title: Antibiotic overuse for acute respiratory tract infections in Sri Lanka: a qualitative study of outpatients and their physicians.
abstract: Acute respiratory tract infections (ARTIs) are a common reason for antibiotic overuse worldwide. We previously showed that over 80% of outpatients presenting to a tertiary care hospital in Sri Lanka with influenza-like illness received antibiotic prescriptions, although almost half were later confirmed to have influenza. The purpose of this qualitative study was to assess Sri Lankan patients' and physicians' attitudes towards ARTI diagnosis and treatment.
  
  
  
  Semi-structured interviews were conducted with 50 outpatients with ARTIs and five physicians in the Outpatient Department (OPD) at a large, public tertiary care hospital in southern Sri Lanka. Interviews were audio-recorded, transcribed, and analyzed for themes related to ARTI diagnosis and treatment.
  
  
  
  Patients frequently sought ARTI care in the public sector due to the receipt of free care and the perception that government hospitals carried a sense of responsibility for patients' health. Patients reported multiple medical visits for their illnesses of short duration and many indicated that they were seeking care in the OPD while at the hospital for another reason. While patients generally expected to receive medication prescriptions at their visit, most patients were not specifically seeking an antibiotic prescription. However, more than 70% of patients received antibiotic prescriptions at their OPD visit. Physicians incorrectly perceived that patients desired antibiotics or "capsules," a common formulation of antibiotics dispensed in this outpatient setting, and cited patient demand as an important cause of antibiotic overuse. Physicians also indicated that high patient volume and fear of bacterial superinfection drove antibiotic overuse.
  
  
  
  Patients in this study were seeking medication prescriptions for their ARTIs, but physicians incorrectly perceived that antibiotic prescriptions were desired. High patient volume and fear of bacterial superinfection were also important factors in antibiotic overuse. Training of physicians regarding guideline-concordant management and dealing with diagnostic uncertainty, education of patients regarding ARTI etiology and management, and systematic changes in the public outpatient care structure may help decrease unnecessary antibiotic prescriptions for ARTIs in this setting.
authors.affiliation: Department of Medicine, Duke University School of Medicine and Duke Global Health Institute, Durham, USA. gayani.tillekeratne@dm.duke.edu.
authors.forename: L Gayani
authors.identifier: 0000-0001-6012-7271
authors.initials: LG
authors.lastname: Tillekeratne
authors.affiliation: Faculty of Medicine, University of Ruhuna, Galle, Sri Lanka.
authors.forename: Champica K
authors.initials: CK
authors.lastname: Bodinayake
authors.affiliation: Nutrition and Indigenous Medicine, Ministry of Health, Colombo, Sri Lanka.
authors.forename: Thushani
authors.initials: T
authors.lastname: Dabrera
authors.affiliation: Faculty of Medicine, University of Ruhuna, Galle, Sri Lanka.
authors.forename: Ajith
authors.initials: A
authors.lastname: Nagahawatte
authors.affiliation: Teaching Hospital Karapitiya, Galle, Sri Lanka.
authors.forename: Wasantha Kodikara
authors.initials: WK
authors.lastname: Arachchi
authors.affiliation: Faculty of Medicine, University of Ruhuna, Galle, Sri Lanka.
authors.forename: Anoji
authors.initials: A
authors.lastname: Sooriyaarachchi
authors.affiliation: Duke Global Health Institute, Durham, USA.
authors.forename: Kearsley
authors.initials: K
authors.lastname: Stewart
authors.affiliation: Duke Global Health Institute, Durham, USA.
authors.forename: Melissa
authors.initials: M
authors.lastname: Watt
authors.affiliation: Department of Community and Family Medicine, Duke University School of Medicine and Duke Global Health Institute, Durham, USA.
authors.forename: Truls
authors.initials: T
authors.lastname: Østbye
authors.affiliation: Department of Medicine, Duke University School of Medicine and Duke Global Health Institute, Durham, USA.
authors.forename: Christopher W
authors.initials: CW
authors.lastname: Woods
mesh_terms: D000208:Acute Disease; D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D001291:Attitude of Health Personnel; D002648:Child; D002675:Child, Preschool; D005260:Female; D007722:Health Knowledge, Attitudes, Practice; D006779:Hospitals, Public; D006801:Humans; D057970:Inappropriate Prescribing; D007223:Infant; D008297:Male; D008875:Middle Aged; D010044:Outpatient Clinics, Hospital; D010045:Outpatients; D017060:Patient Satisfaction; D010820:Physicians; D036301:Qualitative Research; D012141:Respiratory Tract Infections / Q000188:drug therapy*; D013188:Sri Lanka; D062606:Tertiary Care Centers; D055815:Young Adult
chemical_list: D000900:Anti-Bacterial Agents
keywords: Antibiotics; Health care utilization; Outpatients; Respiratory tract infections; Sri Lanka