Education for Primary Care (2013) 24: 291-93 2013 Radcliffe Publishing Limited

Factors influencing inappropriate

antibiotic prescription in Europe
John Oxford
Professor of Virology, Centre for Immunology and Infectious Disease, Blizard Institute, Barts;
London School of Medicine and Dentistry, Queen Mary University of London, UK; Scientific Director,
Retroscreen Virology Ltd, London, UK
Herman Goossens
Professor of Medical Microbiology, University Hospital Antwerp and VAXINFECTIO, Antwerp,
Belgium
Michael Schedler
ENT specialist, Ramstein, Germany
Armine Sefton
Professor of Clinioal Microbiology, Centre for Immunology and Infectious Disease, Blizard Institute,
Barts and the London School of Medicine and Dentistry, Queen Mary University of London, UK
Aurelio Sesisa
General Practitioner, Regional President (Lombardy), Italian College of General Practitioners (SIMG),
Florence, Italy
Alike van der Velden
Assistant Professor, Julius Center for Health Sciences and Primary Care, University Medical Center
Utrecht, Utrecht, The Netherlands
Keywords: antibiotic prescribing, behaviour change, medical education
In 1942, Anne Miller became the first person to have
her life saved by penicillin. Seventy years later, the
development of antibiotic resistance threatens to
render some bacterial infections untreatable. Every
year up to 400 000 patients within the European
Union (EU) contract infections that are resistant
to multiple antibiotics and significant resistance
to last-line antibiotics is beginning to emerge in
several countries.' It is estimated that complications
associated with antibiotic resistance have an
estimated annual cost within Europe of 9 billion.^
Qveruse and misuse of antibiotics are key reasons
for the development of antibiotic resistance.^
Alexander Fleming predicted these issues on receipt
of the Nobel Prize for Medicine in 1945 when he
stated that, 'The time may come when penicillin can
be bought by anyone... Then there is the danger
that... under-dosing will expose microbes to non-
lethal quantities of the drug, making them resistant'.
Antibiotic resistance rates vary greatly between,
and even within, different European countries, both
in terms of levels as well as individual bacterial
strains.''^ There is an over-riding correlation
between high levels of antibiotic resistance and
high levels of antibiotic use. Upper respiratory tract
infections (URTIs), in particular flu, the common
cold, sinusitis, cough and sore throat, are common
reasons why European patients take antibiotics.^
However, prescriptions for these indications are
often inappropriate; for example, only 20% of
sore throats are caused by bacterial infections.'
As a large number of antibiotics are prescribed for
viral URTIs, and antibiotics are only available on
prescription from a physician, or in some countries
over-the-counter (QTC) from a pharmacist,^ it can be
concluded that European healthcare professionals
provide inappropriate access to antibiotics.
Establishing why this occurs and hov^ to manage
contributing factors are key steps to address the
serious problem of antibiotic resistance.
Physicians often face significant external
pressures to prescribe antibiotics. One major driver
is patient demand,^'" with many patients feeling
dissatisfied if they leave the consultation room
292 J Oxford, H Goossens, M Schedler ef al
without a prescription for antibiotics. Despite being
aware of problems associated with inappropriate
prescribing, as well as treatment guidelines from
their own professional group, patient pressure and
lack of suitable alternatives lead doctors to prescribe
antibiotics against their better judgement. This
pressure can include explicit requests, appeals to
non-medical circumstances, accounts of previous
consultations and self-diagnoses. Within the
constraints of consultations that may last only 2-3
minutes, detailed explanations of why prescribing an
antibiotic is inappropriate for self-limiting conditions
is challenging, particularly when doctors want to
maintain good relationships with their patients.
Diagnostic uncertainty is another factor that
contributes to inappropriate prescription of
antibiotics. Although severe complications from
URTIs are rare in most developed countries, doctors
may still fear a diagnostic error that 'misses' a
bacterial infection, and therefore may favour a
cautious 'safety first' approach to prescribing.
Diagnostic point-of-care tests, such as those
for Strep A and C-reactive protein, can increase
diagnostic certainty and may be used as tools to
communicate the unnecessary need for antibiotics
with patients. Such tests may therefore help reduce
inappropriate prescribing,^' but are, however, not
widely included in national guidelines.
Aside from the physician-patient factors, the
level of communication and co-operation between
physicians, pharmacists, microbiologists and
specialists also has an influence on the level of
inappropriate antibiotic prescribing. Development of
clinical guidelines by different medical disciplines
may improve adherence and therefore reduce levels
of the inappropriate prescription of antibiotics.
The contribution of each factor varies widely
between European countries and depends on the
structure of healthcare provisions and cultural
attitudes. Defining the pressures responsible for
the development of antibiotic resistance is only
half the challenge. Deciding how to most effectively
intervene in order to turn back the clock is crucial.
Since patient pressure is a major driving force
behind inappropriate prescribing, patient education
is essential to reduce the demand for antibiotics.
Results from the Eurobarometer survey suggest
a relationship between the level of consumer
knowledge and the level of prescribing within a
country.'' The position of doctors at the forefront
of healthcare provision and the nature of the
doctor-patient relationship means they are ideally
placed to deliver such messages. Informing and
educating doctors based on guidelines, basic
knowledge of and problems arising from over-
prescription, and improving their communication
skills are essential steps towards more prudent
prescription of antibiotics. Clear messages from
doctors, supported by appropriate printed material
and media campaigns, are important for improving
patient awareness. For example, providing printed
material following consultation can reduce antibiotic
prescribing without reducing patient satisfaction.'^
Furthermore, public awareness campaigns, from
simple internet-based to expensive mass media
campaigns, seem to reduce and contribute to more
careful use of antibiotics within the community; the
most effective form of intervention is yet unclear.^^
It is likely that campaigns and physician education
will need to be tailored to address country-specific
issues and attitudes in order to be successful.
Changing ingrained cultural perceptions may
be difficult to achieve in the short term and will
presumably require interventions where all healthcare
professionals deliver a consistent and comprehensible
message. The fundamental difference between viral
and bacterial infection, the problem of antibiotic
resistance and the self-limitedness of disease are
difficult subjects to convey to the public. Advising
bed rest and analgesia without offering any treatment
requires a cultural change amongst both doctors and
their patients.
More radical proposals of how to address
the problem, such as introducing the topic into
secondary school curricula, lobbying governments
to introduce and enforce legislation prohibiting OTC
selling of antibiotics or introducing restrictions on
the marketing of antibiotics may also be required.
Despite almost 70 years since the first documented
use of antibiotics, the scientific and medical
community is still not sure of the best way to use and
protect antibiotics. Antibiotic resistance is mirrored
by antibiotic prescribing practices, with over-
prescribing of antibiotics by doctors being strongly
influenced by their own knowledge and habits, as
well as by patient, time and economic pressures.
Ultimately, all of the approaches discussed carry
a financial cost that must be addressed at local,
national and international levels. However, the
potentially disastrous public health implications of
failing to preserve the effectiveness of antibiotics
means we must act now.
Acknowledgements
Editorial assistance was provided by Elements
Communications Ltd, which was funded by Reckitt
Benckiser Healthcare International Ltd.
Funding
This study was supported by Reckitt Benckiser
Healthcare International Ltd.
Conflicts of interest
John Oxford has received honoraria for lectures
and scientific advice from Reckitt Benckiser,
GlaxoSmithKline, Novartis and Roche. Armine Sefton
has been an advisor on antimicrobial use for Astellas,
Wyeth and the European Panel for Appropriate Use
of Antimicrobials; obtained sponsorship to run an
Inappropriate antibiotic prescription in Europe 293
annual meeting called 'Topics in Infection' from
Astellas, Novartis, Gilead, Eumedica, Carefusion,
Bruker, Kiestra, GlaxoSmithKline, Merck Sharp and
Dohme and Aventis and received sponsorship from
Pfizer and Astellas to attend meetings. Herman
Goossens, Michael Schedler, Aurelio Sessa and
Alike van der Velden have no conflicts of interest
to declare.
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Correspondence to: Professor John Oxford,
Retroscreen Virology Ltd, New Road, London El
2AX, UK. Tel: +44 (0)207 756 1329; fax: +44 (0)203
070 0086; email: j.oxford@retroscreen.com