Is there a conflict between general practitioners applying guidelines for antibiotic prescribing and including their patients’ preferences?

Figures & data

Table 1 Recommendations about the prescribing of antibiotics for the guidelines acute cough, acute rhinosinusitis, and urinary tract infections

Guideline	Acute cough, last version 2013^Citation49	Acute rhinosinusitis, last version 2014^Citation50	Urinary tract infections, last version 2013^Citation51
Diagnoses (ICPC)	Acute cough (R05), Whooping cough (R71), Laryngitis/tracheitis acute (R77), Acute bronchitis/bronchiolitis (R78)	Sinus symptom/complaint (R09), Upper respiratory infection acute (R74), Sinusitis acute/chronic (R75)	Dysuria/painful urination (U01), Urinary frequency/urgency (U02), Cystitis/urinary tract infection (U71)
Antibiotics recommendations in guideline	No antibiotics if pneumonia is not considered likely. Exceptions in which antibiotics should be considered are patients with one or more risk factors: • Age <3 months or >75 years • Relevant comorbidity: heart failure, severe COPD, diabetes mellitus (in particular when using insulin), neurological diseases, severe kidney diseases • Poor immune response CRP in adults: <20 mg/L no indication for antibiotics, 20–100 mg/L indication for antibiotics depends on the clinical presentation, >100 mg/L indication for antibiotics	In principle, no antibiotics. Antibiotics are indicated in patients who are seriously ill. Antibiotics can be considered in patients with poor immune response: • Chronic use of corticosteroids or other immunosuppressive medicines • HIV infection with a reduced number of T-cells • Chemotherapy or radiotherapy • Immune disorders • Frail elderly who are sick • Patients with diabetes mellitus Antibiotics can be considered for patients who have had fever for more than 5 days, or for patients who have recurrent fever after a few fever-free days within one episode of rhinosinusitis	• Healthy women aged 12 years and older who are not pregnant: the GP […] discusses the possibility of wait and see […] and a postponed antibiotics prescription • Recurrent cystitis in healthy women (12 years and older) who are not pregnant: […] (three or more yearly) the following options: self-treatment with a postponed antibiotics prescription, or prophylactic treatment with […] continuous antibiotic prophylaxis • Cystitis in risk groups: patients in risk groups have an increased risk for complications of cystitis. In those patients, cystitis should be treated with antibiotics, in anticipation of the test results. Risk groups include: pregnant women, men, patients with diabetes mellitus, patients with poor immune response, and patients with abnormalities of the kidneys or urinary tract • Urinary tract infection with signs of tissue invasion: explain […] that antibiotic treatment is necessary […]
Antibiotics not indicated…	In patients with cough (R05, R77, R78) between 18 and 75 years, without indications for poor immune response,a with CRP <20 and without relevant comorbidity	In patients with sinus complaints (R09, R74, R75) without indications for poor immune response	In patients with urinary complaints (U01, U02)
Antibiotics can be considered…	In patients with cough (R05, R77, R78) over 75 years, or with indications for poor immune response, or with CRP >20 or with relevant comorbidity and in patients with whooping cough (R71)	In patients with sinus complaints (R09, R74, R75) with an indication for poor immune response	In healthy women, who are not pregnant, with urinary tract infection (U71) without abnormalities of the kidneys or urinary tract and without indications for poor immune response
Antibiotics are indicated…	In patients with cough (R05, R77, R78) and CRP >100	In patients with sinus complaints (R09, R74, R75) and CRP >100	In patients with urinary tract infection (U71) who are male, or pregnant, or have abnormalities of the kidneys or urinary tract, or indications for poor immune response
Remarks	Not all measured CRP values are recorded. CRP limits for indications are only applied if CRP values were recorded Relevant comorbidity includes: heart failure, COPD, neurological diseases, and severe kidney diseases	Being seriously ill and having prolonged or recurrent fever cannot be retrieved from NIVEL Primary Care Database and are consequently not taken into account	Signs of tissue invasion cannot be retrieved from NIVEL Primary Care Database and are consequently not taken into account. No distinction between a single bout of cystitis or recurrent cystitis is made, because in both cases antibiotics can be considered in healthy women who are not pregnant

Notes:

a Patients are considered as having a poor immune response if at least one of the following drugs were prescribed: corticosteroids (chronic use), cytostatic drugs, DMARDs, biologicals, anti-thyroid drugs, phenytoin, neuroleptics, antivirals for systemic use, or if at least one of the following diseases was recorded: HIV infection, cancer, diabetes mellitus, severe alcohol abuse, sickle cell disease, (functional) asplenic, severe renal insufficiency.

Abbreviations: ICPC, International Classification of Primary Care; GP, general practitioner; DMARDs, disease-modifying antirheumatic drugs; NIVEL, Netherlands Institute for Health Services Research.

Table 2 Results of descriptive statistics

	Data source	N	N	%
Number of patients who contacted their GP in 2015 for…	NIVEL-PCD	286
Acute cough			109	38.1
Acute rhinosinusitis			72	25.2
Urinary tract infections			105	36.7
Antibiotics prescribed by GP	NIVEL-PCD	286
Yes			120	42.0
No			166	58.0
Indication for antibioticsa	NIVEL-PCD	286
Yes			48	16.7
“Unsure” (ie, antibiotics can be considered)			144	50.4
No			94	32.9
Patient preference for antibiotics	Consumer panel	240
Yes			50	20.8
No			190	79.2

Note:

a Based on the recommendations in the three guidelines (see Table 1 for extensive recommendations).

Abbreviations: GP, general practitioner; PCD, Primary Care Database; NIVEL, Netherlands Institute for Health Services Research.

Table 3 Results of logistic multilevel regression analysis to examine the relationship between patient preferences and the GP’s prescription of antibiotics (N=240)

GP’s prescription of antibiotics (1= Yes, 0= No)	Odds ratio	95% CI	p-value
Indication for antibioticsa
Yes	Reference	Reference	Reference
“Unsure” (ie, antibiotics can be considered)	0.067	0.018–0.245	0.000
No	0.053	0.014–0.203	0.000
Patient preference for antibiotics
No	Reference	Reference	Reference
Yes	0.401	0.067–2.411	0.318
Patient preference for antibiotics # indication for antibiotics
Preference No and indication Yes	Reference	Reference	Reference
Preference Yes and indication “Unsure”	7.696	1.009–58.679	0.049
Preference Yes and indication No	0.973	0.087–10.851	0.982
Constant	7.558	2.224–25.683	0.001

Notes:

a Based on the recommendations in the three guidelines (see Table 1 for extensive recommendations).

# The interaction effect between preference and indication was tested. Bold type indicates p<0.05.

Abbreviation: GP, general practitioner.

Figure S1 Patient questionnaire on preferences for antibiotic prescribing. Questionnaire sent to members of the Dutch Health Care Consumer Panel (translated to English).

Nederlands huisartsen genootschapAcuut hoesten. [Acute coughing]. [webpage on the Internet] Available from https://www.nhg.org/standaarden/samenvatting/acuut-hoestenAccessed December 5, 2017 Dutch

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Nederlands huisartsen genootschapAcuut rhinosinusitis. [Acute rhinosinusitis]. [webpage on the Internet] https://www.nhg.org/standaarden/samenvatting/acute-rhinosinusitisAccessed December 5, 20171 Dutch

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Nederlands huisartsen genootschapUrineweginfecties. [Urinary tract infections]. [webpage on the Internet] https://www.nhg.org/standaarden/samenvatting/urineweginfectiesAccessed December 5, 2017 Dutch

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