Drivers of Broad-Spectrum Antibiotic Overuse across Diverse Hospital Contexts—A Qualitative Study of Prescribers in the UK, Sri Lanka and South Africa
2. Materials and Methods
3.1. Individual Factors Impacting on BSA Overuse
There’s definitely an advantage, in terms of potentially covering organisms that you were not necessarily expecting initially. (SA008, public hospital)
So broad spectrum I am [using] at the start is like a miracle, the patient gets better and it is like a miracle drug. (SL008, private hospital)
3.2. Social Factors Impacting on BSA Overuse
Majority of people if we try to give feedback [on their prescribing] they would feel offended, people would feel offended and that becomes a territorial thing. (SL007, private hospital)
P7, MC: Amongst ourselves, we often talk about it, you know, if, if I see a prescription for [BSA], I’m like, Why, why did you go there? And then, they will say, Well, this patient’s had had this, they’ve got a recurrent infection, they’ve got sputums or whatever results, and this is now why they’ve gone to the next level. (SA007, private)
I mean here, which is very consultant led, you give the antibiotic that the consultant tells you to. (UK009, public hospital)
3.3. BSA Overuse as a Response to Structural Problems
3.3.1. Structural Drivers Creating Tensions with Stewardship Goals
Given that there’s a, it feels like there’s a pressure, whether it be national or local, for avoidable sepsis deaths, we tend to give [broad spectrum] antibiotics more often now, even there’s a bit of a grey area, because it’s deemed safer, perhaps on an individual level and a medical legal issue rather than for that patient, to give antibiotics. (UK006, public hospital)
So the patient goes to this clinician and they get better faster [with broad spectrum antibiotics]. And the same patient after for some other disease is going to other clinician, he is giving a narrow spectrum antibiotics for a week or for 14 days, the patient got vexed: “why I should take for 14 days when [first consultant] is giving for [fewer]?” So in this kind of competition […] the more patient is going towards the person who is relieving them fast. (SL008, private hospital)
Well obviously the patients, the patient would want you to give them the best antibiotic that would make them feel better. Sometimes that’s not always appropriate. You know, sometimes you need to start with an antibiotic which is appropriate, and if it doesn’t work then upscale to a broader-spectrum antibiotic. And sometimes the patient might not always understand that. (SA002, private hospital)
3.3.2. Limited Hospital Resources
We have to treat the patient as early as possible and to discharge the patient rather than like keeping them for a longer time in the hospital. […] It is very difficult to manage because we have a heavy patient turnover […] and also when patients they might give infection to another one and we have to prevent the spread of infection as well. So that’s, and so we have to like decide on, think of, broad spectrum. (SL015, public hospital)
There are some issues with our [laboratory] set up as well, […] sometimes that there are restrictions on maybe the culture bottles available, the resources available. [When there are problems] getting some isolated so then we can’t go for the targeted one obviously. (SL003, public hospital)
You don’t need to contact people out of hours, you don’t need to get microbiology involved […] you just can prescribe it without having to go through hoops to get the right antibiotic. (UK006, public hospital)
I would say this is increasingly the norm in acute hospital care, sadly. […] A system which has been designed to fit one patient with one problem, coming up against a population with a multiplicity of problems and complexity, which means the system is not responding well to the patients’ complexity and kind of resorts to a learned pattern of behaviour. So “oh, there’s something wrong with this patient, let’s give them some antibiotics and hope it gets better.” (UK002, public hospital)
3.3.3. Lack of Infrastructure and Resources in the Community
The patients […], they are very critically ill patients, because here, being a district where the literacy level is very low, and the education level is very low of the patients, and the infrastructure is also very low, so they often they present at the hospital quite at a late stage. So even when they come with an infection, if we delay the antibiotics [to await test results] the prognosis is definitely going to be poor. (SL006, public hospital)
I think our population in state [public hospitals] is much sicker, and they come at the end of their illness. […] When they present they’re quite sick, so they’re ready to be a sepsis, so you really have to start off with a broad-spectrum. And they come from locum clinics, where initially [they got] antibiotics, there was no cultures beforehand, so you’re sort of shooting in the dark. (SA002, private hospital)
Well, cost to the individual patient. […] Broad spectrums are probably [more] expensive, but, getting it right the first time, again, might be cheaper than repeated doses of [antibiotics]. (SA007, private hospital)
[Investigations are] very costly so that is why rather than doing the [microbiology] investigation most of the doctors are directly prescribing the antibiotics. (SL008, private hospital)
- How can we ensure that doctors feel safe and supported to reduce BSA use in the context of organizational priorities and national drivers around reducing mortality from infection?
- How might we enable doctors to attract patients and succeed in private practice through building a reputation as a responsible prescriber of antibiotics?
- What low-cost interventions would help reduce the risk of infection, encourage help seeking, and enable early and effective treatment in resource-poor communities?
- How can we design infection control interventions that are feasible in suboptimal hospital environments?
- How could pricing systems in private hospitals be redesigned to remove perverse incentives for using BSAs (for example, reducing or removing charges to patients for lab tests)?
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
Appendix A. Topic Guide for Interviews with Staff
- QUESTIONS ABOUT THEIR ROLE
- PRESCRIBING DECISIONS
- How do you go about making the decision whether or not to prescribe an antibiotic?Probe: Are there any ‘rules of thumb’ that you use? What influences this decision?
- Can you tell me about how you decide which antibiotic to use, for an acute medical patient with a suspected infection? Probe: Are there any local or national guidelines on antibiotic prescribing? Do they help in your decision?Are there any limitations/restrictions on the antibiotics you can use? How do you feel about your prescribing freedom being limited?Do you ever get advice on your prescribing decisions? Whom would you be most likely to get advice from? Why? Is this advice available at all times of day?
- How important do you feel it is to collect microbiology specimens, in making antibiotic prescribing decisions? Why?I would be interested to hear your thoughts on using broad-spectrum antibiotics (BSAs) as opposed to narrow spectrum. Broad-spectrum antibiotics being an antibiotic with activity against a wide range of pathogens. A narrow spectrum antibiotic is one that is targeted at a specific organism.
- How easy do you find making decisions about whether to use a BSA? What do you see as the uncertainties and how do you deal with them? What sort of influences are there on your decision? Who influences this decision?
- What would you see as the benefits of using BSAs, as opposed to choosing narrow spectrum antibiotics?Probe: for the individual patient/for your hospital/for society/for you as a doctor?
- What would you see as the risks of using BSAs, as opposed to choosing narrow spectrum antibiotics?Probe: for the individual patient/for your hospital/for society/for you as a doctor?
- Do these different parties we’ve just talked about have different interests? To what extent do you consider these in your day to day prescribing, and how do you balance these interests?
- If you prescribe a BSA, how likely is it that the patient would be switched to a narrow spectrum antibiotic at a later point?Probe: Why? What are the barriers to this? What helps make any switch easier?
- How do you know whether you are making good decisions about antibiotic prescribing? Do you get any feedback about your antibiotic prescribing approach?
- Do you ever feel patients are prescribed BSAs inappropriately? Could you start by saying what you see as inappropriate use? Are there common situations where this happens? Why do you think this happens?
- What steps could be taken to stimulate appropriate use of BSAs?Probe: What would you say are the main barriers to improving the way BSAs are used in this hospital? E.g., local culture/lack of lab facilities/organizational policies/external incentives or pressure Probe: how could guidelines be improved to take account of your prescribing concerns?I’d like to focus now on antibiotic resistance, that is, the ability of a bacteria to stop an antibiotic from working against it, meaning that some antibiotic treatments become ineffective, infections persist and can spread to others. This can mean having reduced or no antibiotic treatment options.
- Do you worry about the problem of antimicrobial resistance in your day to day practice? Why?
- Do you ever see examples of resistance? Have you had cases where you have had to swap antibiotics because the infection is not responding to the first choice antibiotic, or microbiology results indicate the bacteria is likely to be resistant? How often does this happen in your experience?
- How much does the problem of antibiotic resistance influence your decision-making about prescribing antibiotics?
- Do you get information about overall levels of antibiotic resistance in this hospital?
- Do you think that reducing the use of BSAs in hospitals would make an important difference to addressing the overall AMR problem? Why yes or no?
- Is there anything else you’d like to add about the use of BSAs, or the problem of AMR?
- Thanks for participating!
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|Role||Senior doctor, 20|
|Junior doctor, 25|
|Specialty||General medicine, 27|
|Infectious diseases, 4|
|Emergency department, 3|
|Theme||Impact on BSA Overuse|
|Diagnostic uncertainty||-||-||- -||-||-|
|Prioritizing reduction in risk for individual patients||-||-||-||-||-|
|Fear of repercussions from not prescribing||-||-||-||-||-|
|Perceptions of BSAs as ‘powerful’ and effective||-||-||-||-||-|
|Concern about AMR as a pressing problem||+/-||+||+/-||+||+/-|
|Training/knowledge/experience in antibiotic use||+/-||+/-||-||+/-||-|
|Engagement with antibiotic guidelines and policies||+||+/-||+||+/-||-|
|Social norms/culture of antibiotic use||-||+/-||- -|
|Clinical autonomy||-||- -|
|Hierarchy and willingness to challenge colleagues||-||-||-||+||-|
|Conflicting quality and safety agendas||- -|
|Pressure/incentives to satisfy patient demand||-||-||- -|
|Hospital environment||-||- -|
|Limited microbiology facilities||-||- -|
|Level of strain on the system/need for efficiency||-||-||- -|
|Availability and quality of antibiotics in hospital||-|
|Patient poverty||-||- -||-||-|
|Delayed presentation||-||- -|
|Poor/uncontrolled community healthcare resources||-||- -||-||-|
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Tarrant, C.; Colman, A.M.; Jenkins, D.R.; Chattoe-Brown, E.; Perera, N.; Mehtar, S.; Nakkawita, W.M.I.D.; Bolscher, M.; Krockow, E.M. Drivers of Broad-Spectrum Antibiotic Overuse across Diverse Hospital Contexts—A Qualitative Study of Prescribers in the UK, Sri Lanka and South Africa. Antibiotics 2021, 10, 94. https://doi.org/10.3390/antibiotics10010094
Tarrant C, Colman AM, Jenkins DR, Chattoe-Brown E, Perera N, Mehtar S, Nakkawita WMID, Bolscher M, Krockow EM. Drivers of Broad-Spectrum Antibiotic Overuse across Diverse Hospital Contexts—A Qualitative Study of Prescribers in the UK, Sri Lanka and South Africa. Antibiotics. 2021; 10(1):94. https://doi.org/10.3390/antibiotics10010094Chicago/Turabian Style
Tarrant, Carolyn, Andrew M. Colman, David R. Jenkins, Edmund Chattoe-Brown, Nelun Perera, Shaheen Mehtar, W.M.I. Dilini Nakkawita, Michele Bolscher, and Eva M. Krockow. 2021. "Drivers of Broad-Spectrum Antibiotic Overuse across Diverse Hospital Contexts—A Qualitative Study of Prescribers in the UK, Sri Lanka and South Africa" Antibiotics 10, no. 1: 94. https://doi.org/10.3390/antibiotics10010094