General practitioners’ antibiotic prescribing practices in Malta : understanding drivers to inform the implementation of a social marketing behaviour change intervention

Background: Antibiotic resistance is a leading global public health problem and complex challenge. Although a multitude of factors affect its development, antibiotic use is a key driver. In fact, in Europe, a positive correlation between antibiotic use and resistance has been shown. The largest volumes of antibiotics are prescribed in the community setting and respiratory tract infections (RTIs) remain the most common diagnoses despite often being self-limiting. Malta has one of the highest antibiotic consumption rates in Europe with the top two reasons being sore throat and the flu. Since most antibiotics are obtained through a medical prescription, this suggests that antibiotics are overprescribed by doctors, and general practitioners (GPs) in particular are a suitable target group for interventions to improve antibiotic prescribing. However, prescribing decisions are often complex and influenced by numerous interrelated factors. Therefore changing prescribing behaviour first necessitates an in-depth understanding of antibiotic prescribing practices and factors that impact this behaviour. To date, large knowledge gaps remain in Malta which makes the implementation of evidence-based interventions targeting prescribers challenging.

Aim: The aim of this thesis, which forms part of a larger intervention project, was to explore GPs’ views on antibiotic use and resistance in Malta, and to gain a better understanding of their antibiotic prescribing patterns for RTIs including the factors that influence their prescribing behaviour.

Methods: Data were derived from two pre-intervention studies; one qualitative [Papers I & II] and one quantitative [Papers III & IV]. For the qualitative study, individual face-to-face interviews were held in 2014 with a quota sample of 20 GPs. Interviews were audio recorded and transcribed verbatim. Data were analysed iteratively using manifest and latent content analysis [Paper I] and phenomenography [Paper II]. The quantitative study was a repeated cross-sectional surveillance study for which 30 GPs and 3 GP trainees collected monthly data for all patients with an acute respiratory tract complaint during predetermined one week periods between May 2015 and April 2016. Descriptive statistics were used to examine patient, consultation and clinical characteristics, and to describe GPs’ prescribing patterns [Paper III]. In Paper IV, the association between GP-, practice- and consultation-level factors, patient sociodemographic factors and patient health status factors, and antibiotic prescription (yes/no) was investigated using generalised estimating equations to estimate population-averaged effects.

Key findings: GPs’ provided an antibiotic prescription to 45.7% of cases, the majority of which (99.6%) were broad-spectrum. Almost all (84.3%) were for immediate use, whilst 15.7% were delayed prescriptions. Through qualitative interviews five qualitatively different ways by which GPs perceived delayed antibiotic prescribing were described: (i) to maintain a good GP-patient relationship, retain patients and avoid doctor-shopping, (ii) to reach a compromise and provide treatment just in case, (iii) to provide the patient comfort and reassurance, (iv) to empower and educate patients, and limit antibiotic use, and (v) to retain GP responsibility by employing a wait-and-see approach. Surveillance data also revealed that GPs’ antibiotic prescribing is associated with a number of GP-, patient-, clinical- and consultation-level factors. This was largely corroborated by qualitative evidence that showed that antibiotic prescribing is impacted not only by intrinsic GP factors but several other factors, including but not limited to, diagnostic uncertainty, patient demand, interaction with drug reps, availability of guidelines and community resistance data, and access to diagnostic testing.

Conclusions: GPs’ antibiotic prescribing for RTIs in Malta is high. The abundant use of broad-spectrum antibiotics is of particular concern and indicates that antibiotics are not being used appropriately. A number of factors were found to impact GPs’ antibiotic prescribing behaviour. In order to improve this behaviour, targeted and coordinated implementation activities must address barriers identified at all levels of the system and provide GPs with the necessary tools to alleviate diagnostic uncertainty.

List of scientific papers

I. Saliba-Gustafsson EA, Nyberg A, Borg MA, Rosales-Klintz S, Stålsby Lundborg C. General practitioners’ understanding of antibiotic use and resistance, and perceived barriers and facilitators to prudent antibiotic prescribing: a qualitative study. [Manuscript]

II. Saliba-Gustafsson EA, Röing M, Borg MA, Rosales-Klintz S, Stålsby Lundborg C. General practitioners’ perceptions of delayed antibiotic prescription for respiratory tract infections: a phenomenographic study. PLoS One. 2019, 14(11): e0225506.
https://doi.org/10.1371/journal.pone.0225506

III. Saliba-Gustafsson EA, Dunberger Hampton A, Zarb P, Borg MA, Stålsby Lundborg C. Antibiotic prescribing for respiratory tract complaints in Malta: a 1 year repeated cross-sectional surveillance study. J Antimicrob Chemother. 2019, 74(4): 1116-24.
https://doi.org/10.1093/jac/dky544

IV. Saliba-Gustafsson EA, Dunberger Hampton A, Zarb P, Orsini N, Borg MA, Stålsby Lundborg C. Factors associated with antibiotic prescribing in patients with acute respiratory tract complaints in Malta: a 1-year repeated cross-sectional surveillance study. BMJ Open. 2019, 9(12): e032704.
https://doi.org/10.1136/bmjopen-2019-032704