Overtreatment of asymptomatic bacteriuria: a qualitative study

Online Search Strategies and Results From a Crowdsourced Survey on Asymptomatic Bacteriuria

IMPORTANCE

Despite the prevalence of asymptomatic bacteriuria (ASB), what proportion of the population is aware of this condition and the quality of internet resources are currently unknown.

OBJECTIVE

This study aimed to use an online crowdsourcing platform to explore general knowledge and internet search strategies, along with the quality of information, on ASB.

STUDY DESIGN

An online survey was administered through a crowdsourcing platform to women 50 years or older via Qualtrics, which is a sophisticated online survey tool. Participants completed a survey on ASB, and participants were asked how they would search the internet for information both on urinary test results and on ASB. Outcomes included survey responses, and qualitative data were coded and analyzed thematically. χ2 Testing and regression modeling were used to look for variables associated with concern for ASB.

RESULTS

There were a total of 518 participants who passed attention check qualifications, and only 45 respondents (8.7%) had heard of ASB. Many were concerned about progress to a worsening infection (n = 387 [77.6%]). When controlling for confounders, education beyond a college degree was not associated with a lower concern for ASB when compared with those with a high school education or less (adjusted odds ratio, 0.63; 95% confidence interval, 0.25-1.55; P = 0.31). Medical providers were the target audience for a majority of the websites, and many of the patient-facing results were of poor quality.

CONCLUSIONS

Our national survey of women demonstrated a prevalent knowledge deficit surrounding ASB. We must seek to create high-quality, readily available, patient-facing information to increase awareness of ASB, allay concerns, and increase antibiotic stewardship.

Leveraging diagnostic stewardship within antimicrobial stewardship programmes

Novel diagnostic stewardship in infectious disease consists of interventions that modify ordering, processing, and reporting of diagnostic tests to provide the right test for the right patient, prompting the right action. The interventions work upstream and synergistically with traditional antimicrobial stewardship efforts. As diagnostic stewardship continues to gain public attention, it is critical that antimicrobial stewardship programmes not only learn how to effectively leverage diagnostic testing to improve antimicrobial use but also ensure that they are stakeholders and leaders in developing new diagnostic stewardship interventions within their institutions. This review will discuss the need for diagnostic and antimicrobial stewardship, the interplay of diagnostic and antimicrobial stewardship, evidence of benefit to antimicrobial stewardship programmes, and considerations for successfully engaging in diagnostic stewardship interventions. This article is part of the Antibiotic stewardship Special Issue: https://www.drugsincontext.com/special_issues/antimicrobial-stewardship-a-focus-on-the-need-for-moderation.

Why Are We Frequently Ordering Urinalyses in Patients without Symptoms of Urinary Tract Infections in the Emergency Department?

(1) Background: In the emergency department (ED), ordering urine tests in patients without symptoms of a urinary tract infection can lead to inappropriate antimicrobial treatment. We aimed to identify factors contributing to the unnecessary ordering of urinalyses in the ED. (2) Methods: An online survey study among nurses and physicians working in the EDs of five hospitals in the Netherlands was conducted. (3) Results: The overall response rate was 26% (221/850; 85 nurses and 136 physicians). The vast majority of the respondents reported knowing when to order urine tests (197/221; 90%). Almost two-thirds of the respondents (145/221; 66%) agreed that they ordered urinalyses because it is rapid and non-invasive to patients. Most nurses (66/86; 78%) said they informed the doctor if they thought the urine test would not contribute to the patient's diagnosis, but only one-third of the physicians agreed with this statement (44/136; 32%). Most respondents (160/221; 72%) thought guidelines or protocols about urinalyses in the ED would be functional. (4) Conclusions: These results suggest urinalyses were frequently ordered in the ED to achieve a fast work process. Nurses and physicians could improve their communication about the indications for urine tests. Developing diagnostic guidelines for urine testing may be convenient.

Instruments used to measure knowledge and attitudes of healthcare professionals towards antibiotic use for the treatment of urinary tract infections: A systematic review

Background

Urinary tract infections (UTIs) are the second most common condition (after upper respiratory tract infections) for which adults receive antibiotics, and this prevalence may contribute to antibiotic resistance. Knowledge and attitudes have been identified as potential determinants of antibiotic prescribing behaviour among healthcare professionals in the treatment and management of UTIs. An instrument that captures prescribers’ baseline knowledge of and attitudes towards antibiotic prescribing for UTIs could inform interventions to enhance prescribing. The current systematic review evaluates the psychometric properties of instruments already available and describes the theoretical constructs they measure.

Methods

Five electronic databases were searched for published studies and instruments. The Consensus-based Standards for the selection of health status Measurement Instruments checklist was used to assess the psychometric quality reporting of the instruments. The items included in each instrument were mapped onto the theoretical constructs underlying knowledge and attitudes using a mixed-theoretical model developed for this study.

Results

Fourteen studies met the review inclusion criteria. All instruments were available for review. None of the instruments had all the psychometric properties evaluated. Most of the instruments sought to identify knowledge and/or attitude factors influencing antibiotic prescribing for UTIs rather than to measure/assess knowledge and attitudes.

Conclusions

Few instruments for the assessment of knowledge and attitudes of healthcare professionals towards antibiotic use and UTI treatment are available. None of the instruments underwent the full development process to ensure that all psychometric properties were met. Furthermore, none of the instruments assessed all domains of knowledge and attitudes. Therefore, the ability of the instruments to provide a robust measurement of knowledge and attitudes is doubtful. There is a need for an instrument that fully and accurately measures the constructs of knowledge and attitude of healthcare professionals in the treatment of UTIs.

Substantial overlap between symptomatic and asymptomatic genitourinary microbiota states

BACKGROUND

The lack of a definition of urinary microbiome health convolutes diagnosis of urinary tract infections (UTIs), especially when non-traditional uropathogens or paucity of bacteria are recovered from symptomatic patients in routine standard-of-care urine tests. Here, we used shotgun metagenomic sequencing to characterize the microbial composition of asymptomatic volunteers in a set of 30 longitudinally collected urine specimens. Using permutation tests, we established a range of asymptomatic microbiota states, and use these to contextualize the microbiota of 122 urine specimens collected from patients with suspected UTIs diagnostically categorized by standard-of-care urinalysis within that range. Finally, we used a standard-of-care culture protocol to evaluate the efficiency of culture-based recovery of the urinary microbiota.

RESULTS

The majority of genitourinary microbiota in individals suspected to have UTI overlapped with the spectrum of asymptomatic microbiota states. Longitudinal characterization of the genitourinary microbiome in urine specimens collected from asymptomatic volunteers revealed fluctuations of microbial functions and taxonomy over time. White blood cell counts from urinalysis suggested that urine specimens categorized as 'insignificant', 'contaminated', or 'no-growth' by conventional culture methods frequently showed signs of urinary tract inflammation, but this inflammation is not associated with genitourinary microbiota dysbiosis. Comparison of directly sequenced urine specimens with standard-of-care culturing confirmed that culture-based diagnosis biases genitourinary microbiota recovery towards the traditional uropathogens Escherichia coli and Klebsiella pneumoniae.

CONCLUSION

Here, we utilize shotgun metagenomic sequencing to establish a baseline of asymptomatic genitourinary microbiota states. Using this baseline we establish substantial overlap between symptomatic and asymptomatic genitourinary microbiota states. Our results establish that bacterial presence alone does not explain the onset of clinical symptoms. Video Abstract.

Antibiotic use for asymptomatic bacteriuria in children with neurogenic bladder

PURPOSE

Patients with neurogenic bladder (NB) often perform clean intermittent catheterization (CIC) and are predisposed to bladder colonization. Antibiotics are not routinely indicated in those with asymptomatic bacteriuria (ASB). The original purpose of this study was to compare patients that received antibiotics for ASB and those that did not. However, because the non-antibiotic group was very small, the final analysis evaluated treatment patterns of ASB in children with NB.

METHODS

A retrospective chart review was completed, including patients who presented with urinary tract infection (UTI) and NB managed by CIC. Patients with symptoms of UTI were excluded. Basic demographics, urinalysis, culture results, and antibiotic prescriptions were collected.

RESULTS

The sample included 272 patient encounters for 109 unique patients. Of these, 50.7% were female, and the median age was 10.25 years. More than half the urine cultures (56.2%) grew gram-negative organisms, and 31.3% contained 2 or more organisms. Nearly all encounters received treatment with antibiotics. Twenty-three encounters with no culture performed or the culture resulted in no growth received antibiotic therapy.

CONCLUSIONS

Antibiotic resistance and antibiotic stewardship are primary concerns in healthcare today. This organization's current practice pattern shows high antibiotic use for ASB in patients with NB. Future studies are required to identify outcomes associated with treatment versus non-treatment in these patients.

Associations of delirium with urinary tract infections and asymptomatic bacteriuria in adults aged 65 and older: A systematic review and meta-analysis

Objective

To determine the associations of delirium with urinary tract infection (UTI) and asymptomatic bacteriuria (AB) in individuals aged 65 and older.

Methods

The protocol for this systematic review and meta‐analysis was published on PROSPERO (CRD42020164341). Electronic databases were searched for relevant studies, professional associations and experts in the field were additionally contacted. Studies with control groups reporting associations between delirium and UTI as well as delirium and AB in older adults were included. The random effects model meta‐analysis was conducted using odds ratios (ORs) with 95% confidence intervals (CIs) as effect size measures. The Newcastle‐Ottawa scale was used to rate the studies' quality. Heterogeneity was assessed using the Q and I² tests. The effects of potential moderators were investigated by both subgroup and meta‐regression analyses. The risk of publication bias was evaluated using the funnel plot and Egger's test.

Results

Twenty nine relevant studies (16,618 participants) examining the association between delirium and UTI in older adults were identified. The association between delirium and UTI was found to be significant (OR 2.67; 95% CI 2.12–3.36; p < 0.001) and persisted regardless of potential confounders. The association between delirium and AB in older adults in the only eligible study found (192 participants) was insignificant (OR 1.62; 95% CI 0.57–4.65; p = 0.37). All included studies were of moderate quality.

Conclusion

The results of this study support the association between delirium and UTI in older adults. Insufficient evidence was found to conclude on an association between delirium and AB in this age group. These findings are limited due to the moderate quality of the included studies and a lack of available research on the association between delirium and AB. Future studies should use the highest quality approaches for defining both delirium and UTI and consider AB in their investigations.

Understanding the complexities of antibiotic prescribing behaviour in acute hospitals: a systematic review and meta-ethnography

BACKGROUND

Antimicrobial resistance poses a serious global public health threat. Hospital misuse of antibiotics has contributed to this problem and evidence-based interventions are urgently needed to change inappropriate prescribing practices. This paper reports the first theoretical stage of a longer-term project to improve antibiotic prescribing in hospitals through design of an effective behaviour-change intervention.

METHODS

Qualitative synthesis using meta-ethnography of primary studies reporting doctors' views and experiences of antibiotic prescribing in hospitals for example, their barriers to appropriate prescribing. Twenty electronic databases were systematically searched over a 10-year period and potential studies screened against eligibility criteria. Included studies were quality-appraised. Original participant quotes and author interpretations were extracted and coded thematically into NVivo. All study processes were conducted by two reviewers working independently with findings discussed with the wider team and key stakeholders. Studies were related by findings into clusters and translated reciprocally and refutationally to develop a new line-of-argument synthesis and conceptual model. Findings are reported using eMERGe guidance.

RESULTS

Fifteen papers (13 studies) conducted between 2007 and 2017 reporting the experiences of 336 doctors of varying seniority working in acute hospitals across seven countries, were synthesised. Study findings related in four ways which collectively represented multiple challenges to appropriate antibiotic medical prescribing in hospitals: loss of ownership of prescribing decisions, tension between individual care and public health concerns, evidence-based practice versus bedside medicine, and diverse priorities between different clinical teams. The resulting new line-of-argument and conceptual model reflected how these challenges operated on both micro- and macro-level, highlighting key areas for improving current prescribing practice, such as creating feedback mechanisms, normalising input from other specialties and reducing variation in responsibility for antibiotic decisions.

CONCLUSIONS

This first meta-ethnography of doctors` experiences of antibiotic prescribing in acute hospital settings has enabled development of a novel conceptual model enhancing understanding of appropriate antibiotic prescribing. That is, hospital antibiotic prescribing is a complex, context-dependent and dynamic process, entailing the balancing of many tensions. To change practice, comprehensive efforts are needed to manage failures in communication and information provision, promote distribution of responsibility for antibiotic decisions, and reduce fear of consequences from not prescribing.

TRIAL REGISTRATION

PROSPERO registration: CRD42017073740 .

How many urinalysis and urine cultures are necessary?

BACKGROUND

Urinalysis and urine culture are two of the most commonly ordered tests. A positive urine test in asymptomatic patients often leads to overtreatment. Antimicrobials for asymptomatic bacteriuria is one of the most common unnecessary treatments. We aimed to explore the current ordering patterns of urinalysis and cultures.

METHODS

This is a substudy of the multicentre RICAT-trial, a successful quality improvement project to reduce inappropriate use of intravenous and urinary catheters in seven hospitals in the Netherlands. Adult patients with a (central or peripheral) venous or urinary catheter admitted to internal medicine and non-surgical subspecialty wards were eligible for inclusion. Data were collected every other week during baseline (seven months) and intervention periods (seven months). The primary outcome was the proportion of urine cultures performed following a negative urinalysis, i.e. dipstick and/or microscopic analysis, within 24 h.

RESULTS

Between September 2016 and April 2018, we included 3748 patients, of which 3111 (83%) were admitted from the emergency department. Urinalysis and/or urine cultures were obtained in 2610 (70%) of 3748 patients. 626 (23.7%) of 2636 urine cultures and 1351 (55.8%) of 2419 microscopic analysis were unnecessary performed after a negative urinalysis. Cancelling urine testing orders after a negative dipstick would have saved almost € 19.500 during the study period in these seven hospitals.

CONCLUSION

Unnecessary urine testing is frequent in non-surgical patients in the Netherlands. We need to take action to reduce unnecessary urinalysis and cultures, and thereby probably reduce overtreatment of asymptomatic bacteriuria.

Safety, effectiveness and sustainability of a laboratory intervention to de-adopt culture of midstream urine samples among hospitalized patients

OBJECTIVE

To assess the safety, sustainability, and effectiveness of a laboratory intervention to reduce processing of midstream urine (MSU) cultures.

DESIGN

Prospective observational cohort.

SETTING

Medical and surgical inpatients in a tertiary-care hospital.

PARTICIPANTS

The study included 1,678 adult inpatients with an order for MSU culture.

METHODS

From 2013 to 2019, ordered MSU cultures were not processed unless the laboratory was called. Patients were interviewed on days 0 and 4; from 2017 to 2019, day-30 follow-up was added. Primary outcome was serious adverse events due to not processing MSU cultures. Secondary outcomes were nonserious adverse events due to not processing MSU cultures, rates of MSU cultures submitted, proportion of MSU cultures processed, proportion of patients prescribed urinary tract infection (UTI)-directed antibiotics, and laboratory workload.

RESULTS

Among 912 and 459 patients followed to days 4 and 30, respectively, no serious adverse events attributable to not processing MSU cultures were identified. However, 6 patients (0.66%) had prolonged urinary symptoms potentially associated with not processing MSU cultures. We estimated that 4 patients missed having empiric antibiotics stopped in response to negative MSU cultures, and 99 antibiotic courses for asymptomatic bacteriuria (ASB) and 8 antibiotic-associated adverse events were avoided. The rate of submitted MSU samples and proportion of patients receiving empiric UTI-directed antibiotics did not change. The proportion of MSU cultures processed declined from 59% to 49% (P < .0001), and total laboratory workload was reduced by 185 hours.

CONCLUSIONS

De-adopting the processing of MSU cultures from medical and surgical inpatient units is safe and sustainable, and it reduces antibiotic prescriptions for ASB at a cost of prolonged urinary symptoms in a small proportion of patients.

Diagnosis Between Chaos and Control: Affect and Hospital Clinicians' and Older Adult Patients' Narratives of Urinary Tract Infections

Research has observed that older adults are frequently overdiagnosed with urinary tract infection (UTI) and unnecessarily prescribed antibiotics in hospitals. In this article we explore the overlooked affective dimension of experiences of diagnosis and prescribing. Drawing on interviews with doctors, nurses and older adult patients (n = 41) on UTI diagnosis in two UK hospitals and Arthur Frank's work on illness narratives we identified two affective ways of experiencing diagnosis. Some clinicians and older adult patients articulated chaos narratives about being overwhelmed by contradictory evidence and events, doubting the repeated UTI diagnoses and courses of antibiotics but being unable to do anything about their concerns. Other clinicians and patients articulated control narratives about UTIs being frequently diagnosed and antibiotics prescribed to restore patients' health, echoing certainty and security, even if the processes described typically did not follow current guidance. We contend that analyzing the affective dimension offers conceptual insights that push forward sociological discussions on diagnosis as reflective or dogmatic in the context of the contradiction between acute care and chronic illnesses of old age. Our findings contribute practical ideas of why overdiagnosis and overprescribing happen in hospitals and complicate notions of patients pressuring for antibiotics. We also present methodological suggestions for analyzing how participants tell about their experiences in order to explore the typically not directly spoken affective dimension that influences thoughts and actions about diagnosis.

Targeting Asymptomatic Bacteriuria in Antimicrobial Stewardship: the Role of the Microbiology Laboratory

This minireview focuses on the microbiologic evaluation of patients with asymptomatic bacteriuria, as well as indications for antibiotic treatment. Asymptomatic bacteriuria is defined as two consecutive voided specimens (preferably within 2 weeks) with the same bacterial species, isolated in quantitative counts of ≥10⁵ CFU/ml in women, including pregnant women; a single voided urine specimen with one bacterial species isolated in a quantitative count ≥10⁵ CFU/ml in men; and a single catheterized urine specimen with one or more bacterial species isolated in a quantitative count of ≥10⁵ CFU/ml in either women or men (or ≥10² CFU/ml of a single bacterial species from a single catheterized urine specimen). Any urine specimen with ≥10⁴ CFU/ml group B Streptococcus is significant for asymptomatic bacteriuria in a pregnant woman. Asymptomatic bacteriuria occurs, irrespective of pyuria, in the absence of signs or symptoms of a urinary tract infection. The two groups with the best evidence of adverse outcomes in the setting of untreated asymptomatic bacteriuria include pregnant women and patients who undergo urologic procedures with risk of mucosal injury. Screening and treatment of asymptomatic bacteriuria is not recommended in the following patient populations: pediatric patients, healthy nonpregnant women, older patients in the inpatient or outpatient setting, diabetic patients, patients with an indwelling urethral catheter, patients with impaired voiding following spinal cord injury, patients undergoing nonurologic surgeries, and nonrenal solid-organ transplant recipients. Renal transplant recipients beyond 1 month posttransplant should not undergo screening and treatment for asymptomatic bacteriuria. There is insufficient evidence to recommend for or against screening of renal transplant recipients within 1 month, patients with high-risk neutropenia, or patients with indwelling catheters at the time of catheter removal. Unwarranted antibiotics place patients at increased risk of adverse effects (including Clostridioides difficile diarrhea) and contribute to antibiotic resistance. Methods to reduce unnecessary screening for and treatment of asymptomatic bacteriuria aid in antibiotic stewardship.

Impact of a urinary tract infection diagnostic and treatment algorithm for psychiatric inpatients with a communication barrier

INTRODUCTION

Differentiating between a urinary tract infection and asymptomatic bacteriuria is an important distinction to make, especially in noncommunicative patients. An algorithm meant to aid in the diagnosis and treatment of urinary tract infections in this population was implemented within a psychiatric emergency department in January 2019. The primary objective of this project was to assess the impact of the algorithm (the intervention) regarding symptom documentation and antibiotic use. Secondary objectives included assessing changes in inappropriate prescribing and urine culture orders.

METHODS

Preintervention outcomes were measured from August 1, 2018, through November 30, 2018, while the postintervention cohort included patients admitted after January 31, 2019 and discharged before June 1, 2019. Adults admitted to psychiatry with a urinalysis ordered in the emergency department and an ICD-10 code representing dementia, delirium, autism spectrum disorder, or intellectual disability were included; pregnant patients were excluded.

RESULTS

The preintervention (n = 56) and postintervention (n = 34) cohorts were well balanced with an average age of 66.5 and 70 years, respectively. Neurocognitive disorder was the diagnosis for inclusion in approximately two-thirds of both groups. Numerically, postalgorithm implementation, symptoms were documented more frequently (20.6% vs 10.7%, P = .23) and antibiotics used less often (2.9% vs 14.3%, P = .15). Inappropriate prescribing occurred in 12.5% of preintervention cohort compared to no patients postintervention (P = .04).

DISCUSSION

The creation and implementation of an algorithm assisting in the diagnosis and treatment of urinary tract infections in noncommunicative patients was associated with a trend toward increased symptom documentation and decreased overall antibiotic use, and significantly increased appropriate antibiotic prescribing.

Gaps in communication between different staff groups and older adult patients foster unnecessary antibiotic prescribing for urinary tract infections in hospitals: a qualitative translation approach

Background

Studies have reported large scale overprescribing of antibiotics for urinary tract infection (UTI) in hospitalised older adults. Older adults often have asymptomatic bacteriuria, and clinicians have been found to diagnose UTIs inappropriately based on vague symptoms and positive urinalysis and microbiology. However, the joined perspectives of different staff groups and older adult patients on UTI diagnosis have not been investigated.

Methods

Thematic analysis of qualitative interviews with healthcare staff (n = 27) and older adult patients (n = 14) in two UK hospitals.

Results

Interviews featured a recurrent theme of discrepant understandings and gaps in communication or translation between different social groups in three key forms: First, between clinicians and older adult patients about symptom recognition. Second, between nurses and doctors about the use and reliability of point-of-care urinary dipsticks. Third, between nurses, patients, microbiologists and doctors about collection of urine specimens, contamination of the specimens and interpretation of mixed growth laboratory results. The three gaps in communication could all foster inappropriate diagnosis and antibiotic prescribing.

Conclusion

Interventions to improve diagnosis and prescribing for UTIs in older adults typically focus on educating clinicians. Drawing on the sociological concept of translation and interviews with staff and patients our findings suggest that inappropriate diagnosis and antibiotic prescribing in hospitals can be fuelled by gaps in communication or translation between different staff groups and older adult patients, using different languages and technologies or interpreting them differently. We suggest that interventions in this area may be improved by also addressing discrepant understandings and communication about symptoms, urinary dipsticks and the process of urinalysis.

Urinary tract infections in a geriatric sub-acute ward-health correlates and atypical presentations

Purpose

Bacterial urinary tract infections (UTIs) are the most frequently occurring infectious diseases in the geriatric population. The aim of the study was to determine the prevalence and clinical features of UTIs in geriatric in-patients and their association with health and functional ability characteristics.

Methods

A prospective cross-sectional cohort study was conducted among patients hospitalized on the geriatric ward. Patients were interviewed, examined, and had their hospital records analyzed. An uncontaminated midstream urine sample was collected and cultured in all of the cases suspected for UTI. Relative risks for UTI were counted and multivariable logistic regression model was built.

Results

246 patients were included, 179 (72.8%) women, 210 (85.4%) 75 + -year-olds. Bacterial UTIs occurred in 18.3% of the patients. The main etiological agent was Escherichia coli (73.3%). The most significant predictors of UTI were recurrent UTI and urinary catheter. The typical clinical UTI symptoms occurred in less than half of the cases (only in 11.1% of cases fever was observed). More often, than in patients without UTIs, they reported symptoms such as delirium (28.9% vs. 18%), tachycardia (11.1% vs. 1.5%) or hypotension (20% vs. 12.1%).

Conclusions

Bacterial UTIs affect about 1/5 of hospitalized geriatric patients. The clinical picture of these infections very often is atypical and it indicates a need for diagnostic vigilance.

Balancing the risks to individual and society: a systematic review and synthesis of qualitative research on antibiotic prescribing behaviour in hospitals

BACKGROUND

Antimicrobial resistance is a global health threat, partly driven by inappropriate antibiotic prescriptions for acute medical patients in hospitals.

AIM

To provide a systematic review of qualitative research on antibiotic prescribing decisions in hospitals worldwide, including broad-spectrum antibiotic use.

METHODS

A systematic search of qualitative research on antibiotic prescribing for adult hospital patients published between 2007 and 2017 was conducted. Drawing on the Health Belief Model, a framework synthesis was conducted to assess threat perceptions associated with antimicrobial resistance, and perceived benefits and barriers associated with antibiotic stewardship.

FINDINGS

The risk of antimicrobial resistance was generally perceived to be serious, but the abstract and long-term nature of its consequences led physicians to doubt personal susceptibility. While prescribers believed in the benefits of optimizing prescribing, the direct link between over-prescribing and antimicrobial resistance was questioned, and prescribers' behaviour change was frequently considered futile when fighting the complex problem of antimicrobial resistance. The salience of individual patient risks was a key barrier to more conservative prescribing. Physicians perceived broad-spectrum antibiotics to be effective and low risk; prescribing broad-spectrum antibiotics involved low cognitive demand and enabled physicians to manage patient expectations. Antibiotic prescribing decisions in low-income countries were shaped by a context of heightened uncertainty and risk due to poor microbiology and infection control services.

CONCLUSIONS

When tackling antimicrobial resistance, the tensions between immediate individual risks and long-term collective risks need to be taken into account. Efforts to reduce diagnostic uncertainty and to change risk perceptions will be critical in shifting practice.