Abstract
Antimicrobial resistance is a global health threat, partly driven by inappropriate antibiotic prescriptions for acute medical patients in hospitals. To provide a systematic review of qualitative research on antibiotic prescribing decisions in hospitals worldwide, including broad-spectrum antibiotic use. A systematic search of qualitative research on antibiotic prescribing for adult hospital patients published between 2007 and 2017 was conducted. Drawing on the Health Belief Model, a framework synthesis was conducted to assess threat perceptions associated with antimicrobial resistance, and perceived benefits and barriers associated with antibiotic stewardship. The risk of antimicrobial resistance was generally perceived to be serious, but the abstract and long-term nature of its consequences led physicians to doubt personal susceptibility. While prescribers believed in the benefits of optimizing prescribing, the direct link between over-prescribing and antimicrobial resistance was questioned, and prescribers' behaviour change was frequently considered futile when fighting the complex problem of antimicrobial resistance. The salience of individual patient risks was a key barrier to more conservative prescribing. Physicians perceived broad-spectrum antibiotics to be effective and low risk; prescribing broad-spectrum antibiotics involved low cognitive demand and enabled physicians to manage patient expectations. Antibiotic prescribing decisions in low-income countries were shaped by a context of heightened uncertainty and risk due to poor microbiology and infection control services. When tackling antimicrobial resistance, the tensions between immediate individual risks and long-term collective risks need to be taken into account. Efforts to reduce diagnostic uncertainty and to change risk perceptions will be critical in shifting practice.
Highlights
Antimicrobial resistance (AMR) is a global problem forecast to cost more than 10 million lives by 2050 [1]
All antibiotic use contributes to the development of resistance, and while some stewardship activities have been successful in reducing antibiotic prescriptions in the community, hospital prescriptions remain on the rise
Inappropriate prescribing can refer to the excessive prescribing of broad-spectrum antibiotics (BSAs), which are effective against a wider range of pathogens compared with more narrowspectrum antibiotics (NSAs), and as a consequence are stronger drivers of AMR [5]
Summary
Antimicrobial resistance (AMR) is a global problem forecast to cost more than 10 million lives by 2050 [1]. All antibiotic use contributes to the development of resistance, and while some stewardship activities have been successful in reducing antibiotic prescriptions in the community, hospital prescriptions remain on the rise. Up to half of all antibiotic prescriptions for acute medical patients in hospitals are estimated to be inappropriate [3,4]. An additional problem is unnecessary prescribing of antibiotics in situations where infections may clear without drug treatment (e.g. bacterial infections of the throat, including pharyngitis). Efforts to address the growing problem of AMR often target individual prescriber behaviour change, with a focus on optimizing antibiotic prescribing to reduce over-use and inappropriate use of antibiotics
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