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Use of antibiotics by primary care doctors in Hong Kong

Use of antibiotics by primary care doctors in Hong Kong Objectives: To determine the use of antibiotics by primary care doctors. Methods: General practitioners in Hong Kong were invited to fill in a short questionnaire on every patient with infection that they had seen on the first full working day once every three months for four consecutive quarters starting from December 2005. Results: Forty six primary care doctors took part and a total of 3096 completed questionnaires were returned. The top three diagnoses were upper respiratory tract infection (46.7%), gastrointestinal infection (8.2%) and pharyngitis (7.1%). Thirty percent of patient encounters with infections were prescribed antibiotics but only 5.2% of patient encounters with upper respiratory tract infection (URTI) were prescribed antibiotics. Amino-penicillins were the most commonly used antibiotics while beta-lactam/beta-lactamase inhibitor combinations (BLBLIs) were the second most commonly used antibiotics and they accounted for 16.5% and 14.0% of all antibiotics used respectively. Of all patients or their carers, those who demanded or wished for antibiotics were far more likely to be prescribed antibiotics (Pearson chi-square test, p < 0.0001). Those patients who were attending the doctors for follow-up consultations were also more likely to be prescribed antibiotics (Pearson chi-square test, p < 0.001). Conclusion: The antibiotic prescribing patterns of primary care doctors in Hong Kong are broadly similar to primary care doctors in other developed countries but a relatively low rate of antibiotics is used for URTI. In the Fifty-eighth World Health Assembly held in May Introduction Overuse of antibiotics is a worldwide phenomenon [1,2] 2005, it was resolved and agreed by more than 60 coun- and it contributes to the emergence of antimicrobial tries that the containment of antimicrobial resistance is an resistance [3-5]. Unnecessary use of antibiotics also leads international goal; however the strategy for doing this has to an increased risk of side effects [6], increased medical not been widely implemented. This assembly urged mem- care costs [7] and medicalising effects [8]. ber states to (a) enhance the rational use of antimicrobial Page 1 of 6 (page number not for citation purposes) Asia Pacific Family Medicine 2009, 8:5 http://www.apfmj.com/content/8/1/5 agents by developing and enforcing national standard All registered medical practitioners in Hong Kong were practice guidelines for common infections, in both the sent invitation letters to participate in the research study public and private health sectors, (b) monitor the use of in October 2005 and 46 primary care doctors agreed to antimicrobial agents regularly, as well as the level of anti- participate. microbial resistance in all relevant sectors, and (c) actively share knowledge and experience about best practices in Participants were requested to fill in a short instrument on promoting the rational use of antimicrobial agents. every patient with infection that they had seen on the first full working day, once every three months for four consec- Most antibiotics are prescribed by primary care doctors. utive quarters starting from December 2005 (i.e. 1 Decem- Many of these are for infections of the respiratory tract [9] ber 2005; 1 March 2006; 1 June 2006; and 1 September despite research studies demonstrating little or no clinical 2006). The instrument consisted of 9 items (Appendix A benefits [10-17]. Studies done by Lam and Lam revealed [see Additional file 1]). Items 1 and 2 gave the demo- that in Hong Kong antibiotics are frequently used for graphical characteristics including gender and age of patients with respiratory tract infections [18]. Many doc- patient, whereas items 3 and 9 specified the nature of the tors in Hong Kong have also acknowledged that they consultation (acute vs. scheduled; the first vs. a later one). might be prescribing antibiotics too often for upper respi- In item 4, respondents were asked to select only the most ratory tract infections (URTI) [19]. Possible reasons for important one from a range of infections as the main diag- this could involve misconceptions about the significance nosis, and space was provided for them to specify other of fever, discoloured sputum or nasal discharge; the pres- infections not listed. Item 6 represented respondent's best ence of tonsillar exudates and/or cervical lymphadenopa- interpretation of patient's expectations for antibiotics thy [18] as indicators of bacterial infections. Patients' whereas item 5 asked if an antibiotic was prescribed and expectations of receiving antibiotics were also cited as a item 7 requested details of the prescribed antibiotic drug major reason for prescribing them [19]. These findings (including name, frequency, dosage, and duration). Item were however based on the primary care doctors' report of 8 explored the factors influencing the choice of antibiotic their clinical behaviours, which may have resulted in an drugs (multiple answers were allowed). All items needed underestimate, or even an overestimate of their use of to be completed for every patient prescribed antibiotics. antibiotics. At present no other current information is For cases where antibiotics were not prescribed, all except available about the actual usage of antibiotics by primary items 7 and 8 should be filled in. The questionnaire was care doctors in Hong Kong. anonymous, yet participants were encouraged to put down their internal reference of patient code number in This study thus represents a step forward in the under- the space provided for the sake of traceability. Participants standing of the use of antibiotics by primary care doctors were also asked to complete a separate form on some of in Hong Kong. It aims to examine the primary care doc- their personal particulars (including age, gender, years of tors' clinical behaviour in the use of antibiotics by detail- clinical practice after graduation, type of practice, and ing the type of antibiotics they use and the illnesses that qualifications). they use them for. A similar study in Scandinavia demon- strated benefit in reducing antibiotic use in that country Data were analyzed using JMP for Windows (Release [20]. 6.0.2). Pearson chi-square test was performed to test for the existence of any association between two ordinal or nominal variables. A p-value < 0.05 was considered statis- Subjects and methods Hong Kong's health care delivery system is structured tically significant. around general family practice, with specialist support available both privately and through public hospitals. Results Western-trained private medical practitioners provide By September 2006, 3096 completed questionnaires had 75% of primary care while public doctors provide 15% been returned by 46 participating primary care doctors. and the rest by other health care providers, such as Tradi- Thirty five doctors returned questionnaires on all the four tional Chinese Medicine practitioners. In 2005, there were days and the remaining 11 doctors participated for 1 to 3 about 10500 registered doctors. It was estimated that days. There were 37 males and 9 females. Their ages more than 5000 doctors worked in the public hospitals ranged from 28–70 years (median 48). They had been in and clinics, and 5000 in the community (including spe- clinical practice for between 2 and 44 years (median cialists and primary care doctors in both groups). Most of 19.5). There were more primary care doctors working in the others probably spent most of their time outside Hong the private than the public sector (95.6% vs. 4.4%). Kong but continued to be registered. There was no sepa- 58.7% of the participants had higher qualifications in rate list of family doctors. Family Medicine/General Practice. Twenty nine (63.0%) participants obtained their primary medical qualification Page 2 of 6 (page number not for citation purposes) Asia Pacific Family Medicine 2009, 8:5 http://www.apfmj.com/content/8/1/5 from Hong Kong, 7 (15.2%) from Europe (including UK scribed antibiotics vs. 26.3% of those who attended for and Ireland), 4 (8.7%) from Australasia, 4 (8.7%) from first consultation for the episode of infective illness (Pear- Mainland China or Taiwan and the rest from other parts son chi-square test, p < 0.001). of the world. Discussion The joint distribution of age and sex of the patient This study aimed to examine the use, and associated deter- encounters reported is shown in Table 1. Of all patient minants of, antibiotic prescribing by primary care doctors encounters, 58.4% were for female patients and 85.5% in Hong Kong. The findings of this study were able to were for acute consultations. The distribution of the ten reveal that while the antibiotic prescribing behaviour of commonest diagnoses is shown in Table 2 and the top primary care doctors in Hong Kong is broadly similar to three were URTI (46.7%), gastrointestinal infection that of developed countries, however, certain aspects of (8.2%), and pharyngitis (7.1%). Thirty percent of patients their antibiotic prescribing are different from those of with infections were prescribed antibiotic therapy (95% other countries. For instance, the antibiotic prescribing CI 0.285–0.317). rate for patients with URTI was only 5.2% and this was sig- nificantly lower than the 44% reported by Petersen & Hay- Of all patients or their carers, three quarters had no expec- ward [21] on antibiotics used by general practitioners in tation of antibiotics by the doctors wherever such an the UK. Furthermore, a relatively new antibiotic, azithro- assessment was possible (Table 3). However, those who mycin, was the ninth most commonly used antibiotic in demanded or wished for antibiotics (17.9% of all this study, and accounted for 3.9% of total antibiotic used patients) were far more likely to be prescribed antibiotics but it was outside of the top 20 antibiotics used in (Pearson chi-square test, p < 0.0001). Petersen & Hayward's study. This showed that some pri- mary care doctors in Hong Kong are more ready to use Table 4 shows the 10 most frequently prescribed antibiot- newer generations of antibiotics than their UK counter- ics by primary care doctors. Amino-penicillins and beta- parts. This pattern of antibiotic use is worthy of special lactam/beta-lactamase inhibitor combinations (BLBLIs) attention from the health authority and may have contrib- were by far the two most commonly prescribed antibiotics uted to put Hong Kong being in the forefront of antibiotic and they accounted for 16.5% and 14.0% of all antibiotics resistance [22]. used respectively. A relatively new antibiotic, azithromy- cin, accounted for 3.9% of all antibiotics used. It is also interesting to note the close relationship between patients' or carers' expectation of antibiotics and the issue It was also found that 47.2% of patients who attended fol- of "nonpharmacological" prescriptions. This confirms the low up consultations for their infective illnesses were pre- previous findings by Lam and Lam [19] and highlights the importance of factors, other than medical, for the inap- Table 1: Age distribution of patients reported propriate use of antibiotics worldwide [23]. Age Females (%) Males (%) The fact that patients who were being seen again for the same episode of infective illness were more likely to be 0–5 131 (4.2%) 138 (4.5%) prescribed antibiotics could be due to the more serious nature of the infections and/or doctors' concern about the 6–14 129 (4.2%) 135 (4.4%) deterioration of patients' conditions. However, it could also represent the strategy adopted by many primary care 15–20 80 (2.6%) 63 (2.0%) doctors in reducing antibiotic use when they specifically 21–30 366 (11.8%) 182 (5.9%) asked patients to return only if their conditions did not improve. 31–40 419 (13.5%) 216 (7.0%) It is interesting to note that the top 5 conditions that anti- 41–50 276 (8.9%) 202 (6.5%) biotics were most frequently prescribed for in our study were, in descending order, urinary tract infection (91.3%), 51–60 153 (4.9%) 148 (4.8%) conjunctivitis (90.8%), skin and soft tissue infection (81.2%), tonsillitis (79.7%) and sinusitis (76.9%). The 61–70 105 (3.4%) 84 (2.7%) results are quite similar to a large study done in the UK [21] where their findings were impetigo (90.7%), con- Over 70 144 (4.7%) 93 (3.0%) junctivitis (85.4%), sinusitis (84.9%), urinary tract infec- tion (83.4%), lower respiratory tract infection (82.4%). Missing 32 (1.0%) Page 3 of 6 (page number not for citation purposes) Asia Pacific Family Medicine 2009, 8:5 http://www.apfmj.com/content/8/1/5 Table 2: Top 10 diagnoses made by the primary care doctors Diagnosis Number of patients not prescribed antibiotics Number of patients prescribed antibiotics (%) (%) Unspecified upper respiratory tract infection 1372 (94.8%) 75 (5.2%) (URTI) Gastrointestinal infection 241 (94.5%) 14 (5.5%) Pharyngitis 106 (48.0%) 115 (52.0%) Acute bronchitis 70 (38.3%) 113 (61.8%) Skin and soft tissue infection (including 34 (18.8%) 147 (81.2%) erysipelas, cellulitis, abscess, and wound infection) Urinary tract infection 9 (8.7%) 94 (91.3%) Tonsillitis 14 (20.3%) 55 (79.7%) Conjunctivitis 6 (9.2%) 59 (90.8%) Acute infection exacerbating a chronic 11 (26.2%) 31 (73.8%) pulmonary disease Sinusitis 9 (23.1%) 30 (76.9%) doctors unless direct access to patients' medical records is Limitations The participating doctors of this study belong to a volun- allowed. The fact that over 3000 questionnaires were com- teer group of primary care physicians in Hong Kong. Their pleted for this study would make it the biggest of its kind reported prescribing behaviour may be different from in Hong Kong thus far. their usual practice and hence this may have affected the accuracy of our findings. However, it was emphasized to Conclusion the participants that we would like their prescribing The antibiotic prescribing behaviour of primary care doc- behaviour on the reporting days to be the same as other tors in Hong Kong is similar to that of the developed days. There are no reasons to suspect that they might have countries but a relatively low rate of antibiotics is used for reported more socially desirable prescribing behaviour as URTI. their participation was entirely voluntary. Since Hong Kong, like most countries in Asia, does not have a govern- Competing interests ment funded pharmaceutical scheme, studies of this kind The authors declare that they have no competing interests. would have to depend on the reporting behaviour of the Table 3: Patients' or carers' expectation of antibiotics Expectation Patients' or carers' expectation of antibiotics in Number of patients not prescribed Number of patients prescribed number (% of total) antibiotics (%) antibiotics (%) Demanded 71(2.5%) 5 (7.0%) 66 (93.0%) Wished for 432 (15.4%) 72 (16.7%) 360 (83.3%) Neutral 2106 (75.1%) 1622 (77.0%) 484 (23.0%) Reluctant 182 (6.5%) 175 (96.2%) 7 (3.8%) Resisted 12 (0.4%) 12 (100.0%) 0 (0.0%) Page 4 of 6 (page number not for citation purposes) Asia Pacific Family Medicine 2009, 8:5 http://www.apfmj.com/content/8/1/5 Table 4: Top 10 antibiotics prescribed by the primary care doctors Antibiotics* Number of patients prescribed the antibiotics Percentage of patients prescribed the antibiotics Aminopenicillins† 153 16.5% BLBLIs‡ 130 14.0% Clarithromycin 68 7.3% Chloramphenicol 57 6.2% Cefuroxime 40 4.3% Metronidazole 39 4.2% Erthromycin 37 4.0% Levofloxacin 37 4.0% Azithromycin 36 3.9% Ampicillin plus cloxacillin 35 3.8% * These ten antibiotics together account for 68.2% of the total antibiotic use † Including ampicillin and amoxicillin ‡ BLBLI, beta-lactam and beta-lactamase inhibitor combinations including amoxicillin-clavulanate and ampicillin-sulbactam Authors' contributions References 1. Arroll B, Goodyear-Smith F: General practitioner management TPL was the principal investigator of the study and of upper respiratory tract infections: when are antibiotics involved in designing the study, supervising the data col- prescribed? New Zealand Medical Journal 2000, 113(1122):493-496. lection, reviewing/analyzing the data and writing the 2. Wang EE, Einarson TR, Kellner JD, Conly JM: Antibiotics prescrib- ing for Canadian preschool children: evidence of overpre- paper. PLH was involved in conceiving/initiating and scribing for viral respiratory infections. Clinical Infectious Disease designing the study, and writing the paper. KFL was 1999, 29(1):155-160. involved in designing the study and did the statistical 3. Chung A, Perera R, Brueggemann A, Elamin AE, Harnden A, Mayon- White R, Smith S, Crook DW, Mant D: Effect of antibiotic pre- analyses and contributed to the interpretation of data and scribing on antibiotic resistance in individual children in pri- writing the paper. KC and RY was involved in designing mary care: prospective cohort study. BMJ 2007, 335(7617):429. the study and writing the paper. All authors read and 4. Belongia EA, Schwartz B: Strategies for promoting judicious use approved the final manuscript. of antibiotics by doctors and patients. BMJ 1998, 317:668-671. 5. Seppala H, Klaukka T, Vuopio-Varkula J, Muotiala A, Helenius H, Lager K, Huovinen P: The effect of changes in the consumption of Additional material macrolide antibiotics on erythromycin resistance in group A streptococci in Finland. N Eng J Med 1997, 337:441-446. 6. Arroll B, Kenealy T: Antibiotics for the common cold. Cochrane Additional file 1 Database Syst Rev 2000:CD000247. 7. Mainous AG III, Hueston WJ: The cost of antibiotics in treating Appendix A – Instrument for the study on use of antibiotics by primary upper respiratory tract infections in a Medicaid population. care doctors in Hong Kong. The sample instrument sent to the partici- Arch Fam Med 1999, 7:45-49. pating doctors in the study 8. Little P, Gould C, Williamsen I, Warner G, Gantly M, Kinmonth AL: Click here for file Reattendance and complications in a randomised trial of [http://www.biomedcentral.com/content/supplementary/1447- prescribing strategies for sore throat: the medicalising effect of prescribing antibiotics. BMJ 1997, 315:350-352. 056X-8-5-S1.doc] 9. De Melker RA, Kuyvenhoven MM: Management of upper respi- ratory tract infections in Dutch family practice. J Fam Pract 1994, 38:353-357. 10. Little P, Williamson I, Warner G, Gould C, Gantley M, Kinmonth AL: Open randomised trial of prescribing strategies in managing Acknowledgements sore thoat. BMJ 1997, 314:722-727. This work was made possible by a grant from the Research and Conference 11. Orr PH, Scherer K, MacDonald A, Moffatt ME: Randomized pla- Grants of the University of Hong Kong. All the doctors who took the time cebo-controlled trials of antibiotics for acute bronchitis: a critical review of the literature. J Fam Pract 1993, 36:507-512. to participate in this study are also most gratefully acknowledged. 12. Gonzales R, Sande M: What will it take to stop physicians from prescribing antibiotics in acute bronchitis? Lancet 1995, 345:665-666. Page 5 of 6 (page number not for citation purposes) Asia Pacific Family Medicine 2009, 8:5 http://www.apfmj.com/content/8/1/5 13. Verjeij TJ, Hermans J, Mulder JD: Effects of doxycycline in patients with acute cough and purulent sputum: a double- blind, placebo-controlled trial. Br J Gen Pract 1994, 44(386):400-404. 14. Del Mar C: Prescribing antibiotics in primary care. BMJ 2007, 335:407-408. 15. King DE, Williams WC, Bishop L, Shechter A: Effectiveness of erythromycin in the treatment of acute bronchitis. J Fam Pract 1996, 42:601-605. 16. Heikkinen T, Ruuskanen O, Ziegler T, Waris M, Puhakka H: Short- term use of amoxicillin-clavulanate during upper respiratory tract infection for prevention of acute otitis media. J Paediatr 1995, 126:313-316. 17. Kaiser L, Lew D, Hirschel B, Auckenthaler R, Morabia A, Heald A, Benedict P, Terrier F, Wunderli W, Matter L, Germann D, Voegeli J, Stalder H: Effects of antibiotic treatment in the subset of com- mon-cold patients who have bacteria in nasopharyngeal secretions. Lancet 1996, 347:1507-1510. 18. Lam TP, Lam KF: Why do family doctors prescribe antibiotics for upper respiratory tract infection? International Journal of Clin- ical Practice 2003, 57(3):167-169. 19. Lam TP, Lam KF: What are the non-biomedical reasons which make family doctors over-prescribe antibiotics for upper respiratory tract infection in a mixed private/public Asian setting? Journal of Clinical Pharmacy and Therapeutics 2003, 28:197-201. 20. Mikstra Programme – antimicrobial treatment strategies [http://finohta.stakes.fi/EN/mikstra/index.htm] 21. Petersen I, Hayward A, SACAR Surveillance Subgroup: Antibacte- rial prescribing in primary care. J Antimicrob Chemother 2007, 60(Suppl 1):i43-47. 22. Ho PL, Cheung C, Mak GC, Tse CW, Ng TK, Cheung CH, Que TL, Lam R, Lai RW, Yung RW, Yuen KY: Molecular epidemiology and household transmission of community-associated methicil- lin-resistant Staphlococcus aureus in Hong Kong. Diagnostic Microbiology and Infectious Disease 2007, 57(2):145-151. 23. Petursson P: GPs' reasons for "non-pharmacological" pre- scribing of antibiotics. A phenomenological study. Scand J Prim Health Care 2005, 23(2):120-125. Publish with Bio Med Central and every scientist can read your work free of charge "BioMed Central will be the most significant development for disseminating the results of biomedical researc h in our lifetime." Sir Paul Nurse, Cancer Research UK Your research papers will be: available free of charge to the entire biomedical community peer reviewed and published immediately upon acceptance cited in PubMed and archived on PubMed Central yours — you keep the copyright BioMedcentral Submit your manuscript here: http://www.biomedcentral.com/info/publishing_adv.asp Page 6 of 6 (page number not for citation purposes) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Asia Pacific Family Medicine Springer Journals

Use of antibiotics by primary care doctors in Hong Kong

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Springer Journals
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Copyright © 2009 by Lam et al; licensee BioMed Central Ltd.
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Medicine & Public Health; General Practice / Family Medicine; Primary Care Medicine
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1447-056X
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10.1186/1447-056X-8-5
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19460171
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Abstract

Objectives: To determine the use of antibiotics by primary care doctors. Methods: General practitioners in Hong Kong were invited to fill in a short questionnaire on every patient with infection that they had seen on the first full working day once every three months for four consecutive quarters starting from December 2005. Results: Forty six primary care doctors took part and a total of 3096 completed questionnaires were returned. The top three diagnoses were upper respiratory tract infection (46.7%), gastrointestinal infection (8.2%) and pharyngitis (7.1%). Thirty percent of patient encounters with infections were prescribed antibiotics but only 5.2% of patient encounters with upper respiratory tract infection (URTI) were prescribed antibiotics. Amino-penicillins were the most commonly used antibiotics while beta-lactam/beta-lactamase inhibitor combinations (BLBLIs) were the second most commonly used antibiotics and they accounted for 16.5% and 14.0% of all antibiotics used respectively. Of all patients or their carers, those who demanded or wished for antibiotics were far more likely to be prescribed antibiotics (Pearson chi-square test, p < 0.0001). Those patients who were attending the doctors for follow-up consultations were also more likely to be prescribed antibiotics (Pearson chi-square test, p < 0.001). Conclusion: The antibiotic prescribing patterns of primary care doctors in Hong Kong are broadly similar to primary care doctors in other developed countries but a relatively low rate of antibiotics is used for URTI. In the Fifty-eighth World Health Assembly held in May Introduction Overuse of antibiotics is a worldwide phenomenon [1,2] 2005, it was resolved and agreed by more than 60 coun- and it contributes to the emergence of antimicrobial tries that the containment of antimicrobial resistance is an resistance [3-5]. Unnecessary use of antibiotics also leads international goal; however the strategy for doing this has to an increased risk of side effects [6], increased medical not been widely implemented. This assembly urged mem- care costs [7] and medicalising effects [8]. ber states to (a) enhance the rational use of antimicrobial Page 1 of 6 (page number not for citation purposes) Asia Pacific Family Medicine 2009, 8:5 http://www.apfmj.com/content/8/1/5 agents by developing and enforcing national standard All registered medical practitioners in Hong Kong were practice guidelines for common infections, in both the sent invitation letters to participate in the research study public and private health sectors, (b) monitor the use of in October 2005 and 46 primary care doctors agreed to antimicrobial agents regularly, as well as the level of anti- participate. microbial resistance in all relevant sectors, and (c) actively share knowledge and experience about best practices in Participants were requested to fill in a short instrument on promoting the rational use of antimicrobial agents. every patient with infection that they had seen on the first full working day, once every three months for four consec- Most antibiotics are prescribed by primary care doctors. utive quarters starting from December 2005 (i.e. 1 Decem- Many of these are for infections of the respiratory tract [9] ber 2005; 1 March 2006; 1 June 2006; and 1 September despite research studies demonstrating little or no clinical 2006). The instrument consisted of 9 items (Appendix A benefits [10-17]. Studies done by Lam and Lam revealed [see Additional file 1]). Items 1 and 2 gave the demo- that in Hong Kong antibiotics are frequently used for graphical characteristics including gender and age of patients with respiratory tract infections [18]. Many doc- patient, whereas items 3 and 9 specified the nature of the tors in Hong Kong have also acknowledged that they consultation (acute vs. scheduled; the first vs. a later one). might be prescribing antibiotics too often for upper respi- In item 4, respondents were asked to select only the most ratory tract infections (URTI) [19]. Possible reasons for important one from a range of infections as the main diag- this could involve misconceptions about the significance nosis, and space was provided for them to specify other of fever, discoloured sputum or nasal discharge; the pres- infections not listed. Item 6 represented respondent's best ence of tonsillar exudates and/or cervical lymphadenopa- interpretation of patient's expectations for antibiotics thy [18] as indicators of bacterial infections. Patients' whereas item 5 asked if an antibiotic was prescribed and expectations of receiving antibiotics were also cited as a item 7 requested details of the prescribed antibiotic drug major reason for prescribing them [19]. These findings (including name, frequency, dosage, and duration). Item were however based on the primary care doctors' report of 8 explored the factors influencing the choice of antibiotic their clinical behaviours, which may have resulted in an drugs (multiple answers were allowed). All items needed underestimate, or even an overestimate of their use of to be completed for every patient prescribed antibiotics. antibiotics. At present no other current information is For cases where antibiotics were not prescribed, all except available about the actual usage of antibiotics by primary items 7 and 8 should be filled in. The questionnaire was care doctors in Hong Kong. anonymous, yet participants were encouraged to put down their internal reference of patient code number in This study thus represents a step forward in the under- the space provided for the sake of traceability. Participants standing of the use of antibiotics by primary care doctors were also asked to complete a separate form on some of in Hong Kong. It aims to examine the primary care doc- their personal particulars (including age, gender, years of tors' clinical behaviour in the use of antibiotics by detail- clinical practice after graduation, type of practice, and ing the type of antibiotics they use and the illnesses that qualifications). they use them for. A similar study in Scandinavia demon- strated benefit in reducing antibiotic use in that country Data were analyzed using JMP for Windows (Release [20]. 6.0.2). Pearson chi-square test was performed to test for the existence of any association between two ordinal or nominal variables. A p-value < 0.05 was considered statis- Subjects and methods Hong Kong's health care delivery system is structured tically significant. around general family practice, with specialist support available both privately and through public hospitals. Results Western-trained private medical practitioners provide By September 2006, 3096 completed questionnaires had 75% of primary care while public doctors provide 15% been returned by 46 participating primary care doctors. and the rest by other health care providers, such as Tradi- Thirty five doctors returned questionnaires on all the four tional Chinese Medicine practitioners. In 2005, there were days and the remaining 11 doctors participated for 1 to 3 about 10500 registered doctors. It was estimated that days. There were 37 males and 9 females. Their ages more than 5000 doctors worked in the public hospitals ranged from 28–70 years (median 48). They had been in and clinics, and 5000 in the community (including spe- clinical practice for between 2 and 44 years (median cialists and primary care doctors in both groups). Most of 19.5). There were more primary care doctors working in the others probably spent most of their time outside Hong the private than the public sector (95.6% vs. 4.4%). Kong but continued to be registered. There was no sepa- 58.7% of the participants had higher qualifications in rate list of family doctors. Family Medicine/General Practice. Twenty nine (63.0%) participants obtained their primary medical qualification Page 2 of 6 (page number not for citation purposes) Asia Pacific Family Medicine 2009, 8:5 http://www.apfmj.com/content/8/1/5 from Hong Kong, 7 (15.2%) from Europe (including UK scribed antibiotics vs. 26.3% of those who attended for and Ireland), 4 (8.7%) from Australasia, 4 (8.7%) from first consultation for the episode of infective illness (Pear- Mainland China or Taiwan and the rest from other parts son chi-square test, p < 0.001). of the world. Discussion The joint distribution of age and sex of the patient This study aimed to examine the use, and associated deter- encounters reported is shown in Table 1. Of all patient minants of, antibiotic prescribing by primary care doctors encounters, 58.4% were for female patients and 85.5% in Hong Kong. The findings of this study were able to were for acute consultations. The distribution of the ten reveal that while the antibiotic prescribing behaviour of commonest diagnoses is shown in Table 2 and the top primary care doctors in Hong Kong is broadly similar to three were URTI (46.7%), gastrointestinal infection that of developed countries, however, certain aspects of (8.2%), and pharyngitis (7.1%). Thirty percent of patients their antibiotic prescribing are different from those of with infections were prescribed antibiotic therapy (95% other countries. For instance, the antibiotic prescribing CI 0.285–0.317). rate for patients with URTI was only 5.2% and this was sig- nificantly lower than the 44% reported by Petersen & Hay- Of all patients or their carers, three quarters had no expec- ward [21] on antibiotics used by general practitioners in tation of antibiotics by the doctors wherever such an the UK. Furthermore, a relatively new antibiotic, azithro- assessment was possible (Table 3). However, those who mycin, was the ninth most commonly used antibiotic in demanded or wished for antibiotics (17.9% of all this study, and accounted for 3.9% of total antibiotic used patients) were far more likely to be prescribed antibiotics but it was outside of the top 20 antibiotics used in (Pearson chi-square test, p < 0.0001). Petersen & Hayward's study. This showed that some pri- mary care doctors in Hong Kong are more ready to use Table 4 shows the 10 most frequently prescribed antibiot- newer generations of antibiotics than their UK counter- ics by primary care doctors. Amino-penicillins and beta- parts. This pattern of antibiotic use is worthy of special lactam/beta-lactamase inhibitor combinations (BLBLIs) attention from the health authority and may have contrib- were by far the two most commonly prescribed antibiotics uted to put Hong Kong being in the forefront of antibiotic and they accounted for 16.5% and 14.0% of all antibiotics resistance [22]. used respectively. A relatively new antibiotic, azithromy- cin, accounted for 3.9% of all antibiotics used. It is also interesting to note the close relationship between patients' or carers' expectation of antibiotics and the issue It was also found that 47.2% of patients who attended fol- of "nonpharmacological" prescriptions. This confirms the low up consultations for their infective illnesses were pre- previous findings by Lam and Lam [19] and highlights the importance of factors, other than medical, for the inap- Table 1: Age distribution of patients reported propriate use of antibiotics worldwide [23]. Age Females (%) Males (%) The fact that patients who were being seen again for the same episode of infective illness were more likely to be 0–5 131 (4.2%) 138 (4.5%) prescribed antibiotics could be due to the more serious nature of the infections and/or doctors' concern about the 6–14 129 (4.2%) 135 (4.4%) deterioration of patients' conditions. However, it could also represent the strategy adopted by many primary care 15–20 80 (2.6%) 63 (2.0%) doctors in reducing antibiotic use when they specifically 21–30 366 (11.8%) 182 (5.9%) asked patients to return only if their conditions did not improve. 31–40 419 (13.5%) 216 (7.0%) It is interesting to note that the top 5 conditions that anti- 41–50 276 (8.9%) 202 (6.5%) biotics were most frequently prescribed for in our study were, in descending order, urinary tract infection (91.3%), 51–60 153 (4.9%) 148 (4.8%) conjunctivitis (90.8%), skin and soft tissue infection (81.2%), tonsillitis (79.7%) and sinusitis (76.9%). The 61–70 105 (3.4%) 84 (2.7%) results are quite similar to a large study done in the UK [21] where their findings were impetigo (90.7%), con- Over 70 144 (4.7%) 93 (3.0%) junctivitis (85.4%), sinusitis (84.9%), urinary tract infec- tion (83.4%), lower respiratory tract infection (82.4%). Missing 32 (1.0%) Page 3 of 6 (page number not for citation purposes) Asia Pacific Family Medicine 2009, 8:5 http://www.apfmj.com/content/8/1/5 Table 2: Top 10 diagnoses made by the primary care doctors Diagnosis Number of patients not prescribed antibiotics Number of patients prescribed antibiotics (%) (%) Unspecified upper respiratory tract infection 1372 (94.8%) 75 (5.2%) (URTI) Gastrointestinal infection 241 (94.5%) 14 (5.5%) Pharyngitis 106 (48.0%) 115 (52.0%) Acute bronchitis 70 (38.3%) 113 (61.8%) Skin and soft tissue infection (including 34 (18.8%) 147 (81.2%) erysipelas, cellulitis, abscess, and wound infection) Urinary tract infection 9 (8.7%) 94 (91.3%) Tonsillitis 14 (20.3%) 55 (79.7%) Conjunctivitis 6 (9.2%) 59 (90.8%) Acute infection exacerbating a chronic 11 (26.2%) 31 (73.8%) pulmonary disease Sinusitis 9 (23.1%) 30 (76.9%) doctors unless direct access to patients' medical records is Limitations The participating doctors of this study belong to a volun- allowed. The fact that over 3000 questionnaires were com- teer group of primary care physicians in Hong Kong. Their pleted for this study would make it the biggest of its kind reported prescribing behaviour may be different from in Hong Kong thus far. their usual practice and hence this may have affected the accuracy of our findings. However, it was emphasized to Conclusion the participants that we would like their prescribing The antibiotic prescribing behaviour of primary care doc- behaviour on the reporting days to be the same as other tors in Hong Kong is similar to that of the developed days. There are no reasons to suspect that they might have countries but a relatively low rate of antibiotics is used for reported more socially desirable prescribing behaviour as URTI. their participation was entirely voluntary. Since Hong Kong, like most countries in Asia, does not have a govern- Competing interests ment funded pharmaceutical scheme, studies of this kind The authors declare that they have no competing interests. would have to depend on the reporting behaviour of the Table 3: Patients' or carers' expectation of antibiotics Expectation Patients' or carers' expectation of antibiotics in Number of patients not prescribed Number of patients prescribed number (% of total) antibiotics (%) antibiotics (%) Demanded 71(2.5%) 5 (7.0%) 66 (93.0%) Wished for 432 (15.4%) 72 (16.7%) 360 (83.3%) Neutral 2106 (75.1%) 1622 (77.0%) 484 (23.0%) Reluctant 182 (6.5%) 175 (96.2%) 7 (3.8%) Resisted 12 (0.4%) 12 (100.0%) 0 (0.0%) Page 4 of 6 (page number not for citation purposes) Asia Pacific Family Medicine 2009, 8:5 http://www.apfmj.com/content/8/1/5 Table 4: Top 10 antibiotics prescribed by the primary care doctors Antibiotics* Number of patients prescribed the antibiotics Percentage of patients prescribed the antibiotics Aminopenicillins† 153 16.5% BLBLIs‡ 130 14.0% Clarithromycin 68 7.3% Chloramphenicol 57 6.2% Cefuroxime 40 4.3% Metronidazole 39 4.2% Erthromycin 37 4.0% Levofloxacin 37 4.0% Azithromycin 36 3.9% Ampicillin plus cloxacillin 35 3.8% * These ten antibiotics together account for 68.2% of the total antibiotic use † Including ampicillin and amoxicillin ‡ BLBLI, beta-lactam and beta-lactamase inhibitor combinations including amoxicillin-clavulanate and ampicillin-sulbactam Authors' contributions References 1. Arroll B, Goodyear-Smith F: General practitioner management TPL was the principal investigator of the study and of upper respiratory tract infections: when are antibiotics involved in designing the study, supervising the data col- prescribed? New Zealand Medical Journal 2000, 113(1122):493-496. lection, reviewing/analyzing the data and writing the 2. Wang EE, Einarson TR, Kellner JD, Conly JM: Antibiotics prescrib- ing for Canadian preschool children: evidence of overpre- paper. PLH was involved in conceiving/initiating and scribing for viral respiratory infections. Clinical Infectious Disease designing the study, and writing the paper. KFL was 1999, 29(1):155-160. involved in designing the study and did the statistical 3. Chung A, Perera R, Brueggemann A, Elamin AE, Harnden A, Mayon- White R, Smith S, Crook DW, Mant D: Effect of antibiotic pre- analyses and contributed to the interpretation of data and scribing on antibiotic resistance in individual children in pri- writing the paper. KC and RY was involved in designing mary care: prospective cohort study. BMJ 2007, 335(7617):429. the study and writing the paper. All authors read and 4. Belongia EA, Schwartz B: Strategies for promoting judicious use approved the final manuscript. of antibiotics by doctors and patients. BMJ 1998, 317:668-671. 5. Seppala H, Klaukka T, Vuopio-Varkula J, Muotiala A, Helenius H, Lager K, Huovinen P: The effect of changes in the consumption of Additional material macrolide antibiotics on erythromycin resistance in group A streptococci in Finland. N Eng J Med 1997, 337:441-446. 6. Arroll B, Kenealy T: Antibiotics for the common cold. Cochrane Additional file 1 Database Syst Rev 2000:CD000247. 7. Mainous AG III, Hueston WJ: The cost of antibiotics in treating Appendix A – Instrument for the study on use of antibiotics by primary upper respiratory tract infections in a Medicaid population. care doctors in Hong Kong. The sample instrument sent to the partici- Arch Fam Med 1999, 7:45-49. pating doctors in the study 8. Little P, Gould C, Williamsen I, Warner G, Gantly M, Kinmonth AL: Click here for file Reattendance and complications in a randomised trial of [http://www.biomedcentral.com/content/supplementary/1447- prescribing strategies for sore throat: the medicalising effect of prescribing antibiotics. BMJ 1997, 315:350-352. 056X-8-5-S1.doc] 9. De Melker RA, Kuyvenhoven MM: Management of upper respi- ratory tract infections in Dutch family practice. J Fam Pract 1994, 38:353-357. 10. Little P, Williamson I, Warner G, Gould C, Gantley M, Kinmonth AL: Open randomised trial of prescribing strategies in managing Acknowledgements sore thoat. BMJ 1997, 314:722-727. This work was made possible by a grant from the Research and Conference 11. Orr PH, Scherer K, MacDonald A, Moffatt ME: Randomized pla- Grants of the University of Hong Kong. All the doctors who took the time cebo-controlled trials of antibiotics for acute bronchitis: a critical review of the literature. J Fam Pract 1993, 36:507-512. to participate in this study are also most gratefully acknowledged. 12. Gonzales R, Sande M: What will it take to stop physicians from prescribing antibiotics in acute bronchitis? Lancet 1995, 345:665-666. Page 5 of 6 (page number not for citation purposes) Asia Pacific Family Medicine 2009, 8:5 http://www.apfmj.com/content/8/1/5 13. Verjeij TJ, Hermans J, Mulder JD: Effects of doxycycline in patients with acute cough and purulent sputum: a double- blind, placebo-controlled trial. Br J Gen Pract 1994, 44(386):400-404. 14. Del Mar C: Prescribing antibiotics in primary care. BMJ 2007, 335:407-408. 15. King DE, Williams WC, Bishop L, Shechter A: Effectiveness of erythromycin in the treatment of acute bronchitis. J Fam Pract 1996, 42:601-605. 16. Heikkinen T, Ruuskanen O, Ziegler T, Waris M, Puhakka H: Short- term use of amoxicillin-clavulanate during upper respiratory tract infection for prevention of acute otitis media. J Paediatr 1995, 126:313-316. 17. Kaiser L, Lew D, Hirschel B, Auckenthaler R, Morabia A, Heald A, Benedict P, Terrier F, Wunderli W, Matter L, Germann D, Voegeli J, Stalder H: Effects of antibiotic treatment in the subset of com- mon-cold patients who have bacteria in nasopharyngeal secretions. Lancet 1996, 347:1507-1510. 18. Lam TP, Lam KF: Why do family doctors prescribe antibiotics for upper respiratory tract infection? International Journal of Clin- ical Practice 2003, 57(3):167-169. 19. Lam TP, Lam KF: What are the non-biomedical reasons which make family doctors over-prescribe antibiotics for upper respiratory tract infection in a mixed private/public Asian setting? Journal of Clinical Pharmacy and Therapeutics 2003, 28:197-201. 20. Mikstra Programme – antimicrobial treatment strategies [http://finohta.stakes.fi/EN/mikstra/index.htm] 21. Petersen I, Hayward A, SACAR Surveillance Subgroup: Antibacte- rial prescribing in primary care. J Antimicrob Chemother 2007, 60(Suppl 1):i43-47. 22. Ho PL, Cheung C, Mak GC, Tse CW, Ng TK, Cheung CH, Que TL, Lam R, Lai RW, Yung RW, Yuen KY: Molecular epidemiology and household transmission of community-associated methicil- lin-resistant Staphlococcus aureus in Hong Kong. Diagnostic Microbiology and Infectious Disease 2007, 57(2):145-151. 23. Petursson P: GPs' reasons for "non-pharmacological" pre- scribing of antibiotics. A phenomenological study. Scand J Prim Health Care 2005, 23(2):120-125. 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Asia Pacific Family MedicineSpringer Journals

Published: May 22, 2009

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