Why do hospital prescribers continue antibiotics when it is safe to stop? Results of a choice experiment survey

Laurence Roope, James Buchanan, Liz Morrell, Koen Pouwels, Katy Sivyer, Fiona Mowbray, Lucy Abel, Elizabeth Cross, Lucy Yardley, Tim Peto, Sarah Walker, Martin Llewelyn, Sarah Wordsworth

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Background: Deciding whether to discontinue antibiotics at early review is a cornerstone of hospital antimicrobial stewardship practice worldwide. In England this approach is described in government guidance (“Start Smart then Focus”). However, <10% of hospital antibiotic prescriptions are discontinued at review, despite evidence that 20-30% could be discontinued safely. We aimed to quantify the relative importance of factors influencing prescriber decision42 making at review.

Methods: We conducted an online choice experiment, a survey method to elicit preferences. Acute/general hospital prescribers in England were asked if they would continue or discontinue antibiotic treatment in 15 hypothetical scenarios. Scenarios were described according to six attributes, including patients’ presenting symptoms and whether discontinuation would conflict with local prescribing guidelines. Respondents’ choices were analysed using conditional logistic regression.

Results: 100 respondents completed the survey. Respondents were more likely to continue antibiotics when discontinuation would ‘strongly conflict’ with local guidelines (average marginal effect (AME) on probability of continuing +0.194 (p<0.001)); when presenting symptoms more clearly indicated antibiotics (AME of urinary tract infection symptoms +0.173 (p<0.001) versus unclear symptoms); and when patients had severe frailty/comorbidities (AME=+0.101 (p<0.001)). Respondents were less likely to continue antibiotics when under no external pressure to continue (AME=-0.101 (p<0.001)). Decisions were also influenced by the risks to patient health of continuing/discontinuing antibiotic treatment.

Conclusions: Guidelines that conflict with antibiotic discontinuation (e.g. pre-specify fixed durations) may discourage safe discontinuation at review. In contrast, guidelines conditional on patient factors/treatment-response could help hospital prescribers discontinue antibiotics if diagnostic information suggesting they are no longer needed is available.
Original languageEnglish
Article number196
JournalBMC Medicine
Publication statusPublished - 30 Jul 2020


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