Misprescription of antibiotics in primary care: a critical systematic review of its determinants

Background Antibiotic resistance is one of the principal public health problems worldwide. Currently, inappropriate use of antibiotics is regarded as the principal determinant of resistance, with most of these drugs being prescribed outside a hospital setting. This systematic review sought to identify the factors, attitudes and knowledge linked to misprescription of antibiotics. Methods A systematic review was conducted using the MEDLINE-PubMed and EMBASE databases. The selection criteria required that papers: (1) be published in English or Spanish; (2) designate their objective as that of addressing attitudes/ knowledge or other factors related with the prescribing of antibiotics; and (3) use quality and/or quantity indicators to define misprescription. The following were excluded: any paper that used qualitative methodology and any paper that included descriptive analysis only. Results A total of 46 papers that met the inclusion criteria were included in the review. They were very heterogeneous and displayed major methodological limitations. Doctors’ socio-demographic and personal factors did not appear to exert much influence. Complacency (fulfilling what professionals perceived as being patients’/parents’ expectations) and, to a lesser extent, fear (fear of possible complications in the patient) were the attitudes associated with misprescription of antibiotics. Conclusions Before designing interventions aimed at improving the prescription and use of antibiotics, studies are needed to identify precisely which factors influence prescribing

Knowledge, perceptions, and perspectives of medical students regarding the use of antibiotics and antibiotic resistance: a qualitative research in Galicia, Spain

Antibiotic resistance is a significant public health concern, with numerous studies linking antibiotic consumption to the development of resistance. As medical students will play a pivotal role in prescribing antibiotics, this research aimed to identify their perceptions of current use and factors that could influence future inappropriate use of antibiotics. The study employed a qualitative research approach using Focus Group discussions (FGs) consisting of students from the final theoretical course of the Medicine degree. The FGs were conducted based on a pre-script developed from factors contributing to antibiotic misuse identified in previous studies. All sessions were recorded and transcribed for analysis by two independent researchers, with all participants signing informed consent. Seven focus groups were conducted, with a total of 35 participants. The study identified factors that could influence the future prescription of antibiotics, including the low applicability of knowledge, insecurity, clinical inertia, difficulties in the doctor-patient relationship, unawareness of available updates on the topic, and inability to assess their validity. The students did not perceive antibiotic resistance as a current problem. However, the study found several modifiable factors in medical students that could explain the misuse of antibiotics, and developing specific strategies could help improve their useThis research was supported in part by the Instituto de Salud Carlos III (ISCIII) (PI081239, PI09/90609) Spanish State Plan for Scientific and Technical Research and Innovation and co-funded by The European Union (ERDF)S

Attitudes of primary care physicians to the prescribing of antibiotics and antimicrobial resistance: a qualitative study from Spain.

BACKGROUND AND OBJECTIVE: Resistance to antibiotics is a public health threat. A number of studies confirm the relationship between antibiotic use and the resistance rate. As a whole, physicians represent a large proportion of the health professionals involved in the use of this therapeutic group. Our study therefore sought to ascertain the opinions and attitudes of GPs in Spain with respect to antibiotics and resistance. METHODS: We used the focus group (FG) method, with each group comprising 4-12 primary care physicians and a moderator. Based on a previous systematic review, we drew up an agenda to be followed during the holding of the sessions. Group proceedings were recorded and the transcriptions then analysed separately by two researchers. RESULTS: Five FGs were formed, including a total of 33 physicians. The factors/attitudes that influenced the prescribing of antibiotics by GPs were fear, complacency, insufficient knowledge and external responsibility of the pharmaceutical industry, patients and over-the-counter antibiotics. The groups felt that antibiotic resistance was not a problem at a community level. CONCLUSIONS: Identification of attitudes/knowledge related with inappropriate antibiotic prescribing will enable specific interventions to be designed, with the aim of targeting these shortcomings to improve antibiotic use and help reduce resistance

Knowledge, attitudes, perceptions and habits towards antibiotics dispensed without medical prescription: a qualitative study of Spanish pharmacists

Objective To investigate community pharmacists’ knowledge, attitudes, perceptions and habits with regard to antibiotic dispensing without medical prescription in Spain. Methods A qualitative research using focus group method (FG) in Galicia (north-west Spain). FG sessions were conducted in the presence of a moderator. A topic script was developed to lead the discussions, which were audiorecorded to facilitate data interpretation and transcription. Proceedings were transcribed by an independent researcher and interpreted by two researchers working independently. We used the Grounded Theory approach. Setting Community pharmacies in Galicia, region Norwest of Spain. Participants Thirty pharmacists agreed to participate in the study, and a total of five FG sessions were conducted with 2–11 pharmacists. We sought to ensure a high degree of heterogeneity in the composition of the groups to improve our study's external validity. Pharmacists’ participation had no gender or age restrictions, and an effort was made to form FGs with pharmacists who were both owners and non-owners, provided in all cases that they were Official Colleges of Pharmacists-registered community pharmacists. For the purpose of conducting FG discussions, the basic methodological principle of allowing groups to attain their ‘own structural identity’ was applied. Main outcome measurements Community pharmacists’ habits and knowledge with regard to antibiotics and identification of the attitudes and/or factors that influence antibiotic dispensing without medical prescription. Results Pharmacists attributed the problem of antibiotics dispensed without medical prescription and its relationship to antibiotic resistance to the following attitudes: external responsibility (doctors, dentists and the National Health Service (NHS)); acquiescence; indifference and lack of continuing education. Conclusions Despite being a problem, antibiotic dispensing without a medical prescription is still a common practice in community pharmacies in Galicia, Spain. This practice is attributed to acquiescence, indifference and lack of continuing education. The problem of resistance was ascribed to external responsibility, including that of patients, physicians, dentists and the NHS.S

Magnitude and determinants of antibiotic dispensing without prescription in Spain: a simulated patient study

OBJECTIVES: Excessive and inappropriate use of antibiotics increases antimicrobial resistance. The aim of this study was to determine the magnitude and determinants of antibiotic dispensing without prescription in Spain by the simulated patient technique. METHODS: A cross-sectional study was conducted with all the pharmacies in a region of north-west Spain (n = 977), between December 2016 and January 2017. Four actors visited the pharmacies simulating a respiratory infection. Four incremental levels of pressure were used to obtain an antibiotic. The education and sex of the person who was dispensing and the area where the pharmacy was located were recorded. The effect of these independent variables on the dispensing of an antibiotic without prescription (1 = yes, 0 = no) was modelled by logistic regression. RESULTS: An antibiotic was obtained in 18.83% (95% CI = 16.5%-21.41%) of the visits. The area influenced the dispensing of antibiotics without a medical prescription, with a greater likelihood of dispensing in rural (OR = 1.79; 95% CI = 1.20-2.68) or semi-rural (OR = 1.66; 95% CI = 1.13-2.44) areas than in urban areas. No association was found with the sex or the training of the person who dispensed the antibiotic. In the pharmacies in urban areas, a lower level of pressure was needed to obtain the antibiotic. CONCLUSIONS: This study shows that one-fifth of the pharmacies still dispense antibiotics without prescription, especially under patient pressure. A rural setting has been identified as a risk factor for dispensing without prescription, so it must be taken into account for future interventions.Fondo de Investigación SanitariaInstituto de Salud Carlos II

Determinants of antibiotic dispensing without a medical prescription: a cross-sectional study in the north of Spain

Objectives: Antibiotic resistance is a major public health concern and is greatly exacerbated by inappropriate antibiotic use at a community level. The aim of this study was to ascertain which attitudes of community pharmacists were related to inappropriate antibiotic dispensing. Methods: We conducted a cross-sectional study of community pharmacists in a region situated in northern Spain (n = 393). Personal interviews were conducted using a self-administered questionnaire. The degree of agreement with each item of knowledge and attitude was measured using an unnumbered, horizontal visual analogue scale, with replies being scored from 0 (total disagreement) to 10 (total agreement). The data were analysed using logistic regression. Results: Of the total of 286 pharmacists (72.8%) who completed the questionnaire, 185 (64.7%) acknowledged having undertaken dispensing of antibiotics without a medical prescription (DAwMP). Attitudes such as patient complacency, external responsibility, indifference and insufficient knowledge were shown to be related to DAwMP. In contrast, no association was found with any of the pharmacists' personal or professional traits. Conclusions: This study confirms that, albeit unlawful, DAwMP is a common practice in Spanish pharmacies. DAwMP was seen to be usually associated with some of the attitudes evaluated.Fondo de Investigación Sanitari

Effect of Physicians' Attitudes and Knowledge on the Quality of Antibiotic Prescription: A Cohort Study

Resistance increases with the use and abuse of antibiotics. Since physicians are primarily responsible for the decision to use antibiotics, ascertaining the attitudes and knowledge that underlie their prescribing habits is thus a prerequisite for improving prescription. Three-year follow-up cohort study (2008-2010) targeting primary-care physicians (n = 2100) in Galicia, a region in NW Spain. We used data obtained from a postal survey to assess knowledge and attitudes. A physician was deemed to have demonstrated Appropriate Quality Prescription of Antibiotics (dependent variable) in any case where half or more of the indicators proposed by the European Surveillance of Antimicrobial Consumption had values that were better than the reference values for Spain. The mail-questionnaire response rate was 68·0% (1428/2100). The adjusted increase in the interquartile OR of displaying good prescribing of antibiotics for each attitude was: 205% for fear ("When in doubt, it is better to ensure that a patient is cured of an infection by using a broad-spectrum antibiotic"; 95%CI: 125% to 321%); 119% for better knowledge ("Amoxicillin is useful for resolving most respiratory infections in primary care"; 95%CI: 67% to 193%); and 21% for complacency with patients' demands ("Antibiotics are often prescribed due to patients' demands"; 95%CI: 0% to 45%). Due to the fact that physicians' knowledge and attitudes are potentially modifiable, the implementation of purpose-designed educational interventions based on the attitudes identified may well serve to improve antibiotic prescription

Impact of a multifaceted intervention to improve antibiotic prescribing: a pragmatic cluster-randomised controlled trial

Objectives: This study sought to assess the effectiveness and return on investment (ROI) of a multifaceted intervention aimed at improving antibiotic prescribing for acute respiratory infections in primary care. Design: Large-sized, two-arm, open-label, pragmatic, cluster-randomised controlled trial. Setting: All primary care physicians working for the Spanish National Health Service (NHS) in Galicia (region in north-west Spain). Participants: The seven spatial clusters were distributed by unequal randomisation (3:4) of the intervention and control groups. A total of 1217 physicians (1.30 million patients) were recruited from intervention clusters and 1393 physicians (1.46 million patients) from control clusters. Interventions: One-hour educational outreach visits tailored to training needs identified in a previous study; an online course integrated in practice accreditation; and a clinical decision support system. Main outcome measures: Changes in the ESAC (European Surveillance of Antimicrobial Consumption) quality indicators for outpatient antibiotic use. We used generalised linear mixed and conducted a ROI analysis to ascertain the overall cost savings. Results: Median follow-up was 19 months. The adjusted effect on overall antibiotic prescribing attributable to the intervention was − 4.2% (95% CI: − 5.3% to − 3.2%), with this being more pronounced for penicillins − 6.5 (95% CI: − 7.9% to − 5.2%) and for the ratio of consumption of broad- to narrow-spectrum penicillins, cephalosporins, and macrolides − 9.0% (95% CI: − 14.0 to − 4.1%). The cost of the intervention was €87 per physician. Direct savings per physician attributable to the reduction in antibiotic prescriptions was €311 for the NHS and €573 for patient contributions, with an ROI of €2.57 and €5.59 respectively. Conclusions: Interventions designed on the basis of gaps in physicians’ knowledge of and attitudes to misprescription can improve antibiotic prescribing and yield important direct cost savings. Trial registration: Current Controlled Trials ISRCTN24158380. Registered 5 February 2009. © 2020, The Author(s).This work was supported in part by the Instituto de Salud Carlos III (ISCII) (PI081239, PI09/90609, PI19/01006) Spanish State Plan for Scientific and Technical Research and Innovation 2012–2016 and 2017–2020, co-financed by The European Regional Development Fund (ERDF) and the Mutua Madrileña insurance company.publishe

25 anos de SIDA en Galicia. Novos retos para a Atención Primaria

Desde o ano 1981, no que se describíu o primeiro caso, ata os nosos días, pasaron 25 anos durante os cales se foi establecendo de forma progresiva esta epidemia. A infección polo virus de inmunodeficiencia humana (VIH) foise convertendo nun problema socio-sanitario de primeira orde e nunha das pandemias máis virulentas descritas.Desde el año 1981, en el que se describió el primer caso, hasta nuestros días, pasaron 25 años durante los cuales se fue estableciendo de forma progresiva esta epidemia. La infección por el virus de inmunodeficiencia humana (VIH) se convirtió en un problema socio-sanitario de primer orden y una de las pandemias más virulentas descritas

Seroprevalence of Toxoplasma gondii and Neospora caninum in goats from north-western Spain

Introduction and objective: Toxoplasma gondii and Neospora caninum are protozoans involved in reproductive failure especially in ruminant livestock. The objective was to estimate the seroprevalence of both parasites in goats from north-western Spain and to study the influence of some factors on seropositivity. Material and Methods: Blood samples from 638 goats were collected in 50 farms. Presence of T. gondii and N. caninum antibodies were detected by direct agglutination and competitive ELISA techniques, respectively. The risk factor analysis was performed using a mixed-effects logistic regression. Results: Individual (48%) and herd-level (74%) T. gondii seroprevalence values were high; the within-herd prevalence was 53%. In contrast, 6% of animals tested positive to N. caninum and 38% of the herds had at least one positive animal, with a true within-herd prevalence of 10%. Mixed infections were limited; 91% of N. caninum seropositive goats were also positive to T. gondii The risk factor analysis showed that T. gondii seroprevalence is influenced by the presence of sheep in the farm (OR=4.9) and the seropositivity to N. caninum (OR=16.5); goats from the Central-coastal area, more humid and warm, had a 15.7-fold probability of being seropositive to T. gondii than those from the Mountainous area. Cross-breed goats (OR=4.5) and the seropositivity to [i]T. gondii [/i](OR= 9.5) were factors associated with N. caninum seropositivity. Conclusions: The high T. gondii seroprevalence in goats constitute a noticeable zoonotic risk. The consideration of the risk factors identified in designing T. gondii and N. caninum control programs in goat herds should allow the implementation of more efficient measures, avoiding the appearance of outbreaks of reproductive disorders by both protozoans in goatsThe authors express their thank to OVICA (Galician Association of Ovine and Caprine Breeders), BOAGA (Galician Autochthonous Breed Federation) and the veterinarians of the ADSG ACIVO for their collaboration in this study. This work was supported by a Programme for consolidating and structuring competitive research groups (GRC2015/003, Xunta de Galicia) and by the Research Project ‘RUMIGAL: Rede de estudomultidisciplinar dos ruminantesen Galicia’ (R2014/005, REDES, Xunta de Galicia)S