Clinicians Know, but Bend, Rules for Antibiotic Prescribing

Marcia Frellick

November 14, 2014

Clinicians know the recommendations regarding when and when not to prescribe antibiotics, but they do not always follow them, according to in-depth interviews with 36 physicians, nurse practitioners (NPs), and physician assistants (PAs).

Guillermo Sanchez, MPH, from the Centers for Disease Control and Prevention, Atlanta, Georgia, and colleagues report the results of their interview-based study in an article published online November 13 in Emerging Infectious Diseases.

Reasons for straying from the guidelines range from believing that a nonrecommended antibiotic will work better for a patient, particularly when considering allergies or complicated medical histories; concern about patient dissatisfaction; fear of related infection; and concerns about legal action.

Clinicians indicated that although they are concerned patients could build up a resistance to antibiotics, those concerns do not usually affect their choice of drug.

Researchers Recorded Telephone Interviews

The researchers conducted in-depth interviews via digitally recorded telephone calls and transcribed the recordings to accurately assess primary care providers' prescribing behaviors. The breakdown of participants was nine pediatricians, nine family medicine physicians, nine internal medicine physicians, five NPs, and five PAs.

Dr. Sanchez and colleagues used a screening questionnaire to recruit potential participants from a nationwide marketing database. Eligible participants spent at least half of their time with patients in a primary care setting and were older than 30 years. The authors excluded clinicians with a board certification outside of primary care or if they had practiced medicine for more than 30 years.

Before the interview, participants filled out a questionnaire that asked them to rank 12 factors on their influence on antibiotic selection, such as illness severity, patient demand, or practice guidelines. They then discussed their answers with trained interviewees during the recorded interviews.

To evaluate clinical decision-making, each participant received a specialty-appropriate clinical vignette about a patient who had a diagnosis of an acute bacterial infection. The participant was asked to explain why he or she chose an antibiotic and why other primary care providers might choose nonrecommended antibiotics.

The researchers found that participants had inconsistent definitions of broad- and narrow-spectrum antibiotics. "Although some participants correctly identified amoxicillin as a narrow-spectrum agent, and azithromycin as a broad-spectrum agent, many participants were uncertain of the spectrum of antimicrobial activity for these 2 widely used antibiotics."

In addition, clinicians often thought broad-spectrum antibiotics would be more successful in curing an infection, although those beliefs are unfounded, the authors say. That thinking may regularly lead to inappropriate selection and should be addressed, the authors note.

Clinicians, however, were more likely to choose narrow-spectrum drugs when the diagnosis was more certain or when they saw a patient's condition as relatively benign.

The interviews also uncovered a persistent theme that prescribers feel patients expect antibiotics and will lower their ratings on satisfaction surveys if they do not leave a visit with a prescription for them. In line with that thinking, respondents said that changing patient expectations would help take the pressure off prescribers.

When asked why information has not changed some physicians' prescribing behaviors, some respondents said that healthcare providers find it hard to break habits and continue to prescribe the way they always have, even if they have new information.

As to preferences on modes of receiving information about antibiotics, answers ranged from incorporating information in electronic health records, such as a prompt to flag a prescription when it falls outside of guidelines, to having a mobile telephone app available for guidelines or having a quick reference guide easily available for major diagnoses.

The authors conclude that complicating factors such as patient demand and longtime habits, rather than lack of knowledge concerning recommendations, are driving inappropriate antibiotic prescriptions.

"Future research efforts should be aimed at investigating effective incentives for appropriate antibiotic prescribing and determining alternative communication strategies to encourage use of first-line agents. Although most efforts have focused on reducing unnecessary antibiotic use, more research is needed to clarify which interventions improve antibiotic selection," they write.

The authors have disclosed no relevant financial relationships.

Emerging Infect Dis. Published online November 13, 2014. Full text

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