Brief Communication

Prescription of antibiotics and knowledge about antibiotic costs among physicians working in tertiary-care hospitals Helena C. Maltezou1, Efstratios Maltezos2, Anastasia Antoniadou3, Georgios-Michael Gourgoulis1, Panos Katerelos1, Georgios Adamis4, George Petrikkos3, Panagiotis Gargalianos4 1

Department for Interventions in Health-Care Facilities, Hellenic Center for Disease Control and Prevention, Athens, Greece, 22nd Department of Internal Medicine, Democritus University of Thrace, Alexandroupolis, Greece, 34th Department of Internal Medicine, Athens University School of Medicine, Greece, 41st Department of Medicine and Infectious Diseases Unit, The General Hospital of Athens ‘‘G. Gennimatas’’, Greece The objective of this study is to investigate antibiotic prescription practices among hospital-based physicians in Greece, using the 2007 national guidelines as the golden standard. A total of 168 physicians participated. Compliance rate with the first-line antibiotic treatment recommended by the national guidelines was 65.5% for acute bacterial sinusitis; 24% for acute uncomplicated cystitis; 36.4% for an acute febrile diarrheic syndrome; 38% for an afebrile adult with chronic obstructive pulmonary disease and nonproductive cough of 7 days duration; 23.2% for streptococcal pharyngotonsillitis; 55.1% for a surgically sutured, dirty wound; and 48.2% for community-acquired pneumonia. The total mean rate of compliance with the first recommended antibiotic was 41.2%. Keywords: Antibiotics, Brand name, Generic, Cost, Hospital, Physicians, Prescription

Brief Introduction to the Problem Antimicrobial resistance has become a major public health problem worldwide, often associated with increased morbidity and mortality, prolonged hospitalization, and excess health-care costs.1 Inappropriate use of antibiotics is one of the main factors promoting antimicrobial resistance, both in healthcare facilities and the community.2,3 Antibiotic prescription practices, as well as antimicrobial resistance, vary between European countries.4 In Greece, antibiotic consumption rate is among the highest within Europe and subsequently, elevated rates of antimicrobial resistance are observed.5,6 In response to this fact, the Hellenic Center for Disease Control and Prevention (HCDCP), which is the central public health authority in Greece, issued in 2007 the national guidelines for prescription of antibiotics in hospitals and the community. These guidelines were formulated by a working group of experts, taking into consideration the nation-wide epidemiology of antibiotic resistance and offered physicians the flexibility to choose

Correspondence to: Helena C. Maltezou, Department for Interventions in Health-Care Facilities, Hellenic Center for Disease Control and Prevention, 3-5 Agrafon Street, Athens, Greece. Email: [email protected] ath.forthnet.gr

ß 2014 Edizioni Scientifiche per l’Informazione su Farmaci e Terapia DOI 10.1179/1973947813Y.0000000160

among several antibiotics per disease. The guidelines were printed in pocket books and subsequently distributed to all physicians working in the public sector in Greece. These guidelines are available at the HCDCP website.7 The aim of this study is to evaluate the antibiotic prescription practices of physicians working in tertiarycare hospitals in Greece for common communityacquired infections, using the 2007 HCDCP guidelines as the golden standard, as well as their knowledge about antibiotic costs, brand names, and generic drugs.

Methods In November 2012, the HCDCP in collaboration with the Infection Control Committee of three tertiary-care hospitals (two in Athens and one in Alexandroupolis, in northern Greece) conducted this study. A standardized questionnaire was distributed to 304 internists employed in these hospitals, irrespective of demographic or professional characteristics (40 internists were not available). The questionnaire was addressed to internists only, since the majority of communityacquired, adult infectious syndromes are treated by doctors of this specialty, almost exclusively. Physicians were asked to complete the questionnaire on a voluntary basis and anonymously and return it the

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next day. The completed questionnaires were sent to HCDCP for data entry and statistical analysis. The following data were collected using one standardized form per physician: age, gender, and specialty. Seven case scenarios on common, community-acquired infections, requiring health-care services, were presented and the physicians’ first choice of empiric antibiotic treatment was recorded. The mean compliance rate with the antibiotic treatment recommended by the 2007 HCDCP guidelines was estimated. Seven questions about the costs of commonly prescribed antibiotic regimens were included in the questionnaire. Brand name antibiotics were used for cost estimation. Finally, the physicians’ knowledge regarding branded versus generic antibiotics was assessed, by means of five questions incorporated in the questionnaire. Based on the answers, two knowledge scores were calculated; one concerning antibiotic costs and another about brand name drugs and generic drugs. Multiple linear regression (stepwise selection) was applied in order to explore any possible relationships between demographic/professional characteristics of the physicians and their compliance with the 2007 guidelines, as well as their two scores of knowledge. Every detected relationship was re-investigated using the appropriate monoparametric methods: t-test for gender, one-way analysis of variance for specialty, and Pearson’s correlation coefficient for age. Relationships were regarded as reliable if they were traced by both the regression and the univariate analysis techniques. P-values of #0.05 were considered statistically significant. The STATA 8.0 statistical package (StataCorp LP, College Station, TX, USA) was used for statistical analysis.

Results A total of 168 physicians (58.9% males) with a mean age of 39 years (range: 24–69 years) completed the questionnaire (55% response rate). Most participants were internists or pulmonologists (56.6 vs 16.2%, respectively). Table 1 illustrates the physicians’ first, empiric choice for the seven case scenarios, along with the antibiotics recommended by the 2007 HCDCP guidelines. The first choice made by the physicians in terms of treatment was amoxicillin/ clavulanate (65.5%) for acute bacterial sinusitis; ciprofloxacin (34.1%) for acute uncomplicated cystitis in a female patient; symptomatic treatment (36.4%) for an acute febrile diarrheic syndrome; no treatment (38%) for an afebrile adult with chronic obstructive pulmonary disease and non-productive cough for 7 days; amoxicillin/clavulanate (69.6%) for laboratoryconfirmed streptococcal pharyngotonsillitis; amoxicillin/clavulanate (55.1%) for a surgically sutured, dirty wound; and clarithromycin (27.1%) for communityacquired pneumonia. Compliance rate with the

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first-line antibiotic treatment recommended by the national guidelines was 65.5% for acute bacterial sinusitis, 24% for acute uncomplicated cystitis in a woman, 36.4% for an acute febrile diarrheic syndrome, 38% for an afebrile adult with chronic obstructive pulmonary disease and non-productive cough of 7 days duration, 23.2% for streptococcal pharyngotonsillitis, 55.1% for a surgically sutured, dirty wound, and 48.2% for community-acquired pneumonia. The total mean rate of compliance with the first recommended antibiotic by the national guidelines was 41.2%. The answers of the participating physicians in terms of costs of common antibiotic regimens are shown in Table 2. Correct answers ranged from 8% for a 10-day scheme of cefuroxime, to 61.6% for a 10day scheme of clarithromycin. The mean score of knowledge of common antibiotic costs was 36.3%. Correct answers concerning brand name and generic drugs, ranged from 36.4 to 78.2%, with a mean score of knowledge of 59.8%. Logistic regression analysis failed to demonstrate any statistically significant association between the mean rate of compliance with the first recommended antibiotic by the HCDCP guidelines, the knowledge scores concerning costs, branded and generic antibiotics, and the physician characteristics (age, gender, and specialty) (data not shown).

Conclusion This study was conducted in order to explore antibiotic prescription practices by internal medicine physicians, in Greek tertiary-care hospitals. We found that compliance rate of hospital working physicians with the national guidelines, 5 years following their release, was less than 50%. We also found that compliance and prescription patterns varied widely among physicians, depending on infectious syndrome. In particular, the highest compliance rates (.55%) were recorded in the acute bacterial sinusitis and the surgically sutured wound scenarios and the lowest (24 and 23.2%) were noticed in the uncomplicated cystitis in a female patient and the laboratoryconfirmed streptococcal pharyngotonsillitis scenarios, respectively. Inappropriate antibiotic prescription, especially in the context of viral respiratory illnesses, has been reported in various health-care settings in several countries.2,8–12 During the past decade, efforts have been made in order to promote the rational prescription of antibiotics by physicians.8 In addition, there are numerous studies in the literature identifying factors that influence antibiotic prescription practices among physicians.2,13,14 These include, between others, physician specialty, years since medical qualification examination, time in practice, self-efficacy, insufficient knowledge, perception of inappropriate antibiotic use as risky for the patient, age and medical profile of

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patient, type of infection, method of physician remuneration, patient volume, complacency, and external responsibility of the pharmaceutical industry.2,8 We found no association between age, gender, and specialty of physicians and their compliance rates with the national guidelines, in terms of antibiotic use, notwithstanding published data corroborating the association of inappropriate prescription of antibiotics to increased years of clinical practice.9 Our study indicates that physicians in tertiary-care hospitals are not aware of the costs of common antibiotic schemes, despite the fact that this knowledge

Antibiotic prescription in hospitals

has been associated with better antibiotic prescription practices and limitation of health-care costs.15 Within the frame of the current economic crisis, costs should be taken under consideration in every day clinical practice. Participating physicians had a 59.8% mean score of knowledge about brand name and generic drugs, although the Hellenic Ministry of Health promotes the use of the latter in order to limit health-care costs. A limitation of the current study is the absence of data regarding prescription practices before 2007. As a result, we were unable to assess directly the impact of the 2007 national guidelines on the physicians’

Table 1 Prescription practices for common community-acquired infections by hospital physicians Infection/antibiotic (i) Acute bacterial sinusitis (n5168) Amoxicillin/clavulanate Clarithromycin Azithromycin Cefuroxime Other (ii) Acute uncomplicated cystitis (n5167) Ciprofloxacin Amoxicillin/clavulanate Trimethoprim/sulfamethoxazole Norfloxacin Cefuroxime Other (iii) Acute febrile diarrhoic syndrome (n5165) Symptomatic treatment Ciprofloxacin Trimethoprim/sulfamethoxazole Metronidazole Other (iv) Afebrile COPD adult with a non-productive 7 days cough (n5166) No drug treatment Clarithromycin Amoxicillin Moxifloxacin Other (v) Laboratory-confirmed streptococcal pharyngotonsillitis (n5168) Amoxicillin/clavulanate Penicillin V Azithromycin Clarithromycin Other (vi) Wound sutured surgically (n5167) Amoxicillin/clavulanate Cefaclor Clindamycin Ciprofloxacin Amoxicillin Other (vii) Community-acquired pneumonia (n5166) Clarithromycin Amoxicillin/clavulanate Azithromycin Amoxicillin/clavulanate plus clarithromycin Cefuroxime Azithromycin plus amoxicillin/clavulanate Cefuroxime plus clarithromycin Azithromycin plus amoxicillin Amoxicillin plus clarithromycin Amoxicillin Other

Recommended antibiotics

n (%)2 (N5168)

1st choice Alternative Alternative Alternative

110 19 12 9 18

(65.5%) (11.3%) (7.1%) (5.3%) (10.7%)

Alternative 1st choice Alternative Alternative Alternative

57 40 35 20 6 9

(34.1%) (24.0%) (21.0%) (12.0%) (3.6%) (5.4%)

1st choice

60 46 35 18 6

(36.4%) (27.9%) (21.2%) (10.9%) (3.6%)

1st choice

63 43 25 24 11

(38.0%) (25.9%) (15.1%) (14.5%) (6.6%)

Alternative 1st choice Alternative Alternative

117 39 5 4 3

(69.6%) (23.2%) (3.0%) (2.4%) (1.8%)

1st choice Alternative Alternative Alternative Alternative

92 45 17 9 2 2

(55.1%) (26.9%) (10.2%) (5.4%) (1.2%) (1.2%)

1st choice

45 27 23 9 8 8 6 5 4 3 28

(27.1%) (16.3%) (13.9%) (5.4%) (4.8%) (4.8%) (3.6%) (3.0%) (2.4%) (1.8%) (16.8%)

1st choice

1st choice 1st choice 1st choice

COPD: chronic obstructive pulmonary disease; n: number of physicians who answered by question.

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prescription habits. The high response rate, on the other hand, is a clear advantage. Other limitations include the relatively small number of participating tertiary-care physicians and the absence of data about bacterial resistance to antibiotics in the hospitals included in the study. A potentially interesting idea for the future, deriving from the experience we gained on the subject, is the conduction of meta-analyses in order to explore differences between published series. Continuing medical education may contribute to update the physicians’ knowledge regarding local resistance patterns and guidelines for antibiotic use and hence, limit unnecessary and inappropriate prescription of antibiotics. In conclusion, 5 years following the release of the first national guidelines by the HCDCP in Greece, physicians working in tertiary-care hospitals show varying antibiotic prescription behaviors, demonstrating less than 50% compliance rate with the first antibiotic treatment, suggested by the guidelines. Interventions focusing on the education of hospital-based physicians should be scheduled and implemented. Increasing overall awareness regarding antibiotic costs may also affect positively prescription habits. In order to rationalize antibiotic prescription practices and reduce antibiotic costs, the Ministry of Health has implemented during the past 24 months a compulsory, webbased prescription platform, for physicians who Table 2 Knowledge of antibiotic regimens costs Answer

physicians

about

common

Number (%)

Amoxicillin/clavulanic acid (500/125 mg) tid for a 10 days course (n5164) 5–10 J 18 (11.0%) Correct 11–20 J 109 (66.5%) 21–30 J 37 (22.5%) Clarithromycin 500 mg bid for a 10 days course (n5164) 10–20 J 36 (22.0%) 21–40 J 101 (61.6%) Correct 41–60 J 27 (16.5%) Cefuroxime 500 mg bid for a 10 days course (n5162) 5–15 J 53 (32.7%) 16–25 J 96 (59.3%) 26–35 J 13 (8.0%) Correct Ciprofloxacin 750 mg bid for a 28 days course (n5164) 50–100 J 97 (59.1%) 101–200 J 43 (26.2%) Correct 201–300 J 24 (14.6%) Trimethoprim/sulfamethoxazole (800/160 mg) bid for a 28 days course (n5162) 5–10 J 51 (31.5%) 11–20 J 87 (53.7%) Correct 21–30 J 24 (14.8%) Azithromycin 500 mg qd for a 3 days course (n5164) 5–10 J 45 (27.4%) 11–25 J 93 (56.7%) Correct 26–40 J 26 (15.9%) Moxifloxacin 400 mg qd for a 10 days course (n5164) 10–20 J 9 (5.5%) 21–40 J 94 (57.3%) 41–60 J 61 (37.2%) Correct n: the number of physicians who answered by question.

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prescribe antibiotics to citizens with social security. Finally, the HCDCP in close collaboration with the Hellenic Infectious Diseases Society is in the process of finalization, publication, and dissemination of the updated 2013 guidelines.

Conflict of Interest All authors declare that they have no conflict of interest to declare.

Funding No funds were received for this study.

Acknowledgements We would like to thank the physicians who completed the questionnaires.

References 1 Cosgrove SE. The relationship between antimicrobial resistance and patient outcomes: mortality, length of hospital stay, and health care costs. Clin Infect Dis. 2006;42(Suppl 2):S82–9. 2 Hutchinson JM, Foley RN. Method of physician remuneration and rates of antibiotic prescription. CMAJ. 1999;160:1013–7. 3 Costelloe C, Metcalfe C, Lovering A, Mant D, Hay AD. Effect of antibiotic prescribing in primary care on antimicrobial resistance in individual patients: systematic review and metaanalysis. BMJ. 2010;340:c2096. 4 Van de Sande-Bruinsma N, Grundmann H, Verloo D, Tiemersma E, Monen J, Goossens H, et al. Antimicrobial drug use and resistance in Europe. Emerg Infect Dis. 2008;14:1722–30. 5 European Surveillance of Antimicrobial Consumption. What is the burden of antibiotic use in Europe? [document on the Internet]. [cited 2013 July 29]. Available from: http://app. esac.ua.ac.be/public/index.php/en_gb/antibiotic/antibioticconsumption 6 European Centre for Disease Prevention and Control. European Antimicrobial Resistance Surveillance System Annual Reports [document on the Internet]. [cited 2013 July 29]. Available from: http://ecdc.europa.eu/en/activities/surveillance/EARS-Net/publications/Pages/documents.aspx 7 Hellenic Center for Disease Control and Prevention. Guidelines for the diagnosis and empiric treatment of infections [document on the Internet]. Athens; 2007. [cited on 2013 July 29]. Available from: http:// www.keelpno.gr/el-gr/diahe´simouliko´/e´ntupouliko´.aspx [in Greek]. 8 Lucet JC, Nicolas-Chanoine MH, Roy C, Riveros-Palacios O, Diamantis S, Le Grand J, et al. Antibiotic use: knowledge and perceptions in two university hospitals. J Antimicrob Chemother. 2011;66:936–40. 9 Fakih MG, Hilu RC, Savoy-Moore RT, Saravolatz LD. Do resident physicians use antibiotics appropriately in treating upper respiratory infections? A survey of 11 programs. Clin Infect Dis. 2003;37:853–6. 10 Pradier C, Rolity M, Cavailler P, Haas H, Pesce A, Dellamonica P, et al. Factors related to the prescription of antibiotics for young children with viral pharyngitis by general practitioners and paediatricians in southeastern France. Eur J Clin Microbiol Infect Dis. 1999;10:510–4. 11 Abbo L, Sinkowitz-Cochran R, Smith L, Ariza-Heredia E, GomezMarin O, Srinivasan A, et al. Faculty and resident physicians’ attitudes, perceptions, and knowledge about antimicrobial use and resistance. Infect Control Hosp Epidemiol. 2011;32:714–8. 12 Ong S, Nakase J, Moran GJ, Karras DJ, Kuehnert MJ, Talan DA. Antibiotic use for emergency department patients with upper respiratory infections: prescribing practices, patient expectations, and patient satisfaction. Ann Emerg Med. 2007;50:213–20. 13 Fraisse T, Fayad G, Jardy C, Sotto A. Evaluation of empirical antibiotherapy for acute community-acquired pneumonia prescribed in emergency departments. Med Mal Infect. 2012;42:5–9. 14 Choi KH, Park SM, Lee JH, Kwon S. Factors affecting the prescribing patterns of antibiotics and injections. J Korean Med Sci. 2012;27:120–7. 15 Hart J, Salman H, Bergman M, Neuman V, Rudniki C, Gilenberg D, et al. Do drug costs affect physicians’ prescription decisions? J Intern Med. 1997;241:415–20.

Prescription of antibiotics and knowledge about antibiotic costs among physicians working in tertiary-care hospitals.

The objective of this study is to investigate antibiotic prescription practices among hospital-based physicians in Greece, using the 2007 national gui...
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