Clinicians’ Views and Experiences of Interventions to Enhance the Quality of Antibiotic Prescribing for Acute Respiratory Tract Infections

Journal Club

2 September 2015

Facilitated by Dr Malene Plejdrup Hansen

 

1.  Background

  • Excessive and inappropriate use of antibiotics is considered to be the most important cause of the increasing problems with resistant bacteria.
  • Various intervention strategies to reduce unnecessary antibiotic prescribing in general practice are available.
  • More information is needed about why and how interventions are effective or ineffective, and how GPs use the various interventions in their daily practice.
  • This paper1 was of interest as Professor Chris Del Mar and Dr Malene Plejdrup Hansen both are Chief Investigators on The General practitioners Antimicrobial Stewardship Programme Study (GAPS), which aims to improve the use of antibiotics for Acute Respiratory Infections in primary care in Australia by means of a multi-faceted intervention.

 2.  Paper presented

  • Sixty-six GPs from 6 countries (Belgium, England, Wales, Spain, The Netherlands and Poland) were interviewed. All GPs had taken part in the GRACE INTRO trial2 with a 2×2 factorial design, with GPs exposed to one, both, or neither of the two interventions.
  • A qualitative approach was used to explore general practice clinicians’ (GPs) views and experiences of training in communication skills and use of a patient booklet and/or a C-reactive protein (CRP) point of care test.
  • GPs from all countries attributed benefits for themselves and their patients to using both interventions:
  • The CRP test was viewed as a tool to decrease diagnostic uncertainty, to support non-prescription decisions, and to reassure patients.
  • The use of the patient booklet gave GPs greater confidence in addressing patient expectations for an antibiotic by providing answers to common questions and supporting GPs own explanations.

 3.  Discussion/Journal Club commentary

This study gives an excellent insight into GPs’ experiences of two contrasting interventions – training in communication skills (including use of a patient booklet) and the use of a point of care test (CRP).
We found it encouraging that the clinicians reported gaining new knowledge from the interventions. Information, such as expected duration of illness and the benefits and harms of antibiotic treatment of acute respiratory infections should preferably be part of any intervention aimed at either GPs or patients.
Both interventions achieved important reductions in antibiotic prescribing for acute respiratory infections – and combining the interventions was associated with an even greater reduction2. The group discussed if future interventions should be multi-faceted. Anthierens et al. found that the GPs reported that the two interventions were complementary and often used for different situations, i.e. the CRP test when there was uncertainty about the severity of the infection, and the communication skills/booklet when an explanation was required. However, it was mentioned that in some countries, such as Australia, the CRP test is still not used routinely as a point of care test in general practice.
The group found the information in the booklet very useful. However, the sections about “Helping your immune system fight infection” and “How you can care for your cough” were debated. E.g. a Cochrane Review on Echinacea products did not find any benefits for treating colds3 and also in the booklet it is stated that the advice on fluids, rest and stress is based on evidence about how the immune system works. Preferably, information used in interventions to enhance the quality of antibiotic prescribing for acute respiratory infections should be based on solid evidence about the group of patients being examined – i.e. in this case patients with acute respiratory infections. In addition, high quality, primary care-based studies are needed to further explore alternatives such as probiotics, zinc and vitamin C and to develop and test new non-antibiotic treatments.

4.  Reference(s)

  1. Anthierens S, Tonkin-Crine S, Cals JW, et al. Clinicians’ views and experiences of interventions to enhance the quality of antibiotic prescribing for acute respiratory tract infections. J Gen Intern Med 2015; 30(4): 408-16.
  2. Little P, Stuart B, Francis N, et al. Effects of internet-based training on antibiotic prescribing rates for acute respiratory-tract infections: a multinational, cluster, randomised, factorial, controlled trial. Lancet 2013; 382(9899): 1175-82.
  3. Karsch-Volk M, Barrett B, Kiefer D, Bauer R, Ardjomand-Woelkart K, Linde K. Echinacea for preventing and treating the common cold. The Cochrane database of systematic reviews 2014; 2: Cd000530.