Antibiotic prescribing behaviour – what influences prescribing choices and what are the barriers and facilitators to appropriate prescribing?

28 October 2024

Throughout November, the veterinary Antibiotic Amnesty is taking place, which encourages clients to return unused antibiotics to their veterinary practice for safe disposal and shines a spotlight on appropriate antibiotic use and antimicrobial resistance (AMR).

There are many factors and considerations that contribute to antibiotic prescribing decisions in veterinary practice. We take a closer look at research into antimicrobial use in companion animals, the factors that influence veterinary surgeons’ antibiotic prescribing choices, and barriers and facilitators to appropriate prescribing behaviours.

What factors influence antibiotic usage and prescribing?

A study by the Royal Veterinary College looked at factors that influence decision-making of antimicrobial usage in first opinion small animal practices, through interviews with veterinary surgeons at seven practices in the UK1.

Intrinsic factors influencing antimicrobial selection included vet’s personal preference and previous experience (vets were more likely to prescribe a substance again if they’d had a positive experience with it (e.g. resolution of clinical condition) and were less likely to use antimicrobials that they had no previous experience of and were outside of their ‘comfort zone’) and knowledge of infectious and non-infectious diseases.1

Influential factors associated with the antimicrobial substance included perceived efficacy of the substance (with vets likely to select the most effective against the likely microorganism involved), ease and route of administration of medications, and availability of drugs in the practice (vets were sometimes restricted to use substances that wouldn’t have been their first choice). Most vets interviewed preferred broad-spectrum over narrow antimicrobials, and over half of the interviewees often selected antimicrobials without a confirmed diagnosis, based only on clinical examination findings. Discussions with colleagues and effectiveness meetings in practice to agree protocols were influential in prescribing decisions. A difference between older and younger interviewees was noted, with differences in undergraduate training received, and accumulated experience and knowledge sometimes changing prescribing behaviours over time.1

Pet owner understanding and willingness to comply to antibiotic prescription and discuss AMR strongly influence prescribing decisions.1,2 In this study, if an owner could not afford or was not willing to pay for a therapy, vets stated they would consider changing their first choice of antimicrobial to a cheaper option that might not have been as effective, although cost of therapy was only an influential factor in practices located in areas with low, mixed socioeconomic status.1 Owner compliance (vets reported changing their first choice of antimicrobials if they felt that owners weren’t ‘on-board’), previous negative experiences with antimicrobials reported by owners (often meaning vets were less likely to select the same substance) and pressure from owners to prescribe (although most vets reported not yielding to owner’s expectations) all influenced prescribing choice.1 However, another study found that vets and pet owners had conflicting views of where pressure to prescribe antibiotics originated, with vets feeling that it was mostly owners who pushed for prescriptions, whereas owners felt that vets overprescribed.2

Finally, animal characteristics influenced antimicrobial selection, with patient weight (antimicrobial selection was influenced by cost in large dogs), age (specifically when considering the risk of adverse reactions), and clinical signs (particularly the presence of pyrexia) all playing a role, as well as the difficulty in giving tablets and oral preparations in cats.1

What are the barriers to appropriate prescribing?

Through interviews with veterinary surgeons, research has found that prescribing behaviour is influenced by a range of barriers and facilitators which have a ‘push-pull’ effect.3 Barriers to appropriate prescribing include:

  • Client expectation and satisfaction of their pet receiving antibiotics, with clients perceiving antibiotics as a direct action for their pet’s recovery rather than waiting for their pet to recover without medication.3
  • Lack of time during consultations to conduct a diagnostic test or further clinical investigations, even when laboratorial facilities and equipment are available.3
  • Fear of not diagnosing and treating an infection and the potential negative consequences for an animal and the vet themselves through a client complaint or disciplinary action.3
  • The influence of habitual, entrenched prescribing patterns and peer influence, particularly on new graduates, which may encourage poor prescribing behaviours.3
  • The influence of pharmaceutical companies, particularly in the marketing of products to help with the administration of antibiotics, e.g. addressing difficulties in getting cats to swallow tablets.3
  • Limited awareness of recommendations for responsible antibiotic use, and/or recommendations being considered difficult to implement in practice.1

What can assist appropriate prescribing?

Vets have identified the following considerations that could facilitate appropriate prescribing:

  • Educating pet owners and raising awareness about over-use or mis-use of antibiotics and AMR.2 It has been noted that an increase in AMR awareness among the public is affecting clients’ prescribing expectations, possibly through doctors prescribing antibiotics to human patients less frequently.3
  • Increased consultation time to allow more time for discussion about antibiotic prescribing.2
  • Providing more guidance to cat owners on administering oral medications (e.g. clinic videos and leaflets) to decrease reliance on long-acting cefovecin injections.4
  • Implementing routine, post-consultation follow-up with pet owners after they have begun a course of antimicrobials.4
  • The possibility of changing established prescribing behaviours over time, with professional education (both graduate and post-graduate), peer support and influence, and experience.3
  • With good infection prevention practices, many vets felt that antibiotics are not necessary, and a shift away from the prophylactic use of antibiotics after surgery was noted.3
  • Finally, governmental input was seen to have a role in improving prescribing by monitoring antibiotic use and subsidising the cost of diagnostics, although there wasn’t agreement among vets interviewed about what form regulation should take.3

The evidence shows that antibiotic prescribing decisions are influenced by a complex array of factors related to the veterinary surgeon, antimicrobial substance, pet owner and the animal being treated, with many barriers to appropriate prescribing. Understanding how these factors interact and how barriers can be overcome can help to contribute to changing prescribing behaviours over time, to reduce the drivers of antimicrobial resistance.3

More information and resources

Download the free PROTECT ME poster, which gives guidelines on the key principles that should be considered before giving antibiotics to cats and dogs, and rabbits, here.

Download the ‘no antibiotic required’ form, which can be provided to clients to support a decision not to provide antibiotic medication, here.

Find out how your practice can take part in this year’s Antibiotic Amnesty and download the campaign toolkit and resources, here.

References

1Mateus ALP, Brodbelt DC, Barber N et al. (2014) Qualitative study of factors associated with antimicrobial usage in seven small animal veterinary practices in the UK. Preventive Veterinary Medicine. 117, 1, 68-78. https://doi.org/10.1016/j.prevetmed.2014.05.007

2Smith M, King C, Davis M et al. (2018) Pet owner and vet interactions: exploring the drivers of AMR. Antimicrobial Resistance and Infection Control. 7, 46. https://doi.org/10.1186/s13756-018-0341-1

3King C, Smith M, Currie K et al. (2018) Exploring the behavioural drivers of veterinary surgeon antibiotic prescribing: a qualitative study of companion animal veterinary surgeons in the UK. BMC Vet Res. 14, 332. https://doi.org/10.1186/s12917-018-1646-2

4Scarborough RO, Bailey KE, Sri AE et al. (2024) Seeking simplicity, navigating complexity: How veterinarians select an antimicrobial drug, dose, and duration for companion animals. Journal of Veterinary Internal Medicine. https://doi.org/10.1111/jvim.17197