The effect of a general practitioner's perception of a patient request for antibiotics on antibiotic prescribing for respiratory tract infections: secondary analysis of a point prevalence audit survey in 18 European countries.

Background: Illness severity, comorbidity, fever, age and symptom duration influence antibiotic prescribing for respiratory tract infections (RTI). Non-medical determinants, such as patient expectations, also impact prescribing.

Aim: To quantify the effect of general practitioners' (GPs') perception of a patient request for antibiotics on antibiotic prescribing for RTI and investigate effect modification by medical determinants and country.

Design & Setting: Prospective audit in 18 European countries.

Method: Consultation data were registered of 4982 patients presenting with acute cough and/or sore throat. A mixed-effect logistic regression model analysed the effect of GPs' perception of a patient request for antibiotics. Two-way interaction terms assessed effect modification. Relevant clinical findings were added to subgroups of lower RTI (LRTI), throat infection, and influenza-like-illness (ILI).

Results: GPs who perceived a patient request for antibiotics were four times more likely to prescribe antibiotics (OR: 4.4, 95%CI: 3.4-5.5). This effect varied by country: lower in Spain (OR: 0.06), Ukraine (OR: 0.15), and Greece (OR: 0.22) compared to the lowest prescribing country. The effect was higher for ILI (OR: 13.86, 95%CI: 5.5-35) and throat infection (OR: 5.1, 95%CI: 3.1-8.4) than for LRTI (OR: 2.9, 95%CI: 1.9-4.3). For ILI and LRTI, GPs were more likely to prescribe antibiotics with abnormal lung auscultation and/or increased/purulent sputum and for throat infection, with tonsillar exudate and/or swollen tonsils.

Conclusion: GPs' perception of an antibiotic request and specific clinical findings influence antibiotic prescribing. Incorporating exploration of patient expectations, point-of-care testing and discussing watchful waiting into the decision-making process will benefit appropriate prescribing of antibiotics.