Systematic Review Of Factors Influencing Antimicrobial Prescribing Decisions By Physicians

• By: REALI, Savannah (The University of Sydney, Australia)
• Co-author(s): Ms Savannah Reali (School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Camperdown, Australia / Pharmacy Department, Prince of Wales Hospital, Randwick, Australia / Westmead Hospital, Westmead, Australia / The University of Sydney Institute for Infectious Diseases (Sydney ID), Westmead, Australia)
  Ms Yee Chin Kwang (Pharmacy Department, Wagga Wagga Base Hospital, Wagga Wagga, Australia)
  Dr Jin-Gun Cho (Department of Respiratory and Sleep Medicine, Westmead Hospital, Westmead, Australia / Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, Camperdown, Australia)
  Prof Johannes Alffenaar (School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Camperdown, Australia / Westmead Hospital, Westmead, Australia / The University of Sydney Institute for Infectious Diseases (Sydney ID), Westmead, Australia)
  Prof Parisa Aslani (School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Camperdown, Australia)
  
• Abstract:

  Systematic Review of Factors Influencing Antimicrobial Prescribing Decisions by Physicians
  
  Authors
  Savannah Reali
  Yee Chin Kwang
  Jin-Gun Cho
  Jan-Willem Alffenaar
  Parisa Aslani
  
  Abstract
  Introduction:
  Inappropriate and overuse of antimicrobials, in part due to inappropriate prescribing, is increasing antimicrobial resistance (AMR). Evidence has shown that prescribing in accordance with evidence-based guidelines reduces resistance, however, guideline adherence remains low. Understanding physicians’ antimicrobial decision-making is essential for developing interventions to optimise prescribing.
  
  Methods:
  A systematic review of qualitative studies was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to identify the factors that influence physicians’ antimicrobial prescribing decisions. The search was limited to studies published from 2014 onwards to provide an update to a prior systematic review on this topic. Importantly, this review included studies on all infection types, and from all countries and settings. Factors influencing antimicrobial prescribing were extracted and categorised into physician-related, patient-related, medication- and condition-related, and external factors. These factors were compared across patient populations (adults, paediatrics, and geriatrics), infection types, countries (high-income countries [HICs] and low- and middle-income countries [LMICs]), and settings (primary care, hospital setting, and residential aged care facilities). The individual factors were mapped to different stages of the prescribing process to create a model of physicians’ antimicrobial decision-making.
  
  Results:
  Fifty-three studies met the inclusion criteria and were analysed in this review. Forty factors influencing antimicrobial prescribing decisions were identified, including novel factors not previously reported in systematic reviews. The most common factors influencing prescribing were time pressures, patient/carer demand for antimicrobials, diagnostic uncertainty, clinical experience, and the use of evidence-based guidelines. Factors which influenced antimicrobial prescribing considered the harm to the patient and the physician to outweigh the potential population harm of antimicrobial resistance due to overprescribing. Time pressures, patient demand for antimicrobials, and diagnostic uncertainty were all more common factors influencing prescribing in the community when compared with the hospital setting. Patient demand and diagnostic uncertainty were also more common in managing paediatric and geriatric patients compared with adult patients. The use of evidence-based guidelines and diagnostic testing to assist in making prescribing choices is limited in LMIC due to resource constraints. A model of physicians’ antimicrobial prescribing process starting from reviewing the patient to selecting an antimicrobial was created, showing the factors that physicians consider at each stage of decision-making and how each step of the process is influenced by the physician themselves, the patient, the patient’s condition, the antimicrobial, and organizational and external factors. This will be useful for mapping results to existing frameworks when creating future interventions to optimise prescribing.
  
  Conclusion:
  The overarching theme from the studies in this review is that prescribers view the immediate harm to the patient and themselves by underprescribing antimicrobials to outweigh the future population harm of AMR by overprescribing antimicrobials. Future interventions to optimise prescribing must determine how to balance individual and population harms whilst considering the individual factors identified in this review that influence prescribing decisions.