Journal of Antimicrobial Chemotherapy (2003) 51, 379–384

DOI: 10.1093/jac/dkg032
Advance Access publication 6 January 2003

Antimicrobial practice

Laboratory antibiotic susceptibility reporting and antibiotic

prescribing in general practice

Thean Yen Tan1*, Cliodna McNulty2, Andre Charlett3, Nazma Nessa3, Clare Kelly4 and
Trevor Beswick4

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1Public Health Laboratory, University Hospital Wales, Cardiff, South Glamorgan CF14 4XW;
2Public Health Laboratory, Gloucester; 3Statistics Department, Communicable Disease Surveillance Centre,
London; 4NHS Executive South West, Department of Health, Bristol, UK

Received 25 June 2002, returned 26 August 2002, revised 9 October 2002; accepted 9 October 2002

This study set out to investigate whether there was an association between antibiotic
susceptibility reporting from microbiology laboratories and antibiotic prescribing for urinary
tract infections in the community. Data were collected over a 3 month period using a prospective
questionnaire survey of general practitioners, who submitted and received a mid-stream urine
(MSU) result from selected microbiology laboratories in England and Wales. In addition,
prescribing analyses and cost (PACT) data were requested from the Prescription Prescribing
Authority. The study demonstrated an association between laboratory reporting of antibiotic
susceptibilities and antibiotic prescribing for treatment of urinary tract infections. The reporting
of susceptibilities to oral cephalosporins and nitrofurantoin from microbiology laboratories was
associated with increased prescribing of each antibiotic. This association was demonstrated for
the choice of empirical antibiotic therapy and the choice of antibiotic prescribed for each studied
episode of urinary tract infection. PACT data demonstrated a consistently greater use of anti-
biotics that were reported by the servicing laboratory, although this was only statistically
significant for nitrofurantoin. This study demonstrates that there is an association between anti-
biotic susceptibility reporting from microbiology laboratories and antibiotic prescribing for the
treatment of urinary tract infections.

Keywords: antibiotic reporting, prescribing, microbiology laboratory

Introduction microbial susceptibility testing methodology5 but much less

attention has been given to the choice of antibiotics to test and
Infections constitute up to 40% of consultations in general report.
practice.1 General practice surgeries submit 40–400 urine This study aimed to determine whether different antibiotic
samples per 1000 patients and laboratory reports result in a susceptibility reporting protocols for urinary isolates from
change in antibiotic therapy in 28% of cases.2 However, there microbiology laboratories was associated with differences in
is little information to document the influence of micro- antibiotic prescribing in primary care. We hypothesized that
biology reports on antibiotic selection and prescribing. In the general practitioners (GPs) who were served by laboratories
UK, microbiology laboratories invest significant efforts in the that routinely reported particular antimicrobials (e.g. nitro-
process of quality assurance3,4 and the standardization of anti- furantoin, quinolones and cephalosporins) would prescribe
..................................................................................................................................................................................................................................................................

*Corresponding author. Tel: +44-29-2074-4825; Fax: +44-29-2074-2161; E-mail: theanyen.tan@phls.wales.nhs.uk

...................................................................................................................................................................................................................................................................

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© 2003 The British Society for Antimicrobial Chemotherapy
 T. Y. Tan et al.

these agents more frequently for the treatment of urinary tract
infections (UTIs) than doctors who were served by labora-
tories that did not report these antimicrobials.
Materials and methods
A questionnaire-based study was developed to investigate
antibiotic prescribing by GPs for the treatment of UTIs that
were served by laboratories with differing antibiotic reporting
protocols. In addition, antibiotic prescribing for the treatment
of all infections from each participating primary care group
was measured by obtaining prescribing analyses and cost
(PACT) data. PACT data represent the main source of infor-
Analysis of antibiotic prescribing results from
questionnaire survey
Antibiotic prescribing of GPs was examined by two separate
methods. GPs were asked to nominate their first choice of
antibiotic for the treatment of uncomplicated UTIs in general.
These choices were examined in order to detect any differ-
ence in empirical antibiotic choices between GPs serviced by
laboratories with different antibiotic susceptibility reporting
practices.
GPs were then asked to name the actual antibiotic pre-
scribed for the UTIs surveyed in each questionnaire received.
The antibiotic prescribing for these episodes could be sub-
divided into two groups: antibiotics prescribed before receipt

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mation on the prescribing of GPs in England,6 and a similar
of the laboratory report, and antibiotics prescribed after receipt
scheme exists in Wales.
of the laboratory report. From these data, it was possible to
compare the actual antibiotic prescribing for the surveyed
Questionnaire survey of antibiotic prescribing practices
UTIs for GPs serviced by separate laboratories.
from general practice
Nitrofurantoin, quinolones and cephalosporins were chosen
In total, 100 questionnaires were distributed to GPs in each as the indicator antimicrobials for analysis because these were
primary care area serviced by 13 Public Health Laboratories the only antibiotics where differences in reporting existed
over a 4 month period in the year 2000. The primary care area between the various laboratories. It was not possible to
was delineated by obtaining a complete list of GP practices analyse differences in antibiotic prescribing between report-
serviced by each participating laboratory. The geographical ing and non-reporting laboratories for ampicillin and trimeth-
area served by these laboratories included areas throughout oprim, because all laboratories reported these two antibiotics.
England and Wales. Laboratory selection was based on
susceptibility reporting determined by an earlier question-
naire survey of all Public Health Laboratories in England and PACT data
Wales.7 Antibiotic reporting practices for each participating
PACT data provide information about prescribing in general
laboratory were confirmed by the investigators before dis-
practice in England, and include all items prescribed by GPs
tribution of questionnaires. All laboratories reported sus-
and nurse prescribers. The volumes and prices of antibiotic
ceptibilities to trimethoprim and ampicillin. Two laboratories
prescriptions can be measured, but not the specific infection
did not report susceptibilities to nitrofurantoin, five labora-
for which a particular antibiotic was prescribed. However,
tories did not report susceptibilities to cephalosporins and
nitrofurantoin and norfloxacin are almost entirely prescribed
seven did not report susceptibilities to quinolones.
only for the treatment of UTIs. Any regional differences in
Questionnaires were attached to 100 consecutive positive
antibiotic prescribing for UTIs may therefore be measurable
mid-stream urine (MSU) reports at each participating
by PACT data for these two antibiotics.
laboratory. Wherever possible, laboratories were instructed
Primary care groups served solely by each participating
to refrain from sending more than one questionnaire to an
laboratory were identified. PACT data for oral cephalo-
individual GP. A positive report was defined as any MSU
sporins, co-amoxiclav, nitrofurantoin, norfloxacin, quino-
specimen with significant growth of an isolate for which anti-
lones and total antibiotic prescribing were requested for every
biotic susceptibility testing was carried out. Each question-
participating primary care group for the year 1999.
naire contained details of the urinary isolate identified with
reported antibiotic susceptibilities, but contained no patient or
practice identifiers. Completed questionnaires were initially
Analysis of PACT data
returned to each local laboratory, and subsequently forwarded
to the study investigators. GPs were asked to provide informa- Statistical analysis of the PACT data was carried out on
tion on their antibiotic prescribing practices for uncompli- Microsoft Excel and Stata 7. Due to an observed positive
cated UTIs, including the antibiotic that they had prescribed skew in the antibiotic prescribing units, the data were log-
for the current investigated episode of UTI. The antibiotic transformed before the analysis. A t-test was then carried out
choices provided for the questionnaire included amoxi- to assess whether there was a significant difference in pre-
cillin, oral cephalosporins, quinolones, co-amoxiclav, nitro- scribing in the areas where an antibiotic is reported compared
furantoin and trimethoprim (questionnaire available from the with where the antibiotic is not reported. As well as the
authors). reported P values, the estimated ratio of prescribing in the

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 Antibiotic susceptibility reporting and prescribing in general practice

Table 1. Comparison of stated empirical antibiotic of first choice by GPs

Number of GPs (%) who selected this antibiotic as first-choice

empirical therapy for uncomplicated UTIs
Odds ratio for
in areas serviced by laboratories in areas serviced by laboratories prescription
Antibiotic that reported these antibiotics that did not report these antibiotics P value (95% CI)

Oral cephalosporins 52/592 (8) 6/313 (2) <0.01 4.9 (2.1–14.1)

Nitrofurantoin 13/869 (2) 0/169 (0) 0.1 undefined
Quinolones 1/410 (0) 6/474 (1) 0.09 0.2 (0.0–1.6)

Figures in parentheses are reported as a percentage of the denominator.

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Table 2. Actual antibiotic prescribing by GPs for the episode of UTI investigated

Number of GPs who prescribed this antibiotic

for the investigated episodes of UTI (%)
Odds ratio for
in areas serviced by laboratories in areas serviced by laboratories prescription
Antibiotic that reported these antibiotics that did not report these antibiotics P value (95% CI)

Oral cephalosporins 100/616 (16) 31/300 (10) 0.04 1.6 (1.1–2.5)

Nitrofurantoin 35/835 (4) 0/149 (0) 0.01 undefined
Quinolones 45/459 (10) 24/383 (6) 0.06 1.6 (0.95–2.9)

Figures in parentheses are reported as a percentage of the denominator.

reporting to non-reporting areas was calculated together with
the 95% confidence intervals.
Statistical analysis
Data from the questionnaires and PACT data were entered
into Epi-Info, and analysed in Stata 7 and Epi-Info. The χ2 test
and Fisher’s exact test were used to test for statistical signifi-
cance for any associations noted.
Results
In total, 1069 of 1300 (82%, range 65–90%) distributed
questionnaires were returned.
GPs stated empirical antibiotic choices
Overall, 90% of GPs selected trimethoprim as antibiotic of
first choice in uncomplicated UTIs. The other empirical
antibiotic choices selected were an oral cephalosporin (6%)
and a quinolone (1%). However, GPs in areas serviced by a
laboratory that routinely reported cephalosporin susceptibil-
ities on urinary isolates were four times more likely to select
an oral cephalosporin as their first choice of empirical therapy
(Table 1). No statistically significant differences in the choice
of either quinolones or nitrofurantoin were noted for GPs
serviced by laboratories that reported or did not report each
antibiotic.
GPs prescribed antibiotic therapy for the investigated
episode of UTI
With regard to antibiotic prescribing for the reported cases of
UTI in this study, GPs who were serviced by laboratories that
reported cephalosporins or nitrofurantoin were significantly
more likely to prescribe these antibiotics (Table 2). In labora-
tory areas where cephalosporin susceptibilities were reported,
16% of GPs prescribed this antibiotic as opposed to 10% in
non-reporting areas (P < 0.05). The corresponding figures for
quinolone prescribing were 10% in reporting areas, compared
with 6% in non-reporting areas (P = 0.06); 4% of GPs serviced
by laboratories that reported antibiotic susceptibilities to nitro-
furantoin prescribed this antibiotic, compared with 0% in the
corresponding group serviced by a non-reporting laboratory
(P < 0.05).
Subgroup analysis was carried out to compare antibiotic
prescription both before and after receipt of the laboratory
result.

381
 T. Y. Tan et al.

Table 3. Antibiotic therapy prescribed by GPs before receipt of laboratory MSU report

Antibiotic prescribed for investigated episode of

UTI before receipt of microbiology report (%)
Odds ratio for
in areas serviced by laboratories in areas serviced by laboratories prescription
Antibiotic that reported these antibiotics that did not report these antibiotics P value (95% CI)

Nitrofurantoin 16/501 (3) 0/87 (0) 0.07 undefined

Oral cephalosporins 50/364 (14) 16/181 (9) 0.10 1.6 (0.9–3.2)
Quinolones 32/277 (12) 11/226 (5) <0.01 2.6 (1.2–5.8)

Table 4. Antibiotic therapy prescribed by GPs after receipt of laboratory MSU report

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Antibiotic prescribed for investigated episode of
UTI after receipt of microbiology report (%)
Odds ratio for
in areas serviced by laboratories in areas serviced by laboratories prescription
Antibiotic that reported these antibiotics that did not report these antibiotics P value (95% CI)

Nitrofurantoin 19/334 (6) 0/62 (0) 0.04 undefined

Oral cephalosporins 50/252 (20) 15/119 (13) 0.09 1.7 (0.9–3.5)
Quinolones 13/182 (7) 13/157 (8) 0.70 0.85 (0.4–2.1)

Table 5. Comparison of antibiotic prescribing as measured by PACT data from reporting and non-reporting
laboratory areas

Estimated ratio of antibiotic prescribing (laboratories that

Antibiotic report antibiotic/laboratories that do not report antibiotic) 95% CI P value

Cephalosporins 1.40 0.75–2.64 0.26

Quinolones 1.35 0.98–1.86 0.06
Norfloxacin 1.29 (laboratories that report quinolones/laboratories 0.29–5.80 0.72
that do not report quinolones)
Norfloxacin 2.08 (laboratories that report norfloxacin/laboratories 0.10–44.37 0.54
that do not report norfloxacin)
Nitrofurantoin 2.78 1.36–5.69 0.01
Co-amoxiclav 1.61 0.86–3.02 0.10

Combined analysis 1.54 1.06–2.23 0.02

Before receipt of the laboratory result, GPs served by any
laboratory that reported quinolone susceptibilities were more
than twice as likely to have initially prescribed this antibiotic
(12% versus 5%, P < 0.01) (Table 3).
The strongest association between antibiotic reporting and
prescribing following receipt of the laboratory report was for
nitrofurantoin (6% versus 0%, P = 0.04) (Table 4). Although
more GPs who were served by laboratories that reported
cephalosporin susceptibilities prescribed cephalosporins
following receipt of the microbiology report, this increase
was not statistically significant.
PACT data
Analysis of the PACT data was carried out to investigate
whether these reported differences in antibiotic selection and
prescribing were quantifiable as differences in antibiotic
prescription and cost data (Table 5). Prescribing volumes for
nitrofurantoin were nearly three times higher in primary care
areas served by a reporting laboratory (P < 0.05). For all the
other antibiotics concerned, prescribing of an antibiotic was
higher in areas served by the laboratories that reported the
antibiotic, although the results failed to reach statistical sig-

382
 Antibiotic susceptibility reporting and prescribing in general practice
nificance. Initially an interaction was used to test for hetero-
geneity between the estimated ratio of antibiotic prescribing,
and there was no evidence to suggest that the relative
increases in prescribing in the areas served by reporting
laboratories were different (P = 0.33). The final row in Table 5
was obtained by pooling these estimates in a regression
model. These figures demonstrate that, regardless of which
individual antibiotic is examined, laboratory reporting of any
antibiotic is associated with a 54% increase in antibiotic
prescribing (P = 0.024, 95% CI 6–123%).
Discussion
There is conflicting evidence from previous literature regard-
ing the link between laboratory antimicrobial susceptibility
reporting and antibiotic prescribing. An earlier study that
restricted susceptibility reporting on urinary isolates from the
community showed increasing use of the antibiotics for which
susceptibilities were reported.8
This study demonstrates that the prescribing of cephalo-
sporins, nitrofurantoin and quinolones for the treatment of
UTIs varies across general practices. These reported differ-
ences extended from the choice of empirical antibiotics to the
actual prescription of antibiotics for the UTIs surveyed in this
study, and corresponded with local laboratory antibiotic
susceptibility reporting. Laboratory reporting of quinolone or
cephalosporin susceptibilities by a microbiology laboratory
was associated with a 50% increase in prescribing of each
antibiotic by the GPs surveyed in this study, whereas the dif-
ference for nitrofurantoin prescribing was substantially larger.
Other than for nitrofurantoin, these reported differences in
prescribing did not translate into a significant difference in
actual antibiotic prescribing as reported by PACT data. There
was a trend towards increased antibiotic prescribing linked
with antibiotic reporting. However, with such small numbers
of laboratories involved, the analysis did not have sufficient
statistical power to detect the reported differences as being
significant. In addition, PACT data are not specific enough to
differentiate between antibiotics prescribed for the treatment
of UTIs or other infections. Thus, it is difficult to demonstrate
an association between reporting and prescribing of some
antibiotics specifically for the treatment of UTIs. Cephalo-
sporins, co-amoxiclav and quinolones can also be prescribed
for treatment of other infections.
There are several limitations to this study. The sample of
GPs in the study was clearly biased towards those who sub-
mitted urine samples to their local laboratory. The prescribing
practices of doctors who rarely submit urine samples for
testing may be different from those surveyed in this study.
Some GPs may only submit MSU samples for the treatment of
complicated UTIs, which may require different empirical
antibiotic treatment.
383
It may not be possible to extrapolate these results to all pri-
mary care areas in England and Wales. Only 100 GPs were
sampled for each primary care area involved in the study.
Furthermore, only primary care areas served by Public Health
Laboratories were included in the study. Laboratories were
selected for participation in the study by their local antibiotic
reporting practices and not by geographical distribution or
demographic coverage. Because of these factors, the sample
population may not be representative of the general popula-
tion as a whole.
Variation in local antibiotic susceptibility patterns may
also account for the differences in antibiotic prescribing.
For example, higher rates of resistance to ampicillin, nitro-
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furantoin or trimethoprim may account for increased
prescription of cephalosporins or quinolones. Antibiotic sus-
ceptibilities of the reported 100 urinary isolates from each
laboratory were analysed for antibiotic resistance rates to
ampicillin, nitrofurantoin or trimethoprim (data available on
request). The only significant difference in resistance rates
noted was increased resistance to ampicillin/amoxicillin in
laboratories that reported norfloxacin susceptibilities (resist-
ance rate 59% versus 46%, P < 0.05). Even in this laboratory
grouping, there was no significant difference in resistance
rates to trimethoprim or nitrofurantoin.
This study has demonstrated an association between
laboratory susceptibility reporting practices and the prescrib-
ing of specific antibiotics for the treatment of UTIs. This
association was noted at both possible stages of antibiotic
prescribing—in the choice of empirical antibiotic therapy,
and in prescribing for an infection when the susceptibility
results were known. It is less clear whether this association
would be applicable to all antibiotics prescribed for UTIs, or
to antibiotics prescribed for other infections. In a study of this
nature, causality is difficult to demonstrate. For example, one
possible explanation for the association noted in this study is
that microbiology laboratories may selectively choose to
report antibiotics that are more commonly used in their
primary care area. It would be difficult to ascertain the relative
effect of the actual microbiology report itself, and other influ-
ences such as local antibiotic reporting practices in general
and local prescribing guidelines. In addition, the laboratory
report may affect antibiotic prescribing at various stages in
the process—in the overall decision making process, or at the
actual stage of selection and prescribing of the antibiotic. It is
well documented that influences on prescribing habits are
complex and multi-factorial and include prescribing guide-
lines,9 education,10 the pharmaceutical industry11 and patient
expectations.12
Nonetheless, the results from this study suggest that
laboratory reporting of antibiotic susceptibilities may influ-
ence antibiotic prescribing in the community. Further studies
will be needed to clarify this association, for example, by
altering laboratory reporting practices in the study areas and
 T. Y. Tan et al.
examining the effect of this alteration on subsequent anti-
biotic prescribing.
Acknowledgements
We would like to thank the Directors and staff of the follow-
ing Public Health Laboratories without whom this study
would not have been possible: Bangor, Bristol, Cardiff,
Chester, Chelmsford, Coventry, Exeter, Gloucester, Ipswich,
Lincoln, Norwich, Plymouth and Shrewsbury. We also thank
all the GPs who contributed to the questionnaire survey. This
study was funded by a grant from the Public Health Labora-
tory Service.
References
1. UK Department of Health. (2002). Getting ahead of the curve. A
strategy for combating infectious diseases (including other aspects
of health protection) [Online.] http://www.doh.gov.uk/cmo/idstrategy/
(24 July 2002, date last accessed).
2. Tompkins, D. S. & Shannon, A. M. (1993). Clinical value of
microbiological investigations in general practice. British Journal of
General Practice 43, 155–8.
3. Gray, J. (1999). Quality assurance in a diagnostic microbiology
laboratory. Communicable Disease and Public Health 2, 225–6.
4. Bartlett, R. C., Mazens-Sullivan, M., Tetreault, J. Z., Lobel, S. &
Nivard, J. (1994). Evolving approaches to management of quality in
clinical microbiology. Clinical Microbiology Review 7, 55–88.
384
5. Andrews, J. M. (2001). BSAC Working Party on Susceptibility
Testing. BSAC standardized disc susceptibility testing method.
Journal of Antimicrobial Chemotherapy 48, Suppl. 1, 43–57.
6. Majeed, A., Evans, N. & Head, P. (1997). What can PACT tell
us about prescribing in general practice? British Medical Journal
315, 1515–9.
7. Tan, T. Y. & McNulty, C. A. (2002). Survey of public health
laboratory protocols for reporting the antibiotic susceptibility of
urinary isolates submitted from general practice. Communicable
Disease and Public Health 5, 33–7.
8. Langdale, P. & Millar, M. R. (1986). Influence of laboratory
sensitivity reporting on antibiotic prescribing preferences of general
practitioners in the Leeds area. Journal of Clinical Pathology 39,
233–4.
Downloaded from https://academic.oup.com/jac/article/51/2/379/748621 by guest on 19 December 2023
9. Zwar, N., Wolk, J., Gordon, J., Sanson-Fisher, R. & Kehoe, L.
(1999). Influencing antibiotic prescribing in general practice: a trial
of prescriber feedback and management guidelines. Family
Practice 16, 495–500.
10. McNulty, C. A., Kane, A., Foy, C. J., Sykes, J., Saunders, P. &
Cartwright, K. A. (2000). Primary care workshops can reduce and
rationalize antibiotic prescribing. Journal of Antimicrobial Chemo-
therapy 46, 493–9.
11. Orlowski, J. P. & Wateska, L. (1992). The effects of pharma-
ceutical firm enticements on physician prescribing patterns. There’s
no such thing as a free lunch. Chest 102, 270–3.
12. Macfarlane, J., Holmes, W., Macfarlane, R. & Britten, N. (1997).
Influence of patients’ expectations on antibiotic management of
acute lower respiratory tract illness in general practice: question-
naire study. British Medical Journal 315, 1211–4.