General practitioners' perceptions of delayed antibiotic prescription for respiratory tract infections: A phenomenographic study

Abstract

Background: Antibiotic use is a major driver of antibiotic resistance. Although delayed antibiotic prescription is a recommended strategy to reduce antibiotic use, practices vary; it appears less commonly used in southern European countries where antibiotic consumption is highest. Despite these variations, few qualitative studies have explored general practitioners' perceptions of delayed antibiotic prescription. We therefore aimed to explore and describe the perceptions of delayed antibiotic prescription for respiratory tract infections among general practitioners in Malta.

Methods: This qualitative phenomenographic study was conducted in Malta. A semi-structured interview guide was developed in English, pilot tested and revised accordingly. Interview topics included views on antibiotic resistance, antibiotic use and delayed antibiotic prescription for respiratory tract infections, and barriers and facilitators to antibiotic prescription. Individual, face-to-face interviews were held in 2014 with a quota sample of 20 general practitioners and transcribed verbatim. Data were subsequently analysed using a phenomenographic approach.

Findings: General practitioners perceived delayed antibiotic prescription in five qualitatively different ways: (A) "The Service Provider"-maintaining a good general practitioner-patient relationship to retain patients and avoid doctor-shopping, (B) "The Uncertainty Avoider"-reaching a compromise and providing treatment just in case, (C) "The Comforter"-providing the patient comfort and reassurance, (D) "The Conscientious Practitioner"-empowering and educating patients, and limiting antibiotic use, and (E) "The Holder of Professional Power"-retaining general practitioner responsibility by employing a wait-and-see approach. Although general practitioners were largely positive towards delayed antibiotic prescription, not all supported the strategy; some preferred a wait-and-see approach with follow-up. Many delayed antibiotic prescription users selectively practiced delayed prescription with patients they trusted or who they believed had a certain level of knowledge and understanding. They also preferred a patient-led approach with a one to three day delay; post-dating delayed antibiotic prescriptions was uncommon.

Conclusions: In this study we have shown that general practitioners hold varying perceptions about delayed antibiotic prescription and that there is variation in the way delayed antibiotic prescription is employed in Malta. Whilst delayed antibiotic prescription is utilised in Malta, not all general practitioners support the strategy, and motivations and practices differ. In high consumption settings, formal and standardised implementation of delayed antibiotic prescription could help curb antibiotic overuse. Diagnosis-specific delayed antibiotic prescription recommendations should also be incorporated into guidelines. Finally, further investigation into patients' and pharmacists' views on delayed antibiotic prescription is required.

Trial registration number: NCT03218930.

Conflict of interest statement

At the time of the study, SRK was employed at Karolinska Institutet, Sweden. She is currently employed by the European Centre for Disease Prevention and Control (ECDC). The views and opinions expressed herein are the authors’ own and do not necessarily state or reflect those of ECDC. ECDC is not responsible for the data and information collation and analysis and cannot be held liable for conclusions or opinions drawn. This does not alter our adherence to PLOS ONE policies on sharing data and materials. EASG, MR, MAB and CSL have declared no competing interests exist.

Figures

Fig 1. The outcome space.

This figure illustrates how the categories of description relate to each other. They are split into delayed antibiotic prescription (DAP) users and non-users. “Holders of Professional Power” are unwilling to share decision-making and use a wait-and-see strategy. “Conscientious Practitioners”, “Uncertainty Avoiders” and “Comforters” selectively practice DAP; they opt for a wait-and-see approach under certain circumstances, reflecting similarities with “Holders of Professional Power”. “Conscientious Practitioners” represent a deeper level of self-reflection and a higher degree of awareness of DAP as a tool for decreasing antibiotic use. “Services Providers” differ; they are non-selective DAPs users who focus on ensuring patient satisfaction and maintaining a good GP-patient relationship, irrespective of who the patient is or what his/her intentions are.