Antibiotic prescribing behavior among general practitioners – a questionnaire-based study in Germany

Antimicrobial resistance (AMR) jeopardizes the achievements of modern medicine in Europe and worldwide [1‐3]. The consumption of antibiotics is an important driver of AMR [4, 5]. Over the past decade the global antibiotic use increased significantly [6]. In the human sector the primary use of antibiotics in outpatient care is found among general practitioners (GPs) [7, 8]. There is a considerable difference in outpatient antibiotic use worldwide, between European countries and within countries [9‐11]. Considering the use of antibiotics in primary care in Europe, Germany is one of the countries with a lower level of consumption of antibiotics [12, 13]. Nevertheless, it is striking that the proportion of reserve antibiotics in Germany is high [11, 14]. In Germany, the total consumption of antibiotics in human medicine is about 800 tons per year. Approximately 600 tons of this are used in outpatient care [15]. More than half of the antibiotics used in outpatient care are prescribed by GPs in Germany [16, 17]. In GP practices, the majority of antibiotics is prescribed for acute respiratory infections, most of which are caused by a virus [16, 18]. In most cases they do not require antimicrobial therapy [19‐22]. In Germany, antimicrobial resistance is mainly a problem in hospital care and especially in intensive care units [23]. German health care system is divided in primary and secondary care, most people are covered by statutory health insurance [24].

The present survey was carried out in the preparation of a broader intervention study, called “Rational antibiotic Use via information and communication” (RAI-project, www.​rai-projekt.​de). The RAI-project promotes rational antibiotic use in veterinary medicine, in particular in pig farming, as well as in human medicine, surgery and intensive care units, travel medicine, and primary care, with a focus on eastern Germany [25].

The following barriers to rational antibiotic usage have been identified from the scientific literature. But explanations of the barriers to rational antibiotic use vary widely in primary care. Some authors describe that uncertainty about pathogenesis, heavy workflow and patient’s desire for an antibiotic therapy can lead to increased prescription of antibiotics [26‐28] as well as knowledge and health literacy among the general population [29]. This questionnaire survey was carried out to examine whether the barriers identified in the literature can also be found in the intervention area.

The questionnaire was completed by 340 of 987 (34.4%) GPs. The socio-demographic factors are described in Table 1. Most of the participants were female (62.4%). The mean age was 52 (range 33–78) years and the mean work experience was 16.8 years.

We performed a questionnaire-based survey of general practitioners on patterns of antimicrobial use, patient communication, awareness of rising drug-resistance in primary care and the source of information acquisition.

This study demonstrates different specific barriers to rational antibiotic therapy in primary care. First of all, it should be acknowledged that the awareness of antimicrobial resistance among general practitioners has risen during the past few years. In 2007/2008 the Robert Koch Institute distributed a written survey to GPs in Germany. In that survey, 35.8% of the GPs expressed the belief that their prescribing behavior influences drug-resistance in their area [31, 32]. We repeated this question in our survey and 70.2% (239/340) of the participants agreed that their behavior affected drug resistance. This rising awareness might be influenced by international, European and national reports and campaigns that deal with this topic [33‐36].

Second, the reliability of sputum color as an indicator for an antimicrobial therapy was overestimated by a majority of the participants. Our investigation found that over one third (36.2%) of the participants use the color as an indication, another third are uncertain (35.9%) and only 25.9% (88/340) of general practitioners do not use sputum color when deciding whether to start antibiotic therapy. Other studies support these findings [28, 37]. In selected diagnoses, especially in chronic lung diseases, the sputum color has a value for antimicrobial therapy decision [38, 39]. Nevertheless, the reproducibility of the evaluation of sputum color has poor inter-rater reliability [40] and is not recommended in the case of an acute respiratory tract infection [41].

In order to work in Germany as a family doctor a 5 year medical specialization in either internal medicine or in general medicine is required. Alternatives to practicing as a general practitioner exist, however rarely. 84.7% (288/340) of the participants have a specialization in general medicine, 10% (34/340) in internal medicine (Table 1). GPs with a specialization in internal medicine were more likely to prescribe an antibiotic based on the color of the sputum than were GPs with a specialization in general medicine (OR 2.36, 95%CI 1.08–5.17; P = 0.03). One explanation for why GPs with a specialization in internal medicine were 2.4 times more likely than participants who specialized in general or family medicine to prescribe antibiotics based on sputum color is that the recommendation not to use the color of the sputum as an indicator is very prominent in the guidelines of the German Society of General Practice and Family Medicine (Deutsche Gesellschaft für Allgemeinmedizin und Familienmedizin, DEGAM) [42]. To address the diagnostic uncertainty between a severe acute bronchitis and a starting pneumonia the biomarker as point of care tests are promising [43]. However the reimbursement for GPs in Germany is difficult. An alternative strategy to reduce antibiotic use is delayed prescription [44, 45]. The strategy is well known among the participants (337/340) while only one third (74/340) apply it “often” or “very often”. There is room for improvement in the implementation of the strategy in daily outpatient care, considering the fact that only 21.8% (74/340) use this strategy often and only 7.6% (26/340) very often.

Third, some authors emphasize that when GPs feel pressure from their patients, they are more likely to prescribe antibiotics [46‐49]. Accordingly, about one third of the participants (102/340) prescribe antibiotics when a patient requests some or when the patient wants to return to work quickly (97/340). However, in this survey general practitioners who felt pressure from their patients remained a minority. Unfortunately, we did not conduct patient interviews to evaluate patient requests for antibiotic therapy. Nevertheless, supported by other authors, we believe that GPs place too much importance on patient requests for antimicrobial therapy [50, 51] .

Focusing on aspects of communication, it is striking that a lack of time was the main reason not to talk about antimicrobial resistance (172/340). Some authors describe an antibiotic prescription as an effective means to avoid confrontation and to terminate a consultation [28]. Accordingly, the majority of antibiotic prescriptions are inappropriate in ambulatory care [7]. Patient leaflets could be used for this purpose but there is a lack of established German leaflets for acute respiratory tract infections. There are leaflets of the Center for Disease Control and Prevention (CDC) available in English [52].

This study has certain limitations. All answers are self-reported. Furthermore, as a questionnaire study, this survey contains the risk that respondents will give answers believed to be socially acceptable. The representativeness of the study is limited because the sample was not selected purely randomly, but was instead contacted on the basis of existing address data (self-selection bias). On the other hand, the GPs contacted represent about one third of all GPs working in the region. The response rate is comparable to other studies conducted in Germany [30, 53].

Another limitation is that the questionnaire was only distributed in eastern Germany.

This is due to the fact that this survey was performed in preparation for an intervention campaign that started in August 2016 and focused on rational antibiotic use by GPs in eastern Germany. Looking at the socio-demographic parameters of the participants, it is noticeable that they were about 2 years younger (51.9 vs. 54.3) than the GPs average in Germany and were more likely to be female (62.4% vs 41.0 female GPs). There were only minor differences in the type of workplace [54].

When deciding on a therapy, the diagnostic value of sputum color is often overestimated. Delayed prescription is well known but only partially applied. Nevertheless, there is a strong awareness of antimicrobial resistance among the participating GPs. Furthermore, time restrictions disturb doctor-patient communication. Implementation of change to a more rational antibiotic use should address such specific barriers as preconditions to having a sustainable effect. This survey shows clear targets for further approaches to reduce the prevalence of drug-resistant organisms.