Do Antibiotic Adverse Effects Affect Prescribing Practices?

Behavior change is a key aspect of successful antimicrobial stewardship programs (ASPs), as has been described in studies.^1-3,5 Thus, obtaining information on the psychosocial factors that influence a provider’s decision to prescribe antibiotics can impact the effectiveness of ASPs. The results of a qualitative study published in Antimicrobial Stewardship & Healthcare Epidemiology indicate some of the factors that influence provider prescribing of antibiotics, specifically related to knowledge of adverse events (AEs).⁶ The goal of a qualitative study is to gain insights into a particular question or topic, rather than quantify patterns.⁷ Using focus groups is a common and efficient way to obtain this type of data, and therefore, this is an appropriate study design for the aim.⁸

The concern that led to this study was that antibiotic-associated AEs (ABX-AEs) may not factor into a provider’s decision to prescribe or not prescribe antibiotics. To assess this, the investigators asked providers (physicians and advance practice nurses) in their institution to participate in focus groups. A total of 15 participants were put into 4 groups, and their discussions with investigators were recorded with consent and later coded by 2 independent investigators based on commonly observed themes.⁶ The initial prompt for discussion was: “What role do ABX-AEs play in your clinical decision-making when prescribing antibiotics?”

The investigators also included other prompts for clarification and further discussion on the topic. The Figure outlines the key themes identified in these discussions.

Participants were then asked to categorize ABX-AEs based on their level of concern. They were provided with a table of AEs divided into prespecified levels of concern and asked to vote on how they would classify each AE. The ABX-AEs of most clinical concern to providers included drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome, anaphylaxis, Stevens-Johnson syndrome, neuropathy, Clostridioides difficile, and nephrotoxicity requiring dialysis.

Lastly, focus groups were asked about how they would like to receive feedback on their antibiotic prescribing practices, as well as on the AEs their patients may have experienced. Providers stated that feedback was welcomed if it wouldn’t be overwhelming. They would be receptive to hearing about more serious AEs that their patients experienced due to the antibiotics they had prescribed, as well as education on evidence-based prescribing. The main concern was this feedback becoming punitive.

Antimicrobial stewardship requires addressing psychosocial factors,³ which are much easier to elucidate through a qualitative vs a quantitative study. The results of these qualitative studies are important for informing quantitative studies,⁷as well as for gaining insight into the perspectives and thought processes of those surveyed.

Knowledge of provider perceptions can help tailor ASPs at institutions based on their individual cultures.

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This was a small but robust study in which the aims were clear and the methods were in line with the intended objectives. The authors stated that key insights observed in this study included identifying the role ABX-AEs play in provider decision-making, in which ABX-AEs are of the greatest concern, and how providers would prefer to receive feedback on their own practices. The authors bring up important points regarding the challenges ASP teams face when trying to change prescribing habits and plant the seeds for others to conduct similar studies. Focus group–based studies are efficient because, unlike with individual interviews, the ideas discussed can be amplified as each participant contributes their particular views. Participants were asked to stratify AEs as “very concerning,” “moderately concerning,” or “mildly concerning.” The prespecified categories that were presented to participants could have influenced participants toward voting in line with them, and the authors noted this as a potential limitation of their study. In future studies, it would be prudent to present uncategorized AEs and ask providers to separate them into the categories without influence from investigators.

Participants stated that feedback must be given in a way that does not overwhelm providers but alerts them to the effects their prescribed antibiotics have on patients. This is in line with results from other studies^3,7 and makes sense from a psychosocial perspective. Alert fatigue is real, and receiving alerts on every patient who has any AE from their antibiotic would be unreasonable. Participants also commented on the need for tools that antimicrobial stewardship teams could use to provide this type of feedback without manual chart review. This is crucial, as manual review and feedback is time-consuming and inefficient.

In general, the themes identified through the focus groups of this study are not surprising and can be used to develop individual research questions that could provide more details about each theme. The overall results from this study will help inform further studies assessing providers’ perceptions and beliefs around antibiotic prescribing as well as quantitative studies that can provide more structured and concrete data.