Abstract
Background:
Antimicrobial resistance is a worldwide phenomenon that leads to a significant number of unnecessary deaths and costly hospital admissions. More than 90% of antibiotic use happens in the community and of this, family physicians account for two-thirds of these prescriptions. Our study aims to determine whether family medicine residents are optimally trained in antibiotic prescribing for common infectious conditions seen in a primary care setting.
Methods:
This study is a secondary analysis of a prior study of antimicrobial stewardship in two urban primary care clinics in central Toronto, Ontario. A total of 1099 adult patient visits were included that involved family medicine resident trainees, seen between 2015 and 2016. The main outcome measures were resident antibiotic prescription rates for each condition and expert-recommended prescribing practices, the rate prescriptions were issued as delayed prescriptions, and the use of first-line recommended narrow-spectrum antibiotics.
Results:
Compared to expert-recommended prescribing rates, family medicine residents overprescribed for uncomplicated upper respiratory tract infections (URI) (5.0% [95% CI 2.2% to 9.7%] versus 0% expert recommended) and sinusitis (44.2% [95% CI 32.8% to 55.9%] versus 11%–18% expert range), and under prescribed for pneumonia (53.5% [95% CI 37.7% to 68.8%] versus 100% expert range]). Prescribing rates were within expert recommended ranges for pharyngitis (28.6% [95% CI 16.6% to 43.3%]), bronchitis (3.6% [95% CI 0% to 18.4%]), and cystitis (79.4% [95% CI 70.6% to 86.6%]).
Conclusions:
The antibiotic prescribing practices of family medicine residents during their training programs indicated overprescribing of antibiotics for some common infection presentations. Further study of antibiotic prescribing in primary care training programs across Canada is recommended to determine if future family physicians are learning appropriate antibiotic prescribing practices.
Keywords: antibiotic prescribing, infection, primary care, resident
Abstract
Historique :
La résistance antimicrobienne est un phénomène mondial responsable d’un grand nombre de décès inutiles et d’hospitalisations coûteuses. Plus de 90 % des antibiotiques sont utilisés en milieu communautaire, et les deux tiers de ces prescriptions proviennent de médecins de famille. Par la présente étude, les auteurs visent à déterminer si les résidents en médecine de famille reçoivent la formation optimale pour prescrire des antibiotiques en vue du traitement des affections infectieuses courantes en soins primaires.
Méthodologie :
La présente étude est l’analyse secondaire d’une étude antérieure de la gouvernance antimicrobienne dans deux cliniques de soins primaires urbaines du centre de Toronto, en Ontario. Au total, 1 099 consultations de patients adultes effectuées en 2015 et 2016, auxquelles ont participé des résidents en médecine de famille, ont été incluses. Les principales mesures de résultats étaient le taux de prescription d’antibiotiques pour chaque affection et les pratiques de prescription recommandées par les experts, le rythme d’émission d’ordonnances tardives et l’utilisation d’antibiotiques à spectre étroit recommandés en première ligne.
Résultats :
Par rapport aux taux de prescription recommandés par les experts, les résidents en médecine de famille surprescrivaient en cas d’infections des voies respiratoires supérieures (IVRS) (5,0 % [intervalle de confiance (IC) à 95 % = 2,2 % à 9,7 %] par rapport à 0 % recommandé par les experts) et de sinusite (44,2 % [IC à 95 % = 32,8 % à 55,9 %] par rapport à une plage de 11 % à 18 % chez les experts), et sous-prescrivaient en cas de pneumonie (53,5 % [IC à 95 % = 37,7 % à 68,8 %] par rapport à 100 % chez les experts]). Les taux de prescription se situaient dans les plages recommandées par les experts dans les cas de pharyngite (28,6 % [IC à 95 % = 16,6 % à 43,3 %]), de bronchite (3,6 % [IC à 95 % = 0 % à 18,4 %]) et de cystite (79,4 % [IC à 95 % = 70,6 % à 86,6 %]).
Conclusions :
Les pratiques de prescription d’antibiotiques des résidents en médecine de famille pendant leur programme de formation démontrent une surprescription d’antibiotiques lors de présentations infectieuses courantes. Il est recommandé de poursuivre l’étude des prescriptions d’antibiotiques en soins primaires au Canada pour déterminer si les futurs médecins de famille assimilent les pratiques appropriées de prescription d’antibiotiques.
Mots-Clés : infection, prescription d’antibiotiques, résident, soins primaires
Introduction
The discovery of antibiotics in 1928 was one of the greatest discoveries of the 20th century, but excessive use of antibiotics over subsequent decades has led to increasing problems with antimicrobial resistance (AMR) (1). Currently, an estimated 5 million deaths per year are attributed to antibiotic-resistant infections globally (1). Projections are this number may increase to 10 million deaths each year, with costs reaching $100 trillion annually (2). In Canada, efforts to reduce antimicrobial utilization have focused mainly on hospitals and institutions. However, more than 90% of antimicrobial use occurs in the community (3). Of this, family physicians and other primary care providers account for two-thirds of community antibiotic prescriptions (4). These are mainly for uncomplicated respiratory tract infections, most of which are caused by viral organisms and are not helped by antibiotics (5). These represent unnecessary antibiotic prescriptions and provide an important opportunity to address antibiotic overuse in the community.
While antibiotic prescribing by primary care providers in the community has been studied (4), there has been less attention paid to residency training programs that prepare these providers for community practice (6,7). One study of pediatric residents in the United States found 75% of residents surveyed had prescribed antibiotics for a suspected viral infection (5). An Australian study of 856 general practice trainees found antibiotics were prescribed for 71.2% of sinusitis cases (8). Supervisors of trainees had a strong influence on learner prescribing habits (9). As antibiotic prescribing habits, once learned, may be difficult to change, assessing the degree to which primary care trainees are exposed to optimal antibiotic prescribing practices during residency is important (10,11).
In a previous study of antimicrobial stewardship in Toronto family medicine (FM) clinics, information on resident antibiotic prescribing was collected and these data were used to determine their prescribing habits for common infections (12). Their prescribing was compared to what has been defined as optimal prescribing practices in published literature (13,14), to determine how well FM residents were being trained to treat common infections they would manage in the community.
Methods
Study design and setting
This study involved secondary analysis of previously collected data from a study of antimicrobial stewardship in two primary care clinics affiliated with the Department of Family and Community Medicine of the University of Toronto (12). The data were collected between 2015 and 2016 and were approved by the research ethics boards of Mount Sinai Hospital and the University Health Network. Encounters for uncomplicated upper respiratory tract infections (URI), acute sinusitis, acute bronchitis, pharyngitis, pneumonia, and acute cystitis in women were examined. At the time of the study, there were 26 primary care staff at Site 1 and 33 primary care staff at Site 2, with none working at both sites. All resident-patient encounters were supervised by a staff physician. While four sites participated in the original study, only two sites were involved in training family medicine residents (12).
Data collection
The study data consisted of anonymized records of adult patients with selected respiratory or urinary infections during this time period (12). All encounters were first visits of the assessment of an infection by these providers. Follow up visits for an infection after an initial assessment in an Emergency Department (ED) or after hospitalization were excluded. If there was a prior visit in the previous 7 days for the same condition, the initial visit was selected. Also collected was whether the encounter involved a resident supervised by a staff physician, or was conducted by a staff physician alone. Neither the resident's name nor any identifying information about the resident (age, gender, first- or second-year resident) was collected so that the data constitute an anonymized set of information about whether or not an antibiotic was prescribed and whether a resident was involved in that particular visit or not.
Patient encounters for review were identified from ICD-9 (International Classification of Disease) billing codes for uncomplicated upper respiratory tract infection (URI, ICD-9 codes 460,464), sinusitis (461), pneumonia (486), pharyngitis (034, 462, 463), bronchitis (466), and acute uncomplicated cystitis for women only (595). Also selected were non-specific presentations that might have represented a mislabeled eligible infection (cough-786, influenza-487, other urinary tract-599).
For each visit, the following data were abstracted by a trained abstractor: patient age, sex, the provider written diagnosis, whether an antibiotic was prescribed, the antibiotic name and if it was a delayed prescription to be used should a condition worsen, or was to be started immediately. Also abstracted were any follow up office visits, emergency department visits, or hospitalizations in the following 30 days. A final ICD-9 diagnosis code for each encounter was determined from the provider-recorded clinical diagnosis and the billing code using a standardized coding scheme developed for the study (available on request) (12). Briefly, the billing code was retained as the final diagnosis unless the physician diagnosis indicated a condition where an antibiotic might be considered (eg, Billing code 460 URI; physician written diagnosis—pneumonia). In that instance, the physician diagnosis was used.
Study outcomes and statistical analysis
The primary outcome was the resident antibiotic prescribing rate for the selected infections. These were then compared to two expert-derived guidelines for appropriate expected antibiotic prescribing rates for various conditions that were felt to be relevant to the practice setting of the study, which were found following a brief literature review (13,14). The range of expert-defined prescribing rates for these conditions were used to delineate the appropriate antibiotic prescribing ranges. Where resident and staff prescribing fell within these ranges, their prescribing was considered appropriate. Prescribing estimates outside of these ranges were considered either over or underprescribing.
Secondary outcomes assessed were the rate these prescriptions were issued as delayed prescriptions versus immediate prescriptions, the use of first-line recommended narrow-spectrum antibiotics, the rate of these outcomes in encounters involving staff physicians only, and the rate of ER visits, hospitalizations, and repeat office visits 30 days after the initial encounter. Delayed prescriptions are defined as a prescription issued by a physician for use by the patient at a later date if their symptoms did not improve, as opposed to prescriptions to be started immediately (15). First-line recommended antibiotics were defined in a post-hoc analysis using expert recommendations in condition-specific guidelines (16–23).
Prescription rates were described using frequencies, with 95% confidence intervals around prescribing estimates produced for resident and staff prescribing rates. Descriptive frequencies and means, where appropriate, were used to describe the sample characteristics and prescribing rates, utilizing SAS version 9.4 (24). Chi-square testing was used to compare prescribing rates by various characteristics or Fisher exact test where there were fewer than five observations in a category.
Results
The characteristics of visits by patients seen are described in Table 1. There were a total of 1,099 patient encounters involving patients between the ages of 18 and 80, with a smaller proportion of patients over the age of 81. The average patient age was 51.3 years old, with a predominance of female patients, reflecting the inclusion of acute cystitis for women only. The most common diagnosis was URI (26.1%) and there was an equal proportion of patients seen by a resident physician or a staff physician alone. An antibiotic was prescribed in almost one-third (30.8%) of visits.
Table 1:
Characteristics of primary care patients seen at two family medicine residency clinics in Toronto for selected respiratory tract and urinary infections between 2015 and 2016
| Characteristics | Total sample, no. (%); n = 1099 | Site 1, no. (%); n = 576 | Site 2, no. (%); n = 523 | p-value* |
|---|---|---|---|---|
| Age distribution, y | ||||
| 18–40 | 373 (33.9) | 182 (31.6) | 191 (36.5) | 0.03 |
| 41–60 | 363 (33.0) | 185 (32.1) | 178 (34.0) | |
| 61–80 | 287 (26.1) | 159 (27.6) | 128 (24.5) | |
| 81+ | 76 (6.9) | 50 (8.7) | 26 (5.0) | |
| Mean age (SD), y | 51.3 (18.2) | 52.6 (18.7) | 50.0 (17.6) | 0.16 |
| Gender | ||||
| Male | 295 (26.8) | 149 (25.9) | 146 (27.9) | 0.44 |
| Female | 804 (73.2) | 427 (74.1) | 377 (72.1) | |
| Diagnosis | ||||
| Uncomplicated upper respiratory infection | 287 (26.1) | 184 (31.8) | 103 (19.7) | <0.01 |
| Sinusitis | 129 (11.7) | 63 (10.9) | 66 (12.6) | 0.79 |
| Pharyngitis/sore throat | 91 (8.3) | 45 (7.8) | 46 (8.8) | 0.92 |
| Bronchitis | 69 (6.3) | 32 (5.6) | 37 (7.1) | 0.55 |
| Pneumonia | 70 (6.4) | 33 (5.7) | 37 (7.1) | 0.63 |
| Cystitis | 202 (18.4) | 84 (14.6) | 118 (22.6) | 0.02 |
| Other† | 251 (22.8) | 135 (23.4) | 116 (22.2) | 0.23 |
| Seen by | ||||
| Resident and staff physician | 587 (53.4) | 362 (62.9) | 225 (43.0) | <0.01 |
| Staff physician only | 512 (46.6) | 214 (37.2) | 298 (57.0) | |
| Antibiotic prescription | ||||
| No | 761 (69.2) | 420 (72.9) | 341 (65.2) | <0.01 |
| Yes | 338 (30.8) | 156 (27.1) | 182 (34.8) | |
p-value reflects comparison of patient characteristics and prescribing rates for Site 1 compared with Site 2;
Other includes influenza (ICD 487), cough (786), viral illness (079), and other urinary (599)
Table 2 shows antibiotic prescribing rates in encounters attended by residents. There was a statistically significant difference in prescribing rates between the two sites; however, this was not controlled for age or gender. There was also a statistically significant difference in antibiotic prescriptions by individual infection types, for both total and delayed prescriptions. Total prescriptions ranged from a low of 3.2% for other (influenza, cough, viral illness, other urinary disease) to a high of 79.4% for acute cystitis. These were often issued as delayed prescriptions ranging from 14.1% of antibiotics prescribed for cystitis to 75.0% of antibiotics for uncomplicated URI. The one antibiotic prescribed for acute bronchitis was issued as a delayed prescription.
Table 2:
Resident antibiotic prescribing rates in two family medicine clinics, overall and by various visit characteristics
| Characteristic | No./n | Crude prescribing rate, % | p-value |
|---|---|---|---|
| Total sample | 169/587 | 28.8 | - |
| Site | |||
| Site 1 | 93/362 | 25.7 | 0.04 |
| Site 2 | 76/225 | 33.8 | |
| Age group, y | |||
| 18–40 | 59/217 | 27.2 | 0.74 |
| 41–60 | 55/197 | 27.9 | |
| 61–80 | 44/136 | 32.4 | |
| 81+ | 11/37 | 29.7 | |
| Gender* (n = 908) | |||
| Male | 26/115 | 17.2 | 0.90 |
| Female | 58/320 | 18.1 | |
| Total prescriptions by conditions | |||
| Uncomplicated URI | 8/159 | 5.0 | |
| Sinusitis | 34/77 | 44.2 | <0.01 |
| Pharyngitis/sore throat | 14/49 | 28.6 | |
| Bronchitis | 1/28 | 3.6 | |
| Pneumonia | 23/43 | 53.5 | |
| Cystitis | 85/107 | 79.4 | |
| Other† | 4/124 | 3.2 | |
| Delayed prescriptions by conditions | |||
| Uncomplicated URI | 6/8 | 75.0 | |
| Sinusitis | 12/34 | 35.3 | <0.01 |
| Pharyngitis/sore throat | 8/14 | 57.1 | |
| Bronchitis | 1/1 | 100.0 | |
| Pneumonia‡ | 5/21 | 23.8 | |
| Cystitis | 12/85 | 14.1 | |
| Other† | 2/4 | 50.0 | |
595 and 599 cases excluded from gender analysis as they are female only cases; †Other includes influenza, cough, viral illness, and other urinary; ‡Reduced denominator due to two cases of missing information for delayed prescriptions
URI = Upper respiratory infection
The antibiotics chosen by the residents for the various infections are displayed in Table 3. Of the 78 antibiotics prescribed in encounters for respiratory infections (excluding other) that involved residents, 41 (52.6%) were penicillin or amoxicillin, 28 (35.9%) were macrolides or amoxicillin-clavulanate, four (5.1%) were quinolones prescribed for pneumonia, and five (6.4%) were doxycycline.
Table 3:
Antibiotic choices by family medicine residents from two Toronto clinics for select respiratory infections and cystitis, 2015–2016
| Condition | Antibiotic class | No. (%) |
|---|---|---|
| Uncomplicated URI (n = 8) | Azithromycin | 4 (50.0) |
| Penicillin | 3 (37.5) | |
| Amoxicillin clavulanate | 1 (12.5) | |
| Sinusitis (n = 34) | Amoxicillin | 26 (76.5) |
| Doxycycline | 3 (8.8) | |
| Amoxicillin clavulanate | 2 (5.9) | |
| Azithromycin | 2 (5.9) | |
| Clarithromycin | 1 (2.9) | |
| Pharyngitis/sore throat (n = 14) | Penicillin | 8 (57.1) |
| Amoxicillin | 3 (21.4) | |
| Amoxicillin clavulanate | 2 (14.3) | |
| Azithromycin | 1 (7.1) | |
| Bronchitis (n = 1) | Azithromycin | 1 (100) |
| Pneumonia (n = 21) | Amoxicillin clavulanate | 7 (33.3) |
| Azithromycin | 6 (28.6) | |
| Levofloxacin | 3 (14.3) | |
| Doxycycline | 2 (9.5) | |
| Amoxicillin | 1 (4.8) | |
| Clarithromycin | 1 (4.8) | |
| Moxifloxacin | 1 (4.8) | |
| Cystitis (n = 85) | Nitrofurantoin | 54 (63.5) |
| Trimethoprim-sulfamethoxazole | 18 (21.2) | |
| Ciprofloxacin | 6 (7.1) | |
| Fosfomycin | 4 (4.7) | |
| Amoxicillin | 2 (2.3) | |
| Amoxicillin clavulanate | 1 (1.2) | |
| Other* (n = 4) | Azithromycin | 2 (50.0) |
| Amoxicillin clavulanate | 2 (50.0) |
Other includes influenza, cough, viral illness, and other urinary
URI = Upper respiratory infection
We used a set of guidelines for each condition to determine whether the chosen antibiotics were optimal in a post-hoc analysis (16–23). For sinusitis, guideline-recommended first-line antibiotics includes penicillin, tetracyclines, or a respiratory fluoroquinolone, which made up 91% of the antibiotics prescribed (21). For pharyngitis, recommended antibiotics include penicillin, macrolides, cephalosporins, or clindamycin, which accounted for 100% of the antibiotics prescribed (19). In Canada, community-acquired pneumonia is recommended to be treated with a macrolide or doxycycline if previously healthy, or a respiratory fluoroquinolone or beta-lactam plus a macrolide if there are comorbidities (22). Residents chose an antibiotic from one of these groups 100% of the time. For uncomplicated cystitis, first-line antibiotics include nitrofurantoin, trimethoprim-sulfamethoxazole, and fosfomycin, with fluoroquinolones and beta-lactam agents as alternative choices (23). Residents also prescribed from one of these groups 100% of the time. For bronchitis, antibiotic therapy is indicated only in rare circumstances (18). Consistent with this, antibiotics were prescribed in only 1/28 (3.6%) of bronchitis encounters. None of the antibiotic prescriptions for uncomplicated URI were considered optimal.
Table 4 compares resident and staff prescribing rates to prescribing rates suggested by expert groups (12,13). Compared to prescribing rates suggested by expert groups, residents overprescribed for uncomplicated URI and sinusitis, underprescribed for pneumonia, and prescribed within the recommended range for pharyngitis, bronchitis, and cystitis. Of note, prescriptions for acute bronchitis were lower than expert group recommendations. When only prescriptions by residents that were intended to be started immediately were considered, the prescription rate for URI was closer to expert recommend rates (2/159, 1.3%). Immediate use antibiotics for acute sinusitis remained somewhat higher than expert recommendations, although the difference was less (22/77, 28.6%).
Table 4:
Resident antibiotic prescribing rates compared to staff prescribing in two family medicine clinics in Toronto between 2015 and 2016, for select infections, and compared to expert recommended prescribing
| Expert recommended antibiotic prescribing rates, % | |||||
|---|---|---|---|---|---|
| Infection type | Resident antibiotic prescribing rate, no./n (%) [95% CI*] | Staff antibiotic prescribing rate, no./n (%) [95% CI] | p-value | Ontario (Wu et al, 2019) | England (Smith et al, 2018) |
| Uncomplicated URI† | 8/159 (5.0) [2.2% to 9.7%] |
9/128 (7.0) [3.3% to 12.9%] |
0.48 | 0 | 0 |
| Sinusitis | 34/77 (44.2) [32.8% to 55.9%] |
42/52 (80.8) [67.5% to 90.4%] |
<0.01 | 18 | 11 |
| Pharyngitis/sore throat | 14/49 (28.6) [16.6% to 43.3%] |
11/42 (26.2) [13.9% to 42.0%] |
0.80 | 28 | 13 |
| Bronchitis | 1/28 (3.6) [0.0% to 18.4%] |
14/41 (34.2) [20.1% to 50.6%] |
<0.01 | 8 | 13 |
| Pneumonia | 23/43 (53.5) [37.7% to 68.8%] |
17/27 (63.0) [42.4% to 80.6%] |
0.44 | 100 | - |
| Cystitis | 85/107 (79.4) [70.5% to 86.6%] |
71/95 (74.7) [64.8% to 83.1%] |
0.43 | 95 | 75 |
| Other*† | 4/124 (3.2) [0.9% to 8.1%] |
5/127 (3.9) [1.3% to 9.0%] |
1.0 | 0 | 10 |
Other includes influenza, cough, viral illness, and other urinary
Different conditions included in “other” category for the two expert recommended papers
There were no significant differences in the prescribing rates for various conditions by resident or staff physicians in clinic 1 compared with clinic 2 (p > 0.05; data available upon request) and so these results have been combined. Furthermore, there was no difference between the overall resident antibiotic prescription rate (28.8%) and staff antibiotic prescribing (33%, p = 0.13). Of this, 20.7% were immediate prescriptions for residents compared to 23.1% for staff (p = 0.34) and 27.5% were delayed prescriptions for residents compared to 29.8% for staff (p = 0.65). When the total number of antibiotics were broken down by condition, staff physicians prescribed antibiotics more frequently for sinusitis and bronchitis (p < 0.01). Staff physicians were also more likely to prescribe immediate antibiotics for sinusitis (p = 0.02) and bronchitis (p < 0.01).
We further analyzed whether a resident's choice to prescribe antibiotics or not had an impact on subsequent office visits, ED visits, or hospitalizations within 30 days after the initial visit. There was no significant difference in ED visits or hospitalizations for resident encounters where antibiotics were prescribed (4/167, 2.4%) compared to where antibiotics were not prescribed (7/418, 1.7%; p = 0.42). There was a statistically significant difference for a repeat office visit 30 days after the initial visit if the patient received a prescription (84/167, 50.3%) versus for no prescription (168/418, 40.2%; p = 0.03).
Discussion
This study found that family medicine residents in these clinics generally prescribed antibiotics within expert-defined rates for common respiratory and urinary infections during their training. While there was overprescribing of antibiotics for acute sinusitis and acute uncomplicated upper respiratory tract infections, most of these were issued as delayed prescriptions to be taken where clinical improvement did not occur.
Exposure to the use of delayed antibiotic prescriptions by the resident trainees is a potentially important antimicrobial stewardship strategy they will take into practice. Some research suggests such prescriptions may only be filled 30% of the time (15). For uncomplicated URI and bronchitis, two conditions that should not require antibiotics, most prescriptions were for delayed treatment. Moreover, for those conditions that may require antibiotics, residents usually chose antibiotics consistent with guideline-recommended first-line antibiotics. We did not have information about antibiotic allergies in cases that deviated from guideline recommendations.
The study also demonstrated how a staff supervisor's prescribing behaviours is reflected in what the resident trainees learn is appropriate antibiotic prescribing use during their residency. In both sinusitis and bronchitis, staff physicians prescribed antibiotics more frequently than recommended by expert groups (16–23). Similarly, these were the conditions where residents were more likely to overprescribe antibiotics. These observations suggest an important role of primary care faculty in teaching and role-modeling optimal antibiotic prescribing practices, and how this may determine subsequent community patterns of primary care antibiotic utilization. Other studies have also found that supervising physicians had an influential role in the learners’ antibiotic knowledge and selection (5,27). How faculty in family medicine residency programs in Canada are trained in antibiotic appropriateness, and the antimicrobial stewardship curriculum in such programs, warrants further attention.
Studies of other medical trainee programs have also observed antibiotic overprescribing habits for some conditions. Walsh et al (25) reported internal medicine residents overprescribed for sinusitis and pharyngitis. A Swedish study looking at primary care residents found that they under prescribed for pneumonia and overprescribed for uncomplicated URIs (26). Our study corroborates these findings for sinusitis, pneumonia, and uncomplicated URIs, but found prescribing within the recommended range for pharyngitis. Furthermore, our study extends these findings beyond respiratory infections to include urinary tract infections where we observed that residents prescribe antibiotics appropriately for cystitis.
There were some limitations to this study. Firstly, as this study used secondary data, the analysis was limited to the available data. As well, we do not know whether patient encounters were evenly distributed between residents or whether a small group of residents saw a majority of the patients. The residents from the two involved clinics may not be representative of residents across the country, nor may these clinics be representative of other family medicine residency programs across the country. Furthermore, we relied on provider documentation for accurate information. For example, when a patient was prescribed a delayed treatment, we did not know whether antibiotics might have been taken immediately by patients regardless. We also did not have information on whether for patients who made additional office visits this was for the same reason or for a different issue. The selection of visits by specific infection billing codes may have missed visits where a non-infection and infection issue were both assessed but only the non-infection billing code was used. Whether this significantly affects prescribing estimates is unknown, but is a limitation. We were also unable to assess actual appropriateness of antibiotic prescriptions due to a lack of clinical details for each visit. As a result, expert opinion was used as an alternative external standard to reflect appropriate prescribing rates. Future studies that included specific clinical findings would allow for a more accurate assessment of appropriateness. In addition, while we chose two expert guidelines, others may exist and also be relevant. Finally, this study did not examine all antibiotic prescribing by residents as only selected common infections were reviewed.
To our knowledge, this is the first study examining Canadian family medicine residents’ antibiotic prescribing habits. Our study shows that for many common infections seen during family medicine training, residents prescribed antibiotics within expert-defined rates. Furthermore, residents are being trained in the use of delayed antibiotic prescriptions. However, antibiotics were likely to be over prescribed for acute sinusitis and uncomplicated URI, and these practices were similar to the staff physicians who supervised the residents. While there are limitations to the current study, these results suggest it may be appropriate to conduct a more detailed study of the antimicrobial stewardship curricula and antibiotic prescribing practices of both family medicine residents and staff who train residents in family medicine residency programs across Canada.
Funding Statement
Funding: No funding was received for this work.
Contributors:
Conceptualization, B Ho, W McIsaac; Formal Analysis, B Ho, S Kukan, W McIsaac; Methodology, B Ho, S Kukan, W McIsaac; Investigation, W McIsaac; Supervision, W McIsaac; Writing – Original Draft, B Ho; Writing – Review & Editing, B Ho, S Kukan, W McIsaac; Data Curation, B Ho, S Kukan, W McIsaac.
Ethics Approval:
All research meets the ethical guidelines, including adherence to the legal requirements of the study country.
Informed Consent:
N/A
Registry and the Registration No. of the Study/Trial:
N/A
Data Accessibility:
All data will not be made publicly available. Researchers who require access to the study data can contact the corresponding author for further information.
Funding:
No funding was received for this work.
Disclosures:
The authors have nothing to disclose.
Peer Review:
This manuscript has been peer reviewed.
Animal Studies:
N/A
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
All data will not be made publicly available. Researchers who require access to the study data can contact the corresponding author for further information.