Antimicrobial resistance is a global health threat, partly driven by inappropriate antibiotic prescriptions for acute medical patients in hospitals. To provide a systematic review of qualitative research on antibiotic prescribing decisions in hospitals worldwide, including broad-spectrum antibiotic use. 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. 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. 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.

Media framing of sepsis and AMR has been identified as influencing public expectation of antimicrobial prescribing as well as health professionals’ perceptions of optimal prescribing strategies. Sepsis media reports tend to use well-recognised triggers that increase public interest. These include emotive personal narratives that commonly centre on young patients, and which identify immediate solutions that are within the power of individual health professionals and the public (eg, increased awareness/recognition). In contrast, AMR is framed as a vague threat affecting future patients and involving multiple actors, often under the ‘One Health’ umbrella.4 Individual responsibility is diffused by presenting AMR as a global responsibility, which shares conceptual features with a ‘problem of many hands’,5 6 and the types …

Antimicrobial resistance (AMR) is a global health problem threatening safe, effective healthcare delivery in all countries and settings. The ability of microorganisms to become resistant to the effects of antimicrobials is an inevitable evolutionary process. The misuse and overuse of antimicrobial agents have increased the importance of a global focus on antimicrobial stewardship (AMS). This review provides insight into the current AMS landscape and identifies contemporary actors and initiatives related to AMS projects in eight African countries (Ghana, Kenya, Malawi, Nigeria, Sierra Leone, Tanzania, Uganda, and Zambia), which form a network of countries participating in the Commonwealth Partnerships for Antimicrobial Stewardship (CwPAMS) programme. We focus on common themes across the eight countries, including the current status of AMR, infection prevention and control, AMR implementation strategies, AMS, antimicrobial surveillance, antimicrobial use, antimicrobial consumption surveillance, a one health approach, digital health, pre-service and in-service AMR and AMS training, access to and supply of medicines, and the impact of COVID-19. Recommendations suitable for adaptation are presented, including the development of a national AMS strategy and incorporation of AMS in pharmacists’ and other healthcare professionals’ curricula for pre-service and in-service training.

According to the confidence heuristic, people are confident when they know they are right, and their confidence makes them persuasive. Previous experiments have investigated the confidence-persuasiveness aspect of the heuristic but not the integrated knowledge-confidence-persuasiveness hypothesis. We report 3 experiments to test the heuristic using incentivized interactive decisions with financial outcomes in which pairs of participants with common interests attempted to identify target stimuli after conferring, only 1 pair member having strong information about the target. Experiment 1, through the use of a facial identification task, confirmed the confidence heuristic. Experiment 2, through the use of geometric shapes as stimuli, elicited a much larger confidence heuristic effect. Experiment 3 found similar confidence heuristic effects through both face-to-face and computer-mediated communication channels, suggesting that verbal rather than nonverbal communication drives the heuristic. Suggesting an answer first was typical of pair members with strong evidence and might therefore be a dominant cue that persuades. Our results establish the confidence heuristic with dissimilar classes of stimuli and through different communication channels. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

The availability of antibiotics presents medical practitioners with a prescribing dilemma. On the one hand, antibiotics provide a safe and effective treatment option for patients with bacterial infections, but at a population level, over-prescription reduces their effectiveness by facilitating the evolution of bacteria that are resistant to antibiotic medication. A game-theoretic investigation, including analysis of equilibrium strategies, evolutionarily stability, and replicator dynamics, reveals that rational doctors, motivated to attain the best outcomes for their own patients, will prescribe antibiotics irrespective of the level of antibiotic resistance in the population and the behavior of other doctors, although they would achieve better long-term outcomes if their prescribing were more restrained. Ever-increasing antibiotic resistance may therefore be inevitable unless some means are found of modifying the payoffs of this potentially catastrophic social dilemma.

Antimicrobial stewardship programs focus on reducing overuse of broad-spectrum antibiotics (BSAs), primarily through interventions to change prescribing behavior. This study aims to identify multi-level influences on BSA overuse across diverse high and low income, and public and private, healthcare contexts. Semi-structured interviews were conducted with 46 prescribers from hospitals in the UK, Sri Lanka, and South Africa, including public and private providers. Interviews explored decision making about prescribing BSAs, drivers of the use of BSAs, and benefits of BSAs to various stakeholders, and were analyzed using a constant comparative approach. Analysis identified drivers of BSA overuse at the individual, social and structural levels. Structural drivers of overuse varied significantly across contexts and included: system-level factors generating tensions with stewardship goals; limited material resources within hospitals; and patient poverty, lack of infrastructure and resources in local communities. Antimicrobial stewardship needs to encompass efforts to reduce the reliance on BSAs as a solution to context-specific structural conditions.