Beliefs and attitudes on antibiotic use in Malta : informing intervention strategies

Abstract

The use of antibiotics in the treatment and prophylaxis of bacterial diseases has contributed greatly to the reduction of the burden of infectious disease. However, trends show that with time, the emergence and spread of antibiotic resistance IS continuously threatening the effective treatment of some important infections. Amongst the determinants of inappropriate antibiotic use, literature has underlined patient education level, expectations of physicians and patients, cultural aspects, regulatory practice, and antibiotic price as the main contributing factors. The main aim of this research was to assess the knowledge, attitudes and perceptions of antibiotic users and to identify any changes in antibiotic consumption since the last survey done in 2009. The second part of the study was to determine the knowledge, attitudes and perceptions of prescribers. The combined aim was to get information to be able to inform strategies for effective interventions to promote appropriate antibiotic use. After a comprehensive literature review, it was established that the best way to achieve the aims was to carry out two retrospective cross-sectional surveys, one with the public and one with prescribers. Results from these studies showed that since 2009, when antibiotic consumption for Malta was last studied through a Eurobarometer study, there has been a 17% reduction in antibiotic consumption and a further improvement in non-prescribed use, with 96% of respondents having obtained their antibiotics with a prescription. The most commonly used antibiotics are the beta-lactams, particularly co-amoxiclav. The use of the narrow spectrum antibiotics is almost non-existent. Antibiotics were taken primarily for sore throat, followed by chest infection and flu and were almost all prescribed by private community general practitioners. Topical antibiotic use is high and used for minor skin conditions. What is concerning is the high level of non-prescribed use for totally inappropriate indications. The knowledge of the antibiotic users was not good, in particular in terms of the viral cause of cold and flu and the fact that antibiotics do not kill viruses. Their attitudes were also not conducive to proper antibiotic use - more than half stated that they expect a prescription for antibiotics for a cold and that they know they need an antibiotic for a sore throat before they go to the doctor. Knowledge and attitudes were better in females and the better educated. This must be taken into consideration in any intervention strategies to improve antibiotic use. Almost all the physicians had prescribed an antibiotic in the previous week, the majority prescribing more than three. Personal knowledge and previous experience were the factors that doctors considered that influenced them most in their prescribing decisions, possibly showing that most of them work in isolation. Physicians underestimated the level of resistance in the community and attributed it more to hospital rather than ambulatory care. However, general practitioners were more knowledgeable about resistance levels than the non general practitioner cohort. Whilst they identified the major causes for increasing resistance as overprescribing of antibiotics, especially broad spectrum antibiotics and inappropriate use for viral infections, their behaviour was not found to be in congruence, as they admitted that they prescribe mostly broad spectrum antibiotics, the main reason given being lack of laboratory support. Another finding which corroborates the attitudes reported by the public was that more than half said that patients specifically ask them for antibiotics. Prescribers identified the availability of national resistance data and guidelines and protocols as the preferred measures for improving prescribing. Due to the fact that knowledge, attitudes and perceptions in the public survey were only studied in antibiotic users, the results do not necessarily reflect those of the general population. Other limitations which effect validity of the study are response and selection bias. The representativeness of the results of the physician survey is also limited by the low response rate and by responder bias because of the methodology chosen. In conclusion, it is evident that there is no simple relationship between knowledge and attitudes and more prudent antibiotic use. Future national antibiotic campaigns should be targeted to defined audiences and aim to improve use of antibiotics by prescribers and the public. With these data, a number of recommendations were made for the design of strategies to optimise use of antibiotics.