Early-career general practitioners’ antibiotic prescribing for acute infections: a systematic review

Problem

Antimicrobial resistance is growing worldwide, exacerbated by inappropriate antibiotic prescribing. There have been cases of death due to pan-resistant infections, highlighting the consequences of failure to contain antimicrobial resistance. The majority of human antibiotic use occurs in primary care. The early years of a general practitioner’s (GP) career can be pivotal in determining their future prescribing practice, with some evidence for antibiotic prescribing habits remaining stable over time. Despite the importance of a GP’s experiences early in their career for determining their ongoing antibiotic prescribing behaviour, there are currently no systematic reviews of studies on this topic. We aimed to explore the antibiotic prescribing patterns of early-career general practitioners for acute infections, and establish if ‘years of experience’ is associated with antibiotic prescribing.

Approach

The systematic review was registered with PROSPERO (CRD42021273935) and follows Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched PubMed, Embase, and Scopus. Two authors independently screened abstracts and full texts for inclusion. Primary outcomes were antibiotic prescribing rates for common acute infections by GPs with experience 10 years or less. ‘Common acute infections’ were defined as self-limiting or where antibiotics are generally not indicated. Secondary outcomes were any associations between working experience and antibiotic prescribing.

Findings

Of 1,483 records retrieved, we identified 41 relevant studies, of which 14 investigated primary outcomes, 6 examined both primary and secondary outcomes, and 21 investigated secondary outcomes.Primary outcomes: antibiotic prescribing rates for any acute self-limiting respiratory conditions ranged from 14.6% to 52%. Antibiotic prescribing rates for upper respiratory tract infections ranged from 13.5% in Australia, to 29% in Canada. Antibiotic prescribing for acute bronchitis ranged from 4.6% in Sweden to 63-73% in Australia. Two studies including multiple acute self-limiting infections found prescribing ranged from 11% to 26%. Condition specific data for all other included acute infections, such as sinusitis and acute otitis media, was limited to the Australian context.Secondary outcomes: Although highly heterogenous in variables used to describe the outcome, most studies found more years in practice resulted in higher likelihood of antibiotics prescribed. When direct comparisons between early-career and late-career GPs were made, early-career GPs were less likely to prescribe an antibiotic (OR 0.23-0.68).

Consequences

In the majority of studies identified, early-career GPs prescribed less antibiotics than later-career GPs, across a variety of conditions and countries. This is encouraging for the fight against antimicrobial resistance. However, for most conditions, although their prescribing is lower compared to more established peers, antibiotics continue to be overprescribed. Addressing antimicrobial resistance requires an ongoing worldwide effort and early-career GPs could be the target for long-term change.