|Awareness of antibiotic resistance and antibiotic prescribing in UTI treatment: A qualitative study among primary care physicians in Sweden.|
|Jump to Full Text|
|PMID: 23281925 Owner: NLM Status: Publisher|
|Objectives. To improve education and information for general practitioners in relation to rational antibiotic prescribing for urinary tract infection (UTI), it is important to be aware of GPs' views of resistance and how it influences their choice of UTI treatment. The aim of this study was to explore variations in views of resistance and UTI treatment decisions among general practitioners (GPs) in a county in Sweden. Design. Qualitative, semi-structured interviews were analysed with a phenomenographic approach and content analysis. Setting. Primary care in Kronoberg, a county in southern Sweden. Subjects. A purposeful sample of 20 GPs from 15 of 25 health centres in the county. Main outcome measures. The variation of perceptions of antibiotic resistance in UTI treatment. How UTIs were treated according to the GPs. Results. Three different ways of viewing resistance in UTI treatment were identified. These were: (A) No problem, I have never seen resistance, (B) The problem is bigger somewhere else, and (C) The development of antibiotic resistance is serious and we must be careful. Moreover, GPs' perceptions of antibiotic resistance were mirrored in how they reported their treatment of UTIs in practice. Conclusion. There was a hierarchal scale of how GPs viewed resistance as an issue in UTI treatment. Only GPs who expressed concerns about resistance followed prescribing guidelines completely. This offers valuable insights into the planning and most likely the outcome of awareness or educational activities aimed at changed antibiotic prescribing behaviour.|
|Ingeborg Björkman; Johanna Berg; Nina Viberg; Cecilia Stålsby Lundborg|
Related Documents :
|24396265 - Clinical characteristics of turkish women with candida krusei vaginitis and antifungal ...
23430175 - Antibiotic resistance of ocular surface flora with repeated use of a topical antibiotic...
24553805 - In vitro antimalarial activity of tigecycline against plasmodium falciparum culture-ada...
18716225 - Evaluation of a multiplex pcr assay (bruce-ladder) for molecular typing of all brucella...
24173415 - Gene amplification in yeast: cup1 copy number regulates copper resistance.
11594615 - Natronobacterium nitratireducens sp. nov., a aloalkaliphilic archaeon isolated from a s...
|Type: JOURNAL ARTICLE Date: 2013-1-3|
|Title: Scandinavian journal of primary health care Volume: - ISSN: 1502-7724 ISO Abbreviation: Scand J Prim Health Care Publication Date: 2013 Jan|
|Created Date: 2013-1-3 Completed Date: - Revised Date: -|
Medline Journal Info:
|Nlm Unique ID: 8510679 Medline TA: Scand J Prim Health Care Country: -|
|Languages: ENG Pagination: - Citation Subset: -|
|Department of Public Health and Caring Sciences, Health Service Research, Uppsala University , Uppsala , Sweden.|
|APA/MLA Format Download EndNote Download BibTex|
Journal ID (nlm-ta): Scand J Prim Health Care
Journal ID (iso-abbrev): Scand J Prim Health Care
Journal ID (publisher-id): PRI
Publisher: Informa Healthcare, Stockholm
© 2013 Informa Healthcare
Received Day: 21 Month: 6 Year: 2011
Accepted Day: 12 Month: 9 Year: 2012
Print publication date: Month: 3 Year: 2013
Electronic publication date: Month: 3 Year: 2013
Volume: 31 Issue: 1
First Page: 50 Last Page: 55
PubMed Id: 23281925
Publisher Id: 751695
|Awareness of antibiotic resistance and antibiotic prescribing in UTI treatment: A qualitative study among primary care physicians in Sweden Alternate Title:Awareness of antibiotic resistance and antibiotic prescribing in UTI treatment Alternate Title:I. Björkman et al.|
|Ingeborg Björkman1||Email: firstname.lastname@example.org|
|Cecilia Stålsby Lundborg2|
1Department of Public Health and Caring Sciences, Health Service Research, Uppsala University, Uppsala, Sweden
2Department of Public Health Sciences, Division of Global Health (IHCAR), Karolinska Institutet, Stockholm, Sweden
|Correspondence: Correspondence: Ingeborg Björkman, Department of Public Health and Caring Sciences, Health Service Research, Uppsala University, Uppsala, Sweden. E-mail: email@example.com
Antibiotic resistance is increasingly challenging health care . Irrational use of antibiotics is considered to contribute unnecessarily to increasing the rate of resistance . Studies show that it is possible to decrease antibiotic prescribing [3,4]. However, more efforts are needed to implement changes [5–7]. In Swedish primary care uncomplicated urinary tract infection (UTI) is one of the most common diagnoses for which antibiotics are prescribed [8,9]. UTI treatment is usually empirical. In Sweden continual alternative use of first-line drugs is recommended for a duration of 3–5 days, and flouroquinolones are not recommended as first-line drugs, as they are needed in more complicated infections . Today the recommended first-line drugs are pivmecillinam and nitrofurantoin . When this study was conducted in 2004 trimethoprim and cephadroxil were also recommended as first-line drugs . Extended durations and unnecessary prescribing of flouroquinolones were reported for UTI treatment .
The most common pathogen involved in UTI is Escherichia coli. From 1983 to 2001 the level of E. coli resistance to trimethoprim among outpatients in Sweden increased from zero to 12% [12,13], and the level has continued to increase; it was 20.3% in 2009 . In 2004 most studies performed on UTI treatment were focusing on quantifiable aspects [8,10,11], and less was known of how resistance and its influence in the choice of UTI treatment were viewed by the prescribers. An opportunity to explore this issue was at hand along with the decision to reduce trimethoprim prescribing in a county in Sweden in 2004 . The aim of this study was thus to explore variation in views of resistance and UTI treatment decisions among GPs in the county.
Based on the aim of this study two qualitative research methods were chosen . These were the phenomenography approach to identify and describe different ways of understanding antibiotic resistance , and content analysis to capture views of UTI treatment decisions .
The study included 20 GPs in Kronoberg, a county in southern Sweden with a population of 178 000 inhabitants and about 80 GPs. Purposive sampling was used to achieve variations in age, sex, and geography. The GPs were contacted by one of the authors (JB) and asked to participate. Seven of the selected GPs initially declined and a sufficient number of subjects was reached after further contact with GPs fulfilling the inclusion criteria. The GPs (Table I) were working at 15 of 25 health centres, in six of eight municipalities in the county.
Data were collected by face-to-face interviews following a pre-tested, semi-structured interview guide (Table II), containing open-ended initial questions. Probing questions enabled the interviewer to follow up on the answers. The interviews were performed by one of the authors (JB) during October and November 2004, at the GP's workplace, at the Research and Development Centre in Växjö, or in the GPs’ homes. The interviews lasted 15–40 minutes, were tape-recorded, and were transcribed verbatim.
The phenomenographic analysis was first performed by two of the authors separately (JB and IB). The analysis followed a sequence of steps described by Alexandersson :
(1) becoming familiar with the data and gaining an overall impression;
(2) noting similarities and differences in the statements;
(3) determining descriptive categories of conceptions; and
(4) examining the underlying structure of the system of categorization.
The findings of the two analysts were compared and the final categories of description were established in a discussion between the analysts and the two last authors (NV and CSL), who were also familiar with the material.
During the additional content analysis , performed by JB and IB, statements concerning treatment of UTI were gathered and coded. Then the codes were summarized to make up a description of each GP's practice of UTI treatment. The relationships between described practices and identified perceptions were examined. This part of the analysis was discussed among the researchers and the final result was approved by all authors.
The study was approved by the Ethics Committee in Linköping (Dnr 03-04). Informed consent was obtained from all participants.
Three different, mutually exclusive ways of viewing resistance in UTI treatment were identified in the phenomenographic analysis. They were: (A) No problem, I have never seen resistance; (B) The problem is bigger somewhere else; and (C) The development of antibiotic resistance is serious and we must be careful. In Table III the three categories are described and complemented with illustrative quotations, chosen so as to reflect the view of resistance in each category. In general the physicians said that UTI was easy to diagnose and to manage.
In the content analysis, two elements of UTI treatment were examined. They included: (1) the choice of antibiotic and (2) the treatment duration. This part analysed the GPs’ thoughts about UTI treatment in practice and how their practice (according to themselves) correlated to the identified perceptions A–C.
The GPs mainly discussed issues concerning the recommendation to alternate among first-line drugs. Many of them thought that this should be applied in the treatment of a single patient to avoid recurrent infections due to resistance. Some GPs were critical and stated that every infection should be seen as a new infection and that a previously effective prescribed drug could be used again. Instead of alternating, a specific drug was commonly perceived as safe in most situations and hence used in a habitual manner. Lack of records, fear of side effects, patient demand, and costs were mentioned as reasons for the repeated use of a specific drug.
All GPs who expressed perception C reported that they practised continual alternative use of first-line drugs both in individual patients and in the population. These GPs said furthermore that they were careful in the use of flouroquinolones, whereas some of the GPs expressing perceptions A and B reported sporadic use of flouroquinolones as first-line drugs.
Many of the GPs expressed reluctance to follow recommendations for shorter treatment durations. A very few questioned the effectiveness, whereas others found it difficult to change their previous ways of thinking. All GPs who expressed perception C reported that they followed the guidelines and used shorter courses of antibiotics of 3–5 days.
Three separate views of resistance in relation to UTI treatment were identified. The views varied from (A) not seeing resistance as a problem at all in the treatment of UTI, to (B) explaining that the problem does not exist here but somewhere else, in other countries, big cities, or in hospitals, to (C) the notion that there is no real problem today but we must take this issue seriously and be careful.
Only GPs who expressed perception C said they practised UTI treatment according to the stated guidelines in all aspects (continual alternative use of first-line drugs, and short treatment duration).
GPs who expressed perceptions A or B also reported that they followed guidelines for UTI treatment but did not do so in all aspects. For instance, they said they practised the alternative use of drugs but only at the individual level and often for seven days. Or short treatment was used but without alternating, or alternating was used but with flouroquinolones as one of the drugs. Many of these GPs explained that they were aware of all recommendations and knew they must change their practice. However, there was also a common belief that the precautions taken were good enough.
The analysis of perceptions followed experience indicating that 20 participants are enough in an interview study aiming at exploring different ways of viewing a phenomenon [20–22]. To increase trustworthiness the analysis was first done separately by two of the authors, one with long experience of phenomenographic analysis (IB), and in a second step categories were established in a discussion between all of the authors.
A weakness of the results of the study is that the interviews were held in 2004 and the awareness of antibiotic resistance may have developed since then. However, the problem of antibiotic resistance is not less today; instead it is more timely than ever. New strategies in the promotion against antibiotic resistance are still needed. We believe our conclusions are relevant and valuable.
The second part of the analysis examined the GPs’ perception of resistance with the GPs’ reported decisions in the treatment of UTI. A weakness is that we have not studied how the GPs practise in real life. We only know this from what the GPs explained during the interviews. However, the questions were constructed to help the GP to think about a real patient situation and make the collected interview material as true as possible.
Deviations from recommended treatment have been reported, such as the use of second-line drugs and extended treatment durations [23,24]. Prescribing has been described as done in a habitual manner [3,23–25], based on the trust of broad-spectrum antibiotics as being more effective , and being influenced by the structure of the healthcare system . In primary care the patient–physician relationship seems to influence how antibiotics are prescribed [27,28]. However, in hospital care other factors aside from the relation to the patient were important when physicians decided how to manage infections .
Some studies explore whether physicians consider antibiotic resistance or not when infections are managed. GPs have reported concerns about antibiotic resistance but state that they must consider many factors in deciding whether or not to prescribe an antibiotic, and often patient issues are regarded as being more important than the issue of antibiotic resistance [30,31]. Physicians who stressed patient issues were less likely to use many resources (urine culture, microscopic urinalysis, follow-up visits and tests, and prolonged antibiotic treatment) and more likely to recommend treatment over the telephone . However, it has been demonstrated that symptoms of UTI are not conclusive for the diagnosis of uncomplicated UTI . In our study GPs were aware of antibiotic resistance but only a few said that this factor must be specifically considered in the treatment of UTI. The issue of antibiotic resistance may also be thought of as a national problem that does not concern the physician's own practice , a concept that was also seen among participants in our study. When the physicians considered antibiotic resistance as an important factor, they did follow recommended regimens more often, according to their own reports [28,29].
Our findings suggest a relationship between compliance with treatment guidelines for UTI and the perception that antibiotic resistance is a major problem. It seems that when the GP has not adopted this perception he or she is satisfied to follow parts of the recommendations and believe this is good enough. To successfully promote cautious antibiotic prescribing it is probably of importance that the GPs become fully aware of possible threats from developing resistance, with regard to both their own practice and long-term circumstances.
The findings in this study contribute to the understanding of physicians’ ways of thinking about antibiotic resistance and antibiotic prescribing. However, qualitative studies are used to develop hypotheses and our findings can preferably be verified in further studies with a quantitative design. Other factors likely to influence the GPs’ prescribing behaviour, such as patient demand or the GPs’ personalities, were not evaluated. Further research in this area is desirable in order to provide insights into the importance of views on resistance and the changes in prescribing behaviour.
The authors especially thank the GPs who shared their experiences in the interviews. Thanks are offered to Strama (the Swedish strategic programme against antibiotic resistance) and the county council of Kronoberg who supported the study.
Statement of financial support for the reported project
The study was financially supported by Strama and the county council of Kronoberg.
The Ethics Committee in Linköping approved the study (Dnr 03-04). Informed consent was obtained from all participants.
Declaration of interest
The authors report no conflict of interest. The authors alone are responsible for the content and writing of the paper.
|1..||WHO. World Health Day – 7 April 2011Antimicrobial resistance: No action today, no cure tomorrow Available at: http://www.who.int/world-health-day/2011/en/index.html(accessed 27 May 2011)..|
|2..||Cars O,Hogberg LD,Murray M,Nordberg O,Sivaraman S,Lundborg CS,et al. Meeting the challenge of antibiotic resistanceBMJYear: 2008337a143818801866|
|3..||Kuehlein T,Goetz K,Laux G,Gutscher A,Szecsenyi J,Joos S. Antibiotics in urinary-tract infections. Sustained change in prescribing habits by practice test and self-reflection: A mixed methods before–after studyBMJ Quality & SafetyYear: 2011205226|
|4..||Neumark T,Molstad S,Rosen C,Persson LG,Torngren A,Brudin L,et al. Evaluation of phenoxymethylpenicillin treatment of acute otitis media in children aged 2–16Scand J Prim Health CareYear: 2007251667117846935|
|5..||Arason VA,Sigurdsson JA. The problems of antibiotic overuseScand J Prim Health CareYear: 20102865620470017|
|6..||Gjelstad S,Dalen I,Lindbaek M. GPs’ antibiotic prescription patterns for respiratory tract infections: Still room for improvementScand J Prim Health CareYear: 2009272081519929185|
|7..||Neumark T,Brudin L,Engstrom S,Molstad S. Trends in number of consultations and antibiotic prescriptions for respiratory tract infections between 1999 and 2005 in primary healthcare in Kalmar County, Southern SwedenScand J Prim Health CareYear: 200927182419085427|
|8..||Lundborg CS,Olsson E,Molstad S,Swedish Study Group on Antibiotic U. Antibiotic prescribing in outpatients: A 1-week diagnosis-prescribing study in 5 counties in SwedenScand J Infect DisYear: 200234442812160172|
|9..||Swedish Medical Product AgencyNedre urinvägsinfektion (UVI) hos kvinnor – behandlingsrekommendationer [UTI in women – treatment guidelines]Information från LäkemedelsverketYear: 20072 Available at: http://www. lakemedelsverket.se/upload/halso-och-sjukvard/behandlingsrekommendationer/UVI_rek.pdf(accessed 27 May 2011)..|
|10..||Sandberg T,Jodal U,Nyman J. Urinvägsinfektioner [Urinary tract infections]. Läkemedelsboken [Drug therapy handbook]Year: 2003StockholmStockholm Apoteket AB38999|
|11..||Andre M,Molstad S,Lundborg CS,Odenholt I,Swedish Study Group on Antibiotic U. Management of urinary tract infections in primary care: A repeated 1-week diagnosis-prescribing study in five counties in Sweden in 2000 and 2002Scand J Infect DisYear: 200436134815061669|
|12..||Melander E,Petersson A. Resistensläge hos urinvägspatogener isolerade från patienter i öppen vård 1995–2001 [Resistance among urinary tract pathogens isolated from patients in primary care 1995–2001]MikrobiolognyttYear: 2001 [News in Microbiology; Dec 2001]. Available at: http://www.skane.se/upload/Webbplatser/Smittskydd/Dokument/2001(accessed 27 March 2011)..|
|13..||Referensmetodik för laboratoriediagnostik vid kliniskt bakteriologiska laboratorier. 1. Infektionsdiagnostik15. Urinvägsinfektioner/bakteriuri. 2:a upplagan 2000 [Methodology for laboratory diagnostics at clinical bacteriologic laboratories] Available at: http://www.referensmetodik.smi.se/w/Referensmetodik:_Urinv%C3%A4gsinfektioner/bakteriuri,_2:a_upplagan_2000(accessed 27 March 2011)..|
|14..||Strama.se. Antibiotikaresistens [Antibiotic resistance] Available at: http://www.strama.se/dyn//,37,80,70.html?dcid = 36 (accessed 28 March 2011)..|
|15..||Sundqvist M,Geli P,Andersson DI,Sjolund-Karlsson M,Runehagen A,Cars H,et al. Little evidence for reversibility of trimethoprim resistance after a drastic reduction in trimethoprim useJ Antimicrob ChemotherYear: 2010653506019900952|
|16..||Sandbaek A. Qualitative methods used for effect studies and evaluations of healthcare strategies?Scand J Prim Health CareYear: 200624131216923620|
|17..||Marton F,Booth S. Om lärande (also available in English: (1997) Learning and awareness Mahwah, NJ Erlbaum).Lund StudentlitteraturYear: 2000|
|18..||Graneheim UH,Lundman B. Qualitative content analysis in nursing research: Concepts, procedures and measures to achieve trustworthinessNurse Educ TodayYear: 2004241051214769454|
|19..||Alexandersson M. Metod och medvetande [Method and awareness]Year: 1994Dissertation, Acta Universitatis Gothoburgensis|
|20..||Stålsby Lundborg C,Wahlström R,Dall’Alba G. Ways of experiencing asthma management: Variations among general practitioners in SwedenScand J Prim Health CareYear: 1999172263110674300|
|21..||Larsson J,Holmström I,Rosenqvist U. Professional artist, good Samaritan, servant and co-ordinator: Four ways of understanding the anaesthetist's workActa Anaesthesiol ScandYear: 2003477879312859297|
|22..||Björkman IK,Bernsten CB,Schmidt IK,Holmström I. The role of drug and therapeutics committeesInt J Health Care Qual Assur Inc Leadersh Health ServYear: 2005182354816167640|
|23..||Hummers-Pradier E,Denig P,Oke T,Lagerlov P,Wahlstrom R,Haaijer-Ruskamp FM. GPs’ treatment of uncomplicated urinary tract infections: A clinical judgement analysis in four European countries. DEP group. Drug Education ProjectFam PractYear: 199916605710625136|
|24..||Denig P,Witteman CL,Schouten HW. Scope and nature of prescribing decisions made by general practitionersQual Saf Health CareYear: 2002111374312448805|
|25..||Christiaens T,De Backer D,Burgers J,Baerheim A. Guidelines, evidence, and cultural factorsScand J Prim Health CareYear: 200422141515370789|
|26..||Enriquez-Puga A,Baker R,Paul S,Villoro-Valdes R. Effect of educational outreach on general practice prescribing of antibiotics and antidepressants: A two-year randomised controlled trialScand J Prim Health CareYear: 20092719520119958063|
|27..||Petursson P. GPs’ reasons for “non-pharmacological” prescribing of antibiotics: A phenomenological studyScand J Prim Health CareYear: 200523120516036552|
|28..||Bjorkman I,Erntell M,Roing M,Lundborg CS. Infectious disease management in primary care: Perceptions of GPsBMC Fam PractYear: 201112121223592|
|29..||Bjorkman I,Berg J,Roing M,Erntell M,Lundborg CS. Perceptions among Swedish hospital physicians on prescribing of antibiotics and antibiotic resistanceQual Saf Health CareYear: 20101915|
|30..||Simpson SA,Wood F,Butler CC. General practitioners’ perceptions of antimicrobial resistance: A qualitative studyJ Antimicrob ChemotherYear: 200759292617110392|
|31..||Flach SD,Longenecker JC,Tape TG,Bryan TJ,Parenti C,Wigton RS. The relationship between treatment objectives and practice patterns in the management of urinary tract infectionsMedical decision making: An international journal of the Society for Medical Decision MakingYear: 200323131912693875|
|32..||Ferry SA,Holm SE,Stenlund H,Lundholm R,Monsen TJ. Clinical and bacteriological outcome of different doses and duration of pivmecillinam compared with placebo therapy of uncomplicated lower urinary tract infection in women: The LUTIW projectScand J Prim Health CareYear: 200725495717354160|
|33..||Giblin TB,Sinkowitz-Cochran RL,Harris PL,Jacobs S,Liberatore K,Palfreyman MA,et al. Clinicians’ perceptions of the problem of antimicrobial resistance in health care facilitiesArch Intern MedYear: 20041641662815302636|
Gender, age, and geographical distribution of the GPs interviewed.
|Area||Introductory questions||Probing questions|
|Introduction||Could you please think of a patient with uncomplicated urinary tract infection and describe this patient?||Typical patient?
Do you often meet patients like that?
What happens when patients like that comes to you? Symptoms? Diagnosis?
|Treatment||How did you decide on the treatment for this patient?||Symptoms/urine tests? Direct/delayed treatment? Patient attitudes?
Choice of drug?
How frequently do you use that drug?
Continual alternative use of first-line drugs?
|Effect of treatment||How do you usually experience the effect of the treatment?||Recurrent symptoms?
What happens if the symptoms return?
Have you seen treatment failure associated with resistance?
|Resistance||What are your thoughts on resistance in general?||Influence on daily work?
The microbiological laboratory?
Influence of antibiotic use? How can you curb the trend?
|Is there anything else you would like to say?|
The three identified perceptions.
|Category of description||Quotation|
|A. No problem, have never seen:
Resistance was not seen as a problem in the everyday treatment of UTI. The GPs thought that practical problems seldom appear or that they had not experienced treatment failures due to resistance. In this perception, an antibiotic resistance problem at the global level was not considered nor were future consequences.
|As for me, I prescribed for example trimethoprim to almost 90% of my patients, a trimethoprim preparation of short duration, five days. It is enough because it is effective…. No, I have never experienced that [patients cannot be treated by an antibiotic due to resistance]. This is not how it used to be. (Dr 9)|
|B. The problem is bigger somewhere else:
In this perception there was an awareness of the existence of the antibiotic resistance problem. However, this had no or minor impact on the GP's own practice. Some GPs said they must sometimes change antibiotics due to resistance but this was not really a problem. The notion was that the development in Sweden was less urgent than in other countries, or there was a feeling that great efforts are already being made to curb the trend. It was also expressed that maybe the resistance problem was worse in large cities in Sweden but not here in the countryside, or in hospital care but not here in primary care.
|The cases where they don't get well, that is resistance. But, then you have to switch drugs and you can usually do that. There are other drugs to choose. You seldom feel totally helpless…. As I see it in Sweden about the urinary tract infections, it doesn't feel like a big problem for me right now…. If the trimethoprim susceptibility or the resistance rises a bit, it still doesn't feel like a big problem. (Dr 14)|
|C. The development of AR is serious and we must be careful:
Also in this perception was the notion that the problem of antibiotic resistance was worse in other countries and in hospital care and management of UTI was generally not seen as a problem. However, the GPs in this category reflected in broader terms on future consequences and expressed concerns about the increasing resistance. It was said that doctors must take the resistance problem seriously and be careful in the prescribing of antibiotics in order to contain the development of antibiotic resistance.
|Even if you see resistance in vitro, in the test tube, it may still have been effective in vivo, in real life…. But it's worrying that resistance to certain drugs is increasing more and more…. It's also rather worrying that no new antibiotics are being developed … and so, so we have to be careful with the ones we have. (Dr 8)|
Keywords: Key Words: Antibiotics, bacterial resistance, general practice, general practitioners, interviews, urinary tract infection, Sweden, views.
Previous Document: Few differences in hot and cold executive functions in children and adolescents with combined and in...
Next Document: B-cell activating factor targeted therapy and lupus.