Skip to main content

How Do Community Practitioners Decide Whether to Prescribe Antibiotics for Acute Respiratory Tract Infections?

Journal of General Internal Medicine volume 23, Article number: 1615 (2008) Cite this article

Abstract

BACKGROUND

Overuse of antibiotics in the treatment of acute respiratory tract infection (ARI) contributes to the growing problem of antibiotic-resistant infections.

OBJECTIVE

To identify factors that influence community practitioners to prescribe antibiotics and examine how they differ from the recommendations of the Centers for Disease Control and Prevention (CDC) guideline for treatment of ARI.

DESIGN

Paper case vignette study using a fractional factorial design.

PARTICIPANTS

One hundred one community practitioners and eight faculty members.

MAIN MEASUREMENTS

We asked community practitioners to estimate how likely they would be to prescribe antibiotics in each of 20 cases of ARI and then used multiple regression to infer the importance weights of each of nine clinical findings. We then compared practitioners’ weights with those of a panel of eight faculty physicians who evaluated the cases following the CDC guidelines rather than their own judgments.

MAIN RESULTS

Practitioners prescribed antibiotics in 44.5% of cases, over twice the percentage treated by the panel using the CDC guidelines (20%). In deciding to prescribe antibiotic treatment, practitioners gave little or no weight to patient factors such as whether the patients wanted antibiotics. Although weighting patterns differed among practitioners, the majority (72%) gave the greatest weight to duration of illness. When illness duration was short, the rate of prescribing (20.1%) was the same as the rate of the faculty panel (20%).

CONCLUSIONS

Based on hypothetical cases of ARI, community practitioners prescribed antibiotics at twice the rate of faculty following CDC practice guidelines. Practitioners were most strongly influenced by duration of illness. The effect of duration was strongest when accompanied by fever or productive cough, suggesting that these situations would be important areas for practitioner education and further clinical studies.

This is a preview of subscription content, access via your institution.

Access options

Buy single article

Instant access to the full article PDF.

43,34 €

Price includes VAT (Finland)
Tax calculation will be finalised during checkout.

Figure 1

References

  1. Roumie CL, Halasa NB, Grijalva CG, Edwards KM, Zhu Y, Dittus RS, Griffin MR. Trends in antibiotic prescribing for adults in the United States-1995 to 2002. J Gen Intern Med. 2005;20:697–702.

    PubMed  Article  Google Scholar 

  2. Gonzales R, Barrett PH Jr, Crane LA, Steiner JF. Factors associated with antibiotic use for acute bronchitis. J Gen Intern Med. 1998;13(8)541–8. Aug.

    PubMed  Article  CAS  Google Scholar 

  3. Gonzales R, Barrett PH, Steiner JF. The relation between purulent manifestations and antibiotic treatment of upper respiratory tract infections. J Gen Intern Med. 1999;14:151–6.

    PubMed  Article  CAS  Google Scholar 

  4. Macfarlane J, Holmes W, Macfarlane R, Britten N. Influence of patients’ expectations on antibiotic management of acute lower respiratory tract illness in general practice: questionnaire study. BMJ. 1997;315(7117)1211–4. Nov 8.

    PubMed  CAS  Google Scholar 

  5. Scott JG, Cohen D, DiCicco-Bloom B, Orzano AJ, Jaen CR, Crabtree BF. Antibiotic use in acute respiratory infections and the ways patients pressure physicians for a prescription. J Fam Pract. 2001;50(10)853–8. Oct, Erratum in: J Fam Pract 2001 Dec;50(12):1077.

    PubMed  CAS  Google Scholar 

  6. Steinman MA, Landefeld CS, Gonzales R. Predictors of broad-spectrum antibiotic prescribing for acute respiratory tract infections in adult primary care. JAMA. 2003;289:719–25.

    PubMed  Article  Google Scholar 

  7. Little DR, Mann PL, Godbout CJ. How family physicians distinguish acute sinusitis from upper respiratory tract infection: a retrospective analysis. J Am Board Fam Pract. 2000;13:101–6.

    PubMed  CAS  Google Scholar 

  8. Williams JW, Simel DL. Does this patient have sinusitis? Diagnosing acute sinusitis by history and physical examination. JAMA. 1993;270:1242–6.

    PubMed  Article  Google Scholar 

  9. Dosh SA, Hickner JM, Mainous AG, Ebell MH. Predictors of antibiotic prescribing for nonspecific upper respiratory infections, acute bronchitis, and acute sinusitis. An UPRNet study. Upper Peninsula Research Network. J Fam Pract. 2000;49(5)407–14. May.

    PubMed  CAS  Google Scholar 

  10. Sorum PC, Stewart TR, Mullet E, et al. Does choosing a treatment depend on making a diagnosis? US and French physicians’ decision making about acute otitis media. Med Decis Making. 2002;22(5)394–402. Sep-Oct.

    PubMed  Article  Google Scholar 

  11. Wigton RS, Poses RM, Collins M, Cebul RD. Teaching old dogs new tricks: using cognitive feedback to improve physicians’ diagnostic judgments on simulated cases. Acad Med. 1990;65(9)S5–6.

    PubMed  Article  CAS  Google Scholar 

  12. Gonzalez-Vallejo C, Sorum PC, Stewart TR, Chessare JB, Mumpower JL. Physicians’ diagnostic judgments and treatment decisions for acute otitis media in children. Med Decis. 12.

  13. Murray S, Del Mar C, O’Rourke P. Predictors of an antibiotic prescription by GP’s for respiratory tract infections: a pilot. Fam Pract. 2000;17:386–8.

    PubMed  Article  CAS  Google Scholar 

  14. Linder JA, Singer DE. Desire for antibiotics and antibiotic prescribing for adults with upper respiratory tract infections. J Gen Intern Med. 2003;18(10)795–801. Oct.

    PubMed  Article  Google Scholar 

  15. Butler CC, Rollnick S, Pill R, Maggs-Rapport F, Stott N. Understanding the culture of prescribing: qualitative study of general practitioners’ and patients’ perceptions of antibiotics for sore throats. BMJ. 1998;317(7159)637–42. Sep 5.

    PubMed  CAS  Google Scholar 

  16. Avorn J, Soumerai SB. Improving drug-therapy decisions through educational outreach. A randomized controlled trial of academically based “detailing”. N Engl J Med. 1983;308:1457–63.

    PubMed  CAS  Google Scholar 

  17. Plackett RL, Burman JP. The design of optimum multifactorial experiments. Biometrika. 1946;33:305–25.

    Article  Google Scholar 

  18. Gonzales R, Corbett KK, Leeman-Castillo BA, et al. The “minimizing antibiotic resistance in Colorado” project: impact of patient education in improving antibiotic use in private office practices. Health Serv Res. 2005;40(1)101–16. Feb.

    PubMed  Article  Google Scholar 

  19. Gonzales R, Bartlett JG, Besser RE, et al. Principles of appropriate antibiotic use for treatment of acute respiratory tract infections in adults: background, specific aims, and methods. Ann Intern Med. 2001;134(6)479–86. Mar 20.

    PubMed  CAS  Google Scholar 

  20. Gonzales R, Bartlett JG, Besser RE, et al. Principles of appropriate antibiotic use for treatment of uncomplicated acute bronchitis: background. Ann Intern Med. 2001;134(6)521–9. Mar 20.

    PubMed  CAS  Google Scholar 

  21. Hickner JM, Bartlett JG, Besser RE, et al. Principles of appropriate antibiotic use for acute rhinosinusitis in adults: background. Ann Intern Med. 2001;134(6)498–505. Mar 20.

    PubMed  CAS  Google Scholar 

  22. Cooksey RW. Judgment Analysis: Theory, Methods, and Applications. Academic Press; 1996.

  23. Wigton RS. Use of linear models to analyze physicians’ decisions. Journal of Medical Decision Making. 1988;8:241–52.

    Article  CAS  Google Scholar 

  24. Ward JI, Cherry JD, Chang SJ, et al. Efficacy of an acellular pertussis vaccine among adolescents and adults. N Engl J Med. 2005;353(15)1555–63. Oct 13.

    PubMed  Article  CAS  Google Scholar 

  25. Heckerling PS, Tape TG, Wigton RS, et al. Clinical prediction rule for pulmonary infiltrates. Ann Intern Med. 1990;113:664–70.

    PubMed  CAS  Google Scholar 

  26. Metlay JP, Kapoor WN, Fine MJ. Does this patient have community-acquired pneumonia? Diagnosing pneumonia by history and physical examination. JAMA. 1997;278(17)1440–5. Nov 5.

    PubMed  Article  CAS  Google Scholar 

  27. Diehr P, Wood RW, Bushyhead J, Krueger L, Wolcott B, Tompkins RK. Prediction of pneumonia in outpatients with acute cough-a statistical approach. J Chronic Dis. 1984;37(3)215–25.

    PubMed  Article  CAS  Google Scholar 

  28. Wenzel RP, Fowler AA. Clinical practice. Acute bronchitis. N Engl J Med. 2006;355(20)2125–30. 16.

    PubMed  Article  CAS  Google Scholar 

  29. Braman SS. Chronic cough due to chronic bronchitis: ACCP evidence-based clinical practice guidelines. Chest. 2006;129(1 Suppl)104S–15S.

    PubMed  Article  Google Scholar 

  30. Kirwan JR, Chaput de Saintonge DM, Joyce CRB, Holmes J, Currey HLF. Inability of rheumatologists to describe their true policies for assessing rheumatoid arthritis. Ann Rheum Dis. 1986;45:156–61.

    PubMed  Article  CAS  Google Scholar 

  31. Bradley CP. Uncomfortable prescribing decisions: a critical incident study. BMJ. 1992;304(6822)294–6. PMID: 1739831, Feb 1.

    PubMed  CAS  Article  Google Scholar 

Download references

Acknowledgments

Parts of this study were presented at the 2002 Annual Meeting of the Society of General Internal Medicine.

The study was funded through grants and contracts from the Agency for Health Care Research and Quality. Minimizing Antibiotic Resistance in Colorado (MARC) Project (AHRQ R01 HS13001–01), a study testing different types of community educational campaigns to improve appropriate antibiotic use for ARIs18.

The funding source had no role in the design, conduct, and analysis of the study or in the decision to submit the manuscript for publication. Drs. Gonzales, Darr, Corbett, and Nickol had full access to the data.

The authors would like to thank Thomas Tape, MD, for his review and comments on this manuscript.

Conflict of Interest

None disclosed.

Author information

Affiliations

  1. University of Nebraska Medical Center College of Medicine, Omaha, NE, USA

    Robert S. Wigton MD, MS & Devin R. Nickol MD

  2. University of Colorado at Denver and Health Sciences Center, Denver, CO, USA

    Carol A. Darr PhD

  3. Simon Fraser University, Burnaby, BC, Canada

    Kitty K. Corbett PhD, MPH

  4. University of California, San Francisco, CA, USA

    Ralph Gonzales MD, MSPH

Authors
  1. Robert S. Wigton MD, MS
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Carol A. Darr PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Kitty K. Corbett PhD, MPH
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Devin R. Nickol MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Ralph Gonzales MD, MSPH
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Robert S. Wigton MD, MS.

Appendix

Appendix

Sample Case

This patient has the following history:

  • colored nasal drainage

  • no cough

  • no sinus symptoms

  • The patient has had this illness for 14 days

  • Feels this illness is so severe that treatment is needed

Examination:

  • temperature = 99° F

The patient has come in specifically to get antibiotic treatment

Patient is leaving on vacation soon and worries about the illness getting worse

No prior antibiotics for this sort of illness

  1. 1.

    Mark an “x” on the line below to indicate how likely you are to prescribe an antibiotic in this case

  2. 2.

    In your practice, would you prescribe an antibiotic for this patient? (Circle one) Yes No

  3. 3.

    Mark an “x” on the line to indicate how comfortable you are with your decision about antibiotics?

  4. 4.

    Imagine this same patient does not want to take antibiotics: Mark an “x” on the line to indicate how strongly you would urge the patient to start antibiotics right away.

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Wigton, R.S., Darr, C.A., Corbett, K.K. et al. How Do Community Practitioners Decide Whether to Prescribe Antibiotics for Acute Respiratory Tract Infections?. J GEN INTERN MED 23, 1615 (2008). https://doi.org/10.1007/s11606-008-0707-9

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1007/s11606-008-0707-9

KEY WORDS

  • antibiotics for acute respiratory tract illness
  • judgment analysis
  • patient factors
  • bronchitis
  • duration of illness