The Hidden Social Dynamics of Antibiotic Prescribing: Considerations for Antimicrobial Stewardship Programs

An ill child in bed receiving liquid antibiotics.

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As infection preventionists (IPs), we often focus on the clinical aspects of antibiotic use and the impact of multidrug-resistant organisms on the environment and patient care delivery. But have we considered that prescribing antibiotics involves more than clinical decision-making? This eye-opening perspective was the focus of a recent presentation by Julia Szymczak, PhD, associate professor at the University of Utah School of Medicine, which I had the privilege of attending at the Disease Prevention and Control Summit and World Anti-Microbial Congress in Philadelphia on September 5, 2024.

Antibiotic Prescribing: A Medical Intervention or A Social Act?

Szymczak began her presentation by helping us reflect on what we typically think about antibiotic prescribing. From her recent research and experience working with clinicians, IPs, and infectious disease investigators in the US, she determined that prescribing antibiotics is as much a medical act as a social one.

As a social act, it serves multiple purposes: It is a means of communication and a way for clinicians to show that they care about their patients; it demonstrates a clinician's authority and facilitates social control; it produces an income for the clinician; it engages clinicians in social interactions; and it allows them to think more intentionally about the quality-of-care delivery. One intriguing fact Szymczak raised was that clinicians often deal with complex social situations in health care when prescribing antibiotics.

The Invisible Influences That Shape Antibiotic Prescribing Behaviors

“Antibiotic prescribing is shaped by social dynamics," Szymczak said. "Stewardship interventions that aim to improve how antibiotics are used must take into account these dynamics in order to have a lasting effect on prescribing.”

Szymczak identified several social factors that influence antibiotic prescribing habits among clinicians:

1. Professional etiquette: There is an unspoken rule among clinicians that seems to prohibit any criticism or interference with a colleague’s prescribing decisions. This social norm appears to create a significant challenge to addressing the overprescribing of antibiotics.

2. Patient pressures and satisfaction ratings: Health care workers can sometimes deal with patients who may seem demanding, worried, or overly cautious about the care they receive in the health care setting. Nurses and IPs must often address these situations through patient education to promote healthy behaviors. When dealing with infectious patients, clinicians also face challenges when, for example, parents demand antibiotics for their children’s viral infections based on their misconceptions about health care.

During her research, Szymczak found that for some clinicians, prescribing the antibiotic to appease the parent is often easier than arguing or providing negative feedback to combat their misconceptions.¹ With patient satisfaction scores increasingly tied to performance evaluations, some clinicians may prescribe antibiotics to keep patients happy.²

3. Emotional decision-making: Some clinicians struggle with feelings of fear and anxiety towards falling short, which leads them to evaluate the risk of overprescribing versus underprescribing antibiotics. As a result, they may take a "better safe than sorry" approach. The fear of the repercussions of undertreating an infection can lead them to overprescribe it instead because they prefer treating the problem at once rather than not doing so to realize in hindsight that they contributed to adverse patient outcomes.

4. Misperception of the problem: Szymczak highlighted that, according to several studies, many clinicians acknowledge antibiotic overuse as a general problem but don't perceive it as an issue in their practice. They often attribute it to other sectors like agriculture or veterinary medicine.^3,4

What Are the Implications for Antibiotic Stewardship Efforts?

Szymczak's research suggests acknowledging clinicians' social and emotional challenges with antibiotic prescribing. Furthermore, systems should be established to improve communication and feedback among health care providers, manage patient expectations to limit unnecessary antibiotic prescribing, and help clinicians recognize and address antibiotic overuse in their practice.

As IPs, we need to ask ourselves: Have we considered these social challenges clinicians face as a factor in developing antimicrobial resistance?How do we effectively address these issues in our antibiotic stewardship efforts? How can we create policies addressing the clinical and human elements of prescribing decisions?

Where Do We Go From Here?

Szymczak's presentation reminds us that combating antimicrobial resistance isn't just about guidelines and protocols. Our antibiotic stewardship efforts should consider these insights, promote a collaborative mindset to understand the root causes and align our policies and procedures to address these issues.⁵ Understanding these complex social dynamics within the health care setting might be the breakthrough we need to address antimicrobial resistance more effectively.

References

1. Stivers, T. & Timmermans, S. (2021). Arriving at no: Patient pressure to prescribe antibiotics and physicians’ responses. Social Science & Medicine, 290(2021). https://doi.org/10.1016/j.socscimed.2021.114007
2. Szymczak, J. E. et al. (2021). “I Never Get Better Without an Antibiotic”: Antibiotic Appeals and How to Respond. Mayo Clinic Proceedings, 96(3), 543 - 546. https://www.mayoclinicproceedings.org/article/S0025-6196(20)31120-4/abstract#:~:text=Clinicians%20can%20refer%20to%20national%20efforts%20to%20improve%20the%20use
3. McKernan, C., et al. (2021). Antimicrobial use in agriculture: critical review of the factors influencing behaviour, JAC-Antimicrobial Resistance, 3(4). https://doi.org/10.1093/jacamr/dlab178
4. Byrne, M.K., Miellet, S., McGlinn, A. et al. (The drivers of antibiotic use and misuse: the development and investigation of a theory driven community measure. BMC Public Health 19, 1425 (2019). https://doi.org/10.1186/s12889-019-7796-8
5. Meeker, D., Knight, T. K., Friedberg, M. W., Linder, J. A., Goldstein, N. J., Fox, C. R., Rothfeld, A., Diaz, G., & Doctor, J. N. (2014). Nudging guideline-concordant antibiotic prescribing: a randomized clinical trial. JAMA internal medicine, 174(3), 425–431. https://doi.org/10.1001/jamainternmed.2013.14191