Medical Professionals

Some of the factors that may lead to suboptimal prescribing of antibiotics are listed in Table 2.1.

A major factor is imperfect knowledge of the prescriber. This lack of knowledge has to do with insufficient knowledge of infectious diseases, the potential causative microorganisms and their susceptibility to antimicrobials, and expertise on antimicrobial drugs. With regard to the latter, there is probably too little emphasis in most medical curricula on the relevance of prudent antibiotic prescribing. Imperfect knowledge of infectious diseases leads to insecurity about the diagnosis and difficulties of distinguishing in the clinic between bacterial and viral infections. Apparently, many physicians do not know (or ignore) that antibiotics do not influence the outcome in most cases of common infections such as otitis media, sinusitis, acute bronchitis, and chronic obstructive pulmonary disease.5-9 In a series of elegant studies Holmes et al. showed that antibiotics do not alter the natural course of "cough."10 Poor case definition also in the hospital setting will lead to indiscriminate use of antibiotics.11,12

Many doctors tend to take the route of certainty rather than the uncertain one. Many years ago, Dr. Calvin Kunin called antibiotics "drugs of fear."13

In discussions on whether antibiotics are indicated or not, the fear of complications if one refrains from prescribing an antibiotic is often put forward.14,15 Examples are the fear of development of mastoiditis if otitis media is not treated, of pneumonia if acute bronchitis is not treated. Fear of being sued for not prescribing an antibiotic is more common in the United States than in Europe.

Table 2.1. Professional factors that may lead to suboptimal prescribing

Imperfect knowledge

Diagnostic uncertainty

Fear of complications

Fear of disciplinary cases

Communicative aspects

Perceived patient expectations

Financial interests

In an interview study by MacFarlane et al.,16 it was found that doctors felt that probably some 20% of patients with bronchial infections needed antibiotics, but that nonclinical factors determined whether antibiotics were given. Antibiotics were prescribed more commonly to patients from deprived areas and female patients. Pressure exerted on doctors by patients or perceived expectations of patients are major factors that determine prescription. This is probably a global problem.15 Doctors who think that a patient expects an antibiotic will diagnose a bacterial infection more often and more frequently prescribe an antibiotic.17

Patients who expect an antibiotic are 3 times more likely to be prescribed an antibiotic than patients who do not18,19; if the doctor thinks that the patient wants an antibiotic, a prescription is given 7 to 10 times more often.

An interesting study by Mangione-Smith et al. demonstrates that physicians' perceptions of parental expectations for antibiotics increased when parents questioned the doctor's treatment plan.17 Grob has pointed out that a series of contextual factors may play a role in the process of prescribing.20

We should not forget that providing a prescription may also have a symbolic meaning: by marking the end of the consultation.

It is an important question whether we can change prescribing habits. It is generally perceived that clinical behavior is notoriously difficult to change and as noted in the introduction to this chapter, it may be even more difficult for antibiotics. Programs aiming at altering physicians' behavior have reached improvements in a very modest range (5-10%).21 Sbarbaro22 describes that changing physician behavior is viewed by many as "an exercise in futility—an unattainable goal intended only to produce premature aging in those seeking the change." He adds that the more optimistic view might describe the process as uniquely challenging.

From the literature it is clear that a multifaceted approach is needed to influence prescribing of doctors.21,23,24 Education of doctors, feedback about prescribing (with or without comparison to colleagues), financial incentives or sanctions, organizational and logistic measures, regulations, and other measures may have some effect if attuned to the problem.23 Welschen24 performed a systematic review of measures attempting to change antibiotic prescribing for bronchial infections in general practice. Eight studies qualified for that review because these evaluated all kinds of measures (group education, feedback, information for patients, and individual education for the practitioner). Most measures had a small effect (average 6%).

It is clear that traditional education has little if any effect. Greater effects are seen from computerized decision support, in which the computer feeds back messages about proper or improper antibiotic use.25 Another approach is that using outreach visitors, specially trained persons who support and inform practitioners on a one-to-one basis.26,27 Significant reductions in prescribing have been reported using this method. In a combined approach (patient education, feedback to doctors, and outreach visitors), a 35% reduction in prescription was detected.28 An interesting intervention is that in which patients receive a prescription with the explicit instruction only to collect and swallow the drug if they are convinced that they need it. Reductions of 25-54% have been found with these "delayed"

prescriptions.29,30

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