Antibiotic overuse for acute respiratory tract infections in Sri Lanka: a qualitative study of outpatients and their physicians

Abstract

BackgroundAcute respiratory tract infections (ARTIs) are a common reason for antibiotic overuse worldwide. We previously showed that over 80% of outpatients presenting to a tertiary care hospital in Sri Lanka with influenza-like illness received antibiotic prescriptions, although almost half were later confirmed to have influenza. The purpose of this qualitative study was to assess Sri Lankan patients’ and physicians’ attitudes towards ARTI diagnosis and treatment.MethodsSemi-structured interviews were conducted with 50 outpatients with ARTIs and five physicians in the Outpatient Department (OPD) at a large, public tertiary care hospital in southern Sri Lanka. Interviews were audio-recorded, transcribed, and analyzed for themes related to ARTI diagnosis and treatment.ResultsPatients frequently sought ARTI care in the public sector due to the receipt of free care and the perception that government hospitals carried a sense of responsibility for patients’ health. Patients reported multiple medical visits for their illnesses of short duration and many indicated that they were seeking care in the OPD while at the hospital for another reason. While patients generally expected to receive medication prescriptions at their visit, most patients were not specifically seeking an antibiotic prescription. However, more than 70% of patients received antibiotic prescriptions at their OPD visit. Physicians incorrectly perceived that patients desired antibiotics or “capsules,” a common formulation of antibiotics dispensed in this outpatient setting, and cited patient demand as an important cause of antibiotic overuse. Physicians also indicated that high patient volume and fear of bacterial superinfection drove antibiotic overuse.ConclusionsPatients in this study were seeking medication prescriptions for their ARTIs, but physicians incorrectly perceived that antibiotic prescriptions were desired. High patient volume and fear of bacterial superinfection were also important factors in antibiotic overuse. Training of physicians regarding guideline-concordant management and dealing with diagnostic uncertainty, education of patients regarding ARTI etiology and management, and systematic changes in the public outpatient care structure may help decrease unnecessary antibiotic prescriptions for ARTIs in this setting.

Optimizing antibiotic prescribing: collective approaches to managing a common-pool resource

“…Similarly, any use of plastic can be directly linked to the problem of plastic pollution. In contrast, due to variable quality of systems for recording and monitoring prescribing, the measurement of antibiotic use can be problematic [40,41], and the complexity of AMR makes it difficult, but not impossible [42], to link individual prescribing behaviour to local resistance levels. More broadly, in dilemmas such as water conservation, there are direct trade-offs involveddhigher water use in the short run means lower availability of water in the long run.…”

Antibacterial Medicine Consumption in Private and State Sector Outpatient Settings in Colombo District, Sri Lanka

“…Prescribers feel amoxicillin is ineffective and therefore they tend to select coamoxiclav. (14) Studies have documented high resistance rates to amoxicillin in the same settings. (17, 28)…”

“…ABM prescribing pattern is influenced by diverse reasons such as (i) diagnostic uncertainty and concern for bacterial super infection, (ii) perceived expectations from patient, (iii) competition to retain patients and, (iv) influence by the pharmaceutical industry. (14,29). The WHO classification of AWaRe (Access, Watch, Reserve) has helped us to understand the pattern of ABM consumption in both these settings.…”

“…A recent study has shown that prescriptions with ABM for acute respiratory tract infections were common (70%) among outpatient department (OPD) patients. (14) Sri Lanka is a LMIC with an approximate population of 20 million. Sri Lanka published their strategic plan of combating ABR in accordance with the global action plan in 2017.…”

Antimicrobial Use, Prescribing, and Resistance in Selected Ten Selected Developing Countries: A Brief Overview

“…Physicians' of those hospitals claimed that "patient demands, imprecise diagnosis, and fear of bacterial superinfection, as well as structural factors such as high patient volume and short visit times" were the principal cause of antibiotic prescribing. EIs aiming for prescribers, patients, and the public, in conjunction with systematic changes, are immediately desirable to develop and progress the rational and evidence-based prescription of antibiotics in such scarce resource backgrounds [55].…”