Antibiotic Overprescribing for RTIs: PCPs Need Strategies

Diana Swift

April 29, 2015

Almost half of antibiotic prescriptions by general practitioners for respiratory tract indications (RTIs) failed to comply with clinical guidelines, according to new research published online April 24 in Family Practice. The most dominant factor driving unnecessary antibiotic prescriptions was patient expectations, the investigators say.

The observational study is the first to quantify and qualify inappropriate prescribing in the primary care setting across the whole range of respiratory diseases, note Anne R.J. Dekker, MD, PhD, from the Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, the Netherlands, and colleagues.

They analyzed data from 2724 RTI consultations in 48 general practices during the winters of 2008 to 2010. Specially designed registration forms for physicians contained all relevant aspects of the evidence-based Dutch College of General Practitioners guidelines for acute otitis media, rhinosinusitis, acute sore throat, and acute cough. "Dutch prescribing recommendations are not based on specific diagnoses (except for pneumonia) but, rather, on combinations of signs and symptoms, patient characteristics, and disease severity," the authors write.

The cohort, which was 58% female, had a mean age of 34.4 years, with 33% (n = 900) younger than 18 years, 54% (n = 1471) aged 18 to 65 years, and 13% (n = 353) aged 65 years and older. General practitioners prescribed amoxicillin most often for children, and doxycycline for adults and the elderly. They prescribed macrolides and amoxicillin/clavulanate in 12% and 8% of all consultations, respectively. General practitioners prescribed fluoroquinolones more often for the elderly. In 2.5% of cases, patients were referred to secondary care, and in 7.9% they received further testing.

With an overall antibiotic prescribing rate of 38%, the researchers found that 46% of prescriptions were not indicated by the guidelines.

Analyzed separately for ear, throat, nose/sinus and lower RTIs, the data revealed that relative overprescription was highest in consultations for throat indications, and absolute overprescribing was highest for lower RTIs, including bronchitis. Overprescribing was highest for adults aged 18 to 65 years (54%) and lowest for children (32%). Overall, physicians wrote 90 inappropriate prescriptions for children, 73 for elderly patients, and 304 for nonelderly adults.

The following eight factors were associated with antibiotic overprescribing: patient expectations (odds ratio [OR], 5.8; 95% confidence interval [CI], 4.6 - 7.3; P < .001), fever (OR, 3.0; 95% CI, 2.4 - 3.8; P < .001), more severe illness (OR, 4.8; 95% CI, 3.6 - 6.3, P < .001), age younger than 18 years (OR, 2.3; 95% CI, 1.8 - 2.9; P < .001), symptoms lasting 7 or more days (OR, 1.6; 95% CI, 1.3 - 2.0; P < .001), comorbidity (OR, 1.7; 95% CI, 1.3 - 2.1; P < .001), reduced general health (OR, 1.3; 95% CI, 0.9 - 1.9; P = .182), and female sex (OR, 1.2; 95% CI, 1.0 - 1.5; P = .043). Underprescribing was observed in less than 4% of consultations in which no prescription was given.

Despite finding a high rate of unnecessary antibiotic prescriptions, the authors concede that the issue is not always black and white. "We emphasize that we do not regard all overprescription cases as wrong treatment decisions, as guidelines are not laws and [general practitioners] are not computers," Dr Dekker and colleagues write. "However, we feel that our data advocate that improvements in prescribing behaviour are urgently needed."

They add that general practitioners need to be aware of how certain patient groups, certain indications, and their own interpretations drive overprescribing. Acknowledging the difficulty of changing ingrained personal and cultural prescribing habits in the setting of satisfying patients, they recommend that physician improvement programs focus on teaching physicians the skills to explore patients' concerns and expectations while providing understandable arguments for not giving prescriptions.

This study was funded by The Netherlands Organization for Health Research and Development. The authors have disclosed no relevant financial relationships.

Fam Pract. Published online April 24, 2015. Abstract

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