Basic & Clinical Pharmacology & Toxicology

Doi: 10.1111/bcpt.12316

Compliance with Recommendations on Outpatient Antibiotic Prescribing for Respiratory Tract Infections: The Case of Spain Sara Malo1, Lars Bjerrum2, Cristina Feja1, Marıa-Jes us Lallana3, Javier Moliner1 and Marıa-Jose Rabanaque1 1 Department of Microbiology, Preventive Medicine and Public Health, University of Zaragoza, Zaragoza, Spain, 2Section and Research Unit of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark and 3Farmacy Service in Primary Health Care, Aragones Health Service, Zaragoza, Spain

(Received 22 May 2014; Accepted 25 August 2014) Abstract: Inappropriate antibiotic use in primary care, such as in respiratory tract infections (RTIs), is an important cause of bacterial resistance. This study aimed at describing the current pattern of outpatient antibiotic use in acute RTIs in Spain and evaluating adherence to national recommendations. A retrospective observational study was performed including all the episodes of RTIs registered during a 1-year period in a north-eastern Spanish region. Data related to patient demography, diagnoses and antibiotic prescriptions were collected from the electronic medical history database in the region, and adherence to recommendations for antibiotic prescribing was assessed. One third of patients with a RTI were prescribed an antibiotic, with young adults (aged 15–64 years) being the most treated. High prescribing rates were observed in patients with acute otitis, sinusitis and acute tonsillitis (about 70%), whereas low rates were found in acute bronchitis (50%) and non-specific upper RTIs (24%) episodes. A high prescription of broad-spectrum agents and antibiotics not recommended as first choice was observed. In accordance with Spanish guidelines, there exists a potential over-prescribing of antibiotics for all the diagnoses studied, especially in the adult population. Moreover, the choice of antibiotics is frequently based on agents with a high risk of increasing antimicrobial resistance. Multifaceted strategies should be implemented to improve the quality of antibiotic prescribing in primary care.

Antimicrobial resistance is a major concern to the public health and may result from indiscriminate or poor use of antibiotics [1]. Infectious diseases are the most frequent reason for encounter in primary care, and respiratory tract infections (RTIs) account for about two-thirds of all infections seen by the general practitioner (GP) [2]. Despite the fact that the benefit of antimicrobial treatment is rather low [3,4], a substantial number of patients with RTI are treated with antibiotics [5,6]. Diagnostic uncertainty characterizes the management of RTIs and doubt about the diagnosis and the aetiology may lead to antibiotic over-prescribing. Other factors such as patient preferences, fears of getting sued and fear of serious complications may influence the GP’s prescribing decision [7]. Studies have found a substantial gap between recommendations in evidence-based practice guidelines and doctors’ actual prescribing behaviour [8]. Compared with other European countries, Spain has historically displayed a high outpatient antibiotic use. The majority of antibiotics prescribed are broad-spectrum agents, and there are remarkable seasonal fluctuations reflecting an inappropriate prescribing of antibiotic for RTIs caused by viruses [9]. Consequently, resistance rates of the main respiratory pathogens remain high in Spain, although a decreasing trend has been observed in the last years [10].

Author for correspondence: Sara Malo, Department of Microbiology, Preventive Medicine and Public Health, University of Zaragoza, C/ Domingo Miral s/n, 50009 Zaragoza, Spain (e-mail [email protected]).

According to the disease-specific quality indicators for outpatient antibiotic prescribing developed by the European Surveillance Antimicrobial Consumption (ESAC) [11], both the proportion of patients prescribed antibiotics and the choice of antibiotics should be taken into account when evaluating the quality of antibiotic use in general practice. This study aimed at investigating antibiotic prescribing rates and pattern of antibiotic use in patients with RTI in Spain. We assessed adherence to national recommendations in order to evaluate the extent of inappropriate antibiotic prescribing. Material and Methods Aragon is an autonomous community located in the north-eastern part of Spain. It is constituted by both urban and rural zones and shows a population slightly older than in the country as a whole [12]. The 17 autonomous communities forming Spain are responsible for the organization and delivery of health services within their community, while the Spanish Ministry of Health has the mandate of playing the core role in the coordination of the National Health Care System. In 2010, a number of 1,327,827 inhabitants were covered by the Public Aragon Health Service (98.6% of the total population) [12]. There was a total of 959 GPs in the region, 1230 patients were assigned per GP, and health attendance to children was covered by paediatricians, with about one per 1000 children. These numbers were similar to what was reported on average in Spain. In addition, there were no important differences regarding the public health expenditure per person or the distribution of primary healthcare resources among Aragon and the rest of the Spanish regions [13]. This study was carried out based on the database that accumulates electronic medical history data corresponding to all inhabitants insured by the Aragon Health Service. This database is routinely used by all

© 2014 Nordic Association for the Publication of BCPT (former Nordic Pharmacological Society)

SARA MALO ET AL.

2

the GPs in their daily practice and contains diagnoses coded according to the International Classification of Primary Care (ICPC) system. We selected all records corresponding to patients diagnosed with RTIs from 1 September 2009 to 31 August 2010 and encoded as Acute otitis media (H71), Non-specific upper respiratory tract infection (basically common cold, R74), Sinusitis (R75), Acute tonsillitis (R76) and Acute bronchitis/bronchiolitis (R78). Each record corresponded to a single episode or diagnosis of RTI and consisted of patient code number, gender, date of birth, ICPC code and Anatomical Therapeutical Classification (ATC) code of all antibiotics prescribed. A prescription was considered to be associated with an ICPC diagnosis if the prescription was redeemed ≤15 days after the date of the consultation. The total number of episodes and the proportion followed by an antibiotic prescription were calculated by type of diagnosis and age group. The pattern of antibiotic prescribing for each of the five diagnoses mentioned above was described. We classified antibiotics according to the 2010 version of the World Health Organization ATC/ DDD Index [14]. The assessment of adherence to national recommendations was based on the Guideline on Antimicrobial Therapy in the Area of Aljarafe [15]. Although this guideline is aimed at GPs in a specific health area in Andalucıa, it is currently the most complete and updated document included in the Clinical Practice Guidelines Index of the National Health System in Spain and applicable to the whole Spanish territory. The proportion of appropriate prescriptions was calculated for each RTI diagnosis.

Results A total of 320,267 individuals were diagnosed with 520,829 RTI episodes during the study period. This corresponded to 241 patients with a RTI per 1000 inhabitants per year. Mean age of patients was 30 years (range 0–107), and 54.5% were men. Table 1 shows the distribution of RTI diagnoses. Nonspecific upper respiratory tract infection (URTI) was the most frequent diagnosis, representing 72% of the total, whereas

Compliance with recommendations on outpatient antibiotic prescribing for respiratory tract infections: the case of Spain.

Inappropriate antibiotic use in primary care, such as in respiratory tract infections (RTIs), is an important cause of bacterial resistance. This stud...
311KB Sizes 0 Downloads 8 Views