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

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

*Corresponding author for this work

Research output: Contribution to journalArticle (Academic Journal)peer-review

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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 decision-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 (2020)
Number of pages11
JournalBMC Medicine
Publication statusPublished - 30 Jul 2020

Bibliographical note

The ARK-Hospital study is funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research (Grant Reference Number RP-PG-0514-20015). LSJR, JB, TP, ASW, MJL and SW are supported by the Oxford NIHR Biomedical Research Centre, Oxford. LSJR, JB, KBP and ASW are supported by the NIHR Health Protection Research Unit (HPRU) in Healthcare Associated Infections and Antimicrobial Resistance at the University of Oxford in partnership with Public Health England (PHE) [HPRU-2012-10041]. ASW is an NIHR senior investigator. The research programme of Lucy Yardley is partly supported by NIHR Applied Research Collaboration (ARC)-West, NIHR Health Protection Research Unit (HPRU) for Behavioural Science and Evaluation, and the NIHR Southampton Biomedical Research Centre (BRC). The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care.

The study funders had no role in the design of the study; in the collection, analysis or interpretation of the data; in the writing of the paper; or in the decision to submit for publication.

Structured keywords

  • Physical and Mental Health


  • Antibiotic prescribing
  • Antibiotic stewardship
  • hospitals


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