Men with lower UTI in primary healthcare. General practitioners' experiences of diagnosis and treatment in relation to clinical guidelines. A qualitative interview-based study

BACKGROUND

The incidence of lower urinary tract infection (LUTI) in men visiting primary health care (PHC) is low. Hence, GPs do not diagnose and treat men with LUTI very often. Previous studies have shown that adherence to treatment guidelines regarding LUTI in men is low. There is limited knowledge concerning why guidelines are not adhered to.

AIM

To gain knowledge on GPs' experiences and concerns when treating men with LUTI, including their use of clinical guidelines. Furthermore, to explore GPs' knowledge and concern regarding antibiotic resistance.

DESIGN & SETTING

A qualitative study based on semi-structured interviews with GPs was performed.

METHOD

15 GPs from seven PHC centres in southern Sweden were interviewed. The interviews were conducted from September 2022 to March 2023. All interviews were audio recorded and transcribed verbatim. A thematic analysis was performed.

RESULTS

GPs had limited experience with and felt uncertain when diagnosing male LUTI. Extended examinations could partially relieve this feeling. GPs were well informed about the Swedish treatment guidelines for LUTI in men and felt safe to treat their patients according to the guidelines. However, GPs also acknowledged that guidelines do not cover all situations and need to be individualised.

CONCLUSION

Many GPs feel insecure when diagnosing male LUTI. The relatively low prevalence of this condition in PHC could contribute to this feeling. Clear and instructive guidelines regarding both the diagnostic process and adequate antibiotic choices are important to maintain good quality in the management of LUTI in men.

The first outbreak of African swine fever in Sweden: a survey of pig farmers' perceptions of information received, risks, biosecurity measures and future prospects

BACKGROUND

African swine fever (ASF), a viral hemorrhagic disease in domestic pigs and wild boar with up to 100% case fatality, was confirmed in Swedish wild boar in September 2023. The responsible authorities launched a control programme to eradicate the infection. The aim of the current study was to understand (i) how Swedish pig farmers have perceived the information issued by authorities and other stakeholders since the discovery of ASF in wild boar, (ii) which risks they see for introducing the infection to their farm, (iii) what biosecurity measures they have taken on their farms, and (iv) their outlook on the future. Such information is important for evaluating the effectiveness of the early stages of ASF control in Sweden. A questionnaire was designed and distributed to members of the Swedish pig producers' organisation.

RESULTS

A total of 155 farmers responded to the survey (response rate 36%). Almost all respondents had received general information about ASF (91%, n = 138), and 72% (n = 109) had received information about how they can protect their farm from ASF introduction. A majority (87%, n = 118) thought the information was easy to understand, 90% (n = 137) that is was relevant, and 77% (n = 117) that they currently did not lack any information. If given the resources necessary, 58% (n = 84) of the farmers would like to take additional measures such as fencing, and heavily reduce or eradicate the wild boar population. Wild boars were considered the greatest risk for introduction of ASF into their herd (39%, n = 57), followed by people (30%, n = 44), and transports (16%, n = 23). Many farmers (66%, n = 88) had a positive outlook on the future, and 89% (n = 127) have not changed their plans for the future since the ASF outbreak.

CONCLUSIONS

The responding farmers were in general satisfied with the information received in the beginning of the ASF outbreak. The majority have a positive outlook on the future and the outbreak has not caused them to change their plans. Actions that were highlighted as important to safeguard Sweden's pig production included measures to control the wild boar population.

Perspectives of on-farm biosecurity and disease prevention among selected pig veterinarians and pig farmers in Sweden

Background

Biosecurity is important in preventing the spread of infectious diseases in animal production. Previous studies have identified a disparity between the biosecurity recommendations provided by veterinarians and the actual practices implemented by farmers. This study compared group discussions with a few key actors among Swedish pig veterinarians and farmers on pig farm biosecurity.

Methods

Two focus group discussions were conducted, one with five Swedish pig veterinarians and one with three pig farmers, to explore their views on pig farm biosecurity and efficient biosecurity measures. The discussions were analysed to identify differences and similarities in how biosecurity was perceived.

Results

The study identified differences between the veterinarians and pig farmers in how they perceived good biosecurity and the level of biosecurity in Swedish pig herds. The veterinarians perceived that adhering strictly to the farming system and its barriers was essential for good biosecurity. The biosecurity in the pig farms was often considered inadequate. The veterinarians described difficulties in biosecurity-related communication with the farmers. The pig farmers valued the flexibility of the farming system over strict barriers and described that the level of biosecurity was good in Swedish pig herds. However, both groups also shared similar views regarding the challenges in farm biosecurity. They highlighted that biosecurity measures with proven efficacy are important for farmer motivation.

Conclusions

This limited study suggested that different perspectives on biosecurity can contribute to communication difficulties between pig farmers and veterinarians. Acknowledging both the differences and similarities of the different perspectives may help improve cooperation and communication in biosecurity-related questions.

Trust, agreements, and occasional breakdowns: Veterinarians' perspectives on farmer-veterinarian relationships and use of antimicrobials for Swedish dairy cattle

Studies have shown that farmer-veterinarian relationships influence antimicrobial use (AMU) in livestock, though how they do so is unclear. On the one hand, research shows that well-established veterinarian-farmer relationships are positive for implementation of antibiotic stewardship and restrictive AMU. On the other hand, studies also show that farmer demands can increase antimicrobial prescribing and that prescribing antimicrobials can strengthen the veterinarian's relationship with farmer clients. In the present study, we focus on veterinarians' perspectives on the relationships between dairy cattle farmers and veterinarians in Sweden and explore what characterizes these relationships when restrictive AMU is described as unproblematic and when AMU becomes a matter of tension or conflict. The study draws on semistructured interviews with 21 veterinarians working with livestock in Sweden. Interviews were analyzed thematically. The study shows that from the perspectives of veterinarians, well-established veterinarian-farmer relationships generally facilitate restrictive AMU in 3 slightly different but related ways: (1) they create trust in the veterinarian and their prescribing decisions; (2) they create shared understanding concerning when antimicrobials are needed and not needed; and (3) they facilitate constructive discussions between veterinarians and farmers on AMU. To make the farmer feel listened to and to come to an agreement on AMU was described as central for the veterinarians. However, the veterinarians described agreements on restrictive AMU as sometimes requiring strategic work, such as discussions to motivate the farmer and leave the door open for antimicrobials later if needed. Such work takes time and energy and is easier within well-established relationships according to the veterinarians. We also identified examples where veterinarians explained that they occasionally make compromises with farmers concerning antimicrobials-compromises that, according to the veterinarians, facilitate the relationship with the farmer, which in turn facilities restrictive AMU in the longer term. The examples in our interviews where antimicrobials became a matter of tension and even conflict between veterinarians and farmers could, with a few exceptions, be traced to absence of well-established relationships. However, some veterinarians also described AMU as a matter of tension within well-established relationships, especially with older farmers who do not trust new treatment strategies. We also found a small number of examples where disagreements on antimicrobials made a relationship with specific farmers impossible. Thus, even though the interviewed veterinarians generally meant that their restrictive antimicrobial prescribing did not threaten the relationship with the farmer, our study also, to some extent, confirms research showing that restrictive AMU can harm the relationship with some clients who simply choose another, less restrictive, veterinarian. In summary, our study supports that decisions on AMU cannot be reduced to the individual prescriber's behavior, nor to a strict medical judgment. Antimicrobial use for dairy cattle needs to be understood as taking form in relationships in which both veterinarians and farmers are active parts.

Restrictive but not restricted: Perspectives on antimicrobial use and antimicrobial resistance among Swedish dairy veterinarians

BACKGROUND AND AIMS

In Europe, the antimicrobial use (AMU) for food-producing animals has decreased rapidly. However, studies indicate that a too strict policy, with too restrictive AMU, is potentially problematic for veterinarians because it threatens animal welfare and creates tensions between farmers and veterinarians. The AMU in Sweden is among the lowest in Europe, and regulation of AMU in farm animals is strict. The aim of our study was to explore how Swedish veterinarians describe the relations between (1) being restrictive with antibiotics due to the risk of AMR and (2) concerns for animal welfare and/or the veterinarian-client relationship.

METHODS

Semi-structured interviews with 21 veterinarians, working with dairy cattle, were performed. The transcripts were analysed, and a number of dominant patterns which recurred in all, or most of, the interviews were identified.

RESULT

The interviewed veterinarians described AMR prevention and tackling the threat AMR poses towards public health, as central for their profession and as influencing their everyday practice and decisions on AMU. Importantly, veterinarians described accounting for AMR in everyday practice as fairly unproblematic, both in relation to animal welfare as well as in relation to farmers. The veterinarians generally perceived that they could treat animals with antibiotics when justified, and being restrictive with antibiotics was described as an expression of professional skill and not as challenging as animal welfare. Moreover, they stated that restrictive AMU seldom or never caused conflicts with farmers.

CONCLUSION

Strict AMU policy and restrictive AMU do not necessarily put veterinarians in a problematic position where they are caught between conflicting demands and risks.

A study of guidelines for respiratory tract infections and their references from Swedish GPs: a qualitative analysis

Background: National guidelines are important instruments in reducing inappropriate antibiotic prescriptions. Low adherence to guidelines is an acknowledged problem that needs to be addressed.Method: We evaluated established characteristics for guidelines in the guidelines for lower respiratory tract infection, acute otitis media and pharyngotonsillitis in primary care. We studied how doctors used these guidelines by analysing interviews with 29 general practitioners (GPs) in Sweden.Results: We found important between-guidelines differences, which we believe affects adherence. The GPs reported persistent preconceptions about diagnosis and treatment, which we believe reduces their adherence to the guidelines.Conclusion: To increase adherence, it is important to consider doctors' preconceptions when creating new guidelines.

How can evidence-based interventions give the best value for users in social services? Balance between adherence and adaptations: a study protocol

Background

Using evidence-based interventions (EBIs) is a basic premise of contemporary social services (e.g., child and family social services). However, EBIs seldom fit seamlessly into a specific setting but often need to be adapted. Although some adaptions might be necessary, they can cause interventions to be less effective or even unsafe. The challenge of balancing adherence and adaptations when using EBIs is often referred to as the adherence and adaptation dilemma. Although the current literature identifies professionals’ management of this dilemma as problematic, it offers little practical guidance for professionals. This research aims to investigate how the adherence and adaptation dilemma is handled in social services and to explore how structured decision support can impact the management of the dilemma.

Methods

The design is a prospective, longitudinal intervention with a focus on the feasibility and usefulness of the structured decision support. The project is a collaboration between academic researchers, embedded researchers at three research and development units, and social service organizations. A multi-method data collection will be employed. Initially, a scoping review will be performed, and the results will be used in the development of a structured decision support. The decision support will be further developed and tested during a series of workshops with social service professionals. Different forms of data—focus group interviews, questionnaires, and documentation—will be used on several occasions to evaluate the impact of the structured decision support. Qualitative and quantitative analysis will be performed and usefulness for practice prioritized throughout the study.

Discussion

The study will contribute with knowledge on how the adherence and adaption dilemma is handled and experienced by social service professionals. Most importantly, the study will generate rich empirical data on how a structured decision support impacts professionals’ management of adherence and adaptions. The goal is to produce more strategic and context-sensitive implementation of EBIs in social service, which will increase value for service users.

The Emergence of Antimicrobial Resistance as a Public Matter of Concern: A Swedish History of a "Transformative Event"

ArgumentThis article examines how antimicrobial resistance (AMR) came to be constituted as a matter of public concern in Sweden in conjunction with the development of an inter-professional organization called Strama, founded to promote rational prescription of antibiotics. An outbreak of penicillin-resistant pneumococci in the mid-1990s was crucial for this development, because it brought attention to AMR as an urgent public threat. This outbreak fuelled the constitution of AMR as caused by consumption of antibiotics and as a matter of disease control. As a consequence, Strama was able to mobilize the Swedish health officers responsible for disease control. The outbreak is conceptualized as a "transformative event" - an event that makes an issue and its associated risks concrete and urgent. Transformative events play the crucial role of expediting the transformation of issues into matters of public concern.

Harmless, friendly and lethal: antibiotic misuse in relation to the unpredictable bacterium Group A streptococcus

Evidence-based treatment guidelines for managing infections in health care are promoted as tools to prevent unnecessary use of antibiotics. Antibiotic misuse has been examined as regards the doctor-patient relation and the social context of medical practice. Less attention has been paid to how the very conceptualisation of human-microbial relations may influence understandings of antibiotic misuse. The article examines a medical controversy concerning guidelines for managing throat infection and antibiotic treatment in Sweden. It demonstrates how this controversy unfolds around two different ways of relating to a specific bacterium - Group A Streptococcus. The analysis shows how two 'microbiopolitics', involving different understandings of human-microbial relations, are created in the controversy and how different antibiotic prescribing practices are justified. By focusing on Group A Streptococcus, which is commonly observed, but also unpredictable and potentially dangerous, the article provides new insights into the relations between bacteria, humans and policy in an age of antimicrobial resistance. It argues, in particular, that the definition of antibiotic misuse is unstable and consequently that policy measures aimed at reducing misuse must be related to how specific infections and bacteria are conceptualised in the actual context the policy addresses.

Interacting factors associated with Low antibiotic prescribing for respiratory tract infections in primary health care - a mixed methods study in Sweden

Background

Prescribing of antibiotics for common infections varies widely, and there is no medical explanation. Systematic reviews have highlighted factors that may influence antibiotic prescribing and that this is a complex process. It is unclear how factors interact and how the primary care organization affects diagnostic procedures and antibiotic prescribing. Therefore, we sought to explore and understand interactions between factors influencing antibiotic prescribing for respiratory tract infections in primary care.

Methods

Our mixed methods design was guided by the Triangulation Design Model according to Creswell. Quantitative and qualitative data were collected in parallel. Quantitative data were collected by prescription statistics, questionnaires to patients, and general practitioners’ audit registrations. Qualitative data were collected through observations and semi-structured interviews.

Results

From the analysis of the data from the different sources an overall theme emerged: A common practice in the primary health care centre is crucial for low antibiotic prescribing in line with guidelines. Several factors contribute to a common practice, such as promoting management and leadership, internalized guidelines including inter-professional discussions, the general practitioner’s diagnostic process, nurse triage, and patient expectation. These factors were closely related and influenced each other. The results showed that knowledge must be internalized and guidelines need to be normative for the group as well as for every individual.

Conclusions

Low prescribing is associated with adapted and transformed guidelines within all staff, not only general practitioners. Nurses’ triage and self-care advice played an important role. Encouragement from the management level stimulated inter-professional discussions about antibiotic prescribing. Informal opinion moulders talking about antibiotic prescribing was supported by the managers. Finally, continuous professional development activities were encouraged for up-to-date knowledge.

Uncertainty in clinical practice - an interview study with Swedish GPs on patients with sore throat

BACKGROUND

Uncertainty is inevitable in clinical practice in primary care and tolerance for uncertainty and concern for bad outcomes has been shown to vary between physicians. Uncertainty is a factor for inappropriate antibiotic prescribing. Evidence-based guidelines as well as near-patient tests are suggested tools to decrease uncertainty in the management of patients with respiratory tract infections. The aim of this paper was to describe strategies for coping with uncertainty in patients with pharyngotonsillitis in relation to guidelines.

METHODS

An interview study was conducted among a strategic sample of 25 general practitioners (GPs).

RESULTS

All GPs mentioned potential dangerous differential diagnoses and complications. Four strategies for coping with uncertainty were identified, one of which was compliant with guidelines, "Adherence to guidelines", and three were idiosyncratic: "Clinical picture and C-reactive protein (CRP)", "Expanded control", and "Unstructured". The residual uncertainty differed for the different strategies: in the strategy "Adherence to guidelines" and "Clinical picture and CRP" uncertainty was avoided, based either on adherence to guidelines or on the clinical picture and near-patient CRP; in the strategy "Expanded control" uncertainty was balanced based on expanded control; and in the strategy "Unstructured" uncertainty prevailed in spite of redundant examination and anamnesis.

CONCLUSION

The majority of the GPs avoided uncertainty and deemed they had no problems. Their strategies either adhered to guidelines or comprised excessive use of tests. Thus use of guidelines as well as use of more near-patient tests seemed associated to reduced uncertainty, although the later strategy at the expense of compliance to guidelines. A few GPs did not manage to cope with uncertainty or had to put in excessive work to control uncertainty.

Near-patient tests and the clinical gaze in decision-making of Swedish GPs not following current guidelines for sore throat - a qualitative interview study

Background

Excessive antibiotics use increases the risk of resistance. Previous studies have shown that the Centor score combined with Rapid Antigen Detection Test (RADT) for Group A Streptococci can reduce unnecessary antibiotic prescribing in patients with sore throat. According to the former Swedish guidelines RADT was recommended with 2–4 Centor criteria present and antibiotics were recommended if the test was positive. C- reactive protein (CRP) was not recommended for sore throats. Inappropriate use of RADT and CRP has been reported in several studies.

Methods

From a larger project 16 general practitioners (GPs) who stated management of sore throats not according to the guidelines were identified. Half-hour long semi-structured interviews were conducted. The topics were the management of sore throats and the use of near-patient tests. Qualitative content analysis was used.

Results

The use of the near-patient test interplayed with the clinical assessment and the perception that all infections caused by bacteria should be treated with antibiotics. The GPs expressed a belief that the clinical picture was sufficient for diagnosis in typical cases. RADT was not believed to be relevant since it detects only one bacterium, while CRP was considered as a reliable numerical measure of bacterial infection.

Conclusions

Inappropriate use of near-patient test can partly be understood as remnants of outdated knowledge. When new guidelines are introduced the differences between them and the former need to be discussed more explicitly.

Management of patients with sore throats in relation to guidelines: an interview study in Sweden

OBJECTIVE

To explore how a group of Swedish general practitioners (GPs) manage patients with a sore throat in relation to current guidelines as expressed in interviews.

DESIGN

Qualitative content analysis was used to analyse semi-structured interviews.

SETTING

Swedish primary care.

SUBJECTS

A strategic sample of 25 GPs.

MAIN OUTCOME MEASURES

Perceived management of sore throat patients.

RESULTS

It was found that nine of the interviewed GPs were adherent to current guidelines for sore throat and 16 were non-adherent. The two groups differed in terms of guideline knowledge, which was shared within the team for adherent GPs while idiosyncratic knowledge dominated for the non-adherent GPs. Adherent GPs had no or low concerns for bacterial infections and differential diagnosis whilst non-adherent GPs believed that in patients with a sore throat any bacterial infection should be identified and treated with antibiotics. Patient history and examination was mainly targeted by adherent GPs whilst for non-adherent GPs it was often redundant. Non-adherent GPs reported problems getting patients to abstain from antibiotics, whilst no such problems were reported in adherent GPs.

CONCLUSION

This interview study of sore throat management in a strategically sampled group of Swedish GPs showed that while two-thirds were non-adherent and had a liberal attitude to antibiotics one-third were guideline adherent with a restricted view on antibiotics. Non-adherent GPs revealed significant knowledge gaps. Adherent GPs had discussed guidelines within the primary care team while non-adherent GPs had not. Guideline implementation thus seemed to be promoted by knowledge shared in team discussions.