Moral and Contextual Dimensions of "Inappropriate" Antibiotic Prescribing in Secondary Care: A Three-Country Interview Study

Carolyn Tarrant; Eva M Krockow; W M I Dilini Nakkawita; Michele Bolscher; Andrew M Colman; Edmund Chattoe-Brown; Nelun Perera; Shaheen Mehtar; David R Jenkins

doi:10.3389/fsoc.2020.00007

Moral and Contextual Dimensions of "Inappropriate" Antibiotic Prescribing in Secondary Care: A Three-Country Interview Study

Front Sociol. 2020 Feb 20:5:7. doi: 10.3389/fsoc.2020.00007. eCollection 2020.

Authors

Carolyn Tarrant¹, Eva M Krockow², W M I Dilini Nakkawita³, Michele Bolscher⁴, Andrew M Colman², Edmund Chattoe-Brown⁵, Nelun Perera⁶, Shaheen Mehtar⁴, David R Jenkins⁶

Affiliations

¹ Department of Health Sciences, University of Leicester, Leicester, United Kingdom.
² Department of Neuroscience, Psychology and Behaviour, University of Leicester, Leicester, United Kingdom.
³ Faculty of Medicine, General Sir John Kotelawala Defence University, Colombo, Sri Lanka.
⁴ Tygerberg Academic Hospital and Faculty of Health Sciences, Stellenbosch University, Cape Town, South Africa.
⁵ School of Media, Communication and Sociology, University of Leicester, Leicester, United Kingdom.
⁶ Department of Clinical Microbiology, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom.

Abstract

Overuse of broad-spectrum antibiotics in secondary care is a key contributor to the emergence and spread of antimicrobial resistance (AMR); efforts are focused on minimizing antibiotic overuse as a crucial step toward containing the global threat of AMR. The concept of overtreatment has, however, been difficult to define. Efforts to address the overuse of medicine need to be informed by an understanding of how prescribers themselves understand the problem. We report findings from a qualitative interview study of 46 acute care hospital prescribers differing in seniority from three countries: United Kingdom, Sri Lanka and South Africa. Prescribers were asked about their understanding of inappropriate use of antibiotics. Prescriber definitions of inappropriate use included relatively clear-cut and unambiguous cases of antibiotics being used "incorrectly" (e.g., in the case of viral infections). In many cases, however, antibiotic prescribing decisions were seen as involving uncertainty, with prescribers having to make decisions about the threshold for appropriate use. Decisions about thresholds were commonly framed in moral terms. Some prescribers drew on arguments about their duty to protect public health through having a high threshold for prescribing, while others made strong arguments for prioritizing risk avoidance for the patients in front of them, even at a cost of increased resistance. Notions of whether prescribing was inappropriate were also contextually dependent: high levels of antibiotic prescribing could be seen as a rational response when prescribers were working in challenging contexts, and could be justified in relation to financial and social considerations. Inappropriate antibiotic use is framed by prescribers not just in clinical, but also in moral and contextual terms; this has implications for the design and implementation of antibiotic stewardship interventions aiming to reduce inappropriate use of antibiotics globally.

Keywords: antibiotic prescribing; antimicrobial resistance; hospital; international; qualitative investigation.