Guidelines on uncomplicated urinary tract infections are difficult to follow: perceived barriers and suggested interventions

Contains fulltext : 88451.pdf (publisher's version ) (Open Access)BACKGROUND: Urinary tract infections (UTI) are among the most common health problems seen in general practice. Evidence-based guidelines on UTI are available, but adherence to these guidelines varies widely among practitioners for reasons not well understood. The aim of this study was to identify the barriers to the implementation of a guideline on UTI perceived by Dutch general practitioners (GPs) and to explore interventions to overcome these barriers. METHODS: A focus group study, including 13 GPs working in general practices in the Netherlands, was conducted. Key recommendations on diagnosis and treatment of uncomplicated UTI were selected from the guideline. Barriers to guideline adherence and possible interventions to address these barriers were discussed. The focus group session was audio-taped and transcribed verbatim. Barriers were classified according to an existing framework. RESULTS: Lack of agreement with the recommendations, unavailable and inconvenient materials (i.e. dipslides), and organisational constraints were perceived as barriers for the diagnostic recommendations. Barriers to implementing the treatment recommendations were lack of applicability and organisational constraints related to the availability of drugs in pharmacies. Suggested interventions were to provide small group education to GPs and practice staff members, to improve organisation and coordination of care in out of hour services, to improve the availability of preferred dosages of drugs, and to pilot-test guidelines regionally. CONCLUSIONS: Despite sufficient knowledge of the recommendations on UTI, attitudinal and external barriers made it difficult to follow them in practice. The care concerning UTI could be optimized if these barriers are adequately addressed in implementation strategies. The feasibility and success of these strategies could be improved by involving the target group of the guideline in selecting useful interventions to address the barriers to implementation

Outpatient antibiotic prescriptions from 1992 to 2001 in The Netherlands

Objectives: Although Dutch outpatient antibiotic prescription rates are low compared with other European countries, continuing to scrutinize trends in outpatient antibiotic use is important in order to identify possible increases in antibiotic use or inappropriate increases in the use of particular classes of antibiotics.Methods: We assessed the volume of Dutch outpatient antibiotic prescriptions from 1992 to 2001 by calculating the mean number of outpatient antibiotic prescriptions (indicating the number of times physicians decide to prescribe an antibiotic agent) per 1000 patients insured by the Dutch Sickness Fund per year, according to subgroups (narrow-spectrum penicillins, broad-spectrum penicillins, tetracyclines, macrolides, sulphonamides and trimethoprim, and quinolones). Data were obtained from the Dutch Drug Information Project/Health Care Insurance Board.Results: The total volume of outpatient antibiotic prescriptions in 2001 was 394 prescriptions per 1000 patients insured by the Dutch Sickness Fund. Overall, the rates were stable between 1992 and 2001, with small variations across years, but with marked differences in volumes within antibiotic groups across these years: a decrease in prescribing of narrow-spectrum penicillins (-29%), amoxicillin (-23%), tetracycline (-24%), doxycycline (-19%) and trimethoprim and derivatives (-45%) was accompanied by an increase in prescribing of co-amoxiclav (+85%), macrolides (+110%) and quinolones (+86%).Conclusions: The international trend of a decline in the use of narrow-spectrum and older penicillins and prescribing more broad-spectrum and new chemotherapeutics was shown to exist in a low prescribing country, The Netherlands. Therefore, inappropriate antibiotic prescribing should remain prominent on the research agenda in intervention studies in order to improve the appropriate selection of antibiotic class and to reduce the prescription of antibiotics.</p

Primary care based randomised, double blind trial of amoxicillin versus placebo for acute otitis media in children aged under 2 years

Objective To determine the effect of antibiotic treatment for acute otitis media in children between 6 months and 2 years of age. Design Practice based, double blind, randomised, placebo controlled trial. Setting 53 general practices in the Netherlands. Subjects 240 children aged 6 months to 2 years with the diagnosis of acute otitis media. Intervention Amoxicillin 40 mg/kg/day in three doses. Main outcome measures Persistent symptoms at day four and duration of fever and pain or crying, or both. Otoscopy at days four and 11, tympanometry at six weeks, and use of analgesic. Results Persistent symptoms at day four were less common in the amoxicillin group (risk difference 13%; 95% confidence interval 1% to 25%). The median duration of fever was two days in the amoxicillin group versus three in die placebo group (P = 0.004). No significant difference was observed in duration of pain or crying, but analgesic consumption was higher in the placebo group during the first 10 days (4.1 v 2.3 doses, P = 0.004). In addition, no otoscopic differences were observed at days four and 11, and tympanometric findings at six weeks were similar in both groups. Conclusions Seven to eight children aged 6 to 24 months with acute otitis media needed to be treated with antibiotics to improve symptomatic outcome at day four in one child. This modest effect does not justify prescription of antibiotics at the first visit, provided close surveillance can be guaranteed