Lack of Knowledge of Antibiotic Risks Contributes to Primary Care Patients’ Expectations of Antibiotics for Common Symptoms

Lindsey A. Laytner; Barbara W. Trautner; Susan Nash; Roger Zoorob; Jennifer O. Okoh; Eva Amenta; Kiara Olmeda; Juanita Salinas; Michael K. Paasche-Orlow; Larissa Grigoryan

doi:10.1370/afm.3161

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Table 1.

Patient Sociodemographic, Symptom/Illness Characteristics by Health Care System, and Differences Between the Public and Private Health Care Systems (χ² P Value <0.05)

Patient characteristics	All Clinics (n = 564)	Public Clinics (n = 409)	Private Clinics (n = 155)	Public vs Private Clinics
Patient characteristics	n (%)	n (%)	n (%)	P Value
Median age, y [range]	49.7 [19-92]	53 [19-77]	41 [19-92]	P <0.001
Gender/Sex				P = 0.180
Female	407/564 (72.2)	302/409 (73.8)	105/155 (67.7)
Male	157/564 (26.8)	107/409 (26.2)	49/155 (31.6)
Race and ethnicity				P <0.001
Hispanic	263/564 (46.6)	222/409 (54.3)	41/155 (26.5)
Non-Hispanic Black/African American	186/564 (33.0)	144/409 (35.2)	42/155 (27.1)
Non-Hispanic White	89/564 (15.8)	32/409 (7.8)	57/155 (36.8)
Other^{^a}	26/564 (4.6)	11/409 (2.7)	15/155 (9.7)
Education				P <0.001
Less than high school	92/564 (16.3)	82/409 (20.0)	10/155 (6.5)
High school or GED	225/564 (39.9)	184/409 (45.0)	41/155 (26.5)
Some college and above	247/564 (43.8)	143/409 (35.0)	104/155 (67.1)
Health insurance status				P <0.001
Private or Medicare	207/564 (36.7)	94/409 (23)	113/155 (72.9)
Medicaid or county financial assistance program	319/564 (56.6)	308/409 (75.3)	11/155 (7.1)
Self-pay	38/564 (6.7)	7/409 (1.7)	31/155 (20)
Survey language preference				P <0.001
Spanish	155/564 (27.5)	143/409 (35)	12/155 (7.7)
English	409/564 (72.5)	266/409 (65)	143/155 (92.3)
Country of birth				P = 0.230
United States	360/564 (63.8)	243/409 (59.4)	117/155 (75.5)
Other^{^b}	204/564 (36.2)	166/409 (40.6)	38/155 (24.5)
Knowledge of any risks associated with antibiotic use				P = 0.738
No. Lacking knowledge of the risks	210/564 (37.2)	146/409 (35.7)	53/155 (34.2)
Yes. Has knowledge of the risks, as follows:	354/564 (62.8)	255/409 (62.3)	99/155 (63.9)
Anything related to antibiotic resistance	105/354 (29.7)	63/255 (24.7)	42/99 (42.4)	P <0.001
Antibiotics may kill friendly/good bacteria	31/354 (8.8)	20/255 (7.8)	11/99 (11.1)	P = 0.324
Antibiotic side effects (rash, diarrhea or nausea)	270/354 (76.3)	206/255 (80.8)	64/99 (64.6)	P <0.002
It is unhealthy to take medicine in general	25/354 (7.1)	19/255 (7.5)	6/99 (6.1)	P = 0.653
Other^{^c}	29/354 (8.2)	26/255 (10.2)	3/99 (3.0)	P = 0.028
Health literacy^{^d}				P = 0.260
Adequate	391 (69.3)	278 (68.0)	113 (72.9)
Inadequate	173 (30.7)	131 (32.0)	42 (27.1)

Patient characteristics	All Clinics n/N (%)	Public Clinics n/N (%)	Private Clinics n/N (%)	Public vs Private Clinics (P Value)
Taking antibiotics will help to alleviate symptoms quickly or prevent getting sicker^{^e}
Sore throat	370/559 (65.6)	289/405 (71.4)	81/154 (52.6)	P <0.001
Diarrhea	205/505 (36.3)	165/397 (41.6)	40/153 (26.1)	P <0.001
Cold or flu	361/560 (64.0)	274/406 (67.5)	87/154 (56.5)	P = 0.02
Sinus infection	406/538 (72.0)	301/392 (76.8)	105/146 (71.9)	P = 0.240
Bronchitis	369/473 (83.9)	261/333 (78.4)	108/140 (77.1)	P = 0.770
Overall (any symptom/illness)	512/550 (93.1)	377/399 (94.5)	135/151 (89.4)	P = 0.040

GED = general educational development.
Note: Bolded = significant P value (<0.05).
↵a Other includes “mixed” race and Asian.
↵b Other includes all reported countries outside the United States. These include 1 Columbia, 1 Costa Rica, 6 Cuba, 1 Dominican Republic, 14 El Salvador, 6 Guatemala, 15 Honduras, 131 Mexico, 2 Nicaragua, 1 Panama, 1 Peru, and 3 Venezuela (countries are listed in alphabetical order).
↵c Other category includes respondents that reported antibiotics interacting with other medications/alcohol and reported antibiotics to cause urinary tract infection.
↵d Individuals answering “Yes” to: “Difficulty understanding written information,” “Confidence in filling out medical forms by yourself,” or “Someone helps you read clinic or hospital materials.”^19,20
↵e Individuals answering “Yes” to either question, “When you have (diarrhea, sore throat, cold/flu, sinus infection, or bronchitis symptoms), taking antibiotics will help you get better quickly” or “When you have (diarrhea, sore throat, cold/flu, sinus infection, or bronchitis symptoms), you should take antibiotics to avoid getting sicker.”

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Table 2.

Multivariate Results. Sociodemographic Predictors of Patient Expectations of Antibiotics for Diarrhea, Sore Throat, Cold/Flu, and Overall (Any Symptom/Illness)

	Expectation of Antibiotics to Alleviate or Prevent Symptoms:
	Diarrhea		Sore Throat		Cold/Flu		Overall^{^a}
	OR (95% CI)	P Value	OR (95% CI)	P Value	OR (95% CI)	P Value	OR (95% CI)	P Value
Sociodemographic predictors^{^b}
Education	Overall	0.010	Overall		Overall	–	Overall	–
Some college and above	1 (reference)	–	1 (reference)	–	1 (reference)	–	1 (reference)	–
High school or GED	0.9 (0.6-1.4)	0.700	–	–	–	–	–	–
Less than high school	2.0 (1.2-3.5)	0.010	–	–	–	–	–	–
Health care system
Private	1 (reference)	–	1 (reference)	–	1 (reference)	–	1 (reference)	–
Public	1.8 (1.2-2.8)	0.010	2.2 (1.5-3.2)	< 0.001	1.5 (1.0-2.3)	0.002	1.6 (1.1-2.3)	0.016
Knowledge of any risks associated with antibiotic use
Yes. Has knowledge of the risks^{^c}	1 (reference)	–	1 (reference)	–	1 (reference)	–	1 (reference)	–
No. Lacking knowledge of the risks	1.6 (1.1-2.4)	0.010	1.4 (1.0-2.1)	0.06	2.9 (2.0-4.4)	< 0.001	–	–
Health literacy
Inadequate^{^d}	1 (reference)	–	1 (reference)	–	1 (reference)	–	1 (reference)	–
Adequate	0.7 (0.4-0.9)	0.040	–	–	–	–	–	–

GED = general educational development.
↵a Overall includes any symptom or illness, including diarrhea, sore throat, cold/flu, sinus infection, and bronchitis.
↵b Predictors identified in the univariate analyses, but not significant in multivariate analyses, include age, sex/gender, race and ethnicity, health insurance status, survey language preference, and country of birth.
↵c Risks include anything related to antibiotic resistance; antibiotics may kill friendly/good bacteria; side effects (eg, rash, diarrhea, or nausea); it is unhealthy to take medicine in general; and “Other” category (eg, antibiotics interacting with other medications/alcohol, and antibiotics cause urinary tract infections).
↵d Individuals answering “Yes” to: “Difficulty understanding written information,” “Confidence in filling out medical forms by yourself,” or “Someone helps you read clinic or hospital materials.”^19,20

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SUPPLEMENTAL DTA IN PDF FILE BELOW

Supplemental Appendix. Survey guide

Supplemental Table. Univariate results, sociodemographic predictors of patient expectations of antibiotics for diarrhea, sore throat, cold/flu, and overall (any symptom/illness)

Laytner_Supp.pdf -
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PLAIN LANGUAGE ARTICLE SUMMARY

Research Brief

Lack of Knowledge of Antibiotic Risks Contributes to Primary Care Patients’ Expectations of Antibiotics for Common Symptoms

Background and Goal:Patient expectations of receiving antibiotics for common symptoms can trigger unnecessary use, contributing to antibiotic resistance and other health risks. This study examined the prevalence of patient antibiotic expectations for common symptoms. It also compared these expectations between patients in public and private health care settings and identified factors that influenced patients’ expectations of getting antibiotics for these symptoms.

Study Approach:This study surveyed 564 primary care patients in Texas between January 2020 and June 2021 across public and private clinics. The survey assessed patients’ expectations for antibiotics when experiencing five common symptoms—diarrhea, sore throat, cold/flu, sinus infections, and bronchitis—and their knowledge of the risks associated with antibiotic use. Researchers also examined how factors like education and health literacy affected these expectations.

Main Results:Over 93% of the patients surveyed expected antibiotics for at least one of the five common symptoms. Public clinic patients were nearly twice as likely to expect antibiotics for sore throat, diarrhea, and cold/flu compared to those in private clinics. Lack of knowledge about the potential risks of antibiotics was linked to higher expectations for receiving antibiotics for diarrhea and cold/flu symptoms. Patients with lower education levels and inadequate health literacy were more likely to expect antibiotics for diarrhea.

Why It Matters:To reduce unnecessary antibiotic use, future efforts should educate patients on when antibiotics are truly needed and emphasize potential risks. The authors of the study are currently developing a tool to help patients and clinicians discuss appropriate antibiotic use and explore non-antibiotic treatments.

Lack of Knowledge of Antibiotic Risks Contributes to Primary Care Patients’ Expectations of Antibiotics for Common Symptoms

Lindsey A. Laytner, PhD, MPH, et al

Department of Family and Community Medicine, Baylor College of Medicine, Houston, Texas

Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas