Do Primary Care Physicians Underprescribe Antibiotics for Peptic Ulcer Disease?

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Original Research

Do Primary Care Physicians Underprescribe Antibiotics for Peptic Ulcer Disease?

J Fam Pract. 2002 March;51(3):249-253

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References

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Most patients for whom other therapies were prescribed received bismuth-containing combinations. A combination of bismuth and PPI was prescribed to 10 patients (1.8% of the total population). The drug was added to PPI-based triple therapy in 10 patients (1.8% of the total population) and to PPI-based dual therapy in 2 patients (0.4% of the total population). The remaining 10 patients were treated as follows: a combination of 2 antibiotics without PPI (2 patients), H₂-based triple therapy (6 patients), or antibiotic monotherapy (2 patients). None of these combinations is known to eradicate H pylori effectively.

TABLE 1
FREQUENCY OF ERADICATION THERAPY OF HELICOBACTER PYLORI

Diagnosis	Eradication Therapy No. (%)	No Eradication Therapy No. (%)
Peptic ulcer disease (n = 2162)	596* (27.6)	1566 (72.4)
Nonulcer dyspepsia (n = 4704)	94* (2)	4610 (98)
* P = .0001.

TABLE 2
FREQUENCY OF ATTEMPTED ERADICATION BY DEFINITIVE OR PRESUMPTIVE DIAGNOSIS

Diagnosis	Attempted Eradication (%)	Other Therapies (%)
Peptic ulcer disease
Definitive (n = 904)	341 (37.7)*	563 (62.3)
Presumptive (n = 1258)	255 (20.3)*	1003 (79.7)
Nonulcer dyspepsia
Definitive (n = 743)	7 (0.9) †	736 (99.1)
Presumptive (n = 3761)	87 (2.2) †	3684 (97.8)
*P < .0001.
†P < .025.

TABLE 3
ERADICATION REGIMENS USED BY ITALIAN PRIMARY CARE PHYSICIANS

Eradication Regimen	Patients: No. (%)
Dual therapy	301 (54)
PPI + C	242 (43.4)
PPI + A	42 (7.5)
PPI + M	17 (3.1)
Triple Therapy	225 (40.3)
PPI + C + M	192 (34.4)
PPI + C + A	10 (3.6)
PPI + A + M	13 (2.3)
Other	32 (5.7)
A denotes amoxicillin; C, clarithromycin; M, metronidazole; PPI, proton pump inhibitor.

Discussion

The data from our study indicate that from 1998 to 2000, the majority of patients with PUD seen by the PCPs participating in the study were not treated with antibiotic therapy aimed at the eradication of H pylori.

In our series, only approximately one third of patients with a definitive diagnosis of PUD were treated with antibiotic therapy, a figure much lower than the 90% reported in nationwide surveys during 1995 and 1996 in the United States and Germany.^8,9 We believe that the most important factor underlying this difference may be the study design. Our study was based on the actual treatment given by the physicians to their patients; previous studies, however, were based on responses to a mailed questionnaire. While the previous studies may reflect ways in which PCPs would ideally treat their patients, some discrepancy is unavoidable when passing from theory to practice.

Other studies based on real-world prescription data had results similar to ours, despite having a small sample size^15,16 or studying underserved populations.^17,18 In light of these data, we suspect that the underuse of antibiotic therapy for PUD disease is common in many areas of the Western world.

Since PCPs were not required to include information on H pylori testing in the database, we did not have reliable data on the frequency of testing or on the relative frequency of positive and negative results. Therefore, it is possible that the low number of prescriptions of eradication therapy for patients with PUD was caused by a high rate of H pylori–negative peptic ulcer. This seems improbable, however, since a high rate of H pylori–positive peptic ulcers has been reported in Italian patients.¹⁹

One likely reason for the low prescription rate of eradication therapy by PCPs was concern about patient compliance and the side effects of antibiotics. Although a recent study reported discontinuation of therapy because of adverse events or noncompliance in less than 10% of patients,⁷ it is well known that data on compliance coming from research studies are not automatically transferable to clinical practice.²⁰

Since eradication therapy was prescribed by the majority of PCPs involved in our study, our findings suggest that an awareness of new information does not necessarily effect changes in physicians’ prescribing patterns.^21-23 Both knowledge-oriented strategies (ie, purely educational interventions) and behavior-oriented interventions (ie, strategies intended to alter behavior, usually by incentives and penalties) are necessary to change physicians’ prescribing patterns regarding PUD. Furthermore, change strategies should be matched to the type of clinician. Our data suggests that most PCPs involved in our study are pragmatists.²⁴ These physicians will not change their behavior in a way that would increase their workload or conflict with patient expectations. Therefore, to increase the rate of prescriptions of eradication therapy for PUD, it is crucial to remove obstacles (eg, facilitate the performance of H pylori testing and endoscopy) and to focus educational interventions on practical issues (eg, place emphasis on the fact that prescribing eradication therapy to these patients may lead to a reduction of visits in the future).

The very low rate of eradication therapy (less than 3%) for patients with NUD in our study seems at odds with the high prevalence (more than 50%) of eradication therapy prescribed by US physicians for patients with NUD.⁹ The same factors explaining the different rates of eradication therapy for patients with PUD apply to differing rates in patients with NUD.