Physician behaviour for antimicrobial prescribing for paediatric upper respiratory tract infections: a survey in general practice in Trinidad, West Indies

BACKGROUND: Upper respiratory tract infections (URTIs) are among the most frequent reasons for physician office visits in paediatrics. Despite their predominant viral aetiology, URTIs continue to be treated with antimicrobials. We explored general practitioners' (GPs) prescribing behaviour for antimicrobials in children (≤ 16 years) with URTIs in Trinidad, using the guidelines from the Centers for Disease Control and Prevention (CDC) as a reference. METHODS: A cross-sectional study was conducted on 92 consenting GPs from the 109 contacted in Central and East Trinidad, between January to June 2003. Using a pilot-tested questionnaire, GPs identified the 5 most frequent URTIs they see in office and reported on their antimicrobial prescribing practices for these URTIs to trained research students. RESULTS: The 5 most frequent URTIs presenting in children in general practice, are the common cold, pharyngitis, tonsillitis, sinusitis and acute otitis media (AOM) in rank order. GPs prescribe at least 25 different antibiotics for these URTIs with significant associations for amoxicillin, co-amoxiclav, cefaclor, cefuroxime, erythromycin, clarithromycin and azithromycin (p < 0.001). Amoxicillin alone or with clavulanate was the most frequently prescribed antibiotic for all URTIs. Prescribing variations from the CDC recommendations were observed for all URTIs except for AOM (50%), the most common condition for antibiotics. Doctors practicing for >30 years were more likely to prescribe antibiotics for the common cold (p = 0.014). Severity (95.7%) and duration of illness (82.5%) influenced doctors' prescribing and over prescribing in general practice was attributed to parent demands (75%) and concern for secondary bacterial infections (70%). Physicians do not request laboratory investigations primarily because they are unnecessary (86%) and the waiting time for results is too long (51%). CONCLUSIONS: Antibiotics are over prescribed for paediatric URTIs in Trinidad and amoxicillin with co-amoxiclav were preferentially prescribed. Except for AOM, GPs' prescribing varied from the CDC guidelines for drug and duration. Physicians recognise antibiotics are overused and consider parents expecting antibiotics and a concern for secondary bacterial infections are prescribing pressures. Guidelines to manage URTIs, ongoing surveillance programs for antibiotic resistance, public health education on non-antibiotic strategies, and postgraduate education for rational pharmacotherapy in general practice would decrease inappropriate antibiotic use in URTIs

Sick with sugar : the sociocultural dimensions of managing diabetes in a semi-urban Indian Trinidadian community

This dissertation comprises ethnographies and narratives of the ways in which Indian Trinidadians in Debe, Trinidad negotiated their life-worlds, life-course expectations, and ethnic identities around Type 2 diabetes mellitus with family, food, and religion as central themes. In overview, this research explores how Type 2 diabetes mellitus, popularly known as “sugar”, is constructed and responded to, as well as the impact of inequities in access to healthcare on people’s ability to manage this disease. Diabetes is the second most common cause of death in Trinidad and Tobago, and has highest estimated prevalence among Indian Trinidadians. Much of the discourse in Trinidad blames high local rates of Type 2 diabetes mellitus-associated mortality and morbidity on unhealthy patient practices and lifestyles. Through participant observation, interviews, and archival research, I explored normative biomedical notions of disease and untangled who is affected by a diabetes diagnosis, how they are affected, and what they do when their lives change, or to change their lives in this context. This research revealed some ways in which overly simplistic notions of patient autonomy projected upon complex, enmeshed societies and polities can be translated as ineffective recommendations for disease management, producing unintended and detrimental changes to people’s life-worlds. Understanding diabetes and its management in Debe required not only understanding the pathological or biological disease process, but more crucially, the explanatory models of people with this diagnosis, how they coped with associated illness, and the crucial communities of care that facilitated therapeutic efforts. Particularly important were narratives of persons with diagnosis of diabetes, and their caregivers. The case narratives produced are grounded in the ethnography of an economically heterogeneous community that has undergone many transitions in the recent past, including the rise in the rates of diabetes and resultant transformations of everyday socialities. These stories are therefore also inherently concerned with temporality on different scales: the progression of a disease over time, the changes in an individual life course over time, and the temporal shifts in a community as it moves from a shared, agricultural past to an uncertain and multitudinous future.Arts, Faculty ofAnthropology, Department ofGraduat