Antibiotic overuse: junior doctors are at it too

TRAINEE GPs are just as prone to overprescribing antibiotics as their older peers, according to new Australian research.

The first large-scale study of its kind, published in Family Practice looked at the prescribing habits of nearly 900 GP registrars in relation to cases of acute otitis media and acute sinusitis – two conditions where current guidelines frown on the routine prescribing of antibiotics.

Across 100 000 consultations, identified in a cross-sectional analysis of data from the Registrar Clinical Encounters in Training (ReCEnT) study, an ongoing, multicentre prospective cohort study, one of these conditions was diagnosed in around 3000 cases. Antibiotics – mostly amoxicillin – were prescribed for 79% of cases of otitis media and for 71% of cases of sinusitis.

These prescribing rates are far above the 20% benchmark expected if the participating registrars had been prescribing according to evidence-based guidelines, said the study authors from the University of Queensland and other institutions.

While it’s true that junior doctors were prescribing antibiotics a little less than their older colleagues, the difference was not great, suggesting that current training programs were not doing enough to deal with the problem.

“The findings are not that surprising, since it’s established that GPs prescribe highly,” said lead author Dr Anthea Dallas, a Sydney-based GP and researcher at the University of Notre Dame School of Medicine. “But it’s still disappointing, as you’d hope registrars would prescribe less, and that they’d be educated to do so, but it doesn’t seem to be the case.”

Dr Dallas said the reasons why trainee GPs may struggle to say no to antibiotics were complex and multifactorial.

She said one factor was that junior doctors were transitioning from working in hospitals, where infections tended to be more serious and antibiotics were prescribed more liberally than in the community.

“It could be hard for trainees to adjust their mindset from hospital emergencies to community medicine,” Dr Dallas said.

Another problem was diagnostic uncertainty.

“When you don’t have much experience, you tend to prescribe on the side of caution. You may also be more likely to ask advice from your supervisor, who would have started practising in an era when antibiotics were prescribed more freely. And, in fact, our study found that prescribing antibiotics was associated with seeking advice.”

Communication skills also played a role: doctors needed to know the evidence and clearly explain it, but they should also be able to properly understand patients’ needs.

“It may be that the doctor thinks there’s pressure from the patient to prescribe antibiotics, when in fact there isn’t,” Dr Dallas noted.

One finding from the study was that antibiotic prescribing for otitis media was no greater in younger age groups. It was the one area where you may expect to find higher prescribing, since Australian guidelines recommend antibiotics for infants under 6 months of age and state that they “should be considered” in children aged up to 2 years.

This suggested that trainees may be finding the guidelines too complex and confusing to use on a day-to-day basis.

But the biggest surprise was that the registrars who prescribed the most were those in their later stages of training, at the point where they should have developed more confidence in diagnosing and treating their patients.

This again pointed to insufficient training and guidance in this critical aspect of clinical practice.

Dr Dallas said that the problem of overprescribing antibiotics in primary care was a huge concern in antimicrobial resistance because it was GPs who were responsible for the bulk of the prescribing.

“We need to target junior doctors because they’re the future of prescribing. And it’s not that they’re unaware of the resistance problem, it’s that the daily pressures often override the theory.”

She said that another reason to target trainees was that they were at the stage of developing their habits, but those habits were not yet set.

What was needed was targeted educational interventions to help junior doctors transition from hospital to community practice, the study authors wrote. And those interventions needed to address not just the junior doctors but their supervisors as well.

Training should cover the use of guidelines, communications skills and strategies to deal with diagnostic uncertainty.

The study authors said that they had already piloted some modules for improving prescribing for respiratory tract infections, which could be adapted for other indications.

 

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