Determinants of antibiotic prescribing for upper respiratory tract infections in an emergency department with good primary care access: a qualitative analysis

Chan, Y.Y., Bin Ibrahim, Muhamad Alif, Wong, C.M., Ooi, C.K., and Chow, A. (2019) Determinants of antibiotic prescribing for upper respiratory tract infections in an emergency department with good primary care access: a qualitative analysis. Epidemiology and Infection, 147. e111.

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Upper respiratory tract infections (URTIs) account for substantial attendances at emergency departments (EDs). There is a need to elucidate determinants of antibiotic prescribing in time-strapped EDs – popular choices for primary care despite highly accessible primary care clinics. Semi-structured in-depth interviews were conducted with purposively sampled physicians (n = 9) in an adult ED in Singapore. All interviews were analysed using thematic analysis and further interpreted using the Social Ecological Model to explain prescribing determinants. Themes included: (1) reliance on clinical knowledge and judgement, (2) patient-related factors, (3) patient–physician relationship factors, (4) perceived practice norms, (5) policies and treatment guidelines and (6) patient education and awareness. The physicians relied strongly on their clinical knowledge and judgement in managing URTI cases and seldom interfered with their peers’ clinical decisions. Despite departmental norms of not prescribing antibiotics for URTIs, physicians would prescribe antibiotics when faced with uncertainty in patients’ diagnoses, treating immunocompromised or older patients with comorbidities, and for patients demanding antibiotics, especially under time constraints. Participants had a preference for antibiotic prescribing guidelines based on local epidemiology, but viewed hospital policies on prescribing as a hindrance to clinical judgement. Participants highlighted the need for more public education and awareness on the appropriate use of antibiotics and management of URTIs. Organisational practice norms strongly influenced antibiotic prescribing decisions by physicians, who can be swayed by time pressures and patient demands. Clinical decision support tools, hospital guidelines and patient education targeting at individual, interpersonal and community levels could reduce unnecessary antibiotic use.

Item ID: 69784
Item Type: Article (Research - C1)
ISSN: 1469-4409
Keywords: Antibiotic prescribing; emergency department; physician; qualitative; upper respiratory tract infections
Copyright Information: © The Author(s) 2019. This is an Open Accessarticle, distributed under the terms of theCreative Commons Attribution licence (, whichpermits unrestricted re-use, distribution, andreproduction in any medium, provided theoriginal work is properly cited.
Funders: National Healthcare Group, Singapore (NHG)
Projects and Grants: NHG (Clinician-Scientist Career Scheme [Mid])
Date Deposited: 28 Oct 2021 03:00
FoR Codes: 42 HEALTH SCIENCES > 4202 Epidemiology > 420209 Occupational epidemiology @ 50%
32 BIOMEDICAL AND CLINICAL SCIENCES > 3202 Clinical sciences > 320211 Infectious diseases @ 50%
SEO Codes: 20 HEALTH > 2004 Public health (excl. specific population health) > 200401 Behaviour and health @ 50%
20 HEALTH > 2003 Provision of health and support services > 200311 Urgent and critical care, and emergency medicine @ 50%
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