Early-career general practitioners' antibiotic prescribing for acute infections: a systematic review.

BACKGROUND: Antimicrobial resistance is a worldwide threat, exacerbated by inappropriate prescribing. Most antibiotic prescribing occurs in primary care. Early-career GPs are important for the future of antibiotic prescribing and curbing antimicrobial resistance. OBJECTIVES: To determine antibiotic prescribing patterns by early-career GPs for common acute infections. METHODS: A systematic literature search was conducted using PubMed, Embase and Scopus. Two authors independently screened abstracts and full texts for inclusion. Primary outcomes were antibiotic prescribing rates for common acute infections by GPs with experience of 10 years or less. Secondary outcomes were any associations between working experience and antibiotic prescribing. RESULTS: Of 1483 records retrieved, we identified 41 relevant studies. Early-career GPs were less likely to prescribe antibiotics compared with their more experienced colleagues (OR range 0.23-0.67). Their antibiotic prescribing rates for 'any respiratory condition' ranged from 14.6% to 52%, and for upper respiratory tract infections from 13.5% to 33%. Prescribing for acute bronchitis varied by country, from 15.9% in Sweden to 26% in the USA and 63%-73% in Australia. Condition-specific data for all other included acute infections, such as sinusitis and acute otitis media, were limited to the Australian context. CONCLUSIONS: Early-career GPs prescribe fewer antibiotics than later-career GPs. However, there are still significant improvements to be made for common acute conditions, as their prescribing is higher than recommended benchmarks. Addressing antimicrobial resistance requires an ongoing worldwide effort and early-career GPs should be the target for long-term change.

Diagnosis and management of acute infections during telehealth consultations in Australian general practice: a qualitative study.

BACKGROUND: The use of telehealth has increased dramatically since the beginning of the COVID-19 pandemic. Little is known about how GPs manage acute infections during telehealth, and the potential impact on antimicrobial stewardship. AIM: To explore the experiences and perceptions of GP trainees' and supervisors' use of telehealth, and how it influences their management of acute infections. DESIGN & SETTING: Australian GP registrars (trainees) and supervisors were recruited via email through their training organisations. Semi-structured interviews with 18 participants were conducted between July and August 2022. METHOD: Interviews were transcribed verbatim and analysed using a reflexive thematic approach. RESULTS: We identified six overall themes. 1. Participants experienced impaired diagnostic capacity during telehealth consultations. 2. Attempts to improve diagnostic acuity included various methods, such as having patients self-examine. 3. The management of clinical uncertainty frequently entailed referring patients for in-person assessment, overinvestigating, or overtreating. 4. Antibiotic prescribing decisions during telehealth were informed by less information than were in-person consults, with varying impact. 5. Participants believed that other GPs improperly prescribed antibiotics during telehealth. 6. Supervisors believed that registrars hadn't developed the knowledge or skills to determine when conditions could be managed appropriately via telehealth. CONCLUSION: Telehealth has potential for reducing transmission of acute infections and increasing access to healthcare. However, the implications of GPs, especially less experienced GPs, making diagnoses with less certainty, and consequently compromising antimicrobial stewardship, are a concern. Patient self-assessment tools may improve outcomes of telehealth consultations for acute infections.

Temporal patterns of antibiotic prescribing for sore throat, otitis media, and sinusitis: a longitudinal study of general practitioner registrars.

BACKGROUND: Antibiotics provide minimal benefit for sore throat, otitis media, and sinusitis. Antibiotic stewardship, with reduced prescribing, is required to address antibiotic resistance. As most antibiotic prescribing occurs in general practice and prescribing habits develop early, general practitioner (GP) trainees (registrars) are important for effective antibiotic stewardship. OBJECTIVES: To establish temporal trends in Australian registrars' antibiotic prescribing for acute sore throat, acute otitis media, and acute sinusitis. DESIGN: A longitudinal analysis of data from the Registrar Clinical Encounters in Training (ReCEnT) study from 2010 to 2019. PARTICIPANTS: ReCEnT is an ongoing cohort study of registrars' in-consultation experiences and clinical behaviours. Pre-2016, 5 of 17 Australian training regions participated. From 2016, 3 of 9 regions (42% of Australian registrars) participate. MAIN MEASURES: The outcome was prescription of an antibiotic for a new acute problem/diagnosis of sore throat, otitis media, or sinusitis. The study factor was year (2010-2019). KEY RESULTS: Antibiotics were prescribed in 66% of sore throat diagnoses, 81% of otitis media, and in 72% of sinusitis. Prescribing frequencies decreased between 2010 and 2019 by 16% for sore throat (from 76% to 60%) by 11% for otitis media (from 88% to 77%) and by 18% for sinusitis (from 84% to 66%). In multivariable analyses, "Year" was associated with reduced prescribing for sore throat (OR 0.89; 95%CI 0.86-0.92; p < 0.001), otitis media (OR 0.90; 95%CI 0.86-0.94; p < 0.001), and sinusitis (OR 0.90; 95%CI 0.86, 0.94; p < 0.001). CONCLUSIONS: Registrars' prescribing rates for sore throat, otitis media, and sinusitis significantly decreased during the period 2010-2019. However, educational (and other) interventions to further reduce prescribing are warranted.

Antibiotic prescribing for upper respiratory tract infections and acute bronchitis: a longitudinal analysis of general practitioner trainees.

BACKGROUND: Most antibiotic prescribing for upper respiratory tract infections (URTIs) and acute bronchitis is inappropriate. Substantive and sustained reductions in prescribing are needed to reduce antibiotic resistance. Prescribing habits develop early in clinicians' careers. Hence, general practice (GP) trainees are an important group to target. OBJECTIVES: We aimed to establish temporal trends in antibiotic prescribing for URTIs and acute bronchitis/bronchiolitis by Australian GP trainees (registrars). METHODS: A longitudinal analysis, 2010-2019, of the Registrars Clinical Encounters in Training (ReCEnT) dataset. In ReCEnT, registrars record clinical and educational content of 60 consecutive consultations, on 3 occasions, 6 monthly. Analyses were of new diagnoses of URTI and acute bronchitis/bronchiolitis, with the outcome variable a systemic antibiotic being prescribed. The independent variable of interest was year of prescribing (modelled as a continuous variable). RESULTS: 28,372 diagnoses of URTI and 5,289 diagnoses of acute bronchitis/bronchiolitis were recorded by 2,839 registrars. Antibiotic prescribing for URTI decreased from 24% in 2010 to 12% in 2019. Prescribing for acute bronchitis/bronchiolitis decreased from 84% to 72%. "Year" was significantly, negatively associated with antibiotic prescribing for both URTI (odds ratio [OR] 0.90; 95% confidence interval [CI]: 0.88-0.93) and acute bronchitis/bronchiolitis (OR 0.92; 95% CI: 0.88-0.96) on multivariable analysis, with estimates representing the mean annual change. CONCLUSIONS: GP registrars' prescribing for URTI and acute bronchitis/bronchiolitis declined over the 10-year period. Prescribing for acute bronchitis/bronchiolitis, however, remains higher than recommended benchmarks. Continued education and programme-level antibiotic stewardship interventions are required to further reduce registrars' antibiotic prescribing for acute bronchitis/bronchiolitis to appropriate levels.

It is well known that antibiotic consumption can cause antibiotic resistance. Most antibiotic prescribing happens in general practice. The common cold (upper respiratory tract infections) and cough (acute bronchitis) are 2 conditions that antibiotics are often prescribed for, but are not needed. There is considerable evidence that antibiotics do not help these conditions improve, and guidelines in Australia state that they are not a treatment option. General practitioners at the beginning of their career form prescribing habits early on. In light of the problem of antibiotic resistance, it is important to know how new doctors prescribe antibiotics, as they may do this for the rest of their career. We investigated their prescribing for the common cold and cough, from 2010 to 2019. We found that overall their prescribing has been declining over the last 10 years, but prescribing for cough is still too high. There needs to be more interventions in this group of doctors to reduce prescribing for this condition.