Systematic review of public-targeted communication interventions to improve antibiotic use

Ongoing strategies to improve the management of upper respiratory tract infections and reduce inappropriate antibiotic use particularly among lower and middle-income countries: findings and implications for the future

Introduction: Antibiotics are indispensable to maintaining human health; however, their overuse has resulted in resistant organisms, increasing morbidity, mortality and costs. Increasing antimicrobial resistance (AMR) is a major public health threat, resulting in multiple campaigns across countries to improve appropriate antimicrobial use. This includes addressing the overuse of antimicrobials for self-limiting infections, such as upper respiratory tract infections (URTIs), particularly in lower- and middle-income countries (LMICs) where there is the greatest inappropriate use and where antibiotic utilization has increased the most in recent years. Consequently, there is a need to document current practices and successful initiatives in LMICs to improve future antimicrobial use.Methodology: Documentation of current epidemiology and management of URTIs, particularly in LMICs, as well as campaigns to improve future antimicrobial use and their influence where known.Results: Much concern remains regarding the prescribing and dispensing of antibiotics for URTIs among LMICs. This includes considerable self-purchasing, up to 100% of pharmacies in some LMICs. However, multiple activities are now ongoing to improve future use. These incorporate educational initiatives among all key stakeholder groups, as well as legislation and other activities to reduce self-purchasing as part of National Action Plans (NAPs). Further activities are still needed however. These include increased physician and pharmacist education, starting in medical and pharmacy schools; greater monitoring of prescribing and dispensing practices, including the development of pertinent quality indicators; and targeted patient information and health education campaigns. It is recognized that such activities are more challenging in LMICs given more limited resources and a lack of healthcare professionals.Conclusion: Initiatives will grow across LMICs to reduce inappropriate prescribing and dispensing of antimicrobials for URTIs as part of NAPs and other activities, and these will be monitored.

General practitioners' accounts of negotiating antibiotic prescribing decisions with patients: a qualitative study on what influences antibiotic prescribing in low, medium and high prescribing practices

BACKGROUND

Antimicrobial resistance (AMR) is high on the UK public health policy agenda, and poses challenges to patient safety and the provision of health services. Widespread prescribing of antibiotics is thought to increase AMR, and mostly takes place in primary medical care. However, prescribing rates vary substantially between general practices. The aim of this study was to understand contextual factors related to general practitioners' (GPs) antibiotic prescribing behaviour in low, high, and around the mean (medium) prescribing primary care practices.

METHODS

Qualitative semi-structured interviews were conducted with 41 GPs working in North-West England. Participants were purposively sampled from practices with low, medium, and high antibiotic prescribing rates adjusted for the number and characteristics of patients registered in a practice. The interviews were analysed thematically.

RESULTS

This study found that optimizing antibiotic prescribing creates tensions for GPs, particularly in doctor-patient communication during a consultation. GPs balanced patient expectations and their own decision-making in their communication. When not prescribing antibiotics, GPs reported the need for supportive mechanisms, such as regular practice meetings, within the practice, and in the wider healthcare system (e.g. longer consultation times). In low prescribing practices, GPs reported that increasing dialogue with colleagues, having consistent patterns of prescribing within the practice, supportive practice policies, and enough resources such as consultation time were important supports when not prescribing antibiotics.

CONCLUSIONS

Insight into GPs' negotiations with patient and public health demands, and consistent and supportive practice-level policies can help support prudent antibiotic prescribing among primary care practices.

Cost-benefit analysis of a population-based education program on the wise use of antibiotics

OBJECTIVE

In 2005, the Do Bugs Need Drugs (DBND) program was imported to British Columbia (BC) from Alberta with the goal of reducing unnecessary antibiotic use in the community. The objective of this study was to estimate the impact of the program on antibiotic-associated costs and cost-benefit.

METHODS

We used data on antibiotic prescription and costs from BC PharmaNet for the period of 1996 to 2014. We conducted interrupted time series regression to formally interpret the impact of the DBND program.

RESULTS

The average monthly prescription rate fell by 14.5%, from 54.3 to 46.4 per 1000 population between 2005 and 2014. The proportionate contribution of macrolide prescription decreased from 19.2% in 2005 to 13.2% in 2014 and for quinolones decreased from 13.1% in 2005 to 12% in 2014. The proportion of prescriptions for both penicillins and tetracyclines increased by > 35.5%. Before the program, the average monthly cost of antibiotics was increasing by CAD $8.12 per 1000 population (p < 0.001). After program introduction, average monthly cost decreased by CAD $18.19 per 1000 population (p < 0.001), creating an annual savings for BC in 2014 of CAD $83.6 million. In 2014, one Canadian dollar spent on the DBND program was associated with conservative savings of CAD $76.20.

CONCLUSION

Significant cost savings have been observed in association with a community antimicrobial stewardship program focused on both public and prescribers. Such programs are an effective strategy in cost-benefit terms and should therefore be considered for universal adoption in Canadian healthcare systems.

Effectiveness of interventions to improve the public's antimicrobial resistance awareness and behaviours associated with prudent use of antimicrobials: a systematic review

Background

A global antimicrobial resistance (AMR) awareness intervention targeting the general public has been prioritized.

Objectives

To evaluate the effectiveness of interventions that aim to change AMR awareness and subsequent stewardship behaviours amongst the public.

Methods

Five databases were searched between 2000 and 2016 for interventions to change the public's AMR awareness and/or antimicrobial stewardship behaviours. Study designs meeting the Cochrane Effective Practice and Organization of Care (EPOC) criteria, non-controlled before-and-after studies and prospective cohort studies were considered eligible. Participants recruited from healthcare settings and studies measuring stewardship behaviours of healthcare professionals were excluded. Quality of studies was assessed using EPOC risk of bias criteria. Data were extracted and synthesized narratively. Registration: PROSPERO international prospective register of systematic reviews (PROSPERO 2016: CRD42016050343).

Results

Twenty studies were included in the review with nine meeting the EPOC criteria. The overall risk of bias was high. Nineteen studies were conducted in high-income countries. Mass media interventions were most common (n = 7), followed by school-based (n = 6) and printed material interventions (n = 6). Seventeen studies demonstrated a significant effect on changing knowledge, attitudes or the public's antimicrobial stewardship behaviours. Analysis showed that interventions targeting schoolchildren and parents have notable potential, but for the general public the picture is less clear.

Conclusions

Our work provides an in-depth examination of the effectiveness of AMR interventions for the public. However, the studies were heterogeneous and the quality of evidence was poor. Well-designed, experimental studies on behavioural outcomes of such interventions are required.

Intrinsic and external determinants of antibiotic prescribing: a multi-level path analysis of primary care prescriptions in Hubei, China

Background

Irrational use of antibiotics is a major driver of development of antibiotic resistance, which heavily threatens population health worldwide. Understanding the mechanism of physician's antibiotic prescribing decisions is increasingly highlighted to promote prudent use of antibiotics. Therefore, the current study aimed to fill the gap, modelling physician's antibiotic prescribing and identifying the potential intrinsic and external determinants of antibiotic prescribing in primary care.

Methods

A total of 428,475 prescriptions from 499 prescribers in 65 primary care facilities in Hubei of China were audited. Teixeira Antibiotic Prescribing Behavioral Model (TAPBM) was referred as theoretical basis to identify intrinsic and external predictors of antibiotic prescriptions. A questionnaire survey was conducted, covering potential physician's intrinsic determinants (knowledge, attitudes and individual characteristics) and external factors both in individual level (patient pressure, time pressure and financial incentives) and institutional level (setting and local socio-economic development). A two-level path analysis was performed linking potential determinants of antibiotic use with physician's actual practices.

Results

About 44.28% of the prescriptions contained antibiotics, with 9.28% containing two or more antibiotics. The multi-level path analysis revealed that knowledge was a significant predictor of attitudes (β = 0.154, p < 0.05), but higher knowledge and attitudes failed to translate into antibiotic prescribing practices ((β = - 0.076 - 0.039, p > 0.05). Instead, external factors played a more important role and physician's antibiotic use was significantly associated with patient pressure (β = 0.102, p = 0.022), time pressure (β = - 0.164, p = 0.002), financial incentives (β = - 0.133- - 0.155, p = 0.027) and institutional environments (rural area, β = 0.408, p = 0.002; and high socioeconomic setting, β = - 0.641 - -0.578, p < 0.001 ). The prescribers who were male (β = - 0.168, p = 0.007) or had lower qualification (β = - 0.114, p = 0.028) were also more likely to prescribe antibiotics than others.

Conclusion

Antibiotic prescribing practices are complex process and associated with both intrinsic (prescriber) and external (patients and institutional environment) factors. A systematic approach is required to curb over-prescription of antibiotics. Apart from educating prescribers, it is equally important, if not more, to educate patients, break incentives and nurture professional culture within organization to reduce the overuse of antibiotics.

Effects of economic and health policies on the consumption of antibiotics in a Spanish region

OBJECTIVES

Inappropriate and indiscriminate use of antibiotics is one of the main factors contributing to the increasing bacterial resistance. Surveillance of antibiotic consumption is fundamental for assessing the effects of rational use-oriented measures introduced under economic or health policies. This study quantifies and assesses the introduction of a pharmaceutical co-payment and implementation of campaigns to increase awareness about and rational use in the consumption of antibiotics (volume and expenditure).

METHODS

Monthly official dispensations recorded by a health authority (La Rioja, Spain) between January 2009 and December 2017 (108 observations). Total and disaggregated (by active principle and patient's income level) time series for a number of packages and expenditure were studied using intervention and counterfactual analyses (Box-Jenkins methodology).

RESULTS

Co-payment reduced the total antibiotic consumption (number of packages -8.52% and expenditure -8.61%) and the difference was greater for the highest-priced antibiotics. Only two of the four campaigns had a significant effect, which lasted 6 months. Counterfactual analysis estimated the savings.

CONCLUSION

Economic and health policies helped to reduce antibiotic consumption. Each policy has different effects, co-payment reduces overall drug consumption through a price effect (loss of purchasing power), awareness campaigns depend on other elements for their success (media, scope and patient income).

Public Awareness about Antibiotic Use and Resistance among Residents in Highland Areas of Vietnam

Background

Antibiotic resistance (AR) remains a global crisis. However, the literature on public awareness about antibiotic use and AR in the highland provinces of Vietnam has been constrained. This study explores the awareness of antibiotic use and resistance among general people in highland provinces in Vietnam and detects associated factors.

Methods

A cross-sectional study was performed in five highland provinces with 1000 households. Information about socioeconomic status and awareness regarding prescription medicine use, antibiotic use, and AR was surveyed. Multivariate logistic regression was used to identify associated factors with awareness.

Results

64.2% of people were aware of prescription drugs. More than two-thirds (67.4%) of participants were aware of antibiotic use, of whom only 55.8% were aware of AR. Higher age, education, and family income were positively associated with being aware of prescription medicine, antibiotic, and AR. Females had a lower likelihood of being aware of prescription medicine (OR=0.64; 95%CI=0.45-0.90) compared to male counterparts. Those being freelancers were more likely to be aware of antibiotic resistance (OR=2.30; 95%CI=1.13-4.67) compared to those working in agriculture/fishery/forestry sector. Compared to Kinh ethnic, most ethnic minorities were less likely to be aware of prescription medicine, antibiotic, and AR.

Conclusions

This study showed a low awareness regarding prescription medicine, antibiotic use, and AR among public people in the highland provinces of Vietnam. Further systemic and didactic educational interventions targeting females, low education, low income, ethnic minorities, and those working in agriculture/fishery/forestry sector in this setting should be performed and evaluated to improve the awareness about antibiotic use and resistance.

How to improve antibiotic awareness campaigns: findings of a WHO global survey

INTRODUCTION

We aimed to examine the characteristics of antibiotic awareness campaigns (AAC) conducted on a national or regional level since 2010.

METHODS

In October 2016, the WHO invited stakeholders involved in the planning or conduct of AACs to answer a web questionnaire. We solicited general information about the characteristics of the AAC, with a particular focus on key messages supporting optimal use of antibiotics.

RESULTS

Stakeholders in 93 countries were contacted and 55 countries responded. Overall, 60 AACs from 16 low/middle-income countries (LMIC) and 31 high-income countries were identified. Forty-five campaigns (75%) were conducted on a national level and most of them (47/60; 78%) were organised by public health authorities and publicly funded. There were no major differences between LMICs and high-income countries in the types of key messages. The scientifically questionable 'Finish your prescription' slogan was used by 31 AACs (52%). A One Health approach was mentioned in 13/60 AACs (22%). Most messages were universally applicable; adaptation to locally prevalent public misconceptions was not systematic. The evaluation of the impact of campaigns was still incomplete, as only 18 AACs (30%) assessed their impact on antibiotic use.

CONCLUSION

For future AACs, it seems essential to base messages more rigorously on scientific evidence, context specificities and behavioural change theory. A new generation of messages that encourage first-choice use of narrow spectrum antibiotics is needed, reflecting international efforts to preserve broad spectrum antibiotic classes. Evaluation of the impact of AACs remains suboptimal.

Knowledge of antibiotics and antibiotic resistance among Norwegian pharmacy customers - a cross-sectional study

BACKGROUND

Antibiotic resistance is a global health threat. Public knowledge is considered a prerequisite for appropriate use of antibiotics and limited spread of antibiotic resistance. Our aim was to examine the level of knowledge of antibiotics and antibiotic resistance among Norwegian pharmacy customers, and to assess to which degree beliefs, attitudes and sociodemographic factors are associated with this knowledge.

METHODS

A questionnaire based, cross-sectional study was conducted among pharmacy customers in three Norwegian cities. The questionnaire covered 1) knowledge of antibiotics (13 statements) and antibiotic resistance (10 statements), 2) the general beliefs about medicines questionnaire (BMQ general) (three subdomains, four statements each), 3) attitudes toward antibiotic use (four statements), and 4) sociodemographic factors, life style and health. High knowledge level was defined as > 66% of maximum score. Factors associated with knowledge of antibiotics and antibiotic resistance were investigated through univariate and multiple linear regression. Hierarchical model regression was used to estimate a population average knowledge score weighted for age, gender and level of education.

RESULTS

Among 877 participants, 57% had high knowledge of antibiotics in general and 71% had high knowledge of antibiotic resistance. More than 90% knew that bacteria can become resistant against antibiotics and that unnecessary use of antibiotics can make them less effective. Simultaneously, more than 30% erroneously stated that antibiotics are effective against viruses, colds or influenza. Factors positively associated with antibiotic knowledge were health professional background, high education level, and a positive view on the value of medications in general. Male gender, a less restrictive attitude toward antibiotic use, and young age were negatively associated with antibiotic knowledge. The mean overall antibiotic knowledge score was relatively high (15.6 out of maximum 23 with estimated weighted population score at 14.8).

CONCLUSIONS

Despite a high level of knowledge of antibiotics and antibiotic resistance among Norwegian pharmacy customers, there are obvious knowledge gaps. We suggest that action is taken to increase the knowledge level, and particularly target people in vocational, male dominated occupations outside the health service, and primary/secondary school curricula.

Regional variability in outpatient antibiotic use in Ontario, Canada: a retrospective cross-sectional study

BACKGROUND

Regional variability in antibiotic use is associated with both antibiotic overuse and antimicrobial resistance. Our objectives were to benchmark outpatient antibiotic use and to evaluate geographic variability among health regions in the province of Ontario, Canada.

METHODS

This was a cross-sectional study of antibiotics dispensed from outpatient retail pharmacies in Ontario between March 2016 and February 2017. We analyzed variability in the number of antibiotic prescriptions dispensed per 1000 population among Ontario's 14 health regions with crude and adjusted Poisson regression models. Adjusted models controlled for rurality, 4 physician characteristics and 6 population characteristics.

RESULTS

There were 8 352 578 antibiotics dispensed during the 1-year study period or 621 per 1000 population. The most commonly prescribed antibiotic classes were narrow-spectrum penicillins, macrolides, first-generation cephalosporins and second-generation fluoroquinolones, with adult women receiving the highest rate of prescriptions: 985 antibiotic prescriptions per 1000 population. There was geographic variability in total and class-specific antibiotic use. In the health region with the highest use 778 antibiotics were dispensed per 1000 population whereas in the health region with the lowest use 534 antibiotics were dispensed per 1000 population. The adjusted marginal standardized antibiotic prescription rates for the health regions with the highest and lowest use were 787 (95% confidence interval [CI] 658-934) and 546 (95% CI 494-606) antibiotic prescriptions per 1000 population, respectively.

INTERPRETATION

We described baseline antibiotic usage in Ontario over a 12-month period, noting variability among some health regions. Our findings highlight the need for interventions to optimize antibiotic use and slow the emergence of antimicrobial resistance.

How do general practitioners and pharmacists experience antibiotic use in out-of-hours primary care? An exploratory qualitative interview study to inform a participatory action research project

RATIONALE

Antibiotics (ABs) are one of the most prescribed medications in out-of-hours (OOH) care in Belgium. Developing a better understanding of why ABs are prescribed in this setting is essential to improve prescribing habits.

OBJECTIVES

To assess AB prescribing and dispensing challenges for general practitioners (GPs) and pharmacists in OOH primary care, and to identify context-specific elements that can help the implementation of behaviour change interventions to improve AB prescribing in this setting.

DESIGN

This is an exploratory qualitative study using semistructured interviews. This study is part of a participatory action research project.

SETTING AND PARTICIPANTS

Participants include 17 GPs and 1 manager, who work in a Belgian OOH general practitioners cooperative (GPC), and 5 pharmacists of the area covered by the GPC. The GPC serves a population of more than 187 000 people.

RESULTS

GPs feel the threshold to prescribe AB in OOH care is lower in comparion to office hours. GPs and pharmacists talk about the difference in their professional identity in OOH (they define their task differently, they feel more isolated, insecure, have the need to please and so on), type of patients (unknown patients, vulnerable patients, other ethnicities, demanding patients and so on), workload (they feel time-pressured) and lack of diagnostic tools or follow-up. They are aware of the problem of AB overprescribing, but they do not feel ownership of the problem.

CONCLUSION

The implementation of behaviour change interventions to improve AB prescribing in OOH primary care has to take these context specifics into account and could involve interprofessional collaboration between GPs and pharmacists.

TRIAL REGISTRATION NUMBER

NCT03082521; Pre-results.

Factors affecting the public awareness and behavior on antibiotic use

To evaluate the effects of demographic and perceptive factors on the knowledge, perception, and behavior regarding antibiotic use in the general public, we conducted three serial telephone interview surveys in 2010, 2012, and 2015. Computer-aided telephone interview was conducted, with a predetermined quota stratified by sex, age, and geographic location. Respondents who answered correctly to four or more questions were categorized as having better knowledge. A total of 3013 respondents participated. Better knowledge was associated with age < 60 years (OR 1.37, 95% CI 1.04-1.82), college education (OR 1.57, 95% CI 1.26-1.97), healthcare-related occupation or education (OR 2.26, 95% CI 1.52-3.36), and media exposure (OR 1.25, 95% CI 1.02-1.54). In contrast, correct antibiotic use behavior was associated with male sex (OR 1.48, 95% CI 1.27-1.73), older age (OR 1.63, 95% CI 1.34-1.99), and being married (OR 1.26, 95% CI 1.04-1.52), along with better knowledge (OR 1.43, 95% CI 1.19-1.71). However, multifaceted analysis indicated that better knowledge was associated with correct behavior in all subgroups. Other demographic factors were associated only in respondents with poor knowledge. Various factors other than knowledge on antibiotics, many of them traditionally underappreciated, affect antibiotic use behavior.

How effective and cost-effective are behaviour change interventions in improving the prescription and use of antibiotics in low-income and middle-income countries? A protocol for a systematic review

INTRODUCTION

Antibiotic resistance endangers effective prevention and treatment of infections, and places significant burden on patients, families, communities and healthcare systems. Low-income and middle-income countries (LMICs) are especially vulnerable to antibiotic resistance, owing to high infectious disease burden, and limited resources for treatment. High prevalence of antibiotic prescription and use due to lack of provider's knowledge, prescriber's habits and perceived patient needs further exacerbate the situation. Interventions implemented to address the inappropriate prescription and use of antibiotics in LMICs must address different determinants of antibiotic resistance through sustainable and scalable interventions. The aim of this protocol is to provide a comprehensive overview of the methods that will be used to identify and appraise evidence on the effectiveness and cost-effectiveness of behaviour change interventions implemented in LMICs to improve the prescription and use of antibiotics.

METHODS AND ANALYSIS

Two databases (Web of Science and PubMed) will be searched based on a strategy developed in consultation with an essential medicines and health systems researcher. Additional studies will be identified using the same search strategy in Google Scholar. To be included, a study must describe a behaviour change intervention and use an experimental design to estimate effectiveness and/or cost-effectiveness in an LMIC. Following systematic screening of titles, abstracts and keywords, and full-text appraisal, data will be extracted using a customised extraction form. Studies will be categorised by type of behaviour change intervention and experimental design. A meta-analysis or narrative synthesis will be conducted as appropriate, along with an appraisal of quality of studies using the Grading of Recommendation, Assessment, Development and Evaluation (GRADE) checklist.

ETHICS AND DISSEMINATION

No individual patient data are used, so ethical approval is not required. The systematic review will be disseminated in a peer-reviewed journal and presented at a relevant international conference.

PROSPERO REGISTRATION NUMBER

CRD42017075596.

Development of an intervention to reduce antibiotic use for childhood coughs in UK primary care using critical synthesis of multi-method research

Background

Overuse of antibiotics contributes to the global threat of antimicrobial resistance. Antibiotic stewardship interventions address this threat by reducing the use of antibiotics in occasions or doses unlikely to be effective. We aimed to develop an evidence-based, theory-informed, intervention to reduce antibiotic prescriptions in primary care for childhood respiratory tract infections (RTI). This paper describes our methods for doing so.

Methods

Green and Krueter’s Precede/Proceed logic model was used as a framework to integrate findings from a programme of research including 5 systematic reviews, 3 qualitative studies, and 1 cohort study. The model was populated using a strength of evidence approach, and developed with input from stakeholders including clinicians and parents.

Results

The synthesis produced a series of evidence-based statements summarizing the quantitative and qualitative evidence for intervention elements most likely to result in changes in clinician behaviour. Current evidence suggests that interventions which reduce clinical uncertainty, reduce clinician/parent miscommunication, elicit parent concerns, make clear delayed or no-antibiotic recommendations, and provide clinicians with alternate treatment actions have the best chance of success. We designed a web-based within-consultation intervention to reduce clinician uncertainty and pressure to prescribe, designed to be used when children with RTI present to a prescribing clinician in primary care.

Conclusions

We provide a worked example of methods for the development of future complex interventions in primary care, where multiple factors act on multiple actors within a complex system. Our synthesis provided intervention guidance, recommendations for practice, and highlighted evidence gaps, but questions remain about how best to implement these recommendations. The funding structure which enabled a single team of researchers to work on a multi-method programme of related studies (NIHR Programme Grant scheme) was key in our success.

Trial registration

The feasibility study accompanying this intervention was prospectively registered with the ISRCTN registry (ISRCTN23547970), on 27 June 2014.

Electronic supplementary material

The online version of this article (10.1186/s12874-017-0455-9) contains supplementary material, which is available to authorized users.

Optimising the quality of antibiotic prescribing in out-of-hours primary care in Belgium: a study protocol for an action research project

INTRODUCTION

Antimicrobial resistance is a major public health threat driven by inappropriate antibiotic use, mainly in general practice and for respiratory tract infections. In Belgium, the quality of general practitioners' (GPs) antibiotic prescribing is low. To improve antibiotic use, we need a better understanding of this quality problem and corresponding interventions. A general practitioners cooperative (GPC) for out-of-hours (OOH) care presents a unique opportunity to reach a large group of GPs and work on quality improvement. Participatory action research (PAR) is a bottom-up approach that focuses on implementing change into daily practice and has the potential to empower practitioners to produce their own solutions to optimise their antibiotic prescribing.

METHODS

This PAR study to improve antibiotic prescribing quality in OOH care uses a mixed methods approach. In a first exploratory phase, we will develop a partnership with a GPC and map the existing barriers and opportunities. In a second phase, we will focus on facilitating change and implementing interventions through PDSA (Plan-Do-Study-Act) cycles. In a third phase, antibiotic prescribing quality outside and antibiotic use during office hours will be evaluated. Equally important are the process evaluation and theory building on improving antibiotic prescribing.

ETHICS

The study protocol was approved by the Ethics Committee of the Antwerp University Hospital/University of Antwerp. PAR unfolds in response to the needs and issues of the stakeholders, therefore new ethics approval will be obtained at each new stage of the research.

DISSEMINATION

Interventions to improve antibiotic prescribing are needed now more than ever and outcomes will be highly relevant for GPCs, GPs in daily practice, national policymakers and the international scientific community.

TRIAL REGISTRATION NUMBER

NCT03082521; Pre-results.

Individual care versus broader public health: A qualitative study of hospital doctors' antibiotic decisions

OBJECTIVES

This study aimed to examine how hospital doctors balance competing concerns around antibiotic use and resistance, with a focus on individual care versus broader public health considerations.

METHODS

Sixty-four doctors across two hospitals in Australia participated in semi-structured interviews about their perspectives on antibiotic resistance and prescribing decisions. Results were analysed using the framework approach.

RESULTS

The first theme focused on the significance of antimicrobial resistance (AMR) and the role of hospital doctors. Participants did not perceive resistance to be central to clinical decision-making, and externalised the resistance threat. They perceived themselves as separated from the issue of escalating resistance, viewing the key drivers to be overseas use, use in agriculture, and community prescribing. The second theme was around balancing risks. Immediate clinical risks were described as prioritised over long term population risk. Participants described concern around reputational and legal risks, which were perceived to be associated with under-prescribing of antibiotics. Over-prescribing was described by participants to be easier and without perceived immediate risk to them or to patients.

CONCLUSION

Hospital doctors perceived antimicrobial resistance as externally produced and described clinical concerns taking precedence in individual antibiotic decisions. These dual processes mean that a population health model has limited traction in the hospital context. The externalisation of resistance leads to a sense of futility in changing practice, which combines with the pressures of acute medicine to prioritise immediate patient outcomes. Such dynamics are leading to antibiotic optimisation as a low or absent priority in hospital clinician antibiotic decision-making.

Antibiotic stewardship in low- and middle-income countries: the same but different?

BACKGROUND

Antibiotic resistance (ABR) is a quickly worsening problem worldwide, also in low- and middle-income countries (LMICs). Appropriate antibiotic use in humans and animals, i.e. antibiotic stewardship (ABS), is one of the cornerstones of the World Health Organization's global action plan for ABR. Many LMICs are in the process of developing stewardship programs.

AIMS

We highlight challenges for ABS initiatives in LMICs, give an outline of (inter)national recommendations and demonstrate examples of effective, contextualized stewardship interventions.

SOURCES

We searched PubMed for articles on ABS interventions in humans in LMICs. Relevant websites and experts were consulted for additional sources.

CONTENT

Evidence on effective and feasible stewardship interventions in LMICs is limited, and challenges for implementation of interventions are numerous. Nevertheless, several initiatives at the international and local levels in Latin America, Africa and Asia have shown that ABS effective interventions are feasible in LMICs, although contextualization is essential.

IMPLICATIONS

Specific guidance for setting up antimicrobial stewardship programs in LMICs should be developed. Strategic points might need to be progressively addressed in LMICs, such as (a) ensuring availability of diagnostic testing, (b) providing dedicated education in ABR both for healthcare workers and the general public, (c) creating or strengthening (inter)national agencies towards better regulations and audit on production, distribution and dispensing of drugs, (d) strengthening healthcare facilities, (e) exploring a broader synergism between policy makers, academia, professional bodies and civil society and (f) designing and studying easy and scalable ABS interventions for both hospital and community settings.