Antibiotics in urinary-tract infections. Sustained change in prescribing habits by practice test and self-reflection: a mixed methods before-after study

Background: The German guideline recommends trimethoprim (TMP) for the treatment of uncomplicated lower-urinary-tract infections (uLUTI) in primary care. In the authors' research network, the participating general practitioners (GPs) were asked why they prescribe mostly quinolones instead. The GPs stated the perception of a high rate of therapy failure of TMP and strongly rejected the guideline. Objective: To examine prescribing behaviour for uLUTI and whether a practice test of TMP might effect a change in prescribing habits. Methods: The study was conducted using observational and qualitative elements. A first focus-group (n=6) assessed reasons for current prescribing behaviour. In a 3-month practice test, patients with uLUTI were prescribed TMP (150 mg twice for 3 days). In a second focus group, the GPs (n-12) were presented with the results of the practice test. Results: The first focus group revealed that prescribing was mainly driven by former hospital training and what was perceived as common therapy. GPs felt no need to change a successful regimen. In the practice test, TMP had a success rate of 94% (84 episodes of uLUTI). The second focus group revealed that the practice test had strongly changed opinions in favour of TMP. Self-reflection and ownership of data acquisition were seen as major contributions for change in prescribing. After the test period, TMP remained the antibiotic most often prescribed. Conclusion: Internal evidence and peer-group opinion are strong determinants for clinical decisions. A self-conducted practice test, together with self-reflection in a peer group, strongly supports the process of change.