Risks of use and non-use of antibiotics in primary care: qualitative study of prescribers’ views

Purpose The emergence of antimicrobial resistance has led to increasing efforts to reduce unnecessary use of antibiotics in primary care, but potential hazards from bacterial infection continue to cause concern. This study investigated how primary care prescribers perceive risk and safety concerns associated with reduced antibiotic prescribing. Methods Qualitative study using semistructured interviews conducted with primary care prescribers from 10 general practices in an urban area and a shire town in England. A thematic analysis was conducted. Results Thirty participants were recruited, including twenty-three general practitioners, five nurses and two pharmacists. Three main themes were identified: risk assessment, balancing treatment risks and negotiating decisions and risks. Respondents indicated that their decisions were grounded in clinical risk assessment, but this was informed by different approaches to antibiotic use, with most leaning towards reduced prescribing. Prescribers’ perceptions of risk included the consequences of both inappropriate prescribing and inappropriate withholding of antibiotics. Sepsis was viewed as the most concerning potential outcome of non-prescribing, leading to possible patient harm and potential litigation. Risks of antibiotic prescribing included antibiotic resistant and Clostridium difficile infections, as well as side effects, such as rashes, that might lead to possible mislabelling as antibiotic allergy. Prescribers elicited patient preferences for use or avoidance of antibiotics to inform management strategies, which included educational advice, advice on self-management including warning signs, use of delayed prescriptions and safety netting. Conclusions Attitudes towards antibiotic prescribing are evolving, with reduced antibiotic prescribing now being approached more systematically. The safety trade-offs associated with either use or non-use of antibiotics present difficulties especially when prescribing decisions are inconsistent with patients’ expectations.

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INTRODUCTION
Inappropriate antibiotic prescribing is widespread but may impose risks from drug sideeffects as well as from the risks of antimicrobial resistance(AMR) for individual (1) and population health. (2) Non-use of antibiotics may be associated with risks from serious bacterial infections that could be avoided through earlier treatment of infection episodes. (3) Many studies have provided insights into the reasons for inappropriate antibiotic prescribing and several syntheses have been published (4)(5)(6), but the safety gradient associated with reducing antibiotic prescribing appears as a new and highly relevant area of research. In this paper, patient safety is understood as 'the avoidance, prevention and amelioration of adverse outcomes or injuries stemming from the process of healthcare'. (7) Risks associated with antibiotic prescribing decisions are a key component of patient safety concerns and require in-depth analysis. This paper addresses the gap in knowledge about prescribers' perceptions of potential adverse outcomes associated with reduced antibiotic prescribing.
In the UK, primary care services account for nearly 80% of all medical antibiotic use but antibiotic utilisation in primary care has been declining in recent years and choice of antimicrobial agents has become more selective. (8,9) A national target proposes a further reduction in antimicrobial use of 15% by 2024 (10) with antimicrobial resistance making a legitimate case for the reduction in antibiotic prescribing. There were an estimated 60,788 antibiotic resistant infections in England in 2018 (9). Bacteria associated with AMR in primary care include E. coli, Group B streptococcus, Klebsiella pneumonia, tuberculosis, typhoid fever and others (11), and the scale of the problem is also increasing across middleand low-income countries. (12) Unnecessary exposure to antibiotics is itself potentially harmful. As a result of prescribing in the community, antibiotic-associated adverse events including allergic reactions lead to many emergency visits with antibiotics accounting for up to 20% of hospital admissions from drug reactions in the US. (13,14) On the other hand, withholding antibiotics might potentially carry risks and reduced antibiotic prescribing in general practice is associated with a small increase in complications such as treatable pneumonia and peritonsillar abscess. (15) (16) The perceived priority of risks from either prescribing or not prescribing antibiotics requires a nuanced explanation within the broader realm of professionals' perceptions of safety and associated risk management. Fear of the risk of bacterial complications (5,17) and prognostic uncertainty about potential outcomes when not prescribing (4,18) are reportedly among key factors that influence the prescription of antibiotics. Among hospital doctors, there is evidence that overtreatment is preferred to the potential for adverse patient outcomes from not prescribing. (19,20) Klein et al (21) and Broniatowski et al (22) for example, demonstrate that medical decision-making tends to favour views that favour prescription ('why take risks') rather than on prescription avoidance ('antibiotics can be harmful'). In primary care, general practitioners and other prescribers also deal with safety concerns in their decision-making, and a better understanding needs to be developed concerning the balance of risk between prescribing or non-prescribing of antibiotics.. Patient factors influencing decision-making on antibiotic prescribing include compliance with patient expectations and pressures. (17,(23)(24)(25) Reducing AB prescribing in primary care is therefore highly dependent on successful management of patient expectations (26-28) and on shared decision-making. (29-32) It is known that clinicians weigh individual best practice against perceived patient satisfaction so that the complex balancing acts are enacted. (33) Therefore, of research interest is also how the issues of safety and risk information are communicated to patients.
In the present study we investigate how primary care prescribers perceived risk and safety concerns associated with reduced antibiotic prescribing. The research is a part of the larger study to inform the safest way to reduction of antibiotic prescribing.

Study design
Semi-structured interviews were conducted with primary care prescribers including general practitioners, nurses and pharmacists in two English regions, one an urban metropolitan area and the other shire-town in England with a high demand for primary care services. The study was approved by London Hampstead Research Ethics Committee 18/LO/1874 and participants gave written informed consent to participation.

Interviews
The interview guide was piloted with three GPs to ensure that the questions were appropriate, understandable and covered relevant prescribing behaviours. All interviews were conducted by the first author to ensure consistent quality. The interviewer has a PhD in medical sociology and is an experienced qualitative researcher. All interviews apart from one telephone interview were conducted face-to-face on general practice (n=26) and University (n=4) premises in the period January-July 2019. The participants were offered £60 to acknowledge their contribution. and re-organised to reflect major narratives and themes in the coded data. Finally, (the first, second and the last authors, initials) refined and named the themes and sub-themes.

Public and Patient Involvement
Participants' feedback on the transcripts or the summarised final findings was not sought, however, the process of developing subthemes and themes was discussed at a Patient and Public Involvement meeting.

RESULTS
We recruited 30 participants from 10 general practices (Table 2. Characteristics of the participants). The interviews lasted between 24 minutes and 46 minutes. General practitioners', nurses' and pharmacists' responses were analysed as a single group because of the many commonalities. We found there were no discernible differences in participants' accounts between the shire town and metropolitan settings. We distinguished three major themes from the data: risk assessment; balancing treatment risks; and negotiating decisions and risks.

Identifying treatment thresholds
The primary focus of diagnostic decision-making for participants was concerned with identifying major indications for antibiotic treatment. These were judged to include the severity of illness based on presentation of symptoms and signs, in the context of the patient's medical history. A majority of participants adopted a risk stratification approach in undertaking clinical assessment.  Three prescribers who acknowledged the tendency to overprescribe, did so, in one case, because they assessed antibiotics' benefits to exceed harms and in two cases because of potential litigation following a missed serious bacterial infection:

Facing antimicrobial resistance
Participants shared concern for the global rise in antimicrobial resistance. At the same time, they acknowledged lacking in-depth microbiological knowledge: "we talk more about not prescribing and prescribing correctly than resistance itself' (Int 9, Pharmacist). Meanwhile, they had to deal with the consequences of the antimicrobial resistance in their daily practice: There was mention of difficulties in conveying information about resistance to patientsdiscussing it in the encounters and emphasising community impact may have been less efficient than focussing on individual risks. There was also a worry that primary care is running out of antibiotics despite the strategies of second-and third-line antibiotics: In such cases of failure of several course of antibiotics, referral to secondary care, possibly for intravenous therapy were reported as the only options. Other times, where the resistant organism could be tackled in primary care, the last resort was a longer course or long-term prophylactic antibiotics. More investigations and consultations with microbiologists about unresolved infections appeared to precede these decisions.

Managing patient expectations
Participants identified patient pressure as a factor in their decision-making but they shared the view that patients differ in terms of their expectations regarding antibiotics. On the one hand, increased knowledge of the appropriate indications for antibiotic therapy (not for viruses) and understanding of antimicrobial resistance from public health and media campaigns was noted. On the other hand, patient pressure in a form of implicit expectations or explicit demands remained frequent: readily prescribed in the past, antibiotics had a profile of immediate cure in large parts of patient population: "… so many people have been mis-prescribed antibiotics in the past that I think they j A GP summarised this ambivalence: "There's a reasonable cohort now who come in and say they don't want them [antibiotics]. They've read, they're educated, they know that they're contributing potentially to resistance and they don't want to risk the side effects. "… that helps patients because at least psychologically they have got an antibiotic, but they know they can't use it straightaway". (Int 25, GP)

Communicating risks
As above, participants demonstrated that the commitment to reduced prescribing was dependent on patient understanding of the need for antibiotics. This meant that at times building and maintaining relationships were prioritised and led to prescribing decisions, as an interviewee reported: "Much of my job is trying to build a rapport with someone and build a rapport so that

Main findings in comparison with previous research
The study describes primary care prescribers' perceptions of safety and associated tradeoffs in the context of reduced antibiotic prescribing. We identify three key themes with relevance to safety: risk assessment, balancing treatment risks, and negotiating decisions and risks. These accounts from primary care demonstrated variations in prescribers' approaches to decision-making behaviour, including perceptions of risks associated with prescribing or not prescribing antibiotics and in the communication of these decisions and risks to patients.
Decision-making for appropriate antibiotic prescribing was informed by safety considerations. Guideline-concordant risk assessment was generally preferred to tacit clinical judgement based on informal heuristics in line with previous research (38) Confidence in prescribing can be contrasted with views that accentuate diagnostic uncertainty. (4,18) In complex or uncertain cases, resolution was usually in favour of antibiotic prescribing, but this was in the context of a secular shift to generally more restrictive antibiotic prescribing behaviour. The reduction imperative co-exists with liberal prescribing, which was influenced by low tolerance of risks and patient pressures. This corresponds with extant literature that identifies the co-existence of different prescribing behaviours including antibiotic compromising, antibiotic delaying and antibiotic withholding. and our study also found that both delayed prescribing (49-52) and safety-netting appeared as effective strategies of shared decision making.

What are the indications for AB treatment?
To what extent do NICE (or local) guidelines influence your AM prescribing?
What are the risks of AB prescribing and non-prescribing?
How do you differentiate between infections and patients?
What are the common myths or stereotypes about antibiotics?
Can you give me an example illustrating the inaccurate understanding of their purpose, mechanisms of action, risks and consequences?
In your view, is there the best way to elicit and manage patient expectations regarding antibiotics?
How would you communicate the risks associated with both prescribing and non-prescribing antibiotics?
How confident are you in decision-making around AB prescribing?
Would you assess your approach to AB prescribing as always adequate and if so, what makes you think that?
Could you describe consequences of inappropriate treatment for infections?
What would be/were your actions following unresolved or repeated infections?
What is your understanding of antimicrobial resistance?
What are your goals and priorities in infection management?
Are there any social norms or group pressures that affect your professional practice with regards to AB prescribing and how?
Has your prescribing practice for antibiotics changed over the recent years?
Do you think patient expectations of AB treatment have changed over the recent years?
Are you aware of the prescribing practice of other HCPs (your colleagues) in relation to antibiotics?
Have you ever had to challenge their prescribing decisions?
Has anyone challenged your own decisions?
How hopeful are you usually that the AB treatment is the best course of action?
Is it possible to assess both the short-and long-term impact of AB treatment on the patients?
What is your decision-making strategy?
How anxious do you feel about the uncertainty around prescribing?

ABSTRACT
Purpose: The emergence of antimicrobial resistance has led to increasing efforts to reduce unnecessary use of antibiotics in primary care, but potential hazards from bacterial infection continue to cause concern. This study investigated how primary care prescribers perceive risk and safety concerns associated with reduced antibiotic prescribing.

Methods:
Qualitative study using semi-structured interviews conducted with primary care prescribers from 10 general practices in an urban area and a shire town in England. A thematic analysis was conducted. population health from drug side-effects as well as from growing antimicrobial resistance.

Results
(3) Conversely, antibiotic avoidance may be associated with risks from serious bacterial infections that could be avoided through earlier treatment of infection episodes.
(2) Many studies have provided insights into the reasons for inappropriate antibiotic prescribing and several syntheses have been published (4-6), but the safety gradient associated with reducing antibiotic prescribing has developed as a new and highly relevant area of research.
In this paper, patient safety is understood as 'the avoidance, prevention and amelioration of adverse outcomes or injuries stemming from the process of healthcare'. (7) The risks associated with antibiotic prescribing decisions are a key element of patient safety and require in-depth analysis. This paper addresses the gap in knowledge about prescribers' perceptions of potential adverse outcomes associated with reduced antibiotic prescribing.
In the UK, primary care services account for nearly 80% of all medical antibiotic use but antibiotic utilisation in primary care has been declining in recent years and choice of antimicrobial agents has become more selective. (8,9)   The perceived priority of risks from either prescribing or not prescribing antibiotics requires a nuanced explanation within the broader realm of professionals' perceptions of safety and associated risk management. Fear of the risk of bacterial complications (5,16) and prognostic uncertainty about potential outcomes when not prescribing (4,17) are reportedly among key factors that influence the prescription of antibiotics. Among hospital doctors, there is evidence that overtreatment is preferred to the potential for adverse patient outcomes from not prescribing. (18,19) Klein et al (20) and Broniatowski et al (21) for example, demonstrate that medical decision-making tends to favour views that favour prescription ('why take risks') rather than on prescription avoidance ('antibiotics can be harmful'). In primary care, general practitioners and other prescribers also deal with safety concerns in their decision-making, and a better understanding needs to be developed concerning the balance of risk between prescribing or non-prescribing of antibiotics.
Patient factors influencing decision-making on antibiotic prescribing include compliance with patient expectations and pressures. (16,(22)(23)(24) Reducing AB prescribing in primary care is therefore highly dependent on successful management of patient expectations (25-27) and on shared decision-making. (28-31) It is known that clinicians weigh individual best practice against perceived patient satisfaction so that complex trade-offs are enacted. (32) Therefore, of research interest is also how the issues of safety and risk information are communicated to patients.
In the present study we investigate how primary care prescribers perceive risk and safety concerns associated with reduced antibiotic prescribing.

Interviews
An interview guide was developed (Table 1), this was designed to address key elements of the substantive research topic; it was also loosely informed by elements of the Theoretical Domains Framework, which draws on behaviour change theory to understand factors influencing health care practice. (33-35) The interview guide was piloted with three GPs to ensure that the questions were appropriate, understandable and covered relevant prescribing behaviours. All interviews were conducted by the first author to ensure consistent quality. The interviewer has a PhD in medical sociology and is an experienced qualitative researcher. All interviews apart from one telephone interview were conducted face-to-face on general practice (n=26) and University (n=4) premises in the period January-July 2019.
The participants were offered £60 to acknowledge their contribution.

Recruitment of participants
Metropolitan practices were invited to the study by the local Clinical Research Network who generated the expression of interest. A shire-town high demand practice was recruited through informal Clinical Research Network contact who also helped in liaising with potential respondents. Potential participants were then approached either directly via email using the study information pack or indirectly via the practice manager or lead GP. The information pack included the invitation letter and study information sheet. A reminder was sent out two weeks after the initial approach to those who had not responded. A purposive sampling approach was followed: all participants were prescribers. Forty-nine primary care prescribers from 10 GP practices were invited and 30 agreed to take part. The sample size was determined using the pragmatic concept of 'information power' (36), taking into account the aim of the study, sample specificity, quality of dialogue, and analysis strategy. The uptake varied between practices (in 5 practices only a single participant was interviewed).

Analysis
The interviews were digitally recorded, transcribed by a professional transcriber, imported to an NVivo-12 project and coded through an iterative six phased process described in thematic analysis.(37) Data analysis occurred iteratively and involved familiarisation, coding, theme searching, theme reviewing, theme defining and naming and producing the report.
Repeated patterns in the data formed the basis for the codes, identified by the first author, and one single code for every different concept/idea was generated. To ensure that codes were applied consistently, a co-author (CB) independently coded a random sample of four interview transcripts. Coding was refined after discussion. Data identified by the same code was collated together and all different codes were sorted into potential subthemes and themes using NVivo options of tree building. Then, the potential themes were re-assessed and re-organised to reflect major narratives and themes in the coded data. Finally, the first, second and the last authors refined and named the themes and sub-themes.

Public and Patient Involvement
Participants' feedback on the transcripts or the summarised final findings was not sought, however, the process of developing subthemes and themes was discussed at a Patient and Public Involvement meeting. The purpose of the meeting was to inform the research of patient and service user perspectives. The meeting was attended by six PPI members including four women and two men of diverse ages. The preliminary findings were

RESULTS
We recruited 30 participants from 10 general practices (Table 2. Characteristics of the participants), including 23 general practitioners, 5 nurses and 2 pharmacists. The interviews lasted between 24 minutes and 46 minutes. General practitioners', nurses' and pharmacists' responses were analysed as a single group because of the many commonalities and smaller number of non-medical respondents. We found there were no discernible differences in participants' accounts between the shire town and metropolitan settings. Overall, three participants expressed an overt avoidance of antibiotics, three others acknowledged overprescribing, whilst most prescribers leaned towards reduced prescribing. We distinguished three major themes from the data: risk assessment; balancing treatment risks; and negotiating decisions and risks (Table 3).

Identifying treatment thresholds
The primary focus of diagnostic decision-making for participants was concerned with identifying major indications for antibiotic treatment. These were judged to include the nature and severity of illness based on presentation of symptoms and signs, in the context of the patient's medical history. A majority of participants adopted a risk stratification approach in undertaking clinical assessment.

Confidence in prescribing
Appropriate prescribing and not just a reduction in antibiotics emerged as a priority for participants, who reflected on their own performance from different perspectives. In general,

Risks of prescribing and non-prescribing
Seven participants explicitly identified safety as a priority in infection management. All participants demonstrated vigilance to risks arising both from prescribing antibiotics and not prescribing. The fear was expressed of 'missing something' that could cause deterioration and consequently, participants admitted 'being cautious' and favoured prescribing antibiotics. At the same time, the common concern was also the avoidance of prescribing unnecessarily. Among the risks of prescribing, several side effects were reported, most commonly, gastrointestinal upsets, nausea, Clostridium difficile infection and thrush but also allergic, anaphylactic reactions, antibiotic resistance, and less common side effects such as liver problems (failure). Participants also observed long-term adverse consequences of inappropriate prescribing:

Facing antimicrobial resistance
Participants shared concern for the global rise in antimicrobial resistance. At the same time, they acknowledged lacking in-depth microbiological knowledge: "we talk more about not prescribing and prescribing correctly than resistance itself' (Int 9, Pharmacist). Meanwhile, they had to deal with the consequences of the antimicrobial resistance in their daily practice: There was mention of difficulties in conveying information about resistance to patientsdiscussing it in the encounters and emphasising community impact may have been less efficient than focussing on individual risks. There was also a worry that primary care is running out of antibiotics despite the strategies of second-and third-line antibiotics: unresolved infections appeared to precede these decisions.

Managing patient expectations
Participants identified patient pressure as a factor in their decision-making but they shared the view that patients differ in terms of their expectations regarding antibiotics. On the one hand, increased knowledge of the appropriate indications for antibiotic therapy (not for viruses) and understanding of antimicrobial resistance from public health and media campaigns was noted. On the other hand, patient pressure in a form of implicit expectations or explicit demands remained frequent: readily prescribed in the past, antibiotics had a profile of immediate cure in large parts of patient population: "… so many people have been mis-prescribed antibiotics in the past that I think they just won't believe you that they don't need them" (Int 25).
A GP summarised this ambivalence: "There's a reasonable cohort now who come in and say they don't want them [antibiotics]. They've read, they're educated, they know that they're contributing potentially to resistance and they don't want to risk the side effects.  "… that helps patients because at least psychologically they have got an antibiotic, but they know they can't use it straightaway". (Int 25, GP)

Communicating risks
As above, participants demonstrated that the commitment to reduced prescribing was dependent on patient understanding of the need for antibiotics. This meant that at times building and maintaining relationships were prioritised and led to prescribing decisions, as an interviewee reported:

Main findings in comparison with previous research
The study describes primary care prescribers' perceptions of safety and associated tradeoffs in the context of reduced antibiotic prescribing. We identify three key themes with relevance to safety: risk assessment, balancing treatment risks, and negotiating decisions and risks. These accounts from primary care demonstrated variations in prescribers' approaches to decision-making behaviour, including perceptions of risks associated with prescribing or not prescribing antibiotics and in the communication of these decisions and risks to patients.
Decision-making for appropriate antibiotic prescribing was informed by safety considerations. Guideline-concordant risk assessment was generally preferred to tacit  (38) Confidence in prescribing can be contrasted with views that accentuate diagnostic uncertainty. (4,17) In complex or uncertain cases, resolution was usually in favour of antibiotic prescribing, but this was in the context of a secular shift to generally more restrictive antibiotic prescribing behaviour. The reduction imperative co-exists with liberal prescribing, which was influenced by low tolerance of risks and patient pressures. This corresponds with extant literature that identifies the co-existence of different prescribing behaviours including antibiotic compromising, antibiotic delaying and antibiotic withholding.  term (e.g. side effects) and long-term (e.g. antimicrobial resistance, effect on doctor-patient relationship) trade-offs of prescribing. antimicrobial resistance was generally viewed as a standalone long-term adversity now being encountered in daily practice; it is gaining in prominence in contrast to findings from the earlier qualitative studies (42,43) and now has a more personalised relevance and clinical significance than some recent reviews suggested. Systematic review evidence suggests that shared decision-making reduces prescribing (47) and our study also found that both delayed prescribing (48-51) and safety-netting appeared as effective strategies of shared decision making. 18

Strengths and limitations
The study provided a coherent analysis of the views of primary care prescribers. It drew on participants working in rural and urban settings and included a sample that was diverse with respect to professional training and years of experience. The size of the sample may not have been sufficient to distinguish differences in approach between groups with different professional training but this could be explored further in future studies. However, the study may have reduced transferability to other settings beyond UK primary care or beyond highincome countries. The study is based on interviews with prescribers and may be prone to the limitations associated with qualitative studies. Participants were necessarily informed of the nature and purpose of the research, consequently both their participation in the interview and the interview responses might have been influenced by research participation. It is possible that respondents who were less inclined to reduce antibiotic prescribing might have been less prepared to participate. Interview responses might have been inclined to give what they perceived as 'socially acceptable' responses. We employed a thematic analysis because this enables a flexible investigation of a complex topic without drawing on preexisting theory. In order to reduce the possibility of inconsistency, we employed a systematic, staged approach to analysis and a sample of transcripts was repeat coded by a second analyst.

Implications for further research and practice
This study explored and characterised primary care prescribers' perceptions of safety issues and risk management strategies relevant to reduced antibiotic prescribing. The study offers insights into primary care prescribers' perceptions and as such it emphasises the safety perspective within the current debate on antibiotic prescribing and antimicrobial stewardship.
The study identified dilemmas that are recognisable in the course of daily primary care practice and can form the basis for future improvement and antimicrobial stewardship programs. Our research paves the way for a cross-sectional survey of risk perceptions. It

CONCLUSIONS
Attitudes towards antibiotic prescribing are changing and becoming more nuanced. There is growing confidence in the capacity to reduce the rate of prescribing and to manage patient expectations, which are themselves undergoing change. There is growing recognition that there may be safety trade-offs associated with antimicrobial stewardship and this is linked to concerns about sepsis and other serious bacterial infections. There is a need to develop better quantified estimates of risk that can inform clinical decision making and 'safety netting' advice given to patients. This will require further development of risk stratification estimates, as well as communication tools that enable these to be used in practice. Improved management of risks and benefits will help to inform future antimicrobial stewardship efforts. To what extent do NICE (or local) guidelines influence your AM prescribing?
What are the risks of AB prescribing and non-prescribing?
How do you differentiate between infections and patients?
What are the common myths or stereotypes about antibiotics?
Can you give me an example illustrating the inaccurate understanding of their purpose, mechanisms of action, risks and consequences?
In your view, is there the best way to elicit and manage patient expectations regarding antibiotics?
How would you communicate the risks associated with both prescribing and non-prescribing antibiotics?
How confident are you in decision-making around AB prescribing?
Would you assess your approach to AB prescribing as always adequate and if so, what makes you think that?
Could you describe consequences of inappropriate treatment for infections?
What would be/were your actions following unresolved or repeated infections?
What is your understanding of antimicrobial resistance?
What are your goals and priorities in infection management?
Are there any social norms or group pressures that affect your professional practice with regards to AB prescribing and how?
Has your prescribing practice for antibiotics changed over the recent years?
Do you think patient expectations of AB treatment have changed over the recent years?
Are you aware of the prescribing practice of other HCPs (your colleagues) in relation to antibiotics?
Have you ever had to challenge their prescribing decisions?
Has anyone challenged your own decisions?
How hopeful are you usually that the AB treatment is the best course of action?
Is it possible to assess both the short-and long-term impact of AB treatment on the patients?
What is your decision-making strategy?
How anxious do you feel about the uncertainty around prescribing?
Which resources do you use to support your decisions on AB prescribing?

ABSTRACT
Purpose: The emergence of antimicrobial resistance has led to increasing efforts to reduce unnecessary use of antibiotics in primary care, but potential hazards from bacterial infection continue to cause concern. This study investigated how primary care prescribers perceive risk and safety concerns associated with reduced antibiotic prescribing.

Methods:
Qualitative study using semi-structured interviews conducted with primary care prescribers from 10 general practices in an urban area and a shire town in England. A thematic analysis was conducted.  population health from drug side-effects as well as from growing antimicrobial resistance.

Results
(3) Conversely, antibiotic avoidance may be associated with risks from serious bacterial infections that could be avoided through earlier treatment of infection episodes.
(2) Many studies have provided insights into the reasons for inappropriate antibiotic prescribing and several syntheses have been published (4-6), but the safety gradient associated with reducing antibiotic prescribing has developed as a new and highly relevant area of research.
In this paper, patient safety is understood as 'the avoidance, prevention and amelioration of adverse outcomes or injuries stemming from the process of healthcare'. (7) The risks associated with antibiotic prescribing decisions are a key element of patient safety and require in-depth analysis. This paper addresses the gap in knowledge about prescribers' perceptions of potential adverse outcomes associated with reduced antibiotic prescribing.
In the UK, primary care services account for nearly 80% of all medical antibiotic use but antibiotic utilisation in primary care has been declining in recent years and choice of antimicrobial agents has become more selective. (8,9) A national target proposes a further reduction in antimicrobial use of 15% by 2024 (10)    In the present study we investigate how primary care prescribers perceive risk and safety concerns associated with reduced antibiotic prescribing.

Interviews
An interview guide was developed (Table 1), this was designed to address key elements of the substantive research topic; it was also loosely informed by elements of the Theoretical Domains Framework, which draws on behaviour change theory to understand factors influencing health care practice. (33-35) The interview guide was piloted with three GPs to ensure that the questions were appropriate, understandable and covered relevant prescribing behaviours. All interviews were conducted by the first author to ensure consistent quality. The interviewer has a PhD in medical sociology and is an experienced qualitative researcher. All interviews apart from one telephone interview were conducted face-to-face on general practice (n=26) and University (n=4) premises in the period January-July 2019.
The participants were offered £60 to acknowledge their contribution.

Recruitment of participants
Metropolitan practices were invited to the study by the local Clinical Research Network who generated the expression of interest. A shire-town high demand practice was recruited through informal Clinical Research Network contact who also helped in liaising with potential respondents. Potential participants were then approached either directly via email using the study information pack or indirectly via the practice manager or lead GP. The information pack included the invitation letter and study information sheet. A reminder was sent out two weeks after the initial approach to those who had not responded. A purposive sampling approach was followed: all participants were prescribers. Forty-nine primary care prescribers from 10 GP practices were invited and 30 agreed to take part. The sample size was determined using the pragmatic concept of 'information power' (36), taking into account the aim of the study, sample specificity, quality of dialogue, and analysis strategy. The uptake varied between practices (in 5 practices only a single participant was interviewed).

Analysis
The interviews were digitally recorded, transcribed by a professional transcriber, imported to an NVivo-12 project and coded through an iterative six phased process described in thematic analysis.(37) Data analysis occurred iteratively and involved familiarisation, coding, theme searching, theme reviewing, theme defining and naming and producing the report.
Repeated patterns in the data formed the basis for the codes, identified by the first author, and one single code for every different concept/idea was generated. To ensure that codes were applied consistently, a co-author (CB) independently coded a random sample of four interview transcripts. Coding was refined after discussion. Data identified by the same code was collated together and all different codes were sorted into potential subthemes and themes using NVivo options of tree building. Then, the potential themes were re-assessed and re-organised to reflect major narratives and themes in the coded data. Finally, the first, second and the last authors refined and named the themes and sub-themes.

Public and Patient Involvement
Participants' feedback on the transcripts or the summarised final findings was not sought, however, the process of developing subthemes and themes was discussed at a Patient and Public Involvement meeting. The purpose of the meeting was to inform the research of patient and service user perspectives. The meeting was attended by six PPI members including four women and two men of diverse ages. The preliminary findings were

RESULTS
We recruited 30 participants from 10 general practices (Table 2. Characteristics of the participants), including 23 general practitioners, 5 nurses and 2 pharmacists. The interviews lasted between 24 minutes and 46 minutes. General practitioners', nurses' and pharmacists' responses were analysed as a single group because of the many commonalities and smaller number of non-medical respondents. We found there were no discernible differences in participants' accounts between the shire town and metropolitan settings. Overall, three participants expressed an overt avoidance of antibiotics, three others acknowledged overprescribing, whilst most prescribers leaned towards reduced prescribing. We distinguished three major themes from the data: risk assessment; balancing treatment risks; and negotiating decisions and risks (Table 3).

Identifying treatment thresholds
The primary focus of diagnostic decision-making for participants was concerned with identifying major indications for antibiotic treatment. These were judged to include the nature and severity of illness based on presentation of symptoms and signs, in the context of the patient's medical history. A majority of participants adopted a risk stratification approach in undertaking clinical assessment.

Confidence in prescribing
Appropriate prescribing and not just a reduction in antibiotics emerged as a priority for participants, who reflected on their own performance from different perspectives. In general,

Risks of prescribing and non-prescribing
Seven participants explicitly identified safety as a priority in infection management. All participants demonstrated vigilance to risks arising both from prescribing antibiotics and not prescribing. The fear was expressed of 'missing something' that could cause deterioration and consequently, participants admitted 'being cautious' and favoured prescribing antibiotics. At the same time, the common concern was also the avoidance of prescribing unnecessarily. Among the risks of prescribing, several side effects were reported, most commonly, gastrointestinal upsets, nausea, Clostridium difficile infection and thrush but also allergic, anaphylactic reactions, antibiotic resistance, and less common side effects such as liver problems (failure). Participants also observed long-term adverse consequences of inappropriate prescribing:

Facing antimicrobial resistance
Participants shared concern for the global rise in antimicrobial resistance. At the same time, they acknowledged lacking in-depth microbiological knowledge: "we talk more about not prescribing and prescribing correctly than resistance itself' (Int 9, Pharmacist). Meanwhile, they had to deal with the consequences of the antimicrobial resistance in their daily practice: There was mention of difficulties in conveying information about resistance to patientsdiscussing it in the encounters and emphasising community impact may have been less efficient than focussing on individual risks. There was also a worry that primary care is running out of antibiotics despite the strategies of second-and third-line antibiotics: "… that helps patients because at least psychologically they have got an antibiotic, but they know they can't use it straightaway". (Int 25, GP)

Communicating risks
As above, participants demonstrated that the commitment to reduced prescribing was dependent on patient understanding of the need for antibiotics. This meant that at times building and maintaining relationships were prioritised and led to prescribing decisions, as an interviewee reported:

Main findings in comparison with previous research
The study describes primary care prescribers' perceptions of safety and associated tradeoffs in the context of reduced antibiotic prescribing. We identify three key themes with relevance to safety: risk assessment, balancing treatment risks, and negotiating decisions and risks. These accounts from primary care demonstrated variations in prescribers' approaches to decision-making behaviour, including perceptions of risks associated with prescribing or not prescribing antibiotics and in the communication of these decisions and risks to patients.
Decision-making for appropriate antibiotic prescribing was informed by safety considerations. Guideline-concordant risk assessment was generally preferred to tacit  (38) Confidence in prescribing can be contrasted with views that accentuate diagnostic uncertainty. (4,17) In complex or uncertain cases, resolution was usually in favour of antibiotic prescribing, but this was in the context of a secular shift to generally more restrictive antibiotic prescribing behaviour. The reduction imperative co-exists with liberal prescribing, which was influenced by low tolerance of risks and patient pressures. This corresponds with extant literature that identifies the co-existence of different prescribing behaviours including antibiotic compromising, antibiotic delaying and antibiotic withholding.   (42,43) and now has a more personalised relevance and clinical significance than some recent reviews suggested. Systematic review evidence suggests that shared decision-making reduces prescribing (47) and our study also found that both delayed prescribing (48-51) and safety-netting appeared as effective strategies of shared decision making.  to analysis and a sample of transcripts was repeat coded by a second analyst. A patient group was involved in the research, but we acknowledge that patient involvement contribution must be managed carefully to avoid introducing bias. The thematic analysis was completed by experienced qualitative researchers using participant data; PPI input did not in this case lead to any modification of themes identified. This paper should be read in conjunction with our companion study, which explored the views of patients as participants.(52)

Implications for further research and practice
This study explored and characterised primary care prescribers' perceptions of safety issues and risk management strategies relevant to reduced antibiotic prescribing. The study offers insights into primary care prescribers' perceptions and as such it emphasises the safety

CONCLUSIONS
Attitudes towards antibiotic prescribing are changing and becoming more nuanced. There is growing confidence in the capacity to reduce the rate of prescribing and to manage patient expectations, which are themselves undergoing change. There is growing recognition that there may be safety trade-offs associated with antimicrobial stewardship and this is linked to concerns about sepsis and other serious bacterial infections. There is a need to develop better quantified estimates of risk that can inform clinical decision making and 'safety netting' advice given to patients. This will require further development of risk stratification estimates, as well as communication tools that enable these to be used in practice. Improved management of risks and benefits will help to inform future antimicrobial stewardship efforts. interpretation, or writing of the report. The authors had full access to all the data in the study and all authors shared final responsibility for the decision to submit for publication.

What are the indications for AB treatment?
To what extent do NICE (or local) guidelines influence your AM prescribing?
What are the risks of AB prescribing and non-prescribing?
How do you differentiate between infections and patients?
What are the common myths or stereotypes about antibiotics?
Can you give me an example illustrating the inaccurate understanding of their purpose, mechanisms of action, risks and consequences?
In your view, is there the best way to elicit and manage patient expectations regarding antibiotics?
How would you communicate the risks associated with both prescribing and non-prescribing antibiotics?
How confident are you in decision-making around AB prescribing?
Would you assess your approach to AB prescribing as always adequate and if so, what makes you think that?
Could you describe consequences of inappropriate treatment for infections?
What would be/were your actions following unresolved or repeated infections?
What is your understanding of antimicrobial resistance?
What are your goals and priorities in infection management?
Are there any social norms or group pressures that affect your professional practice with regards to AB prescribing and how?
Has your prescribing practice for antibiotics changed over the recent years?
Do you think patient expectations of AB treatment have changed over the recent years?
Are you aware of the prescribing practice of other HCPs (your colleagues) in relation to antibiotics?
Have you ever had to challenge their prescribing decisions?
Has anyone challenged your own decisions?
How hopeful are you usually that the AB treatment is the best course of action?
Is it possible to assess both the short-and long-term impact of AB treatment on the patients?
What is your decision-making strategy?
How anxious do you feel about the uncertainty around prescribing?

Credentials
What were the researcher's credentials? E.g. PhD, MD P6

Occupation
What was their occupation at the time of the study? P6

Gender
Was the researcher male or female? P1

Presence of nonparticipants
Was anyone else present besides the participants and researchers? P6

Field notes
Were field notes made during and/or after the interview or focus group? P7

Duration
What was the duration of the interviews or focus group? P8

22.
Data saturation Was data saturation discussed? P7

Transcripts returned
Were transcripts returned to participants for comment and/or correction? N/A 30.

Data and findings consistent
Was there consistency between the data presented and the findings? P8-P15

Clarity of major themes
Were major themes clearly presented in the findings? P8-P15

ABSTRACT
Purpose: The emergence of antimicrobial resistance has led to increasing efforts to reduce unnecessary use of antibiotics in primary care, but potential hazards from bacterial infection continue to cause concern. This study investigated how primary care prescribers perceive risk and safety concerns associated with reduced antibiotic prescribing.

Methods:
Qualitative study using semi-structured interviews conducted with primary care prescribers from 10 general practices in an urban area and a shire town in England. A thematic analysis was conducted.  population health from drug side-effects as well as from growing antimicrobial resistance.

Results
(3) Conversely, antibiotic avoidance may be associated with risks from serious bacterial infections that could be avoided through earlier treatment of infection episodes.
(2) Many studies have provided insights into the reasons for inappropriate antibiotic prescribing and several syntheses have been published (4-6), but the safety gradient associated with reducing antibiotic prescribing has developed as a new and highly relevant area of research.
In this paper, patient safety is understood as 'the avoidance, prevention and amelioration of adverse outcomes or injuries stemming from the process of healthcare'. (7) The risks associated with antibiotic prescribing decisions are a key element of patient safety and require in-depth analysis. This paper addresses the gap in knowledge about prescribers' perceptions of potential adverse outcomes associated with reduced antibiotic prescribing.
In the UK, primary care services account for nearly 80% of all medical antibiotic use but antibiotic utilisation in primary care has been declining in recent years and choice of antimicrobial agents has become more selective. (8,9) A national target proposes a further reduction in antimicrobial use of 15% by 2024 (10)   in general practice is associated with a small increase in complications such as treatable pneumonia and peritonsillar abscess. (2,15) The perceived priority of risks from either prescribing or not prescribing antibiotics requires a nuanced explanation within the broader realm of professionals' perceptions of safety and associated risk management. Fear of the risk of bacterial complications (5,16) and prognostic uncertainty about potential outcomes when not prescribing (4,17) are reportedly among key factors that influence the prescription of antibiotics. Among hospital doctors, there is evidence that overtreatment is preferred to the potential for adverse patient outcomes from not prescribing. (18,19) Klein et al (20) and Broniatowski et al (21) for example, demonstrate that medical decision-making tends to favour views that favour prescription ('why take risks') rather than on prescription avoidance ('antibiotics can be harmful'). In primary care, general practitioners and other prescribers also deal with safety concerns in their decision-making, and a better understanding needs to be developed concerning the balance of risk between prescribing or non-prescribing of antibiotics.
Patient factors influencing decision-making on antibiotic prescribing include compliance with patient expectations and pressures. (16,(22)(23)(24) Reducing AB prescribing in primary care is therefore highly dependent on successful management of patient expectations (25-27) and on shared decision-making. (28-31) It is known that clinicians weigh individual best practice against perceived patient satisfaction so that complex trade-offs are enacted. (32) Therefore, of research interest is also how the issues of safety and risk information are communicated to patients.
In the present study we investigate how primary care prescribers perceive risk and safety concerns associated with reduced antibiotic prescribing.

Interviews
An interview guide was developed (Table 1), this was designed to address key elements of the substantive research topic; it was also loosely informed by elements of the Theoretical Domains Framework, which draws on behaviour change theory to understand factors influencing health care practice. (33-35) The interview guide was piloted with three GPs to ensure that the questions were appropriate, understandable and covered relevant prescribing behaviours. All interviews were conducted by the first author to ensure consistent quality. The interviewer has a PhD in medical sociology and is an experienced qualitative researcher. All interviews apart from one telephone interview were conducted face-to-face on general practice (n=26) and University (n=4) premises in the period January-July 2019.
The participants were offered £60 to acknowledge their contribution.

Recruitment of participants
Metropolitan practices were invited to the study by the local Clinical Research Network who generated the expression of interest. A shire-town high demand practice was recruited through informal Clinical Research Network contact who also helped in liaising with potential respondents. Potential participants were then approached either directly via email using the study information pack or indirectly via the practice manager or lead GP. The information pack included the invitation letter and study information sheet. A reminder was sent out two weeks after the initial approach to those who had not responded. A purposive sampling approach was followed: all participants were prescribers. Forty-nine primary care prescribers from 10 GP practices were invited and 30 agreed to take part. The sample size was determined using the pragmatic concept of 'information power' (36), taking into account the aim of the study, sample specificity, quality of dialogue, and analysis strategy. The uptake varied between practices (in 5 practices only a single participant was interviewed).

Analysis
The interviews were digitally recorded, transcribed by a professional transcriber, imported to an NVivo-12 project and coded through an iterative six phased process described in thematic analysis.(37) Data analysis occurred iteratively and involved familiarisation, coding, theme searching, theme reviewing, theme defining and naming and producing the report.
Repeated patterns in the data formed the basis for the codes, identified by the first author, and one single code for every different concept/idea was generated. To ensure that codes were applied consistently, a co-author (CB) independently coded a random sample of four interview transcripts. Coding was refined after discussion. Data identified by the same code was collated together and all different codes were sorted into potential subthemes and themes using NVivo options of tree building. Then, the potential themes were re-assessed and re-organised to reflect major narratives and themes in the coded data. Finally, the first, second and the last authors refined and named the themes and sub-themes.

Public and Patient Involvement
Participants' feedback on the transcripts or the summarised final findings was not sought, however, the process of developing subthemes and themes was discussed at a Patient and Public Involvement meeting. The purpose of the meeting was to inform the research of patient and service user perspectives. The meeting was attended by six PPI members including four women and two men of diverse ages. The preliminary findings were

RESULTS
We recruited 30 participants from 10 general practices (Table 2. Characteristics of the participants), including 23 general practitioners, 5 nurses and 2 pharmacists. The interviews lasted between 24 minutes and 46 minutes. General practitioners', nurses' and pharmacists' responses were analysed as a single group because of the many commonalities and smaller number of non-medical respondents. We found there were no discernible differences in participants' accounts between the shire town and metropolitan settings. Overall, three participants expressed an overt avoidance of antibiotics, three others acknowledged overprescribing, whilst most prescribers leaned towards reduced prescribing. We distinguished three major themes from the data: risk assessment; balancing treatment risks; and negotiating decisions and risks (Table 3).

Identifying treatment thresholds
The primary focus of diagnostic decision-making for participants was concerned with identifying major indications for antibiotic treatment. These were judged to include the nature and severity of illness based on presentation of symptoms and signs, in the context of the patient's medical history. A majority of participants adopted a risk stratification approach in undertaking clinical assessment.

Risks of prescribing and non-prescribing
Seven participants explicitly identified safety as a priority in infection management. All participants demonstrated vigilance to risks arising both from prescribing antibiotics and not prescribing. The fear was expressed of 'missing something' that could cause deterioration and consequently, participants admitted 'being cautious' and favoured prescribing antibiotics. At the same time, the common concern was also the avoidance of prescribing unnecessarily. Among the risks of prescribing, several side effects were reported, most commonly, gastrointestinal upsets, nausea, Clostridium difficile infection and thrush but also allergic, anaphylactic reactions, antibiotic resistance, and less common side effects such as liver problems (failure). Participants also observed long-term adverse consequences of inappropriate prescribing: "I think, certainly for children, I think if you prescribe antibiotics and they don't need them and then they have a rash because they've got a virus and then a penicillin  1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59

Main findings in comparison with previous research
The study describes primary care prescribers' perceptions of safety and associated tradeoffs in the context of reduced antibiotic prescribing. We identify three key themes with relevance to safety: risk assessment, balancing treatment risks, and negotiating decisions and risks. These accounts from primary care demonstrated variations in prescribers' approaches to decision-making behaviour, including perceptions of risks associated with prescribing or not prescribing antibiotics and in the communication of these decisions and risks to patients.
Decision-making for appropriate antibiotic prescribing was informed by safety considerations. Guideline-concordant risk assessment was generally preferred to tacit  1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59  60   F  o  r  p  e  e  r  r  e  v  i  e  w  o  n  l  y   16 clinical judgement based on informal heuristics in line with previous research (38) Confidence in prescribing can be contrasted with views that accentuate diagnostic uncertainty. (4,17) In complex or uncertain cases, resolution was usually in favour of antibiotic prescribing, but this was in the context of a secular shift to generally more restrictive antibiotic prescribing behaviour. The reduction imperative co-exists with liberal prescribing, which was influenced by low tolerance of risks and patient pressures. This corresponds with extant literature that identifies the co-existence of different prescribing behaviours including antibiotic compromising, antibiotic delaying and antibiotic withholding.   1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59  60   F  o  r  p  e  e  r  r  e  v  i  e  w  o  n  l  y 17 (e.g. bleeding). In our situation of antibiotic prescribing, the 'risk' side is associated with prescribing potentially resulting in antimicrobial resistance and side effects, whilst the other side (danger) can be actualised if non-prescribing is chosen and can become the actual risk through complications such as sepsis. We found variation in how the prescribers perceived this duality, with the safety argument contributing in both directions: prescribing and nonprescribing. In other words, professionals' acting on 'doing something' were juxtaposed against 'doing no harm' concerns. The participants were able to distinguish between shortterm (e.g. side effects) and long-term (e.g. antimicrobial resistance, effect on doctor-patient relationship) trade-offs of prescribing. antimicrobial resistance was generally viewed as a standalone long-term adversity now being encountered in daily practice; it is gaining in prominence in contrast to findings from the earlier qualitative studies (42,43) and now has a more personalised relevance and clinical significance than some recent reviews suggested. Systematic review evidence suggests that shared decision-making reduces prescribing (47) and our study also found that both delayed prescribing (48-51) and safety-netting appeared as effective strategies of shared decision making.  1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59  60   F  o  r  p  e  e  r  r  e  v  i  e  w  o  n l y

Strengths and limitations
The study provided a coherent analysis of the views of primary care prescribers drawing on the responses of participants working in rural and urban settings and including a sample that was diverse with respect to professional training and years of experience. The size of the sample may not have been sufficient to distinguish differences in approach between groups with different professional training, but this could be explored further in future studies. The study may possibly have reduced transferability to other settings beyond UK primary care or beyond high-income countries. Participants were necessarily informed of the nature and purpose of the research, consequently both their participation in the interview and the interview responses might have been influenced by research participation. It is possible that respondents who were less inclined to reduce antibiotic prescribing might have been less prepared to participate. Interview responses might have been inclined to give what they perceived as 'socially acceptable' responses. We employed a thematic analysis because this enables a flexible investigation of a complex topic without drawing on pre-existing theory. In order to reduce the possibility of inconsistency, we employed a systematic, staged approach to analysis and a sample of transcripts was repeat coded by a second analyst. A patient group was involved in the research, but we acknowledge that patient involvement contribution must be managed carefully to avoid introducing bias. The thematic analysis was completed by experienced qualitative researchers using participant data; PPI input did not in this case lead to any modification of themes identified. It might be argued that if the PPI group did not materially influence the eventual data presentation, then the information about PPI involvement could be removed from the paper. However, the funders, the journal and the authors remain committed to the importance of patient and public involvement and have retained the PPI statement. This paper should be read in conjunction with our companion study, which explored the views of patients as participants.(52)  1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59

CONCLUSIONS
Attitudes towards antibiotic prescribing are changing and becoming more nuanced. There is growing confidence in the capacity to reduce the rate of prescribing and to manage patient expectations, which are themselves undergoing change. There is growing recognition that there may be safety trade-offs associated with antimicrobial stewardship and this is linked to concerns about sepsis and other serious bacterial infections. There is a need to develop better quantified estimates of risk that can inform clinical decision making and 'safety netting' advice given to patients. This will require further development of risk stratification estimates, as well as communication tools that enable these to be used in practice. Improved management of risks and benefits will help to inform future antimicrobial stewardship efforts.     To what extent do NICE (or local) guidelines influence your AM prescribing?
What are the risks of AB prescribing and non-prescribing?
How do you differentiate between infections and patients?
What are the common myths or stereotypes about antibiotics?
Can you give me an example illustrating the inaccurate understanding of their purpose, mechanisms of action, risks and consequences?
In your view, is there the best way to elicit and manage patient expectations regarding antibiotics?
How would you communicate the risks associated with both prescribing and non-prescribing antibiotics?
How confident are you in decision-making around AB prescribing?
Would you assess your approach to AB prescribing as always adequate and if so, what makes you think that?
Could you describe consequences of inappropriate treatment for infections?
What would be/were your actions following unresolved or repeated infections?
What is your understanding of antimicrobial resistance?
What are your goals and priorities in infection management?
Are there any social norms or group pressures that affect your professional practice with regards to AB prescribing and how?
Has your prescribing practice for antibiotics changed over the recent years?
Do you think patient expectations of AB treatment have changed over the recent years?
Are you aware of the prescribing practice of other HCPs (your colleagues) in relation to antibiotics?
Have you ever had to challenge their prescribing decisions?
Has anyone challenged your own decisions?
How hopeful are you usually that the AB treatment is the best course of action?
Is it possible to assess both the short-and long-term impact of AB treatment on the patients?
What is your decision-making strategy?
How anxious do you feel about the uncertainty around prescribing?
Which resources do you use to support your decisions on AB prescribing?   15.

Presence of nonparticipants
Was anyone else present besides the participants and researchers? P6

Description of sample
What are the important characteristics of the sample? e.g. demographic data, date Table 2 Data collection

Field notes
Were field notes made during and/or after the interview or focus group? P7

Duration
What was the duration of the interviews or focus group? P8

22.
Data saturation Was data saturation discussed? P7

Transcripts returned
Were transcripts returned to participants for comment and/or correction? N/A

Domain 3: analysis and findingsz
Data analysis

Number of data coders
How many data coders coded the data? P7

25.
Description of the coding tree Did authors provide a description of the coding tree? P7

Derivation of themes
Were themes identified in advance or derived from the data? P7

Software
What software, if applicable, was used to manage the data? P7 30.

Data and findings consistent
Was there consistency between the data presented and the findings? P8-P15

Clarity of major themes
Were major themes clearly presented in the findings? P8-P15