Antibiotic resistance and irrational prescribing in paediatric clinics in Greece Abstract
Introduction: Greece is among the countries with the highest rates of antimicrobial resistance (AMR) and simultaneous antibiotic consumption. Aim: The aim of this study was to assess the perceptions and knowledge of AMR and irrational antibiotic prescribing of nurses working in paediatric hospitals in Greece. Method: A self-administered questionnaire was distributed to nurses in paediatric hospitals and paediatric clinics in Greece. Descriptive and multivariate statistical analyses were performed. Levels of significance were two-tailed and statistical significance was p=0.05. Results: A total of 87% of participants reported irrational prescribing to be an important cause of AMR. Diagnostic uncertainty was stated by 55.5% as the main cause of irrational antibiotic prescribing and 94% suggested the use of protocols and guidelines as the main measure to control overprescribing. Parental demand for antibiotics in hospitals has increased according to 51.8% of respondents. Strong correlation was observed between social- demographic characteristics and antibiotic resistance, as well as irrational prescribing. Conclusions: Assessing nurses’ knowledge and perceptions of antimicrobial resistance and irrational prescribing is vital as nurses actively participate in the antibiotics administration process and antimicrobial management in Greece. Their involvement could contribute to educate patients and parents on the public-health implications of overprescribing and antimicrobial resistance. Key words: Microbial drug resistance ■ Paediatric nursing Inappropriate prescribing ■ Paediatric care ■ Greece
■
A
ntimicrobial resistance (AMR) is a serious and costly public health problem worldwide, (Spellberg et al, 2008; De Kraker et al, 2011), leading to increased morbidity and mortality as well as to treatment failure owing to multidrug-resistant bacterial infections (Costelloe et al, 2010). Given that irrational use is the most important factor contributing to the development of antibiotic resistance, both providers and patients should be sufficiently aware of the public health implications of frequent antimicrobial use (Edgar et al, 2009). Aikaterini Toska, Research Fellow; Mary Geitona, Associate Professor of Health Economics, both at Department of Social and Educational Policy, School of Social Sciences, University of Peloponnese, Greece Accepted for publication: December 2014
The worldwide rates of irrational prescribing are particularly high; it has been reported that 20%–50% of antimicrobial prescription is questionable or inappropriate (Hecker et al, 2003; Dellit et al, 2007; Abbo et al, 2012). According to data from the European Center for Disease Prevention and Control (ECDC), the prevalence of non-susceptible invasive isolates of five monitored multiresistant bacterial pathogens, is 11.3% (per million inhabitants) in Greece, a percentage which is higher than those of other European countries of similar population size. In addition to this, according to the European Surveillance of Antimicrobial Consumption data (ECDC, 2010b), Greece has the highest rates in hospital and community antibiotic consumption in Europe; these rates have gradually increased from 25.06 daily doses per 1000 inhabitants in 1997 to 34.73 in 2005. Several determinants of inappropriate prescribing have been reported in the international literature, including diagnostic uncertainty, lack of knowledge, socio-cultural and economic pressures, time limits, fear of litigation, and meeting parental expectations or patient satisfaction (Pichicero, 1999). Especially in paediatrics, antibiotics are among the most frequently prescribed classes of medications (Ferris et al, 1998). Many of these prescriptions are related to acute respiratory diseases (Keogh et al, 2012) in both primary and secondary care, despite bacterial infections accounting for a small minority of such diseases. The majority of respiratory diseases are caused by viral infections and are therefore unlikely to benefit from antibiotic treatment (Nasrin et al, 2002). The overuse and misuse of antibiotics in such situations contributes to the growing worldwide concern over broad-spectrum antibiotic prescribing, which accounts for 50% of antibiotic use in ambulatory paediatrics and in respiratory conditions for which antibiotics are not indicated (Hersh et al, 2011). Irrational prescribing is a significant cause of AMR and it is doctors and nurses who are considered responsible for prescribing. In Greece, nurses are not allowed to prescribe, however they do participate in the administering process of antibiotics to patients. Previous surveys have been conducted to assess physicians’ knowledge about AMR and their attitudes towards prescribing (Wester et al, 2002; Giblin et al, 2004; Antoine et al, 2006; Guerra et al, 2007), however, very little consideration has been given to nurses’ perceptions of AMR and antibiotic use, or to nurses’ contribution to antimicrobial management and the impact this may have on the development of AMR and hospital-acquired infections (Edwards et al, 2011; Abbo et al, 2012; Gillespie et al, 2013). Additionally, international literature is focused mainly on nurse practitioners,
28
© 2015 MA Healthcare Ltd
Aikaterini Toska and Mary Geitona
British Journal of Nursing, 2015, Vol 24, No 1
BJON_2015_24_01_028_033_Antibiotic resistance.indd 28
18/12/2014 14:51
British Journal of Nursing 2015.24:28-33.
research who have the authority to prescribe (Weiss et al, 2004; Abbo et al, 2012). It is important to look at nurses’ knowledge and perceptions of AMR because of the role nurses play in the antibiotic management process, and as patient educators. This study was undertaken with the aim of assessing the perceptions and knowledge of AMR and irrational prescribing of nurses in paediatric hospitals, given the role that nurses play in Greece in the administration process for antibiotics, as well as in the contribution to antimicrobial management.
Methods Study design, sample and setting
n
%
Specialised paediatric hospitals
102
34
Paediatric department in hospitals
199
66
Male
44
15
Female
257
85
20-30
33
12
31-40
102
38
41-50
124
46
51+
10
4
Technological
18
6
University
283
94
None
263
87
Masters
36
12
Doctoral
2
Introduction: Greece is among the countries with the highest rates of antimicrobial resistance (AMR) and simultaneous antibiotic consumption. Aim: The aim of this study was to assess the perceptions and knowledge of AMR and irrational antibiotic prescribing of nurses working in paediatric hospitals in Greece. Method: A self-administered questionnaire was distributed to nurses in paediatric hospitals and paediatric clinics in Greece. Descriptive and multivariate statistical analyses were performed. Levels of significance were two-tailed and statistical significance was p=0.05. Results: A total of 87% of participants reported irrational prescribing to be an important cause of AMR. Diagnostic uncertainty was stated by 55.5% as the main cause of irrational antibiotic prescribing and 94% suggested the use of protocols and guidelines as the main measure to control overprescribing. Parental demand for antibiotics in hospitals has increased according to 51.8% of respondents. Strong correlation was observed between social- demographic characteristics and antibiotic resistance, as well as irrational prescribing. Conclusions: Assessing nurses’ knowledge and perceptions of antimicrobial resistance and irrational prescribing is vital as nurses actively participate in the antibiotics administration process and antimicrobial management in Greece. Their involvement could contribute to educate patients and parents on the public-health implications of overprescribing and antimicrobial resistance. Key words: Microbial drug resistance ■ Paediatric nursing Inappropriate prescribing ■ Paediatric care ■ Greece
■
A
ntimicrobial resistance (AMR) is a serious and costly public health problem worldwide, (Spellberg et al, 2008; De Kraker et al, 2011), leading to increased morbidity and mortality as well as to treatment failure owing to multidrug-resistant bacterial infections (Costelloe et al, 2010). Given that irrational use is the most important factor contributing to the development of antibiotic resistance, both providers and patients should be sufficiently aware of the public health implications of frequent antimicrobial use (Edgar et al, 2009). Aikaterini Toska, Research Fellow; Mary Geitona, Associate Professor of Health Economics, both at Department of Social and Educational Policy, School of Social Sciences, University of Peloponnese, Greece Accepted for publication: December 2014
The worldwide rates of irrational prescribing are particularly high; it has been reported that 20%–50% of antimicrobial prescription is questionable or inappropriate (Hecker et al, 2003; Dellit et al, 2007; Abbo et al, 2012). According to data from the European Center for Disease Prevention and Control (ECDC), the prevalence of non-susceptible invasive isolates of five monitored multiresistant bacterial pathogens, is 11.3% (per million inhabitants) in Greece, a percentage which is higher than those of other European countries of similar population size. In addition to this, according to the European Surveillance of Antimicrobial Consumption data (ECDC, 2010b), Greece has the highest rates in hospital and community antibiotic consumption in Europe; these rates have gradually increased from 25.06 daily doses per 1000 inhabitants in 1997 to 34.73 in 2005. Several determinants of inappropriate prescribing have been reported in the international literature, including diagnostic uncertainty, lack of knowledge, socio-cultural and economic pressures, time limits, fear of litigation, and meeting parental expectations or patient satisfaction (Pichicero, 1999). Especially in paediatrics, antibiotics are among the most frequently prescribed classes of medications (Ferris et al, 1998). Many of these prescriptions are related to acute respiratory diseases (Keogh et al, 2012) in both primary and secondary care, despite bacterial infections accounting for a small minority of such diseases. The majority of respiratory diseases are caused by viral infections and are therefore unlikely to benefit from antibiotic treatment (Nasrin et al, 2002). The overuse and misuse of antibiotics in such situations contributes to the growing worldwide concern over broad-spectrum antibiotic prescribing, which accounts for 50% of antibiotic use in ambulatory paediatrics and in respiratory conditions for which antibiotics are not indicated (Hersh et al, 2011). Irrational prescribing is a significant cause of AMR and it is doctors and nurses who are considered responsible for prescribing. In Greece, nurses are not allowed to prescribe, however they do participate in the administering process of antibiotics to patients. Previous surveys have been conducted to assess physicians’ knowledge about AMR and their attitudes towards prescribing (Wester et al, 2002; Giblin et al, 2004; Antoine et al, 2006; Guerra et al, 2007), however, very little consideration has been given to nurses’ perceptions of AMR and antibiotic use, or to nurses’ contribution to antimicrobial management and the impact this may have on the development of AMR and hospital-acquired infections (Edwards et al, 2011; Abbo et al, 2012; Gillespie et al, 2013). Additionally, international literature is focused mainly on nurse practitioners,
28
© 2015 MA Healthcare Ltd
Aikaterini Toska and Mary Geitona
British Journal of Nursing, 2015, Vol 24, No 1
BJON_2015_24_01_028_033_Antibiotic resistance.indd 28
18/12/2014 14:51
British Journal of Nursing 2015.24:28-33.
research who have the authority to prescribe (Weiss et al, 2004; Abbo et al, 2012). It is important to look at nurses’ knowledge and perceptions of AMR because of the role nurses play in the antibiotic management process, and as patient educators. This study was undertaken with the aim of assessing the perceptions and knowledge of AMR and irrational prescribing of nurses in paediatric hospitals, given the role that nurses play in Greece in the administration process for antibiotics, as well as in the contribution to antimicrobial management.
Methods Study design, sample and setting
n
%
Specialised paediatric hospitals
102
34
Paediatric department in hospitals
199
66
Male
44
15
Female
257
85
20-30
33
12
31-40
102
38
41-50
124
46
51+
10
4
Technological
18
6
University
283
94
None
263
87
Masters
36
12
Doctoral
2
