Article Text

Clinical influences on antibiotic prescribing decisions for lower respiratory tract infection: a nine country qualitative study of variation in care
  1. Lucy Brookes-Howell1,
  2. Kerenza Hood1,
  3. Lucy Cooper2,
  4. Samuel Coenen3,4,
  5. Paul Little5,
  6. Theo Verheij6,
  7. Maciek Godycki-Cwirko7,
  8. Hasse Melbye8,
  9. Jaroslaw Krawczyk7,
  10. Alicia Borras-Santos9,
  11. Kristin Jakobsen8,
  12. Patricia Worby10,
  13. Herman Goossens4,
  14. Christopher C Butler11
  1. 1South East Wales Trials Unit, Cardiff University, Cardiff, UK
  2. 2Institute of Psychology, Health and Society, University of Liverpool, Liverpool, UK
  3. 3Centre for General Practice, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium
  4. 4Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium
  5. 5Community Clinical Sciences Division, University of Southampton, Southampton, UK
  6. 6Julius Center for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, Netherlands
  7. 7Department of Family and Community Medicine, Medical University of Łódź, Łódź, Poland
  8. 8Institute of Community Medicine, University of Tromsø, Tromsø, Norway
  9. 9IAMR, Applied Research in Respiratory Diseases, Barcelona, Spain
  10. 10Research and Innovation Services, University of Southampton, Southampton, UK
  11. 11Institute of Primary Care and Public Health, Cardiff University, Cardiff, UK
  1. Correspondence to Dr Lucy Brookes-Howell; brookes-howelllc{at}


Objectives There is variation in antibiotic prescribing for lower respiratory tract infections (LRTI) in primary care that does not benefit patients. This study aims to investigate clinicians' accounts of clinical influences on antibiotic prescribing decisions for LRTI to better understand variation and identify opportunities for improvement.

Design Multi country qualitative interview study. Semi-structured interviews using open-ended questions and a patient scenario. Data were subjected to five-stage analytic framework approach (familiarisation, developing a thematic framework from the interview questions and emerging themes, indexing, charting and mapping to search for interpretations), with interviewers commenting on preliminary reports.

Setting Primary care.

Participants 80 primary care clinicians randomly selected from primary care research networks based in nine European cities.

Results Clinicians reported four main individual clinical factors that guided their antibiotic prescribing decision: auscultation, fever, discoloured sputum and breathlessness. These were considered alongside a general impression of the patient derived from building a picture of the illness course, using intuition and familiarity with the patient. Comorbidity and older age were considered main risk factors for poor outcomes. Clinical factors were similar across networks, apart from C reactive protein near patient testing in Tromsø. Clinicians developed ways to handle diagnostic and management uncertainty through their own clinical routines.

Conclusions Clinicians emphasised the importance of auscultation, fever, discoloured sputum and breathlessness, general impression of the illness course, familiarity with the patient, comorbidity, and age in informing their antibiotic prescribing decisions for LRTI. As some of these factors may be overemphasised given the evolving evidence base, greater standardisation of assessment and integration of findings may help reduce unhelpful variation in management. Non-clinical influences will also need to be addressed.

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See: and

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  • To cite: Brookes-Howell L, Hood K, Cooper L, et al. Clinical influences on antibiotic prescribing decisions for lower respiratory tract infection: a nine country qualitative study of variation in care. BMJ Open 2012;2:e000795. doi:10.1136/bmjopen-2011-000795

  • Contributors All authors contributed to either the conception and design or the analysis and interpretation of the data. All authors contributed to drafting and revising the manuscript. All authors have approved this final version of the manuscript.

  • Funding Financial support for this study was provided by the 6th Framework Programme of the European Commission (LSHM-CT-2005-518226). The South East Wales Trials Unit is funded by the National Institute for Social Care and Health Research. The Antwerp Network was funded by the University of Antwerp (KP BOF 2147). In Flanders (Belgium), this work was supported by the Research Foundation, Flanders (G.0274.08N). The funding agreement ensured the authors' independence in designing the study, interpreting the data, writing and publishing the report.

  • Competing interests None.

  • Patient consent The participants in this study were clinicians not patients. All participants provided signed informed consent prior to participation in the study.

  • Ethics approval Ethics approval was provided by MREC for Wales.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement No additional data available.

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