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Disease and treatment

Busy doctors prescribe more antibiotics

Avoiding a post-antibiotic era in which antibiotics become ineffective against common infections requires that doctors prescribe fewer antibiotics. New research shows that using too few or too many diagnostic tests and being busy are the main reasons why doctors prescribe extra antibiotics. The researchers believe that patients should be better informed about the risks of taking antibiotics.

It is well known that using antibiotics is the major cause of the ever-increasing challenges of multidrug-resistant bacteria. In Denmark, about 90% of antibiotics are prescribed in primary care – 75% in general practice.

New Danish research focused on the reasons for the variation in antibiotic prescribing between general practices in Denmark. The study revealed that general practitioners with many consultations prescribed more antibiotics than those with fewer consultations.

“Busy doctors may feel that writing a prescription is easier than explaining to patients why they will not benefit from antibiotics,” explains one of the study’s driving forces, doctor and senior research fellow Malene Plejdrup Hansen, Research Unit for General Practice, Aalborg University and Section for General Practice, Department of Public Health, University of Copenhagen.

The study was based on figures from 98% of the general practices in Denmark and therefore provides a very precise picture of the current situation. Even after considering patient factors such as age, sex and chronic diseases, the study revealed substantial variation in the antibiotics prescribed by practices. The 10% highest prescribers issued 644 prescriptions per 1000 patients per year versus 259 prescriptions 1000 patients per year for the 10% of the practices with the fewest antibiotic prescriptions.

“The top 10% prescribed many more antibiotics than average, but even more worrying was that this group prescribed four times as many of the critically important antibiotics. These antibiotics should be used as little as possible and reserved for treating infections among seriously ill people and infections caused by antibiotic-resistant bacteria,” says the study’s lead author, general practitioner Rune Aabenhus, Section for General Practice, Department of Public Health, University of Copenhagen.

Using too few or too many tests

In addition to being busy, the study also identified other factors associated with some general practices prescribing more antibiotics than others. General practices that did not have access to the C-reactive protein (CRP) test prescribed more antibiotics than those with access to this point-of-care test. The finding is in accordance with previous research demonstrating that using CRP testing can reduce antibiotic prescribing.

The researchers found the opposite for general practices that often used a strep A test, which detects whether a person is infected with group A streptococci, which can lead to a throat infection. Practices that used the test frequently prescribed more antibiotics. Although this may seem surprising, there is a good explanation.

“If all patients with a sore throat were to take a test, some patients who would not benefit from antibiotic treatment would be treated. In Denmark, we recommend that the test should only be used for people who are at greatest risk of having an infection with group A streptococci,” explains Rune Aabenhus.

Dialogue needed

In addition to causing the increasing problems of antibiotic-resistant bacteria at the community level, using antibiotics can also have major effects for individuals. 

“Studies show that people treated with antibiotics risk developing antibiotic-resistant bacteria. This poses a risk that the antibiotics will not work the next time they are needed,” says Malene Plejdrup Hansen.

Further, some people may experience adverse reactions such as rashes and diarrhoea. Malene Plejdrup Hansen thinks that doctors must inform patients about these risks and involve them in the doctor’s deliberations about achieving optimal treatment. 

“Outside Denmark, it has been demonstrated that general practitioners trained in communication skills, and specifically shared decision-making, prescribe significantly less antibiotics than those without training,” explains Malene Plejdrup Hansen.

Identifying practice-related factors for high-volume prescribers of antibiotics in Danish general practice” has been published in the Journal of Antimicrobial Chemotherapy. In 2013, the Novo Nordisk Foundation awarded a grant to Malene Plejdrup Hansen for the project Identifying Practice-related Factors for High-volume Prescribers of Antibiotics in Danish General Practice.

Malene Plejdrup Hansen
Postdoc
Malene Plejdrup Hansen is a medical doctor, who has worked both in general practice and at the Department of Clinical Microbiology. During the past nine years she has been working as a full-time researcher and in 2012 she completed her PhD entitled 'Quality Indicators for Diagnosis and Treatment of Acute Respiratory Tract Infections in General Practice' at the University of Southern Denmark. From 2007-2010 she took part of the EU-funded project Health Alliance for Prudent prescribing, Yield and Use of Antimicrobial Drugs (HAPPY AUDIT) which involved more than 600 GPs from six different countries. In July 2014 she moved to Australia to work with worldleading researchers in evidence-based practice and antibiotic use in primary care - Chris Del Mar and Paul Glasziou - at the Centre for Research in Evidence-Based Practice, Bond University. Malene's research interests include optimising GP's management of patients with acute respiratory tract infections in general practice, the evidence for benefits and harms of using antibiotics, and she is also interested in conducting primary reserach in primary care settings.