.95, 1.70 and 2.11, respectively), compared with those who did not receive an antibiotic prescription.

CONCLUSIONS

GPs overestimate symptoms and probably patients' expectations when indicating antibiotic therapy in RTI cases in daily practice. Correct interpretation of combinations of symptoms for antibiotic treatment should be emphasized, combined with adopting more patient-centred consulting skills to rationalize the prescribing of antibiotics.

Influence of patient symptoms and physical findings on general practitioners' treatment of respiratory tract infections: a direct observation study

BACKGROUND

The high rate of antibiotic prescriptions general practitioners (GPs) make for respiratory tract infections (RTI) are often explained by non-medical reasons e.g. an effort to meet patient expectations. Additionally, it is known that GPs to some extent believe in the necessity of antibiotic treatment in patients with assumed bacterial infections and therefore attempt to distinguish between viral and bacterial infections by history taking and physical examination. The influence of patient complaints and physical examination findings on GPs' prescribing behaviour was mostly investigated by indirect methods such as questionnaires.

METHODS

Direct, structured observation during a winter "cough an cold period" in 30 (single handed) general practices. All 273 patients with symptoms of RTI (age above 14, median 37 years, 51% female) were included.

RESULTS

The most frequent diagnoses were 'uncomplicated upper RTI/common cold' (43%) followed by 'bronchitis' (26%). On average, 1.8 (95%-confidence interval (CI): 1.7-2.0) medicines per patient were prescribed (cough-and-cold preparations in 88% of the patients, antibiotics in 49%). Medical predictors of antibiotic prescribing were pathological findings in physical examination such as coated tonsils (odds ratio (OR) 15.4, 95%-CI: 3.6-66.2) and unspecific symptoms like fatigue (OR 3.1, 95%-CI 1.4-6.7), fever (OR 2.2, 95%-CI: 1.1-4.5) and yellow sputum (OR 2.1, 95%-CI: 1.1-4.1). Analysed predictors explained 70% of the variance of antibiotic prescribing (R2 = 0,696). Efforts to reduce antibiotic prescribing, e.g. recommendations for self-medication, counselling on home remedies or delayed antibiotic prescribing were rare.

CONCLUSIONS

Patient complaints and pathological results in physical examination were strong predictors of antibiotic prescribing. Efforts to reduce antibiotic prescribing should account for GPs' beliefs in those (non evidence based) predictors. The method of direct observation was shown to be accepted both by patients and GPs and offered detailed insights into the GP-patient-interaction.

Prescribing antibiotics for respiratory tract infections by GPs: management and prescriber characteristics

BACKGROUND

Due to clinical and non-clinical factors, considerable variation exists in the prescribing of antibiotics for respiratory tract infections (RTIs) by GPs based in the Netherlands.

AIM

To assess, in patients with RTIs in Dutch general practice: the prescribing rates of antibiotics; the relationship between GP characteristics and antibiotic prescribing; and the type of antibiotics prescribed.

DESIGN OF STUDY

Descriptive and prognostic.

SETTING

Eighty-four GPs in the middle region of the Netherlands.

METHOD

All patient consultations for RTIs were registered by 84 GPs during 3 weeks in autumn and winter 2001 and 2002. In addition, all GPs completed a questionnaire related to individual and practice characteristics.

RESULTS

The mean proportion of consultations in which GPs prescribed antibiotics was 33% (95% CI = 29 to 35%) of all RTIs. This proportion varied from 21% for patients with upper RTIs or an exacerbation of asthma/COPD, to about 70% when patients had sinusitis-like complaints or pneumonia. Amoxycillin and doxycycline were the most frequently prescribed antibiotics, while 17% of the antibiotics prescribed were macrolides. Multiple linear regression analysis showed that the longer GPs had practised, the more frequently they prescribed antibiotics, especially in combination with relatively little knowledge about RTIs or the less time GPs felt they had available per patient. The final model, with seven factors, explained 29% of the variance of antibiotic prescribing.

CONCLUSION

The prescribing behaviour of Dutch GPs might be improved with regard to choice of type and indication of antibiotics.

Optimizing antibiotic prescribing for acute cough in general practice: a cluster-randomized controlled trial

OBJECTIVES

To assess the effect of a tailored professional intervention, including academic detailing, on antibiotic prescribing for acute cough.

METHODS

In a cluster-randomized controlled before and after study 85 Flemish GPs included adult patients with acute cough consulting in the periods February-April 2000 and 2001. The intervention consisted of a clinical practice guideline for acute cough, an educational outreach visit and a postal reminder to support its implementation in January 2001. Antibiotic prescribing rates and patients' symptom resolution were the main outcome measures.

RESULTS

Thirty-six of 42 GPs received the intervention and 35 of 43 GPs served as controls; 1503 patients were eligible for analysis. Only in the intervention group were patients less likely to receive antibiotics after the intervention [OR(adj) (95% CI)=0.56 (0.36-0.87)]. Prescribed antibiotics were also more in line with the guideline in the intervention group [1.90 (0.96-3.75)] and less expensive from the perspective of the National Sickness and Invalidity Insurance Institute [MD(adj) (95% CI)= Euro -6.89 [-11.77-(-2.02)]]. No significant differences were found between the groups for the time to symptom resolution.

CONCLUSIONS

An (inter)actively delivered tailored intervention implementing a guideline for acute cough is successful in optimizing antibiotic prescribing without affecting patients' symptom resolution. Further research efforts should be devoted to cost-effectiveness studies of such interventions.