Keywords: Antibiotic use, Family medicine, Primary care, Qualitative research, Prescribing behavior

Background:

Antibiotic prescribing in primary care plays a critical role in individual patient outcomes and public health, particularly in the context of antimicrobial resistance. Despite the availability of clinical guidelines, inappropriate antibiotic use remains common, especially for respiratory tract infections. Understanding the complex factors influencing primary care physicians’ prescribing decisions is essential to inform effective antimicrobial stewardship strategies.

Research questions:

How do patient expectations, diagnostic uncertainty, and systemic pressures interact to shape antibiotic prescribing behavior among primary care physicians?
What nonclinical and systemic factors contribute to antibiotic prescribing in primary care beyond physicians’ clinical knowledge and guidelines?

Method:

This qualitative study employed a phenomenological design to explore primary care physicians’ experiences and perceptions regarding antibiotic prescribing. Semi-structured, in-depth interviews were conducted with 19 primary care physicians selected using criterion sampling. Data were analyzed using a hybrid thematic analysis approach, combining inductive and deductive coding to identify key themes influencing prescribing behavior.

Results:

Four major themes emerged as determinants of antibiotic prescribing decisions. These included: (1) physicians’ clinical decision-making processes, particularly diagnostic uncertainty in respiratory tract infections; (2) patient expectations and the dynamics of the physician–patient relationship, with perceived pressure arising from patient demands for antibiotics; (3) physician-related and non-patient influences, such as professional experience and educational background; and (4) systemic pressures, including limited consultation time, performance-based evaluation systems, and the anticipation of repeat patient visits (“escape options”). Physicians reported that these social and systemic factors often led to antibiotic prescribing even when clinical indications were uncertain.

Conclusions:

Antibiotic prescribing in primary care is shaped not only by clinical knowledge but also by social interactions and systemic constraints. Efforts to promote rational antibiotic use should extend beyond physician education to include structural improvements in healthcare systems and interventions aimed at increasing patient awareness. Addressing these multidimensional influences is essential for sustainable antimicrobial stewardship in primary care.

Points for discussion:

Diagnostic uncertainty as a central driver of antibiotic prescribing

The influence of patient expectations and the physician–patient relationship

Systemic pressures and structural constraints shaping prescribing behavior