Determinants of antibiotic prescribing for URTIs among emergency department physicians: a qualitative analysis

Abstract

Upper Respiratory Tract Infections (URTIs) account for a substantial proportion of attendances at emergency departments. Although the majority are due to viruses, about one-quarter of URTI patients were inappropriately prescribed antibiotics at emergency departments. It is therefore imperative to understand factors influencing prescribing decisions, in order to develop effective interventions to reduce inappropriate antibiotic use. In-depth interviews were conducted using a semi-structured interview guide on purposively sampled junior physicians working at the emergency department in a 1600-bed adult acute-care general hospital in Singapore. In addition to questions regarding the clinical management of URTI cases, physicians were asked about the antibiotic prescribing practices at the emergency department. Responses were transcribed in verbatim and analysed using thematic analysis. Data saturation was reached with nine physicians. Using the Social Ecological Model, the physician’s decision on antibiotic prescribing for URTIs were found to be influenced by individual, interpersonal, organizational, and community level factors. Physicians were cognizant of departmental norms of not prescribing antibiotics for URTIs. However, they still prescribed antibiotics when uncertain of patients’ diagnoses, treating older patients with comorbidities, and for demanding patients especially when they were time-strapped. Physicians highlighted the need for more public education and awareness on the management of URTIs. When faced with time and patient pressures, physicians were likely to prescribe antibiotics in spite of departmental norms. To reduce inappropriate antibiotic prescribing, it is important to educate patients on the viral cause of URTI and to dispel misconceptions on the use of antibiotics in the treatment of uncomplicated URTIs.