How, why and when are delayed (back-up) antibiotic prescriptions used in primary care? A realist review integrating concepts of uncertainty in healthcare
Authors: Mcleod Monsey , Campbell Anne , Hayhoe Benedict , Borek Aleksandra J. , Tonkin-Crine Sarah , Moore Michael V. , Butler Christopher C. , Walker A. Sarah , Holmes Alison , Wong Geoff 
Published: November 2023

ABSTRACTBackgroundAntimicrobial resistance is a global patient safety priority and inappropriate antimicrobial use is a key contributing factor. Trials have shown that delayed (back-up) antibiotic prescriptions (DP) are an effective and safe strategy for reducing unnecessary antibiotic use but its uptake is controversial.MethodsWe conducted a realist review (a literature review which goes beyond assessing whether an intervention works) to ask why, how, and in what contexts general practitioners (GPs) use DP. The review is focused on those who wish to use DP and not for those who are against using DP. We searched five electronic databases for relevant articles and included DP-related data from interviews with healthcare professionals in a related study. Data were analysed using a realist theory-driven approach – theorising which context(s) influenced (mechanisms) resultant outcome(s) (context-mechanism-outcome-configurations: CMOCs).ResultsData were included from 76 articles and 41 interviews to develop a program theory comprising nine key and 56 related CMOCs. These explain the reasons for GPs’ tolerance of risk to different uncertainties—epistemological (knowledge-orientated); scientific (data-orientated); hermeneutic (interpretation-orientated); practical (structures/processes-orientated); technological (skills/software/equipment-orientated), and existential (world-view-orientated). These interact with GPs’ work environment, self-efficacy and perceived patient concordance to make using DP as a safety-net or social tool more or less likely, at a given time-point. Our program theory explains how DP can be used to mitigate some uncertainties but also provoke or exacerbate others.ConclusionThis review explains how, why and in what contexts GPs are more or less likely to use DP, as well as various uncertainties GPs face which DP may mitigate or provoke. We recommend that efforts to plan and implement interventions to optimise antibiotic prescribing in primary care should consider these uncertainties and the contexts when DP may be (dis)preferred over other interventions to reduce antibiotic prescribing. We also recommend the following and have included example activities for: (i) reducing demand for immediate antibiotics; (ii) framing DP as an ‘active’ prescribing option; (iii) documenting the decision-making process around DP; and (iv) facilitating social and system support.SUMMARY BOXWhat is already known on this topic– Trials have shown that delayed (back-up) antibiotic prescriptions (DP) are an effective and safe strategy for reducing unnecessary antibiotic use but its variable uptake in primary care remains to be understood.What this study adds– This realist review provides a program theory to explain the complexity and interactivity of influencing factors on general practitioners’ (GPs) antibiotic prescribing decisions. It explains how GPs have a reasoned tolerance of risk to various uncertainties (beyond clinical uncertainty) which interact with GPs’ work environment, self-efficacy and perceived patient concordance to make using DP as a safety-net or a social tool more or less likely, at a given time-point. It applies nuanced concepts from the uncertainty literature - epistemological uncertainty (knowledge-orientated), scientific uncertainty (data-orientated), hermeneutic uncertainty (data interpretation-orientated), practical uncertainty (structures/processes-orientated), technological uncertainty (skills/software/equipment-orientated), and existential uncertainty (world-view and identity-orientated) - to better understand DP clinical decision-making.How this study might affect research, practice or policy– Policy makers, commissioners, and prescribers who would like to optimise antibiotic prescribing should become familiar with the varieties of uncertainties at play when GPs consult with patients and consider how these different uncertainties are mitigated and/or provoked when developing support interventions to optimise DP or implementation support.