Background Antibiotic prescribing in primary care has decreased over the last five years. Nevertheless, this remains an area of concern as antibiotic resistance rates continue to increase. Some prescribers continue to prescribe inappropriately – i.e. in contradiction of clinical guidelines. This qualitative study undertakes thematic analysis to determine the attitudes and perceptions of these professionals about inappropriate prescribing.

Methods We draw on data from our evaluation of the UK’s five-year antimicrobial resistance strategy, undertaken from 2015–18 funded by the Department of Health and Social Care. We conducted 73 semi-structured interviews across six case study sites at the CCG level or equivalent in each of the four nations in the UK. Relevant informants in each trust were theoretically sampled in order to capture a mix of professionals in each case study site (including GPs, nurse prescribers, antimicrobial pharmacists, medicines management trust professionals, microbiologists, hospital doctors with opinions on primary care, and commissioners with oversight roles). Analysis was undertaken drawing on inductive and deductive logics.

Results In primary care, antibiotics have a symbolic potency that is constructed and mediated through the interactions of the prescriber and the patient. These interactions produce a negotiated understanding between both parties in relation to the significance and symbolism of an antibiotic prescription. Our analysis highlights how decisions to prescribe an antibiotic may be influenced by the context of competing pressures extrinsic to the patient-provider relationship, including time, risk, and responsibility. In certain circumstances this may lead to the inappropriate prescription of an antibiotic script.

Influenced by the theory of negotiated order,¹ we explore how different approaches towards antibiotic-seeking behaviour by patients are interpreted by prescribers. We highlight how extrinsic factors may influence co-produced care, and consequently impact upon a patient or provider’s agency, including: (1) rapid diagnostics, which aim to reduce uncertainty in a consultation; and (2) disruptions to medical hierarchies, such as attaching an antimicrobial pharmacist to a GP practice in order to monitor the appropriateness of antibiotic prescriptions.

Conclusion How providers negotiate their patients‘ antibiotic-seeking behaviour is linked to temporal factors, professional experience, perceptions of risk, and culturally mediated understandings of ‘appropriateness’. Future efforts to reduce antibiotic prescribing in community settings may be achievable by pulling on extrinsic levers, rather than sacrificing the patient-provider relationship.

Reference

1. Strauss A, Schatzman L, Ehrlich D, Bucher R, Sabshin M. (1963). The hospital and its negotiated order. In Friedson E. (ed). The Hospital in Modern Society. Free Press, Glencoe, NY, 147–169.