A scientific committee composed of one specialist in venereal diseases, one epidemiologist, one general internist and one microbiologist developed a vignette 13 14 designed to examine current practice patterns in the antibiotic treatment of uncomplicated male urethritis using scientific literature and guidelines 9 13 14 . The vignette was developed using a standardized protocol 13 14 . This approach has been shown to be an effective and cost-efficient method for measuring physicians' clinical decision making 13 14 . A pilot study was conducted with eight volunteer GPs of the Sentinelles Network that validated the vignette.

The scientific committee defined a master criteria list to review GP responses using scientific literature and guidelines 9 13 14 15 . We submitted the candidate criteria to a panel of 12 academic and community physicians of various specialities (general practice, infectious diseases, venereal diseases, microbiologists and public health). Based on their recommendations and group consensus, we finalized a master criteria list. Responses were considered appropriate if the hypothetical patient was treated simultaneously for N. gonorrhoeae and C. trachomatis infections with the following recommended first-line antibiotics:

a) ceftriaxone (250 to 500 mg intravenously or intramuscularly, in a single dose) or cefixime (400 mg orally in a single dose) or, as an alternative regimen, spectinomycin (2 g intramuscularly in a single dose) for N. gonorrhoeae treatment

b) azithromycin (1 g orally in a single dose) or doxycycline (100 mg orally twice a day for 7 days) for C. trachomatis treatment.

The vignette was submitted to the GPs via a web-based electronic format (see additional file): the GPs were asked to write a description of their treatment plan in an open-ended format. A time constraint of 20 minutes was imposed for completing the vignette. After answering a given section, participants could not return to the previous section to revise their answers.

After the clinical vignette, a new section measuring the GPs' knowledge of French guidelines and of the increasing resistance to ciprofloxacin for gonorrhoea treatment through two questions completed the survey:

1. "Are you aware of the increasing rate of ciprofloxacin resistance for gonorrhoea?"

2. "Are you aware of the existence of the new guidelines for the management of urethritis?"

At the end of the study, each participating GP received an individual report of his results, the average performance of the group and the responses to the vignette.

Data were analysed using the R software program (http://www.r-project.org) using descriptive statistics for frequencies and chi-square tests for the comparisons of independent proportions, with Fisher's tests where appropriate. The level of significance was set as p < 0.05.

The GPs' answers were reviewed by two independent reviewers. An inter-rater reliability analysis using the Kappa statistic was performed to determine consistency among the raters 16 . The inter-rater reliability for the raters was found to be Kappa = 0.83 (p < 0.001), suggesting a very good agreement.

By the end of the survey period, 350 vignettes were received, yielding a response rate of 35%. The vignette was fully completed by 327 GPs (93.4%).

The responders were predominantly male (83.4%) with a mean age of 52 ± 7.5 years (min = 29; max = 69). Their practices were mainly located in urban zones (60%) (Table 1).

Demographic characteristics (age, sex and location) of the GP responders, non-responders and of the GPs of the Sentinelles Network are shown in Table 1.

Among the 70 non-responding GPs, 67% (n = 47) declared that they had no experience of urethritis management in their practice, 26% (n = 18) did not participate because of a lack of time and 7% (n = 5) did not participate for other several reasons (e.g. holidays, the survey was too complex or they were not interested.

Sixty-six GPs (20.2%) prescribed the simultaneous administration of the recommended antibiotics for N. gonorrhoeae and C. trachomatis infections (Table 2) for the hypothetical patient.

One hundred and fourteen (34.8%) GPs prescribed only one recommended antibiotic against N. gonorrhoeae (n = 69) or against C. trachomatis (n = 45). One hundred and thirty-two GPs (40.4%) prescribed only non-recommended antibiotics, including ciprofloxacin, in 69 cases (Table 2).

When asked about the fluoroquinolone resistance of N. gonorrheoae, 26% (n = 84) of the respondents declared that they were aware of the high rate of resistance in France. The existence of the French guidelines was declared known by 25% (n = 81) of GPs. Among the 69 GPs who prescribed ciprofloxacin as first-line treatment, 84% (n = 58) were not aware of the emergence of fluoroquinolone resistance.

General practitioners who had been in practice for 10 years or less were more likely to prescribe the recommended antibiotics than GPs with more years in practice (p < 0.0001; Table 3). General practitioners who had been in practice for 10 years or less were also more likely to be aware of the high rate of fluoroquinolone resistance and of the existence of guidelines (p < 0.0001; Table 3). Gender and geographic location (urban, suburban or rural) of the GP was not associated with the treatments prescribed or knowledge of the guidelines (p > 0.05).

In this study, only a minority of the GPs (20.2%) correctly co-prescribed the first-line treatment recommended for N. gonorrhoeae and C. trachomatis co-infection. Moreover, the GPs frequently prescribed non-recommended first-line treatment, including ciprofloxacin, despite the high level of fluoroquinolone resistance of N. gonorrhoeae in France (43% during 2006) 7 8 .

The relatively low level of prescribed treatment against C. trachomatis could be explained by the description of the purulent discharge of the urethritis in the vignette, which is a typical sign of N. gonorrhoeae infection. These results are in agreement with a previous study on the compliance of emergency department practitioners with the Centers for Disease Control (CDC) recommendations for diagnosing and treating sexually transmitted diseases. This study showed that the recommended antibiotic regimens for N. gonorrhoeae and C. trachomatis were correctly co-prescribed in only one third of cases 17 .

In this study, GPs who had been in practice for 10 years or less were more likely to prescribe first-line treatment in accordance with the guidelines and they were better informed about the increasing rate of fluoroquinolone resistance and about the new national strategy for the therapeutic management of probabilistic treatment for uncomplicated male urethritis than physicians who had been in practice longer.

The results suggested that the overall rate of compliance with national guidelines concerning antibiotic choice must be improved among GPs. In particular, the subgroups of physicians who have been in practice for longer are at risk of providing lower-quality care.

These findings are consistent with other studies that suggested an inverse relationship between years in practice and the quality of care provided 18 19 . A systematic review which evaluated the relationship between clinical experience and performance suggested that physicians who have been in practice for a longer period and those who are older possess less factual knowledge, are less likely to adhere to appropriate standards of care, and may also have poorer patient outcomes. These effects seemed to persist in studies that adjusted for other known predictors of quality, such as patient comorbidity and physician volume or specialization 18 .

As observed in this study, barriers to guideline adherence, such as a lack of agreement and a lack of familiarity, seem improbable in the case of urethritis, for which the recent guidelines are easily justified (a high rate of quinolone resistance) and quite straightforward to apply (a simple antibiotic prescription) 7 8 9 . One reason for the clinicians prescribing contrary to the guidelines is most probably unawareness of the guidelines. The fact that an increasing number of years in practice is associated with prescribing non-recommended antibiotics favours this hypothesis, although we cannot exclude other reasons. For example, GPs may find that prescribing an intramuscular treatment such as ceftriaxone might create a barrier because the patient has to buy the injectable drug and then go back to the GP to be injected with it. Another possible reason for little knowledge of the guidelines could be due to the volume of biomedical information available and the time needed to learn about new developments. The guidelines rationalizing antibiotic prescription for the probabilistic treatment of uncomplicated male urethritis were published in France in 2005 and disseminated to GPs at the national level by Afssaps 9 , preferably by electronic means (mailing lists and publication on health websites). The fact that the recommendations were preferentially disseminated using electronic sources, of which younger GPs are greater users than older practitioners, could have added another barrier against compliance with the recommendations. It must be noted that, according to a survey by the Centers for Disease Control and Prevention's National Center for Health Statistics 20 , it seems that a majority of office-based physicians use electronic medical record (EMRs) systems. A 2010 report by the Centers for Disease Control and Prevention's National Center for Health Statistics 20 reported that the younger the doctor, the more likely he or she was to embrace electronic medical records (EMRs), although the resistance to them by older physicians seems to have decreased as EMRs have become more common in offices and hospitals.

There were several limitations to this study. The first was that we used a self-reported survey to measure compliance with guideline recommendations as it is possible that physicians answered questions in ways that reflected professional desirability rather than their own practices. The second limitation of this study was that we only proposed one scenario that did not cover the full clinical presentation of urethritis. However, the principal objective was to evaluate the application of guideline recommendations for the management and treatment of male uncomplicated urethritis, mostly due to gonorrhoea. Thirdly, there may have been limitations in generalizability to the French GP population, as reflected by the response rate of 35%. Moreover, the GPs who participated in this study were more concerned about urethritis than non-responders, as shown by the non-responders' answers, and therefore their practices might differ. However, we found no differences in the demographic data between responders and non-responders regarding age, gender, and location of the practice.

This study suggests that interventions to improve physicians' knowledge about the management of public health issues are warranted, especially regarding the subgroup of physicians who have been in practice the longest. Moreover, because drug-resistant N. gonorrhoeae is becoming an increasing problem worldwide, such an evaluation of treatment practices would probably be useful in other countries.