Inappropriate antibiotic prescribing: understanding clinicians’ perceptions to enable changes in prescribing practices
Mah Laka A , Adriana Milazzo A and Tracy Merlin
A B C
A School of Public Health, University of Adelaide, Adelaide, SA, Australia. Email: mah.laka@adelaide.edu.au; adriana.milazzo@adelaide.edu.au
B Adelaide Health Technology Assessment (AHTA), School of Public Health, University of Adelaide, Adelaide, SA, Australia.
C Corresponding author. Email: tracy.merlin@adelaide.edu.au
Australian Health Review 46(1) 21-27 https://doi.org/10.1071/AH21197
Submitted: 9 June 2021 Accepted: 6 July 2021 Published: 5 October 2021
Journal Compilation © CSIRO 2022 Open Access CC BY-NC-ND
Abstract
Objective The aim of this study was to identify perceived barriers to appropriate antibiotic prescribing across different healthcare settings.
Methods A cross-sectional survey of clinicians in Australian hospitals and primary care was undertaken between June and October 2019. The perceived barriers to appropriate antibiotic prescribing were considered as dependent variables, whereas age, sex, clinical experience, healthcare setting and the use of guidelines were considered independent variables. We used multivariate logistic regression to identify factors predictive of inappropriate antibiotic prescribing. Content analysis of free-text responses provided additional insights into the impediments to appropriate prescribing.
Results In all, 180 clinicians completed the survey. Overall, diagnostic uncertainty and limited access to guidelines and prescribing information were significant barriers to appropriate antibiotic prescribing. Factors associated with these barriers were clinical experience, care setting (hospitals vs primary care) and the use of guidelines. Experienced clinicians (>11 years) were less likely to consider that limited access to information negatively affected prescribing practices (experience 11–20 years, odds ratio (OR) 0.66, 95% confidence interval (CI) 0.31–0.84; experience >20 years, OR 0.51, 95% CI 0.24–0.91). Conversely, general practitioners considered diagnostic uncertainty (OR 1.31, 95% CI 1.09–1.63) and patient expectations (OR 1.41, 95% CI 1.12–1.84) were more likely to be perceived barriers to appropriate prescribing. The use of guidelines and clinical experience may counteract this.
Conclusion Years of experience, use of guidelines and type of setting were predictors of clinicians’ perceptions regarding antibiotic prescribing. Our data highlight the importance of individual and setting characteristics in understanding variations in prescribing practices and designing targeted interventions for appropriate antibiotic prescribing.
What is known about the topic? Inappropriate antibiotic prescribing is a significant health issue in Australia. Drivers of inappropriate prescribing are known, but how individual and setting characteristics contribute to variations in prescribing behaviour has not been fully understood.
What does this paper add? Diagnostic uncertainty and limited access to prescribing information, including guidelines, formulary restrictions and antibiotic resistance patterns, can limit appropriate antibiotic prescribing. Clinicians’ years of experience, the healthcare settings and clinician use of guidelines are important predictors of antibiotic prescribing behaviour.
What are the implications for practitioners? The findings of this study can inform the design of tailored interventions to promote rational antibiotic prescribing practices in general practice and hospital settings.
References
[1] Machowska A, Stålsby Lundborg C. Drivers of irrational use of antibiotics in Europe. Int J Environ Res Public Health 2019; 16 27| Drivers of irrational use of antibiotics in Europe.Crossref | GoogleScholarGoogle Scholar |
[2] Munita JM, Arias CA. Mechanisms of Antibiotic Resistance Microbiol Spectr 2016; 4 4.2.15
| Mechanisms of Antibiotic ResistanceCrossref | GoogleScholarGoogle Scholar |
[3] Klein EY, Van Boeckel TP, Martinez EM, Pant S, Gandra S, Levin SA, et al Global increase and geographic convergence in antibiotic consumption between 2000 and 2015. Proc Natl Acad Sci USA 2018; 115 E3463–70.
| Global increase and geographic convergence in antibiotic consumption between 2000 and 2015.Crossref | GoogleScholarGoogle Scholar | 29581252PubMed |
[4] Hardy-Holbrook R, Aristidi S, Chandnani V, DeWindt D, Dinh K. Antibiotic resistance and prescribing in Australia: current attitudes and practice of GPs. Healthc Infect 2013; 18 147–51.
| Antibiotic resistance and prescribing in Australia: current attitudes and practice of GPs.Crossref | GoogleScholarGoogle Scholar |
[5] Australian Commission on Safety and Quality in Health Care (ACSQHC). AURA 2019: Third Australian report on antimicrobial use and resistance in human health. Sydney: ACSQHC; 2019.
[6] Morse J, Blackburn L, Hannam JA, Voss L, Anderson BJ. Compliance with perioperative prophylaxis guidelines and the use of novel outcome measures. Paediatr Anaesth 2018; 28 686–93.
| Compliance with perioperative prophylaxis guidelines and the use of novel outcome measures.Crossref | GoogleScholarGoogle Scholar | 29961951PubMed |
[7] Fischer F, Lange K, Klose K, Greiner W, Kraemer A. Barriers and Strategies in Guideline Implementation—A Scoping Review. Health Care 2016; 4 36
| Barriers and Strategies in Guideline Implementation—A Scoping Review.Crossref | GoogleScholarGoogle Scholar |
[8] Schwartz KL, Brown KA, Etches J, Langford BJ, Daneman N, Tu K, et al Predictors and variability of antibiotic prescribing amongst family physicians. J Antimicrob Chemother 2019; 74 2098–105.
| Predictors and variability of antibiotic prescribing amongst family physicians.Crossref | GoogleScholarGoogle Scholar | 31002333PubMed |
[9] Charani E, Castro-Sanchez E, Sevdalis N, Kyratsis Y, Drumright L, Shah N, et al Understanding the determinants of antimicrobial prescribing within hospitals: the role of “prescribing etiquette”. Clin Infect Dis 2013; 57 188–96.
| Understanding the determinants of antimicrobial prescribing within hospitals: the role of “prescribing etiquette”.Crossref | GoogleScholarGoogle Scholar | 23572483PubMed |
[10] Manne M, Deshpande A, Hu B, Patel A, Taksler GB, Misra-Hebert AD, et al Provider Variation in Antibiotic Prescribing and Outcomes of Respiratory Tract Infections. South Med J 2018; 111 235–42.
| Provider Variation in Antibiotic Prescribing and Outcomes of Respiratory Tract Infections.Crossref | GoogleScholarGoogle Scholar | 29719037PubMed |
[11] Nowakowska M, van Staa T, Mölter A, Ashcroft DM, Tsang JY, White A, et al Antibiotic choice in UK general practice: rates and drivers of potentially inappropriate antibiotic prescribing. J Antimicrob Chemother 2019; 74 3371–8.
| Antibiotic choice in UK general practice: rates and drivers of potentially inappropriate antibiotic prescribing.Crossref | GoogleScholarGoogle Scholar | 31430365PubMed |
[12] Teixeira Rodrigues A, Roque F, Falcão A, Figueiras A, Herdeiro MT. Understanding physician antibiotic prescribing behaviour: a systematic review of qualitative studies. Int J Antimicrob Agents 2013; 41 203–12.
| Understanding physician antibiotic prescribing behaviour: a systematic review of qualitative studies.Crossref | GoogleScholarGoogle Scholar | 23127482PubMed |
[13] Dempsey PP, Businger AC, Whaley LE, Gagne JJ, Linder JA. Primary care clinicians’ perceptions about antibiotic prescribing for acute bronchitis: a qualitative study. BMC Fam Pract 2014; 15 194
| Primary care clinicians’ perceptions about antibiotic prescribing for acute bronchitis: a qualitative study.Crossref | GoogleScholarGoogle Scholar | 25495918PubMed |
[14] Laka M, Milazzo A, Merlin T. Factors That Impact the Adoption of Clinical Decision Support Systems (CDSS) for Antibiotic Management. Int J Environ Res Public Health 2021; 18 1901
| Factors That Impact the Adoption of Clinical Decision Support Systems (CDSS) for Antibiotic Management.Crossref | GoogleScholarGoogle Scholar | 33669353PubMed |
[15] Neuendorf KA, Kumar A. Content analysis. Int Encyclop Politic Comm 2015; 8 1–10.
| Content analysis.Crossref | GoogleScholarGoogle Scholar |
[16] Md Rezal RS, Hassali MA, Alrasheedy AA, Saleem F, Md Yusof FA, Godman B. Physicians’ knowledge, perceptions and behaviour towards antibiotic prescribing: a systematic review of the literature. Expert Rev Anti Infect Ther 2015; 13 665–80.
| Physicians’ knowledge, perceptions and behaviour towards antibiotic prescribing: a systematic review of the literature.Crossref | GoogleScholarGoogle Scholar | 25813839PubMed |
[17] Jeffs L, McIsaac W, Zahradnik M, Senthinathan A, Dresser L, McIntyre M, et al Barriers and facilitators to the uptake of an antimicrobial stewardship program in primary care: A qualitative study. PloS one 2020; 15 e0223822
| Barriers and facilitators to the uptake of an antimicrobial stewardship program in primary care: A qualitative study.Crossref | GoogleScholarGoogle Scholar | 32134929PubMed |
[18] Lum EPM, Page K, Whitty JA, Doust J, Graves N. Antibiotic prescribing in primary healthcare: Dominant factors and trade-offs in decision-making. Infect Dis Health 2018; 23 74–86.
| Antibiotic prescribing in primary healthcare: Dominant factors and trade-offs in decision-making.Crossref | GoogleScholarGoogle Scholar |
[19] Australian Commission on Safety and Quality in Health Care. AURA 2017 – Second Australian report on antimicrobial use and resistance in human health. Sydney; 2017.
[20] Pinder R, Berry D, Sallis A, Chadborn T. Behaviour change and antibiotic prescribing in healthcare settings: Literature review and behavioural analysis. London: Department of Health & Public Health England; 2015. Available at: http://hdl.handle.net/10044/1/22194.
[21] Mangione-Smith R, McGlynn EA, Elliott MN, McDonald L, Franz CE, Kravitz RL. Parent expectations for antibiotics, physician-parent communication, and satisfaction. Arch Pediatr Adolesc Med 2001; 155 800–6.
| Parent expectations for antibiotics, physician-parent communication, and satisfaction.Crossref | GoogleScholarGoogle Scholar | 11434847PubMed |
[22] Rose J, Crosbie M, Stewart A. A qualitative literature review exploring the drivers influencing antibiotic over-prescribing by GPs in primary care and recommendations to reduce unnecessary prescribing. Perspect Public Health 2021; 141 19–27.
| A qualitative literature review exploring the drivers influencing antibiotic over-prescribing by GPs in primary care and recommendations to reduce unnecessary prescribing.Crossref | GoogleScholarGoogle Scholar | 31633458PubMed |
[23] Kianmehr H, Sabounchi NS, Seyedzadeh Sabounchi S, Cosler LE. Patient expectation trends on receiving antibiotic prescriptions for respiratory tract infections: A systematic review and meta-regression analysis. Int J Clin Pract 2019; 73 e13360
| Patient expectation trends on receiving antibiotic prescriptions for respiratory tract infections: A systematic review and meta-regression analysis.Crossref | GoogleScholarGoogle Scholar | 31066959PubMed |
[24] Papoutsi C, Mattick K, Pearson M, Brennan N, Briscoe S, Wong G. Social and professional influences on antimicrobial prescribing for doctors-in-training: a realist review. J Antimicrob Chemother 2017; 72 2418–30.
| Social and professional influences on antimicrobial prescribing for doctors-in-training: a realist review.Crossref | GoogleScholarGoogle Scholar | 28859445PubMed |
[25] Carlsen B, Glenton C, Pope C. Thou shalt versus thou shalt not: a meta-synthesis of GPs’ attitudes to clinical practice guidelines. Br J Gen Pract 2007; 57 971–8.
| Thou shalt versus thou shalt not: a meta-synthesis of GPs’ attitudes to clinical practice guidelines.Crossref | GoogleScholarGoogle Scholar | 18252073PubMed |
[26] Teixeira Rodrigues A, Roque F, Falcão A, Figueiras A, Herdeiro MT. Understanding physician antibiotic prescribing behaviour: a systematic review of qualitative studies. Int J Antimicrob Agents 2013; 41 203–12.
| Understanding physician antibiotic prescribing behaviour: a systematic review of qualitative studies.Crossref | GoogleScholarGoogle Scholar | 23127482PubMed |
[27] Cho YI, Johnson TP, VanGeest JB. Enhancing Surveys of Health Care Professionals: A Meta-Analysis of Techniques to Improve Response Eval Health Prof 2013; 36 382–407.
| Enhancing Surveys of Health Care Professionals: A Meta-Analysis of Techniques to Improve ResponseCrossref | GoogleScholarGoogle Scholar | 23975761PubMed |
[28] Joyce CM, Scott A, Jeon S-H, Humphreys J, Kalb G, Witt J, et al The” Medicine in Australia: Balancing Employment and Life (MABEL)” longitudinal survey-Protocol and baseline data for a prospective cohort study of Australian doctors’ workforce participation. BMC Health Serv Res 2010; 10 50
| The” Medicine in Australia: Balancing Employment and Life (MABEL)” longitudinal survey-Protocol and baseline data for a prospective cohort study of Australian doctors’ workforce participation.Crossref | GoogleScholarGoogle Scholar | 20181288PubMed |
[29] Simpkin AL, Schwartzstein RM. Tolerating uncertainty—the next medical revolution? N Engl J Med 2016; 375 1713–15.
| Tolerating uncertainty—the next medical revolution?Crossref | GoogleScholarGoogle Scholar | 27806221PubMed |
[30] van Esch TE, Brabers AE, Hek K, van Dijk L, Verheij RA, de Jong JD. Does shared decision-making reduce antibiotic prescribing in primary care? J Antimicrob Chemother 2018; 73 3199–205.
| Does shared decision-making reduce antibiotic prescribing in primary care?Crossref | GoogleScholarGoogle Scholar | 30165644PubMed |
