Understanding the culture of prescribing: qualitative study of general practitioners’ and patients’ perceptions of antibiotics for sore throats

Objectives: To better understand reasons for antibiotics being prescribed for sore throats despite well known evidence that they are generally of little help. Design: Qualitative study with semi-structured interviews. Setting: General practices in South Wales. Subjects: 21 general practitioners and 17 of their patients who had recently consulted for a sore throat or upper respiratory tract infection. Main outcome measures: Subjects’ experience of management of the illness, patients’ expectations, beliefs about antibiotic treatment for sore throats, and ideas for reducing prescribing. Results: Doctors knew of the evidence for marginal effectiveness yet often prescribed for good relationships with patients. Possible patient benefit outweighed theoretical community risk from resistant bacteria. Most doctors found prescribing “against the evidence” uncomfortable and realised this probably increased workload. Explanations of the distinction between virus and bacterium often led to perceived confusion. Clinicians were divided on the value of leaflets and national campaigns, but several favoured patient empowerment for self care by other members of the primary care team. Patient expectations were seldom made explicit, and many were not met. A third of patients had a clear expectation for antibiotics, and mothers were more likely to accept non-antibiotic treatment for their children than for themselves. Satisfaction was not necessarily related to receiving antibiotics, with many seeking reassurance, further information, and pain relief. Conclusions: This prescribing decision is greatly influenced by considerations of the doctor-patient relationship. Consulting strategies that make patient expectations explicit without damaging relationships might reduce unwanted antibiotics. Repeating evidence for lack of effectiveness is unlikely to change doctors’ prescribing, but information about risk to individual patients might. Emphasising positive aspects of non-antibiotic treatment and lack of efficacy in general might be helpful.

Key messages

• Doctors know that antibiotics do not help most sore throat sufferers but try not to jeopardise relationships with patients over this issue
• Patients’ expectations are seldom explicit, and satisfaction is not necessarily related to receiving an antibiotic: information and reassurance are sometimes more important
• Consulting techniques that make expectations explicit, preserve relationships, and facilitate acceptable management are important
• Opportunities for empowering patients who are not acutely ill could be better used, and emphasising positive aspects of non-antibiotic treatment, especially in children, could be fruitful
• Risks to individuals from unnecessary antibiotics (rather than trial evidence for marginal benefit) should be emphasised

     

Protective effect of antibiotics against serious complications of common respiratory tract infections: retrospective cohort study with the UK General Practice Research Database

Objective To determine the extent to which antibiotics reduce the risk of serious complications after common respiratory tract infections.Design Retrospective cohort study.Setting UK primary care practices contributing to the general practice research database.Data source 3.36 million episodes of respiratory tract infection.Main outcome measures Risk of serious complications in treated and untreated patients in the month after diagnosis: mastoiditis after otitis media, quinsy after sore throat, and pneumonia after upper respiratory tract infection and chest infection. Number of patients needed to treat to prevent one complication.Results Serious complications were rare after upper respiratory tract infections, sore throat, and otitis media, and the number needed to treat was over 4000. The risk of pneumonia after chest infection was high, particularly in elderly people, and was substantially reduced by antibiotic use, with a number needed to treat of 39 for those aged ≥65 and 96-119 in younger age groups. Conclusion Antibiotics are not justified to reduce the risk of serious complications for upper respiratory tract infection, sore throat, or otitis media. Antibiotics substantially reduce the risk of pneumonia after chest infection, particularly in elderly people in whom the risk is highest.     

Sensitivity of beta-hemolytic streptococci to antibiotics]

Susceptibility of 64 beta-hemolytic streptococcal strains isolated from the patients with sore throat was studied by the method of serial dilutions in fluid nutrient medium (Konikov broth). Heterogenecity with respect to the sensitivity was investigated in 34 strains among separate populations of the microbes (10 to 15 in every strain). The MIC of benzylpenicillin, oxacillin and erythromycin ranged within 0.007--0.24 U/ml, 0.02--0.36 gamma/ml and 0.005--0.1 gamma/ml respectively. The MIC of benzylpenicillin with respect to separate populations most sensitive to it was 0.007--0.015 U/ml, while that with respect to the lease sensitive populations ranged from 0.015 to 0.24 U/ml. The respective values for oxacillin were 0.02--0.12 and 0.18--0.36 gamma/ml and those for erythromycin were 0.005--0.025 and 0.05--0.1 gamma/ml. Therefore, the beta-hemolytic streptococci isolated from the patients with sore throat were characterized by a rather high sensitivity to the antibiotics which was important precondition for their efficiency in treatment of the patients with the above disease.     

咽拭子快速培养在肺炎支原体感染中的临床应用价值

目的:探讨咽拭子快速培养在肺炎支原体感染中的临床应用价值。方法:收集2014年2月~2016年2月期间我院收治的呼吸道感染患儿220例,用肺炎支原体专用液体培养基进行肺炎支原体快速培养,用胶体金法检测肺炎支原体MP-Ig M。比较两种方法的阳性率。结果:咽拭子培养快速培养阳性率与血清MP-Ig M检测阳性率比较,差异无统计学意义(P0.05)。MP-Ig检测显示,≤1岁阳性率最低,其阳性率随年龄增加不断增高(P0.05)。肺炎支原体咽拭子培养显示,≤1岁阳性率最高,2~8岁最低(P0.05)。病程≤7 d患者肺炎支原体咽拭子培养阳性率(34.21%)显著高于肺炎支原体MP-Ig检测阳性率(14.04%)(P0.05)。病程7 d患者肺炎支原体咽拭子培养阳性率(11.32%)显著低于肺炎支原体MP-Ig检测阳性率(52.83%)(P0.05)。肺炎支原体咽拭子培养的灵敏度性以及特异性显著高于肺炎支原体MP-Ig检测,差异具有统计学意义(P0.05)。结论:咽拭子快速培养对肺炎支原体感染的早期诊断有一定临床应用价值,方法简单,无创伤,值得临床进一步研究和应用。     

大肠埃希菌泌尿系统感染患者临床分布及药物敏感性分析

摘要 目的：探讨大肠埃希菌引起泌尿系统感染患者的临床分布情况及其药物敏感性分析,为临床诊断及合理使用抗菌药物提供理论性依据。方法：选取2015年1月至2020年12月期间诊治的2052例大肠埃希菌泌尿系统感染患者为研究对象,使用MALDI-TOF MS全自动微生物鉴定质谱仪对细菌进行鉴定,应用VITEK 2 Compact全自动微生物鉴定及药敏分析仪进行药物敏感性分析。结果：2052例大肠埃希菌泌尿系统感染患者中泌尿外科患者占比最高,为17.50%,其次为肾病科患者,占12.87%。其中检出803株产ESBLs的大肠埃希菌,泌尿外科占比最高,为18.56%,其次是肾病科占13.95%,内分泌科占11.71%,重症医学科10.09%。2052株大肠埃希菌整体药敏分析结果显示,大肠埃希菌对美罗培南、亚胺培南、阿米卡星、哌拉西林/他唑巴坦、呋喃妥因、米诺环素、头孢西丁等药物敏感率高,均>90%,头孢唑啉、环丙沙星、左氧氟沙星、氨苄西林/舒巴坦、复方新诺明、氨苄西林敏感率低,均<50%,其中氨苄西林敏感率最低,只有28.17%。结论：大肠埃希菌泌尿系统感染主要发生在泌尿外科,产ESBLs大肠埃希菌整体检出率较高,临床应重视泌尿系统感染患者的尿细菌培养及药物敏感性分析,尽量避免仅凭经验性用药,根据药物敏感性结果合理选择抗菌药物。     

Treatment of streptococcal pharyngitis with amoxycillin once a day.

OBJECTIVE--To evaluate treatment of group A beta haemolytic streptococcal pharyngitis with amoxycillin once daily compared with phenoxymethylpenicillin three or four times a day. DESIGN--Randomised controlled study of consecutive patients presenting with symptoms suggestive of group A beta haemolytic streptococcal pharyngitis in whom culture of a throat swab yielded positive results. SETTING--Five family medicine practices. SUBJECTS--157 patients aged over 3 years who required treatment with antibiotics. MAIN OUTCOME MEASURES--Clinical response, bacteriological response, days at work and school lost, and compliance. RESULTS--During the period of the study 393 patients presented with symptoms suggesting streptococcal pharyngitis; 157 of them had throat swabs that yielded positive results on culture. Eighty two were treated with phenoxymethylpenicillin and 75 with amoxycillin. No difference was observed in the clinical response, days at work and school lost (139 days for 64 patients taking phenoxymethylpenicillin v 100 days for 57 patients taking amoxycillin; p > 0.2), or residual positive cultures after two days (6 (7.3%) v 3 (4%); p > 0.5). A significant difference in the bacteriological response was found after 14 days (5 (6.1%) v 0; p < 0.04) with no positive cultures observed in the amoxycillin group. CONCLUSIONS--These findings support the hypothesis that amoxycillin once daily is as effective as phenoxymethylpenicillin in the treatment of group A beta haemolytic streptococcal pharyngitis.     

Bacterial determinants of persistent throat colonization and the associated immune response in a primate model of human group A streptococcal pharyngeal infection

Group A streptococcal (GAS) pharyngitis and the subsequent bacterial colonization of the human throat elicit an immune response that may precipitate acute rheumatic fever in a susceptible host. To study the bacterial determinants that influence throat colonization and induction of humoral immunity, we characterized the behavior of GAS strains in a baboon model. An M-type 3 clinical isolate of GAS typical of strains that cause pharyngitis and invasive infection was recovered from the pharynx of six out of six baboons for at least 6 weeks after oral inoculation. By contrast, an isogenic mutant deficient in M protein failed to colonize most animals or was rapidly cleared. An isogenic mutant deficient in hyaluronic acid capsule colonized five out of six animals, but only persisted in the pharynx for 14–21 days. Colonized animals developed serum anti- streptolysin O (SLO) and anti-M protein immunoglobulin (Ig)G. The kinetics of the antibody responses were similar to those seen after human infection. Peak titres increased with the duration of throat carriage. Colonization with GAS prevented recurrent colonization after challenge with the homologous wild-type strain, but not after challenge with a strain of different M protein type. Early clearance of the M protein-deficient strain was associated with increased susceptibility of this strain to phagocytic killing in non-immune serum, whereas clearance of the acapsular strain was associated with increased susceptibility to phagocytic killing in the presence of specific antibody. These studies support critical and distinct effects of the GAS M protein and capsule on throat colonization and induction of humoral immunity in a model that reproduces important features of pharyngeal colonization and immune response following human infection.     

Public Beliefs on Antibiotics and Symptoms of Respiratory Tract Infections among Rural and Urban Population in Poland: A Questionnaire Study

Introduction

General public views and expectations around the use of antibiotics can influence general practitioners'' antibiotic prescribing decisions. We set out to describe the knowledge, attitudes and beliefs about the use of antibiotics for respiratory tract infections in adults in Poland, and explore differences according to where people live in an urban-rural continuum.

Material and Methods

Face to face survey among a stratified random sample of adults from the general population.

Results

1,210 adults completed the questionnaire (87% response rate); 44.3% were rural; 57.9% were women. 49.4% of rural respondents and 44.4% of urban respondents had used an antibiotic in the last 2 years. Rural participants were less likely to agree with the statement “usually I know when I need an antibiotic,” (53.5% vs. 61.3% respectively; p = 0.015) and reported that they would consult with a physician for a cough with yellow/green phlegm (69.2% vs. 74.9% respectively; p = 0.004), and were more likely to state that they would leave the decision about antibiotic prescribing to their doctor (87.5% vs. 85.6% respectively; p = 0.026). However, rural participants were more likely to believe that antibiotics accelerate recovery from sore throat (45.7% vs. 37.1% respectively; p = 0.017). Use of antibiotic in the last 2 years, level of education, number of children and awareness of the problem of developing antimicrobial resistance predicted accurate knowledge about antibiotic effectiveness.

Conclusions

There were no major differences in beliefs about antibiotics between urban and rural responders, although rural responders were slightly less confident in their knowledge about antibiotics and self-reported greater use of antibiotics. Despite differences in the level of education between rural and urban responders, there were no significant differences in their knowledge about antibiotic effectiveness.     

Ethically problematic treatment decisions: a physician survey

BACKGROUND: Experiencing ethical problems requires both ethically problematic situations and ethical sensitivity. Ethically problematic treatment decisions are distressing and might reflect health care quality problems. Whether all physicians actually experience ethical problems, what these problems are and how they vary according to physician age, gender and work sector are largely unknown. METHODS: A mail survey of all non-retired physicians licensed in Finland (n = 17,172, response rate 75.6%). RESULTS: The proportion of physicians reporting having made ethically problematic treatment decisions decreased in linear fashion from 60% at ages below 30 years to 21% at ages over 63 years. The only problem that did not decrease in frequency with age was having withdrawn necessary treatments. Women and primary care physicians reported problematic decisions most often, although gender differences were small. Primary care physicians most often reported having performed too many investigations or having pressured patients, whereas hospital physicians emphasized having withdrawn necessary treatments. Performing unnecessary treatments or investigations was explained by pressure from patients or relatives, and performing too few treatments or investigations was explained by inadequate resources. CONCLUSIONS: In general, young physicians felt pressured to do too much, whereas older physicians felt they could not do enough due to inadequate resources. Older physicians might be less exposed to ethically problematic situations, be more able to handle them or have lower ethical sensitivity. Young physicians could benefit from support in resisting pressure to perform unnecessary treatments, whereas older physicians might benefit from training in recognizing ethical issues.