Drivers of Broad-Spectrum Antibiotic Overuse across Diverse Hospital Contexts—A Qualitative Study of Prescribers in the UK, Sri Lanka and South Africa

Abstract

Antimicrobial stewardship programs focus on reducing overuse of broad-spectrum antibiotics (BSAs), primarily through interventions to change prescribing behavior. This study aims to identify multi-level influences on BSA overuse across diverse high and low income, and public and private, healthcare contexts. Semi-structured interviews were conducted with 46 prescribers from hospitals in the UK, Sri Lanka, and South Africa, including public and private providers. Interviews explored decision making about prescribing BSAs, drivers of the use of BSAs, and benefits of BSAs to various stakeholders, and were analyzed using a constant comparative approach. Analysis identified drivers of BSA overuse at the individual, social and structural levels. Structural drivers of overuse varied significantly across contexts and included: system-level factors generating tensions with stewardship goals; limited material resources within hospitals; and patient poverty, lack of infrastructure and resources in local communities. Antimicrobial stewardship needs to encompass efforts to reduce the reliance on BSAs as a solution to context-specific structural conditions.

Addressing long-term and repeat antibiotic prescriptions in primary care: considerations for a behavioural approach

“…Given time constraints in general practice, pressures exist to minimise workload and this may contribute to patient prescriptions not being reviewed 8. Previous research provided evidence that limited time and cognitive resources may shape antibiotic treatment choices, with hospital doctors describing antibiotic prescribing as an ‘easy’ option, especially out of hours 14. Cognitive effort is likely to be even further reduced when choosing to continue a previous course of medication in general practice.…”

Understanding antibiotic use: practices, structures and networks

“… 66 The use of broad-spectrum antibiotics, in contravention to stewardship messaging, offered Sri Lankan hospital clinicians a partial response to missing infrastructures and patient poverty that can only be addressed with huge investment and extensive regulatory and policy interventions. 67 An ethnographic study conducted in Bangladeshi public hospitals found adherence to antibiotic use guidelines for diarrhoea patients was hampered by overcrowding, understaffing and lacking hygiene and sanitation. 68 In Ghana, a mixed-methods study identified how ‘inappropriate’ antibiotic use was driven by out-of-pocket payments, limiting patients’ contact with the formal health system and the unaffordability of complete antibiotic courses.…”

The social dilemmas of climate change and antibiotic resistance: an analytic comparison and discussion of policy implications

“…Similarly, in the healthrelated context of AMR, the diverse range of decision makers includes different types of doctors, patients, healthcare institutions and pharmaceutical companies. Additionally, these decision makers will be influenced by their respective national contexts and healthcare systems including differences between private and public healthcare (Tarrant et al, 2021). Given these various levels of impact, one solution is therefore to identify larger "superusers" (Quail et al, 2017), e.g., actors within the fossil-fuel or pharmaceutical industry, and ensuring they are held accountable for their imminently more significant actions.…”

“…Typically, any treatment decision is preceded by a sequence of choices, which form part of a longer decision making process. This, in turn, is further influenced by macro-and mezzo-level factors such as the state's healthcare policy, pharmaceutical distribution and health insurance systems (Tarrant et al, 2021). Initially, a general (binary) judgement about the existence of a bacterial infection has to be made.…”