'Some patients demand for a prescription of an antibiotic': an assessment of barriers and facilitators to rational antimicrobial use in a private health facility in Uganda.

Background: Antimicrobial misuse and overuse propagate antimicrobial resistance, yet data on factors influencing antibiotic prescription decisions in low-resource settings are limited. We describe factors influencing antimicrobial prescription at a large tertiary care private not-for-profit hospital in Uganda.

Methods: We conducted a descriptive phenomenology qualitative study involving face-to-face in-depth interviews of 12 purposively selected prescribers (four intern doctors, six medical officers and two Internal Medicine physicians) in a private not-for-profit hospital in Kampala, Uganda. Audio recordings and filed notes were transcribed verbatim and analysed manually by content analysis. Emerging themes and sub-themes were recorded and reported.

Results: Three broad themes emerged: experience with antimicrobial use in Uganda, barriers and facilitators to rational antimicrobial prescription and measures to address irrational antimicrobial use. Participants recognized that antibiotics are often used irrationally, prescribed even when there is uncertainty regarding clinical evidence for infection, and influenced by drug promoters, and noted high levels of antibiotic resistance. Patients' symptoms and clinical signs, previous experience using antibiotics, fear of bad outcomes, patient demand and expectations, influence from senior colleagues, the turnaround time of clinical investigations and drug marketers were the barriers and facilitators to antimicrobial prescription. Prescribers also acknowledged the need to update clinical guidelines, set up hospital antibiograms, and provide continuous medical education on rational antimicrobial use.

Conclusions: A complex interplay of intrinsic and extrinsic factors influences antibiotic prescribing decisions in this hospital. Targeted interventions through continuous education and training for prescribers, providing local prescription guidelines and antibiograms and implementing regulations on over-the-counter antibiotic sales are needed to implement robust antimicrobial stewardship programmes to curb antimicrobial resistance successfully.