# Determinants of third-generation oral cephalosporin prescribing by general practitioners: A regional survey in France

Astrid Descolas, Jérôme Ramassamy, Thibaut Riom, Jérémy Lellouch, Matthieu Peurois

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Astrid Descolas, Jérôme Ramassamy, Thibaut Riom, Jérémy Lellouch, Matthieu Peurois. Determinants of third-generation oral cephalosporin prescribing by general practitioners: A regional survey in France. Clinical Infection in Practice, 2025, 28, 10.1016/j.clinpr.2025.100514. hal-05284839

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Clinical Audits/Service improvements

# Determinants of third-generation oral cephalosporin prescribing by general practitioners: A regional survey in France

Astrid Descolas<sup>a,b,*</sup>, Ramassamy Jérôme<sup>c</sup>, Thibaut Riom<sup>d</sup>, Lellouch Jérémy<sup>e</sup>, Peurois Matthieu<sup>b,f,g</sup>

ARTICLE INFO

Keywords:

Cephalosporins

Beta-lactam resistance

Drug prescription

General practice

Ambulatory care

ABSTRACT

**Introduction:** Oral third-generation cephalosporins (3GC) are a major source of antibiotic resistance, with 70 % of prescriptions issued by general practitioners (GPs). The main objective of this study was to identify the factors that lead GPs to prescribe oral 3GCs. The secondary objective was to identify the physician profiles most likely to prescribe them.

**Materials and Methods:** This was an observational, descriptive, declarative study. A questionnaire was distributed to GPs in a french area (Pays de le Loire).

**Results:** We included 74 responses from GPs. Several determinants were identified that positively influenced the prescription of oral 3GCs: situations of therapeutic failure (64.9 % of GPs), penicillin allergy (49.5 %), altered general condition (35.2 %), age over 65 (33.8 %). Physicians practising in semi-rural and rural areas seemed to be more inclined to prescribe 3GCs in cases of altered general condition (p < 0.027) or diagnostic doubt (p < 0.025).

**Conclusion:** The results of this study can be used to tailor GP training to the context in which they provide care.

Introduction

According to the World Health Organization, antibiotic resistance is one of the most serious threats to public health. Oral third-generation cephalosporins (3GC) are a class of broad-spectrum antibiotics that are frequently used, with high selection pressure for bacterial resistance. For example, in 2021, globally (data from 49 countries), 36.0 % (IQ 15.2-63.0) of E. coli strains were resistant to 3GC (Ahluwalia et al., 2018; Antimicrobial resistance, 2023). 3GC are also strongly associated to clinically important antibiotic-related adverse events (Dote et al., 2025).

In France, the PRIMO mission (Prevention and Control of Infection in medico-social establishments and outpatient care), describes bacterial ecology, particularly in ambulatory medicine, in order to alert and raise awareness among those involved in the field (PRIMO). Some of their

data are encouraging: since 2016, overall antibiotic consumption has been falling, and 3GC resistance in *E.coli* is beginning to decline after 10 years of constant increase, in outpatient care, in establishments for dependent elderly people (EHPAD) and in healthcare establishments (Santé Publique France, 2018).

Like most other classes of antibiotics, outpatient consumption of 3GC fell by almost half between 2013 and 2020, stabilizing between 2020 and 2023 (Lehur et al., 2020; Arias et al., 2021; Santé Publique France 2023).

Several studies shows the impact of General Practitioners (GP) training on the reduction in 3GC prescriptions (Ahluwalia et al., 2018; Mestrallet et al., 2021).

France remains a country that over-consumes antibiotics compared to its European neighbors (30 % higher than the European average) (Légifrance, 2015).

<footnote><sup>a</sup> General Practitioner, 49610 Juigné-sur-Loire, France</footnote>

<footnote><sup>b</sup> Univ Angers, Département de médecine générale, F-49000 Angers, France</footnote>

<footnote><sup>c</sup> General Practitioner, 72200 La Flèche, France</footnote>

<footnote><sup>d</sup> General Practitioner, 49100 Angers, France</footnote>

<footnote><sup>e</sup> Pôle Santé Sarthe Loir, Le Bailleul, 72205 La Flèche, France</footnote>

<footnote><sup>f</sup> General Practitioner, 53260 Entrammes, France</footnote>

<footnote><sup>g</sup> Univ Angers, POPS, SFR ICAT, F-49000 Angers, France</footnote>

<footnote>* Corresponding author at: Univ Angers, Département de médecine générale, F-49000 Angers, France.
E-mail address: docteurastriddescolas@gmail.com (A. Descolas).</footnote>
The majority of antibiotic prescriptions are made by GPs (75 %) (HAS).

Oral 3GC are not recommended as first-line treatment for any in-
fectious pathology (HAS; Faure et al., 2009).

The primary objective of this study was to describe the determinants
of oral 3GC prescribing by GPs in a French region (Pays de la Loire).

The secondary objective was to identify the profiles of GPs most
likely to prescribe 3GC, in order to target awareness campaigns and
better support them in their prescribing practices.

Method

This was a descriptive, analytical, cross-sectional study using a self-reported survey on the practices of GPs in the Pays de la Loire region (France).

A questionnaire was distributed by e-mail in April 2022 via the
network of the Regional Union of Liberal Doctors of Pays de la Loire
(URML). This network includes 90 % of GPs practicing in the region. GPs
could click on a link to respond to the online survey. No follow-up e-
mails were sent.

The questionnaire was organized into four groups of elements that
could influence prescribing (Appendix 1):

* Information about the GP (age, gender, place and method of practice, training),

* Clinico-biological and socio-environmental aspects,

* The infectious pathologies most commonly found in outpatient set-
tings that may prompt the prescription of oral 3GC,

* Consultation conditions and prescription objectives.

The authors developed this questionnaire based on the shared
medical decision model (Sackett, and al 1996) and based on data from
scientific literature.

GPs were asked to place the level of influence of the proposal be-
tween 0 and 5 in several situations. These were only closed-ended
questions, such as scale questions (Likert scale). The response options
followed a logical progression with six response options, including two
extremes: "When deciding whether to prescribe oral 3GC, how do these
statements influence you...?": 0 (the statement has no positive influence
on your prescription) to 5 (the proposal has a positive and total influence
on your prescription).

Responses ranging from 3 to 5 on the scale were assigned a high
probability of prescription, while responses ranging from 0 to 2 were
assigned a low probability.

We decided to exclude very incomplete questionnaires from the
analysis because the responses were not usable.

The statistical tests used were the Chi-square test for sample sizes >5 and Fisher's exact test for sample sizes <5. Results were considered significant for a p-value < 0.05.

The data were entered and analyzed using Excel® and BiostaTGV®
software for descriptive and comparative analyses.

This was a study on the evaluation of professional practices. The data
were collected anonymously. The study therefore did not require any
ethical opinion or regulatory procedure.

Results

Of the 2830 GPs who received the e-mail from the URML, 109 responded to the questionnaire (response rate of 4 %). Of these 109 responses, we included 74 complete questionnaires (Fig. 1).

1. Characteristics of the GPs population

The practitioner population was balanced (50 % women, 50 % men).
The median age was 38.5 years (IQ 34; 45). A large majority of GPs
(90.5 %) worked in multidisciplinary practices.

<figure><img src="image_2.png" /><figcaption>(1) URML mailing list comprising 90% of GPs practicing in the Pays de la Loire region</figcaption></figure>

<caption>Fig. 1. Flow chart.</caption>

GPs surveyed worked in semi-rural areas for 44.6 %, 35.1 % in urban areas and 20.2 % in rural areas. Most practitioners (64.9 %) benefited from a nearby hospital, 57.8 % of GPS took part in infectious diseases training, 93.2 % of GPs had already prescribed oral 3GC.

2. Factors influencing the prescription of oral 3GC by GPs

a. Influence of patient characteristics

The main clinico-biological aspects that prompted GPs to prescribe
oral 3GC were: the patient's declared allergy to penicillin (49.5 % of GPs
said they were influenced by this item), age over 65 (positive influence
for 33.8 % of GPs), severe deterioration in the patient's general condi-
tion for 35.2 % of GPs and, therapeutic failure for 65 % of GPs (Table 1).

There was very little influence from the patient's socio-environmental aspects (Table 2).

b. Influence of beliefs about 3GC

The notion of oral 3GC efficacy emerged as influencing 51 % of
practitioners in their prescribing, with an average close to the median at
2.4. The oral route of administration was also significant, with an
average response of 2.1 (Table 3).

c. Influence of different pathologies

A greater influence on prescribing was found in pyelonephritis, acute
community-acquired pneumonia and otitis, with respective averages of
1.9, 1.3 and 1.0. It should be noted that dermatological pathologies did
not encourage the prescription of oral 3GC (90 % of practitioners).

d. Influence of consultation circumstances

Consultation conditions had a more marked effect on the prescrip-
tion of oral 3GC on the eve of a weekend, as well as in emergency sit-
uations (averages 0.9 and 1.2 respectively).

e. Influence of the practitioner's intentionality

Reducing the risk of complications and shortening the progression of
the pathology were significant prescribing factors for 37.84 % and
32.43 % of practitioners respectively.

3. Profiles of GPs most likely to prescribe 3GC
<caption>**Table 1**</caption>

Probability of prescribing oral 3GC according to patients' clinical-biological characteristics.

<table><thead><tr><th rowspan="2">Clinico-biological aspects</th><th colspan="5">Probability of influence</th></tr><tr><th>0</th><th>1</th><th>2</th><th>3</th><th>4</th><th>5</th></tr></thead><tbody><tr><td>Fever in consultation</td><td>45<br>(60.8 %)</td><td>12<br>(16.2 %)</td><td>8<br>(10.8 %)</td><td>2 (2.7 %)</td><td>6 (8.1 %)</td><td>1 (1.4 %)</td></tr><tr><td>Age of patient<br>&lt;2 years</td><td>46<br>(62.2 %)</td><td>7 (9.4 %)</td><td>5 (6.8 %)</td><td>2 (2.7 %)</td><td>12<br>(16.2 %)</td><td>2 (2.7 %)</td></tr><tr><td>2-18 years</td><td>43<br>(58.1 %)</td><td>11<br>(14.8 %)</td><td>7 (9.5 %)</td><td>5 (6.8 %)</td><td>5 (6.8 %)</td><td>3 (4.1 %)</td></tr><tr><td>18-65 years</td><td>46<br>(62.2 %)</td><td>19<br>(25.7 %)</td><td>3 (4.1 %)</td><td>2 (2.7 %)</td><td>2 (2.7 %)</td><td>2 (2.7 %)</td></tr><tr><td>&gt;65 years</td><td>41<br>(55.4 %)</td><td>5 (6.8 %)</td><td>3 (4.1 %)</td><td>15<br>(20.3 %)</td><td>8<br>(10.8 %)</td><td>2 (2.7 %)</td></tr><tr><td>Severe impairment of general condition</td><td>34<br>(46 %)</td><td>5 (6.8 %)</td><td>9<br>(12.2 %)</td><td>9<br>(12.2 %)</td><td>8<br>(10.8 %)</td><td>5 (6.8 %)</td></tr><tr><td>Renal failure GFR<br>&lt;30 mL/min</td><td>38<br>(51.4 %)</td><td>5 (6.8 %)</td><td>5 (6.8 %)</td><td>14<br>(18.9 %)</td><td>8<br>(10.8 %)</td><td>0 (0.0 %)</td></tr><tr><td>Pregnancy</td><td>50<br>(67.6 %)</td><td>6 (8.1 %)</td><td>9<br>(12.2 %)</td><td>5 (6.8 %)</td><td>8<br>(10.8 %)</td><td>2 (2.7 %)</td></tr><tr><td>Palliative situation</td><td>43<br>(58.1 %)</td><td>10<br>(13.5 %)</td><td>4 (5.4 %)</td><td>7 (9.5 %)</td><td>8<br>(10.8 %)</td><td>4 (5.4 %)</td></tr><tr><td>Mild allergy to penicillin</td><td>27<br>(36.5 %)</td><td>8<br>(10.8 %)</td><td>5 (6.8 %)</td><td>10<br>(13.5 %)</td><td>8<br>(10.8 %)</td><td>12<br>(16.2 %)</td></tr><tr><td>Cognitive disorders</td><td>52<br>(70.3 %)</td><td>4 (5.4 %)</td><td>6 (8.1 %)</td><td>6 (8.1 %)</td><td>8<br>(10.8 %)</td><td>0 (0.0 %)</td></tr><tr><td>Immunodepression</td><td>44<br>(59.5 %)</td><td>5 (6.8 %)</td><td>9<br>(12.2 %)</td><td>7 (9.5 %)</td><td>8<br>(10.8 %)</td><td>5 (6.8 %)</td></tr><tr><td>Addictive behavior (alcohol, drugs, medication, etc.)</td><td>65<br>(87.8 %)</td><td>5 (6.8 %)</td><td>2 (2.7 %)</td><td>1 (1.4 %)</td><td>8<br>(10.8 %)</td><td>0 (0.0 %)</td></tr><tr><td>Recent use of non-steroidal inflammatory drugs</td><td>60<br>(81.1 %)</td><td>6 (8.1 %)</td><td>4 (5.4 %)</td><td>3 (4.1 %)</td><td>8<br>(10.8 %)</td><td>0 (0.0 %)</td></tr><tr><td>Hyperalgesia</td><td>59<br>(79.7 %)</td><td>9<br>(12.2 %)</td><td>3 (4.1 %)</td><td>2 (2.7 %)</td><td>8<br>(10.8 %)</td><td>0 (0.0 %)</td></tr><tr><td>Treatment failure</td><td>12<br>(16.2 %)</td><td>3 (4.1 %)</td><td>11<br>(14.9 %)</td><td>15<br>(20.3 %)</td><td>8<br>(10.8 %)</td><td>9<br>(12.2 %)</td></tr></tbody></table>

In the case of severe impairment of general condition, analyses showed a greater intention (p < 0.027) to prescribe in semi-rural and rural areas (21/48 GPs, 44 %) than in urban areas (5/26 GPs, 19 %).

No differences were found in the subgroup analyses according to the age, place of practice or access to training of GPs for the influence of patients' socio-environmental aspects.

In case of diagnostic doubt, the prescription of oral 3GC appeared to be higher (p < 0.025) in semi-rural areas (36 % of GPs in semi-rural areas (12/21) versus 1 % in urban areas (2/24)).

In sub-group analyses, the influence of prescribing oral 3GC on the eve of a weekend and in emergency situations did not appear to be significant, for the age, location or type of practice of the responding GPs. Nor did the presence of a local hospital influence prescribing.

Regarding the positive influence of 3GC on the prescription of certain pathologies (otitis, acute community-acquired pneumonia, and pyelonephritis), no significant difference was found in the subgroups according to participation in infectious disease training, use of prescription

<caption>**Table 2**</caption>

Probability of prescribing oral 3GC according to the patient's socio-environmental aspects.

<table><caption>**Table 3**</caption><thead><tr><th rowspan="2">Patient's socio-environmental aspects</th><th colspan="5">Probability of influence</th></tr><tr><th>0</th><th>1</th><th>2</th><th>3</th><th>4</th><th>5</th></tr></thead><tbody><tr><td>Patient strongly insisting on antibiotics</td><td>54<br>(73.0 %)</td><td>13<br>(17.6 %)</td><td>4<br>(5.4 %)</td><td>3<br>(4.1 %)</td><td>8<br>(10.8 %)</td><td>0 (0.0 %)</td></tr><tr><td>Patient beliefs about 3rd generation oral cephalosporins</td><td>61<br>(82.4 %)</td><td>8<br>(10.8 %)</td><td>2<br>(2.7 %)</td><td>2<br>(2.7 %)</td><td>8<br>(10.8 %)</td><td>1 (1.4 %)</td></tr><tr><td>High consultation frequency</td><td>58<br>(78.4 %)</td><td>7 (9.5 %)</td><td>2<br>(2.7 %)</td><td>4<br>(5.4 %)</td><td>8<br>(10.8 %)</td><td>0 (0.0 %)</td></tr><tr><td>Socio-economic vulnerability</td><td>63<br>(85.1 %)</td><td>6 (8.1 %)</td><td>1<br>(1.4 %)</td><td>4<br>(5.4 %)</td><td>8<br>(10.8 %)</td><td>0 (0.0 %)</td></tr><tr><td>Patient known to the doctor's practice</td><td>59<br>(79.7 %)</td><td>3 (4.1 %)</td><td>5<br>(6.8 %)</td><td>2<br>(2.7 %)</td><td>8<br>(10.8 %)</td><td>0 (0.0 %)</td></tr><tr><td>Patient unknown to the doctor's practice</td><td>66<br>(89.2 %)</td><td>5 (6.8 %)</td><td>2<br>(2.7 %)</td><td>1<br>(1.4 %)</td><td>8<br>(10.8 %)</td><td>0 (0.0 %)</td></tr></tbody></table>

Probability of prescribing oral 3GC according to practitioner-related situations.

<table><thead><tr><th rowspan="2">Practitioner-related parameters</th><th colspan="5">Probability of influence</th></tr><tr><th>0</th><th>1</th><th>2</th><th>3</th><th>4</th><th>5</th></tr></thead><tbody><tr><td>Diagnostic doubt</td><td>36<br>(48.7 %)</td><td>7 (9.5 %)</td><td>12<br>(16.2 %)</td><td>13<br>(17.6 %)</td><td>8<br>(10.8 %)</td><td>2 (2.7 %)</td></tr><tr><td>Efficacy of 3rd generation oral cephalosporins</td><td>15<br>(20.3 %)</td><td>10<br>(13.5 %)</td><td>11<br>(14.9 %)</td><td>18<br>(24.3 %)</td><td>8<br>(10.8 %)</td><td>10<br>(13.5 %)</td></tr><tr><td>Tolerance of 3rd generation oral cephalosporins</td><td>28<br>(37.9 %)</td><td>8<br>(10.8 %)</td><td>14<br>(18.9 %)</td><td>12<br>(16.2 %)</td><td>8<br>(10.8 %)</td><td>2 (2.7 %)</td></tr><tr><td>Reduce the intensity of symptoms (pain, complaints, etc.)</td><td>57<br>(77.0 %)</td><td>10<br>(13.5 %)</td><td>3 (4.1 %)</td><td>3 (4.1 %)</td><td>8<br>(10.8 %)</td><td>0 (0.0 %)</td></tr><tr><td>Negative feedback (side effects, etc.)</td><td>53<br>(71.6 %)</td><td>8<br>(10.8 %)</td><td>6 (8.1 %)</td><td>5 (6.8 %)</td><td>8<br>(10.8 %)</td><td>0 (0.0 %)</td></tr><tr><td>Route of administration, galenic form</td><td>26<br>(35.1 %)</td><td>7 (9.5 %)</td><td>5 (6.8 %)</td><td>15<br>(20.3 %)</td><td>8<br>(10.8 %)</td><td>11<br>(14.9 %)</td></tr><tr><td>Influence of remuneration based on public health objectives (ROSP)</td><td>57<br>(77.0 %)</td><td>3 (4.1 %)</td><td>10<br>(13.5 %)</td><td>2 (2.7 %)</td><td>8<br>(10.8 %)</td><td>0 (0.0 %)</td></tr><tr><td>Influencing colleagues/ Feedback from colleagues</td><td>51<br>(68.9 %)</td><td>7 (9.5 %)</td><td>11<br>(14.9 %)</td><td>4 (5.4 %)</td><td>8<br>(10.8 %)</td><td>0 (0.0 %)</td></tr></tbody></table>

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## Discussion

Our study shows that the prescription of oral 3GC by GPs is mainly influenced by patient characteristics (allergy, advanced age, altered general condition, treatment failure).

A French study had already shown that clinical criteria were the main factors influencing antibiotic prescription (Faure et al., 2009).

However, we observe discrepancies of prescribing habits with French recommendations for good practice in infectiology:

One third of GPs were influenced by age over 65, without any significant association with a particular physician profile. However, in
current recommendations, there is no age requirement for prescribing oral 3GC (SPILF). This finding is consistent with the fact that antibiotic resistance is more pronounced in establishment for the elderly: 9.9 % of E. coli strains are resistant to 3GC, compared with 3.4 % in people living at home (Santé Publique France).

In the event of treatment failure, two-thirds of respondents reported a greater likelihood of prescribing oral 3GC, whereas the latest recommendations for primary care suggest that specialist advice should be sought.

For common pathologies such as otitis, acute community-acquired pneumonia and pyelonephritis, practitioners maintain a positive prescribing influence. GPs may be confused between prescribing oral and injectable 3GC for pyelonephritis.

Benign allergy to penicillin seemed to be a positive factor influencing prescribing. The recommendations are in line with this, but only concern certain infectious pathologies (otitis, sinusitis, severe impetigo, streptococcal angina, COPD exacerbation).

A French study in 2015 showed that one in two GPs is confronted with antibiotic resistance, and that all doctors admit they have a role to play in the fight against antibiotic resistance. In one of their reports, eight out of ten doctors say they find it difficult to refuse an antibiotic requested by a patient (DREES). In contrast, in our study, 73 % of practitioners declared that they were not influenced by the patient's insistence.

Regarding the profile of GPs most likely to prescribe 3GC, we found that it was more likely to be prescribed by GPs practicing in rural areas when there was severe deterioration in the patient's general condition.

The GPs were influenced by certain pathologies, this influence remains homogeneous across the GPs population, with no particular profile emerging. In our study, it is therefore independent of awareness of training.

The results of our study are interesting in terms of adapting the training of GPs to ensure they use antibiotics properly. The fact that oral 3GC are more likely prescribed in cases of treatment failure, eve of weekend, in emergency situations, severe health deterioration particularly in areas with limited access to healthcare (semi-rural and rural areas), indicates a perception of their high efficacy. However, despite their broad spectrum, oral 3GC are not recommended as they have low bioavailability in such situations.

Therefore, questioning GPs about their beliefs regarding oral 3GC at the beginning of their training and focusing on their experiences and healthcare contexts could improve efforts to raise awareness of the proper use of antibiotics.

The study is original: no study has been found looking specifically at the determinants of oral 3GC prescribing in primary care. The main limitation of our study lies in the low response rate to the questionnaire (4 %) and the size of the sample. The length of the questionnaire may have deterred some practitioners. There is also a bias in the selection of doctors interested in the topic, and a memorization and prevarication bias.

Complementary studies on infectious pathologies in other areas of general medicine (gynecology, gastroenterology, stomatology, etc.) would provide a better reflection of the overall use of oral 3GC.

Further studies would also be useful to evaluate training provided to general practitioners on the proper use of antibiotics and the impact on their practice.

## Conclusion

GPs seemed more inclined to prescribe oral 3GC in cases of diagnostic doubt, penicillin allergy, severe general deterioration and therapeutic failure. Acute community-acquired pneumonia, otitis and pyelonephritis were the three pathologies that seemed to positively influence the prescription of oral 3GC. Working in a semi-rural or rural environment seemed to be an aspect that favored the prescription of oral 3GC in cases of severe impairment of general condition, and in cases of

diagnostic doubt.

Taking these prescribing determinants into consideration would enable us to adapt training programs and provide better support for GPs in their care context.

## Ethical approval statement

This study was conducted in accordance with the principles outlined in the Declaration of Helsinki. It was an observational, descriptive, and declarative survey aimed at evaluating general practitioners' prescribing practices. The questionnaire was completed voluntarily, anonymously, and without any intervention or collection of sensitive personal data.

In accordance with French regulations, this type of practice evaluation study does not require prior approval from an ethics committee or regulatory authority. Participation was entirely voluntary, and responses were collected in a non-identifiable format, ensuring full confidentiality.

As such, no formal ethical approval was sought.

## Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

## Appendix A. Supplementary data

Supplementary data to this article can be found online at https://doi.org/10.1016/j.clinpr.2025.100514.

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