JAC Advance Access originally published online on November 16, 2006
Journal of Antimicrobial Chemotherapy 2007 59(2):292-296; doi:10.1093/jac/dkl467
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General practitioners' perceptions of antimicrobial resistance: a qualitative study
Department of General Practice, Cardiff University 3rd Floor Neuadd Merionnydd, Heath Park, Cardiff CF14 4XN, UK
*Corresponding author. Tel: +44-29-20687181; Fax: +44-29-20687129; E-mail: simpsonsa{at}cf.ac.uk
Received 27 June 2006; returned 3 September 2006; revised 10 October 2006; accepted 20 October 2006
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Abstract |
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Objectives: Interventions aimed at enhancing the quality of antibiotic prescribing often highlight the threat of antimicrobial resistance. Although most antibiotics are prescribed by general practitioners (GPs), little is known of their perceptions of this issue. The aim of this study was therefore to achieve a deeper understanding of GPs' perceptions of antimicrobial resistance.
Methods: A qualitative interview, grounded theory study. Forty GPs were interviewed, 26 from high fluoroquinolone prescribing practices and 14 from average fluoroquinolone prescribing practices.
Results: Most GPs were concerned about the broad issue of antimicrobial resistance and agreed that it was a growing problem. However, many said they infrequently encountered its consequences in their everyday practice and some questioned the evidence linking their prescribing decisions to resistance and poorer outcomes for their patients. They felt conflicted by their apparent inability to influence the problem in the face of many other competing demands. A number said they would welcome more information from their microbiological colleagues about resistance patterns locally, and felt that undergraduate and graduate education about antimicrobial prescribing and resistance should be enhanced. However, a few mentioned that a heightened awareness of antimicrobial resistance locally may cause them to prescribe more second line agents as empirical therapy.
Conclusions: Antimicrobial resistance is only one of a range of important influences on GPs decisions whether or not to prescribe an antibiotic and is not the most immediate. These influences all need to be taken into account when promoting a more cautious use of antibiotics in primary care. More information from microbiologist colleagues about local resistance would be clinically useful, but on its own, may paradoxically influence some GPs to prescribe newer, broader spectrum agents more often.
Keywords: grounded theory , primary care , decision making
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Introduction |
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Antimicrobial resistance has been identified as a high priority nationally and internationally. The WHO strategy to contain antimicrobial resistance and the UK Department of Health Antimicrobial Resistance Strategy and Action Plan call for prudent antimicrobial use, professional education and patient empowerment.1,2 Inappropriate prescribing wastes money, exposes people to unnecessary side effects, encourages future consulting and drives antimicrobial resistance.3,4 About 85–90% of all antibiotics are prescribed in primary care with
50% of these of questionable value.5 Changing antibiotic prescribing has been associated with reduced levels of antimicrobial resistance.6 Previous qualitative studies have identified a number of factors influencing general medical practitioners' (GPs) decision to prescribe antibiotics, including patient pressure,7 a desire to preserve the doctor–patient relationship, the doctor's personal characteristics,8,9 uncertainty about which patients will benefit from antibiotics, a tension between the need to respond to external pressures (policy and research) and the daily pressures of clinical general practice,10 the patient's presenting complaints, and findings on physical examination.11 While studies in primary care have considered clinicians' perceptions of antimicrobial resistance this was not their main focus.9,10
As containing antimicrobial resistance is the rationale given for many interventions aimed at GPs to enhance their antimicrobial prescribing, we set out to explore in depth GPs' views regarding antimicrobial resistance, and locate their perceptions in the context of other influences on their decision whether or not to prescribe an antibiotic.
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Methods |
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We used qualitative research methods because these are the most appropriate for identifying and exploring the perspectives of the respondents themselves, rather than quantifying the researcher's preconceptions. Qualitative methods do not seek to generate statistically representative data; rather the goal is to generate important themes from a range of relevant respondents. Our research methods were based on a grounded theory approach.12 This involved a cyclical process of collecting data, analysing it and developing a provisional coding scheme. Early analysis then suggests further data collection and analysis. The method of ‘constant comparison’ was central to this process; the notion being that interpretation of data moves forward through comparing codes (themes) and cases.
Subjects
This analysis was completed as part of a larger study examining GPs choice of antibiotic. We interviewed a ‘purposive sample’ of clinicians from practices that were high prescribers of fluoroquinolones, and also a ‘theoretical sample’ of clinicians from practices that prescribed fluoroquinolones close to the Welsh mean.12 Since GPs are generally advised to use fluoroquinolone antibiotics as second line in order to contain the development of resistance,13 we hypothesized that views about resistance would differ among high and average levels of fluoroquinolone prescribing, and so considered these appropriate samples from which to gain a broad range of views from GPs on antibiotic resistance. Data on fluoroquinolone dispensing at the level of general practice was obtained from the Prescribing Audit Reports and Prescribing Catalogues (PARC) data (7 quarters 2002–2003), which are routinely collected data on all prescriptions dispensed in Wales. This was used to identify suitable practices for the purposive and theoretical sample. Analysis of data concerning the choice of antibiotic will be reported elsewhere.
Data collection and analysis
FW and SS, both social scientists, conducted semi-structured interviews with GPs at their practices. An interview guide was used and interviewing was ‘iterative’: as new, interesting themes emerged from the interviews, these were further explored in subsequent interviews. The interview guide was piloted with three GPs (not included in this analysis) and consisted of open questions designed to encourage GPs to freely discuss issues around antibiotic prescribing, including factors influencing prescribing and choice of antibiotic, and perception of the problem of antimicrobial resistance. Written consent was obtained prior to interview. We stressed that the goal was to understand relevant issues from the point of view of practitioners, not to pass judgements. In line with the grounded theory approach, data collection stopped when themes had become saturated and no new themes emerged.12
All interviews were audio taped and transcribed. However, the recording device failed during two interviews and two GPs did not wish to be recorded. The interviewer made additional, detailed field notes in these cases. The interviews were anonymized on transcription. Standard thematic analysis techniques were used, where transcripts are closely examined to identify themes and categories. Codes were applied to the broad themes which were then broken down further into sub-themes. This process was facilitated by NUD*IST software. Agreement on themes and sub-themes, and coding was sought between members of the research team, and a sample of 20% of the transcripts were coded by both FW and SS. Inconsistencies were discussed and resolved by the research team.
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Results |
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We approached 32 practices and none of the GPs were able to agree to an interview in nine of these. Our sample consisted of 26 GPs from high fluoroquinolone prescribing practices and 14 GPs whose practices prescribed fluoroquinolones close to the Welsh mean. We interviewed all the GPs from six of the practices and more than half from 11 practices. The interviews lasted between 25 min and 2.5 h. The GPs who were interviewed had between 1 and 7 partners, had been in practice for between 1 and 35 years, and eight had qualified abroad. Fifteen worked in practices which had Townsend scores indicating they served deprived populations, 11 were from practices in average areas and 14 were from practices which had Townsend scores suggesting they served affluent populations (Table 1).
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Antimicrobial resistance: awareness and concern
Around a third of participants felt that antimicrobial resistance is an important issue relevant to their practice at the moment, and interestingly, these were mainly from the high fluoroquinolone prescribing practices. Some indicated they chose these agents to minimize treatment failure associated with resistance, but overall, it was a minority of respondents that reported their prescribing decisions had been influenced by concerns about antimicrobial resistance. Twenty-nine GPs explicitly indicated that they were aware that prescribing antibiotics inappropriately increased levels of antimicrobial resistance. The GPs most concerned about antimicrobial resistance often had lengthy clinical experience in hospitals, or worked in areas with high numbers of COPD patients, older people, or served nursing homes or continuing care wards. Certain patient groups were perceived to be more likely to be affected by antimicrobial resistance and GPs suggested that this was due to previous prescribing for that individual patient.
"My perception of it is resistance does affect those people who are a lot sicker, more immunosuppressed and who have had possibly a whole load of antibiotics shoved at them." (GP33, average prescribing practice)
However, more than half of the GPs did not perceive antimicrobial resistance as a problem within their practice, since the infections they managed were generally susceptible to first line antibiotics, and they rarely experienced treatment failure with these agents. In addition, requesting analysis of microbiological samples was not feasible for most patients with infections. However, they generally agreed that antimicrobial resistance was increasing in urinary tract infections (UTIs). Six GPs felt there was a lack of evidence linking their own prescribing behaviour to resistance. A few GPs suggested that resistance may become a problem at some point, but was not a major current concern.
"I don't feel resistance is a huge problem. No, I mean I'm aware of it, that it's probably a developing problem, but in terms of affecting our own clinical practice ... I don't find it a huge problem and I don't worry about it." (GP35, average prescribing practice)
"If somebody was to prove to me that their (antibiotics) use is a major factor in antibiotic resistance then yes, but I'd want to see that evidence first." (GP26, high prescribing practice)
Others regarded antimicrobial resistance as a hospital problem, and observed that this was also the perception of most of their patients.
Antimicrobial resistance: responding to resistance
GPs said they were aware of antimicrobial resistance, but just over a quarter felt they were limited in what they as individuals could do about the problem. They had to strike a balance between their main immediate duty to their patient, cost, patient pressure, legal issues and public health considerations. Some GPs felt frustrated by attempting to manage the contradictory pressures of prescribing appropriately on the one hand and pressures of ‘coal face’ clinical practice on the other.
"The choice of whether you prescribe an antibiotic ... is more complicated than the issue of just the likely microbe and the probability of an antibiotic working for that, or you know, causing problems with community resistance in the future. I think that the issue of community resistance is probably, you know, tenth out of ten of issues that come into whether you prescribe an agent or not. I think that you know, safety from the point of view of not wishing to miss an infection that may get very much worse is pretty high up there and so the effectiveness of the antibiotic, the tolerability, you know, satisfying patients and things like that." (GP14, high prescribing practice)
GPs felt that the consequences of not prescribing antibiotics, especially in situations where patients might go on to develop more serious problems worried them more than the theoretical, ‘downstream’ complication of antimicrobial resistance.
"If you have given antibiotics, and if they developed pneumonia later, still you know that you started treating and that time it was just a chest infection. So you can protect yourself. Everybody is playing more of the safe medicine." (GP1, high prescribing practice)
Antimicrobial resistance: education
A number of GPs, in particular those from average fluoroquinolone prescribing practices, felt frustrated that they did not receive sufficient information about antimicrobial resistance in their communities. They suggested that regular updates from their microbiological colleagues about antimicrobial resistance, as it applied to their practice population, would enable them to make more-informed decisions about the most appropriate drugs to prescribe for individual patients. A few GPs suggested that their knowledge on microbiology and antibiotic prescribing in general needed updating and that targeted education was required. GPs reflected that young doctors should be given more education during their training regarding resistance and appropriate prescribing. They felt this was a crucial time period in which to emphasize the importance of these issues, because once the doctors are qualified it is difficult to change entrenched behaviours.
"I'd like once in a while to have some kind of feedback saying what resistance is like ... When we've spoken to the laboratories they say oh well it's not that easy to give you information. You know, if they said ‘look at the last 100 MSUs we received 9% of the bugs were sensitive to x or y’ that would give us a better suggestion as to what we should be using ... Now whether that's technically difficult or it just doesn't work like that I don't know, but we don't seem to be getting that information, which is I think is a frustration to us and doesn't give us you know an idea of what the picture is in the community." (GP20, high prescribing practice)
Antimicrobial resistance: knowledge of resistance locally and choice of empirical antibiotics
Some GPs said that they were more likely to prescribe broad spectrum antibiotics if they perceived there might be a problem with antimicrobial resistance.
"Unless you know you've got a patient who's got a history of you know resistance to first line treatments, then yes we would yes, but generally yes second line [quinolone] sure." (GP26, average prescribing practice)
"You will get drug resistance. I think personally in the general population, in my area I cannot stop at amoxicillin I have to give something else in the winter, when there is a flu epidemic." (GP3, high prescribing practice)
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Discussion |
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TopAbstractIntroductionMethodsResultsDiscussionConclusions and implicationsTransparency declarationsReferences |
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This is one of the first studies to conduct an in-depth exploration of GPs' views on antimicrobial resistance and locate these views in the context of their accounts of other influences on the decision whether or not to prescribe antibiotics. We have found that views about resistance vary widely between GPs, but that many GPs do not often knowingly experience resistance-associated problems in their practice, apart from perhaps in the management of UTIs. A number felt there was a lack of evidence linking their prescribing to the development of antimicrobial resistance and poor clinical outcomes for their patients. GPs felt conflicted by their apparent inability to influence antimicrobial resistance because of a variety of other factors including their immediate duty to do the best for the patient and concerns about complications from infections. Some GPs also felt that their clinical practice would be improved if they were provided with information on antimicrobial resistance levels in their practice communities. They also reflected that enhanced undergraduate and post graduate education on prescribing and resistance would be welcomed. However, several felt that it was appropriate to respond to increasing levels of antimicrobial resistance locally by increasing their prescribing of newer, broad spectrum agents.
A secondary care study in the United States found that although many doctors felt that resistance was a national problem, fewer felt that it was a problem for them locally and although they agreed that antibiotic prescribing was a major driver of resistance, they were not in favour of having their own prescribing choices restricted.14 These findings suggest that clinicians in a wide range of settings may respond to complex challenges in a comparable way. Family Physicians in the US have also described their antibiotic prescribing decisions as balancing acts.7
We used open questions and reassured GPs that the purpose of the interview was not to judge their prescribing, but to understand their decision-making processes. Since GPs were typically frank in describing their usual practice (including accounts of prescribing antibiotics over the telephone), we have confidence that they expressed their true feelings. In addition, GPs were not generally defensive about their practice.
The GPs that we spoke to would not all have prescribed these agents close to the practice mean, and fluoroquinolone prescribing in these practices may not have been congruent with their overall antibiotic prescribing. However, the practices served populations with a range of deprivation, and were a mix of urban, rural and city settings, thereby enhancing judgements of applicability. Our aim was not to generate statistically representative data, but rather to identify important themes from interviews with GPs who were likely to have a wide range of views on the subject.
The UK Antimicrobial Resistance Strategy and Action Plan15 emphasized the importance of education for professionals and greater coverage of appropriate antibiotic prescribing and resistance in undergraduate and postgraduate curricula and in continuing professional development. Topics covered in the new undergraduate curricula in UK medical schools relating to appropriate antimicrobial prescribing and antimicrobial resistance typically include properties of classes of antibiotics, mechanisms of action and adverse effects of different antimicrobial agents, mechanisms of resistance, indications for use of antibiotics, unwanted side effects of antibiotic treatment, contraindications to their use and antibiotic susceptibility testing. However, given the importance of the topic, the amount of time spent on these issues is relatively small. In addition, the emphasis of the teaching is often hospital rather than community based. Recent studies have indicated that doctors continue to prescribe antibiotics inappropriately and that education on this topic could be enhanced for both undergraduates and practising clinicians.16–18 This view was echoed by a number of the GPs in our study.
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Conclusions and implications |
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Microbiologists seem best placed to provide the information regarding local resistance patterns, but systems to collate these data and feed them back appropriately to GPs need to be put in place. Linking resistance data to GPs' own prescribing would be ideal. Microbiologists may also consider linking their reporting of sensitivities to their recommendations for antibiotic choice.
Many individual initiatives to reduce antibiotic prescribing have generated no effect or small effect sizes.19–21 Current guidelines on antibiotic prescribing for GPs highlight the importance of antibiotic prescribing to contain the problem of antimicrobial resistance. Some studies have shown that the use of guidelines on their own has limited effect on GP prescribing behaviour.22 Our study suggests that attempting to change GPs' antibiotic prescribing through focusing on containing antimicrobial resistance may indeed positively influence some prescribers. However, other GPs may paradoxically increase their use of broad spectrum agents with a heightened perception of rising levels of antimicrobial resistance. Interventions will therefore be enhanced if they take into account a range of other influences on the decision to prescribe antibiotics in primary care.
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Transparency declarations |
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None to declare.
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Acknowledgements |
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We would like to thank the GPs who participated in this study. Funding: research costs for this study were met by the Department of General Practice, Cardiff University. Contributions: all authors contributed to study design, data collection, analysis and report writing. CB conceived of the study and acts as guarantor. Ethical approval: South East Wales LREC confirmed that the study raised no ethical concerns and that a full ethical application was not required for this study.
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References |
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1 World Health Organization. (2001) WHO Strategy for Containment of Antimicrobial Resistance(WHO, Switzerland).
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Srinivasan A, Song X, Richards A, et al. (2004) A survey of knowledge, attitudes, and beliefs of house staff physicians from various specialties concerning antimicrobial use and resistance. Arch Intern Med 164:1451–6.
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