Awareness of antibiotic resistance and antibiotic prescribing in UTI treatment: A qualitative study among primary care physicians in Sweden

Figures & data

Table I. Gender, age, and geographical distribution of the GPs interviewed.

Characteristics
Gender	Women	Men	Total
Age
31–40	2	1	3
41–50	4	5	9
51–60	2	5	7
61–70	–	1	1
Geographical location
Rural area	4	5	9
Urban area	4	7	11
Total	8	12	20

Table II. Interview guide.

Area	Introductory questions	Probing questions
Introduction	Could you please think of a patient with uncomplicated urinary tract infection and describe this patient?	Typical patient? Do you often meet patients like that? What happens when patients like that comes to you? Symptoms? Diagnosis?
Treatment	How did you decide on the treatment for this patient?	Symptoms/urine tests? Direct/delayed treatment? Patient attitudes? Choice of drug? How frequently do you use that drug? Continual alternative use of first-line drugs? Treatment duration?
Effect of treatment	How do you usually experience the effect of the treatment?	Recurrent symptoms? What happens if the symptoms return? Similar diagnosis? Have you seen treatment failure associated with resistance?
Resistance	What are your thoughts on resistance in general?	Influence on daily work? The microbiological laboratory? Update? Influence of antibiotic use? How can you curb the trend?
Is there anything else you would like to say?

Table III. The three identified perceptions.

Category of description	Quotation
A. No problem, have never seen: Resistance was not seen as a problem in the everyday treatment of UTI. The GPs thought that practical problems seldom appear or that they had not experienced treatment failures due to resistance. In this perception, an antibiotic resistance problem at the global level was not considered nor were future consequences.	As for me, I prescribed for example trimethoprim to almost 90% of my patients, a trimethoprim preparation of short duration, five days. It is enough because it is effective…. No, I have never experienced that [patients cannot be treated by an antibiotic due to resistance]. This is not how it used to be. (Dr 9)
B. The problem is bigger somewhere else: In this perception there was an awareness of the existence of the antibiotic resistance problem. However, this had no or minor impact on the GP's own practice. Some GPs said they must sometimes change antibiotics due to resistance but this was not really a problem. The notion was that the development in Sweden was less urgent than in other countries, or there was a feeling that great efforts are already being made to curb the trend. It was also expressed that maybe the resistance problem was worse in large cities in Sweden but not here in the countryside, or in hospital care but not here in primary care.	The cases where they don't get well, that is resistance. But, then you have to switch drugs and you can usually do that. There are other drugs to choose. You seldom feel totally helpless…. As I see it in Sweden about the urinary tract infections, it doesn't feel like a big problem for me right now…. If the trimethoprim susceptibility or the resistance rises a bit, it still doesn't feel like a big problem. (Dr 14)
C. The development of AR is serious and we must be careful: Also in this perception was the notion that the problem of antibiotic resistance was worse in other countries and in hospital care and management of UTI was generally not seen as a problem. However, the GPs in this category reflected in broader terms on future consequences and expressed concerns about the increasing resistance. It was said that doctors must take the resistance problem seriously and be careful in the prescribing of antibiotics in order to contain the development of antibiotic resistance.	Even if you see resistance in vitro, in the test tube, it may still have been effective in vivo, in real life…. But it's worrying that resistance to certain drugs is increasing more and more…. It's also rather worrying that no new antibiotics are being developed … and so, so we have to be careful with the ones we have. (Dr 8)