Tarrant Carolyn, Krockow Eva M, Nakkawita W M I Dilini, Bolscher Michele, Colman Andrew M, Chattoe-Brown Edmund, Perera Nelun, Mehtar Shaheen, Jenkins David R
Department of Health Sciences, University of Leicester, Leicester, United Kingdom.
Department of Neuroscience, Psychology and Behaviour, University of Leicester, Leicester, United Kingdom.
Front Sociol. 2020 Feb 20;5:7. doi: 10.3389/fsoc.2020.00007. eCollection 2020.
Overuse of broad-spectrum antibiotics in secondary care is a key contributor to the emergence and spread of antimicrobial resistance (AMR); efforts are focused on minimizing antibiotic overuse as a crucial step toward containing the global threat of AMR. The concept of overtreatment has, however, been difficult to define. Efforts to address the overuse of medicine need to be informed by an understanding of how prescribers themselves understand the problem. We report findings from a qualitative interview study of 46 acute care hospital prescribers differing in seniority from three countries: United Kingdom, Sri Lanka and South Africa. Prescribers were asked about their understanding of inappropriate use of antibiotics. Prescriber definitions of inappropriate use included relatively clear-cut and unambiguous cases of antibiotics being used "incorrectly" (e.g., in the case of viral infections). In many cases, however, antibiotic prescribing decisions were seen as involving uncertainty, with prescribers having to make decisions about the threshold for appropriate use. Decisions about thresholds were commonly framed in moral terms. Some prescribers drew on arguments about their duty to protect public health through having a high threshold for prescribing, while others made strong arguments for prioritizing risk avoidance for the patients in front of them, even at a cost of increased resistance. Notions of whether prescribing was inappropriate were also contextually dependent: high levels of antibiotic prescribing could be seen as a rational response when prescribers were working in challenging contexts, and could be justified in relation to financial and social considerations. Inappropriate antibiotic use is framed by prescribers not just in clinical, but also in moral and contextual terms; this has implications for the design and implementation of antibiotic stewardship interventions aiming to reduce inappropriate use of antibiotics globally.
二级医疗中过度使用广谱抗生素是导致抗菌药物耐药性（AMR）出现和传播的关键因素；目前的工作重点是尽量减少抗生素的过度使用，这是遏制全球AMR威胁的关键一步。然而，过度治疗的概念一直难以界定。解决药物过度使用问题的努力需要基于对开处方者自身如何理解该问题的认识。我们报告了一项定性访谈研究的结果，该研究对来自英国、斯里兰卡和南非三个国家的46名不同资历的急性护理医院开处方者进行了访谈。研究人员询问开处方者对不当使用抗生素的理解。开处方者对不当使用的定义包括抗生素“错误”使用的相对明确和毫不含糊的情况（例如，在病毒感染的情况下）。然而，在许多情况下，抗生素处方决策被视为存在不确定性，开处方者必须就适当使用的阈值做出决定。关于阈值的决定通常是以道德术语来阐述的。一些开处方者提出论据，认为通过设定高处方阈值来保护公众健康是他们的职责，而另一些人则强烈主张优先为眼前的患者避免风险，即使这会以耐药性增加为代价。处方是否不当的观念也取决于具体情境：当开处方者在具有挑战性的环境中工作时，高水平的抗生素处方可能被视为一种合理反应，并且可以从财务和社会考虑方面得到正当理由。开处方者不仅从临床角度，而且从道德和情境角度来界定不当使用抗生素的问题；这对于旨在全球范围内减少抗生素不当使用的抗生素管理干预措施的设计和实施具有重要意义。
