What the old doc­tor or­dered

Late-ca­reer fam­ily MDs more apt to pre­scribe an­tibi­otics longer, boost­ing the risk of drug re­sis­tance, study finds


A new study shows On­tario fam­ily doc­tors late in their ca­reers are more likely to pre­scribe an­tibi­otics for longer than their newly grad­u­ated coun­ter­parts, a pre­scrib­ing prac­tice shown to in­crease the risk of build­ing dru­gre­sis­tant mi­crobes.

On­tario’s an­tibi­otic pre­scrib­ing pat­terns are well-doc­u­mented — with Sar­nia-Lambton, Chatham-Kent and Wind­sorEs­sex pre­scrip­tion rates tops in the prov­ince — but the new study high­lights the most likely cul­prits for dis­pens­ing the drugs longer than nec­es­sary.

“This vari­abil­ity is not re­ally nec­es­sar­ily be­ing driven by dif­fer­ent pa­tient pop­u­la­tions or dif­fer­ent di­ag­noses . . . but physi­cian habits and the way physi­cians were trained,” study co-au­thor and Pub­lic Health On­tario re­searcher Kevin Schwartz said. “That’s some­thing we need to tar­get and change mov­ing for­ward.”

Re­searchers looked at oral an­tibi­otics pre­scribed by 10,616 fam­ily physi­cians in On­tario be­tween March 1, 2016, and Feb. 28, 2017. The group pre­scribed a to­tal of 5.6 mil­lion an­tibi­otic cour­ses.

Study au­thors clas­si­fied the physi­cians by their ca­reer stage, defin­ing early-ca­reer physi­cians as ones with less than 11 years since they grad­u­ated from med­i­cal school, mid-ca­reer physi­cians as hav­ing 11 to 24 years prac­tis­ing since grad­u­a­tion, and late­ca­reer doc­tors with 25 years or more since they fin­ished med­i­cal school.

Re­searchers found late-ca­reer doc­tors sig­nif­i­cantly more likely to pre­scribe a pro­longed course of an­tibi­otics — longer than eight days — than early-ca­reer fam­ily physi­cians.

An av­er­age of 38.6 per cent of an­tibi­otic pre­scrip­tions writ­ten by late-ca­reer fam­ily doc­tors were for long cour­ses of the drug, com­pared to 30.5 per cent for ear­ly­ca­reer physi­cians.

Pre­scrib­ing an­tibi­otics for a shorter pe­riod is a key part of an­tibi­otic stew­ard­ship, Schwartz said. Shorter cour­ses of the drugs give bac­te­ria less op­por­tu­nity to de­velop re­sis­tance. A quick round of an­tibi­otics also lim­its the chance for waste or abuse by pa­tients.

“There’s ev­i­dence that’s been build­ing over the last decades show­ing that shorter du­ra­tions of an­tibi­otics are equiv­a­lent to longer cour­ses of ther­apy with less side- ef­fects and less im­pact on re­sis­tance,” Schwartz said.

The an­tibi­otic pre­scrip­tion is­sue hits home in South­west­ern On­tario, where doc­tors in Sar­nia-Lambton, Chatham-Kent and Windsor-Es­sex lead the prov­ince in pre­scrib­ing rates.

From March 2016 to Fe­bru­ary 2017, the Erie St. Clair Lo­cal Health In­te­gra­tion Net­work had the high­est an­tibi­otic pre­scrib­ing rate in the prov­ince, 778 pre­scrip­tions per 1,000 peo­ple each year.

Though pa­tient ex­pec­ta­tions and de­mo­graphic char­ac­ter­is­tics — in­clud­ing so­cioe­co­nomic sta­tus and ru­ral or ur­ban clinic set­tings — can play a role in how doc­tors dole out the drugs, Schwartz said doc­tors’ own habits play a role, too.

Schwartz wants to see more fo­cus on an­tibi­otic stew­ard­ship among the older gen­er­a­tion of doc­tors, who may not be as well versed as their younger col­leagues in the op­ti­mal way to dis­pense the drugs.

“Med­i­cal ed­u­ca­tion was prob­a­bly very dif­fer­ent back then about an­tibi­otic pre­scrib­ing and the risks of over-pre­scrib­ing . . . weren’t well ap­pre­ci­ated,” he said.

But it’s not all doom and gloom, he said.

“On the other side, this gives us some hope for the fu­ture. We know that the younger doc­tors are do­ing this more ap­pro­pri­ately,” Schwartz said. “There’s more of a fo­cus on us­ing an­tibi­otics more ju­di­ciously. It shows that we’re do­ing at least some things right.”

The study ap­pears in the lat­est edi­tion of the Ox­ford Univer­sity Press aca­demic jour­nal, Clin­i­cal In­fec­tious Dis­eases.

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